Wednesday, February 24, 2010

My DSM-5 Report Card: Grading Bipolar - Part III

Today’s grading assignment began with an apparently niggly issue that suddenly turned severe. Severity is the topic. Let’s get into it ...

Severity, Mania/Hypomania

The DSM-5 Task Force mandated its various workgroups to come up with sophisticated severity measures analogous to assessing hypertension. This would place far greater emphasis on functional impairment (such as inability to hold down a job) rather than simply ticking off symptoms.

It’s too bad this message got lost in the mail.

Until someone comes up with a foolproof diagnostic test, severity is the only way of separating out mania from hypomania (and thus bipolar I from bipolar II). Indeed, the current DSM already red flags severity (“not severe enough to cause marked impairment”) to distinguish hypomania from mania.

What we need now are some precise measures that would aid clinicians in dialing in the diagnosis, plus perhaps detect the types of subtle “ups” that signal there is more to many depressions than simply depression. A lot of deep thinking is required to come up with the right indicator. Expect, instead, to find a last minute generic patch along the lines of the CGI.

Grade: F-minus.

Severity, General

The workgroup indicated it is considering various standard measures (such as the CGI) for severity for the bipolar diagnosis. One problem is these measures don’t seem to apply to episodes. Thus, for mania, the workgroup notes: “This is not a codeable disorder; therefore, there are no severity criteria proposed.”


Grade: F-minus.

Severity, Cycling

What sets bipolar (including cyclothymia and recurrent depression) apart from other ills is that it is essentially a cycling illness. Thus, “feeling better” may actually be a sign of trouble, of the cycle about to ramp up or change course.

It’s all about the cycle. Fast or slow, extreme or subtle. Without an accurate read, we are literally flying in the dark. Does the workgroup have something in mind? If so, they haven’t told us.

Grade: F-minus.

Severity, Context

Perhaps you are feeling okay now, but you know if you went back to work or had to deal with some troublesome family issues you would fall apart. Is there a severity indicator for that? Consider this assignment extra credit.

No grade.

Severity, Stress

Where there’s smoke there’s fire. A smoke detector would not be difficult to devise. Another extra credit project.

No grade.

The Bipolar Report Card So Far ...

  • Depression: F-minus
  • Euphoric and Dysphoric Mania: F
  • The Mania Minimum Time Limit: D
  • Hypomania as a Marker for Depression: Incomplete
  • Hypomania as a Marker for Mania: F
  • Dysphoric and Euphoric Hypomania: F
  • Antidepressant-Induced Mania/Hypomania: C-minus.
  • Mixed Episodes, Symptoms: C-minus.
  • Mixed Episodes, Spectrum Considerations: C-plus.
  • Bipolar III: D
  • Recurrent Depression: F-minus.
  • Rapid cycling: Incomplete
More to come ...

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