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

Part I, Part II, and Part III to Grading Bipolar placed heavy emphasis on that largely unmapped middle ground where bipolar bleeds over into clinical depression. Why this is critically important is that clinical ignorance leads to misdiagnosis and wrong treatments, which translates into years and even decades of unnecessary suffering.

The current DSM abets numerous opportunities for bad psychiatric practice, which the DSM-5 was supposed to redress. Unfortunately, the Task Force and its various workgroups suffered an extreme outbreak of dereliction of duty.

So, can the DSM-5 do better where bipolar bleeds over in the other direction into schizophrenia? First a little background ...

Back in the early twentieth century, the pioneering diagnostician Emil Kraepelin separated out “manic depression” (bipolar and recurrent depression) from “dementia praecox” (schizophrenia). This distinction provided psychiatry with its first real navigational aid, which continues to guide diagnostic practice to this very day.

But Kraepelin also recognized the limits to making a clear categorical split, and recent genetic findings are backing his reservations. Virtually all the leading candidate genes for bipolar happen to be leading candidate genes for schizophrenia, as well.

The current DSM recognizes some of the crucial fine shadings. Thus we have “with psychotic features” as specifiers to both major depressive disorder and bipolar disorder. In addition, there exists the separate diagnosis of “schizoaffective disorder” that is widely interpreted as a hybrid between bipolar and schizophrenia.

The issue: Should those charged with the DSM-5 attempt to fix what doesn’t appear to be broken? Or is there considerable room for improvement?

On with the grading ...

Psychosis, a Clear Definition

The current DSM makes various references to psychotic features, but what precisely is “psychotic”? To find out, one needs to flip the pages to the rather obscure diagnosis of “brief psychotic disorder,” which mandates one or more of the following symptoms:

Delusions; hallucinations; disorganized speech; psychomotor symptoms, including catatonic behavior.

The DSM-5 would leave this unchanged.

Fine, that provides a breakdown of the component parts to psychosis, but what is psychosis? The glossary to the DSM-IV concedes that none of the historic definitions “has achieved universal acceptance.” Narrowly viewed, psychosis refers to hallucinations and delusions to which the patient lacks insight. A wider view would incorporate patient insight. Still wider are the symptoms listed for the positive symptoms of schizophrenia (same as for a brief psychotic episode) and wider still would incorporate “loss of ego boundaries or gross impairment in reality testing.”

The current DSM punted in coming up with an authoritative definition and set of distinctions. It appears the DSM-5 is similarly opting out.

Grade: F.

With Psychotic Features

Psychosis looms large in mania and less so in depression. The DSM-IV operative term is “with psychotic features,” which the DSM-5 would leave unchanged. Presumably, a “feature” is less intense than a “symptom,” but it would be helpful to see this spelled out. Is this asking too much? Apparently yes.

Grade: F.

Mood Congruent/Incongruent

When adding a “with psychotic features” specifier to depression or mania, the DSM-5 would mandate clinicians to differentiate “mood congruent” from “mood incongruent.” In a depression context, mood congruent psychosis might translate to, say, irrational feelings of deserved punishment. A manic context might involve delusions of a special relationship to a deity.

Mood incongruent, by contrast, involves no apparent linkage between mood and disordered thinking.

The current DSM buries this distinction way back in Appendix C. Moving this up front and center is a major step forward. But will clinicians have to flip to the back pages to find the definitions?

Grade: B.

How Psychotic is Psychotic?

We know we can have a mood disorder “with psychotic features.” What is unclear is whether we can have a mood disorder with full-blown psychosis. Or is that something else? Say schizophrenia or schizoaffective disorder?

Misinterpreting psychosis leaves no room for error, as a diagnosis of schizophrenia sends (very wrongly) a clear message to abandon all hope.

Grade: F.

Schizoaffective Disorder

The DSM-5 spells it out: “The current DSM-IV-TR diagnosis schizoaffective disorder is unreliable.”

To start, the current DSM classifies schizoaffective under “Schizophrenia and Other Psychotic Disorders,” but is this the right place to put it?

Too often, schizoaffective is employed as a glorified NOS diagnosis by clinicians who can’t decide whether their patient has bipolar or schizophrenia. As Goodwin and Jamison and others point out, the current DSM leaves wide room for mutually exclusive interpretations, such as:

A form of bipolar with psychosis, a form of schizophrenia with mood swings, co-occurring schizophrenia and bipolar, a separate illness, or a different phenomenon entirely occupying the psychosis spectrum.

Just to make things more confusing, a patient may appear to have schizophrenia during one phase of his or her life and bipolar in another.

So how would the DSM-5 fix a diagnosis it regards as “unreliable”?

“We recommend the following, minor change in the text ..."

A MINOR textual change? Is that it? Yes, apparently.

Grade: F-minus.

More to come ...