Thursday, March 11, 2010

Grading Bipolar - Looking Back At My DSM-5 Report Cards

Let’s review the six DSM-5 bipolar report cards I issued:


My first report card noted that the current DSM and its would-be replacement look at various mood states (depression, mania, hypomania, mixed) in isolation, as if they bear no relation to each other. I started out by challenging that assumption, a theme I kept returning to in subsequent report cards.

We’re all familiar with the symptom checklists. The draft DSM-5 got off to a bad start by repeating the errors of previous DSMs, namely by copying and pasting the unipolar depression checklist into bipolar as if all depressions are the same. Not only are they different, but anomalies in depression can tip off clinicians to dig deeper for evidence of past mania/hypomania episodes.

One thing that needs to be constantly borne in mind: The DSM is not a science project. It’s not a codeable reimbursement system set up for the convenience of the healthcare industry. The only reason for its existence is to guide clinicians in making an accurate diagnosis, based on the best information we have.

So right off the bat, we have the draft DSM-5 perpetuating old mistakes that are only going to encourage misdiagnosis. As I concluded here: “What were these people thinking? They weren’t. Grade: F-minus.”

I also turned it the other way around, namely that evidence of “up” points to how one’s depressions cycle. So how high, then, does “up” have to be? Only high enough to separate it from down and thus identify that the depression is not unipolar. Who needs to count symptoms? I wimped out with a grade of “incomplete.” I should have issued an F.

I also noted that the draft DSM-5 did nothing to clear up the myth concerning good time manias and hypomanias. In fact, a lot of us are miserable in these states, what can best be described as energized psychic pain, or, more technically, “dysphoric” mania/hypomania. Why no symptom list to separate this out from “euphoric” mania/hypomania? As I concluded: “Is there a secret DSM with accurate information that only a privileged few are allowed access to? And a fantasy DSM for all the rest of us? Grade F.” (I was way too generous.)

Mixed Episodes and Spectrum Considerations

My second report card focused on where mania and depression meet. The draft DSM-5 got off to a good start by recognizing for the first time the reality of antidepressant-induced mania/hypomania, but turned a potential A into a C-minus by burying this in the boilerplate fine print that no one reads.

The recognition that one doesn’t have to be fully depressed and manic at the same time to experience a mixed episode was also an encouraging development. The next DSM-5 is likely to acknowledge the reality of depression symptoms inside mania/hypomania and mania/hypomania symptoms inside depression, which would embrace the bipolar II population for the first time.

But what does a mixed state look like? Presumably we are talking about symptoms strong enough to turn “euphoric” manias “dysphoric” and mind-numbing depressions “agitated.” The problem is the DSM leaves us presuming. Thus a potential A got knocked down to a C-minus. “Do we have to Google the answers ourselves?” I asked.

Also, the DSM-5 could have gone a lot wider in its recognition of mixed states, thus turning another potential A into a C-plus.

The other dimension to the bipolar spectrum includes “soft bipolar” not recognized by the current DSM (unless you stick NOS to the diagnosis). These are so-called unipolar depressions that behave like bipolar and need to be treated as such. There are three ways the DSM-5 could have approached this: 1) Widening the bipolar II diagnosis, 2) Adding a bipolar III diagnosis, 3) Getting creative with the unipolar recurrent depression diagnosis.

I issued two grades in this category. One was an F-minus. The draft DSM-5 managed to turn my second potential F-minus into a D by indicating that it was willing to tweak hypomania (the threshold for bipolar II) just a tad.


My third report card looked at severity issues. As I noted in my piece:

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.

Severity is vital in separating out “normal” from hypomanic and hypomanic from manic. The current DSM already uses this as its main criteria (“not severe enough to cause marked impairment”) to distinguish hypomania from mania, but a lot more deep thinking is required, which I decided wasn’t going to happen when I handed out my standard F-minus.

I had already introduced the theme on my first report card, noting:

How do we delineate “normal” (that include ups that are characteristic of a particular individual) from hypomanic from manic? Get it wrong and we will never find the patient’s treatment sweet spot.

A minor tweak to the symptom list would have done wonders, but this, apparently, was asking too much. My grade of F was far too generous.

Of all things, the draft DSM-5 decided severity didn’t apply to episodes. Huh? F-minus. The same group of people also didn’t think to have regard for the cardinal feature of bipolar, namely cycling. Another F-minus.

There were opportunities for the draft DSM-5 to get creative by coming up with severity measures for stress and context (as in you may feel okay right now, but are you okay to go back to work?). F-minus or incomplete? I was a softee on this one.

Psychosis and Schizoaffective

My previous report cards placed considerable emphasis on bipolar bleeding into unipolar. My fourth installment looked in the other direction toward schizophrenia. The current DSM seemed to have the issue covered with its recognition of “psychotic features” to both depression and mania, plus the diagnostic hybrid of schizoaffective disorder.

But closer examination revealed considerable room for clarification. As I noted in my piece: “Misinterpreting psychosis leaves no room for error, as a diagnosis of schizophrenia sends (very wrongly) a clear message to abandon all hope.”

For one, we had no clear definition of psychosis (F), or an explanation as to the difference between a psychotic symptom and psychotic feature (F) or an adequate guide for when a clinician should stop going with a specifier in favor of a different diagnostic call (such as schizoaffective).

The draft DSM-5 explicitly pointed out a major problem with schizoaffective, namely: “The current DSM-IV-TR diagnosis schizoaffective disorder is unreliable.” Their remedy was no remedy. You gotta be kidding! F-minus.

Somewhere in the middle of all of this, I actually handed out a B, but that’s like praising Charles Manson for being a model prisoner.

Child Bipolar

For my fifth report card, the draft DSM-5 outdid itself, with a string of F-minus’ as my highest grade. For one topic, an F-minus would have been way too generous, so I issued a “no-grade” in protest.

Essentially, the draft DSM-5 refused to acknowledge “pediatric bipolar” as a diagnosis in its own right. Even an “early onset” specifier would have at least acknowledged the reality that one doesn’t have to be of voting age to qualify for a bipolar diagnosis. Technically, the draft DSM does not dismiss the possibility of kids with bipolar, but lumping kids with adults offers no guide to clinicians.

In a nutshell, bipolar kids tend to act out somewhat differently than bipolar adults, with emphasis on extreme rapid cycling and raging mixed states.

The draft DSM-5 thought it solved the problem by introducing the entirely new diagnosis of “temper dysregulation disorder with dysphoria.” These are basically raging kids who don’t cycle, and thus are not be be regarded as having bipolar. There may be some merit in the diagnosis, but the draft DSM-5 failed to cover its tracks. The justifications its working group put out literally scream internal politicking and nasty turf wars.

The result was an ill-considered and hastily-conceived new diagnosis that violated the draft DSM-5’s own standards for scientific validity. Had the new diagnosis been presented in the context of a pediatric bipolar diagnosis, this may have been acceptable, instead, as I noted:

The result is an unmitigated disaster, one that shames psychiatry and performs a considerable disservice to the public, whose interest is supposed to come first.


Cycling is bipolar’s cardinal symptom, though you would never know it by going to the current DSM or its would-be successor. By this time, my sixth report card, I had decided no more Mr Nice Guy. No more easy grading. This time, an unbroken string of F-minuses.

As I noted in my piece:  “We cycle up, we cycle down. Strip bipolar to its most essential element and what we’re left with can be best described as ‘cycling illness.’”

This brings me back to the theme I introduced in my first report card: that episodes (such as depression) make no sense in isolation, with no regard to where and when and how severe the cycle may trend next (such as mania).

I also observed that there was more to cycling than simply mood, including sleep/energy and thoughts, and that these didn’t necessarily have to occur in sync with our moods. This is classic Kraepelin, dating from the early twentieth century. In addition, Kraepelin also figured out that mixed states were the result of out-of-alignment cycles (including physical activity).

As I concluded: “Kraepelin got it right the first time. The DSM is about to get it wrong the fifth time.”

My DSM-5 bipolar report cards:

My DSM-5 Report Card: Grading Bipolar - Part VI
My DSM-5 Report Card: Grading Bipolar - Part V
My DSM-5 Report Card: Grading Bipolar - Part IV
My DSM-5 Report Card: Grading Bipolar - Part III
My DSM-5 Report Card: Grading Bipolar - Part II
My DSM-5 Report Card: Grading Bipolar - Part I

1 comment:

Colby said...

Bipolar disorder is a severe and complicated mental illness. Many doctors are unable or unwilling to diagnose bipolar disorder in children and young teens. It is important to get help and recognize the different treatment options available. Silver Hill Hospital, a substance abuse and psychiatric hospital, has some helpful information and resources.