Tuesday, March 9, 2010

My DSM-5 Report Card: Grading Bipolar - Part VI, Stating What's Obvious

We’re all familiar with the metaphor of the elephant in the room with six blind men. Now how the elephant got in the room in the first place we’ll never know. So what is bipolar? We grab it by the tusk ... We grab it by the tail ...

How does the draft DSM-5 deal with this mysterious elephant? Time to start grading ...

Bipolar is a cycling illness

This is easy. 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 is what sets bipolar apart from other mental illnesses. Individuals with borderline personality disorder, for instance, may flip from high to low, but they don’t cycle from one state to the other.

Cycling is also complex. To get a true handle on our illness, we need to get a fix on how our ups and downs relate. Is our hypomania, for instance, a prelude to a crushing depression, or is it a warning that we are about to get swept up in full blown mania?

We also need to know our cycling patterns (such as seasonal changes) and the types of things that can throw off our cycles (such as cross-country travel).

In short, cycling is the signature symptom to our illness. The “episode” symptom lists (depression, mania, hypomania, mixed episodes) by contrast pale to insignificance. Our episodes only make sense in the context of the cycle that drives them, but you would never know that from looking at the current DSM and its would-be successor.

A smart clinician aware of the turning wheel will seek out evidence of past mania in a patient presenting with depression. That same clinician will also treat the cycle rather than the episode of the day. Precise diagnosis, appropriate treatment. Isn’t that what a diagnostic manual is supposed to encourage? Not this one.

Grade: F-minus.

Bipolar is a cycling illness - again

Gene studies are linking bipolar to a defect in our brain’s “master clock.” The evidence is not yet there to drop the term bipolar in favor of “master clock dysregulation syndrome,” but we do know enough to confidently state that our moods are tied into circadian rhythms that affect sleep and energy.

“Insomnia or hypersomnia” is a symptom for depression, along with “fatigue or loss of energy” while “decreased need for sleep” is a symptom for mania. In addition, the DSM-5 is likely to add “increased energy/activity” as a mania symptom.

But why think of sleep/energy as symptoms of the mood episode? How about looking at it the other way around -  perhaps mood is really a downstream effect of sleep/energy. Think how shitty you feel when you haven’t had enough sleep. And we know that missed sleep is the royal road to mania.

So maybe bipolar should be called “sleep dysregulation syndrome with mood effects.” Okay, that’s not going to fly. But how about at least some recognition? Something that makes clinicians sit up and pay attention. How hard can that be? Very, apparently.

Grade: F-minus.

Bipolar is a cycling illness - yet again

Our brains can be on rocket fuel one day, mired in molasses the next. One minute, we’re Albert Einstein, the next Alfred E Neuman on a bad day. Yes, our thoughts can alternatively be racing in a manic episode and incapable of booting up during depression, but a lot of this also seems to happen independent of mood.

Or maybe thought, mood, energy, and fatigue share a lot of the same underlying pathways.

The bottom line is a good percentage of us don’t think straight a lot of the time. Certainly, what is obvious to us and the people around us, not to mention the people who have studied us, has to be obvious to those preparing the next DSM, right? Don’t ask.

Grade: F-minus.

Bipolar is a cycling illness - one more time

In 1913, the pioneering diagnostician Emil Kraepelin recognized six mixed states. Basically, our moods cycled, but so did our mental and physical activity, though not necessarily in sync. Thus, according to Kraepelin, we could wind up in manic stupor and excited depression.

Parallel cycles tied up in knots - Kraepelin got it right the first time. The DSM is about to get it wrong the fifth time.

Grade: F-minus.

Bipolar is a cycling illness - conclusion

By now you’ve figured out the mystery of the bipolar elephant. The tusk is cycling. The trunk is cycling. The tail is cycling. The ears are cycling. The sum total of the elephant is cycling. So simple even a caveman can understand it. No, let’s not go there ...

Previous report cards:

More report cards to come ...

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