Wednesday, March 31, 2010

The People’s DSM: My Alternative Bipolar (Cycling) Diagnosis - Part III

Thus far (in Part I and Part II), I have kept what I refer to as “cycling illness” simple. As long as we appreciate that down and up are connected as different phases in the same cycle, there is little room for confusion. But there is a major complication called psychosis. If the psychosis is severe enough and prevalent enough, suddenly clinicians are faced with some very tricky diagnostic calls.

The current DSM recognizes psychosis as an illness in its own right and acknowledges its occurrence in other illnesses, including depression, bipolar, and schizophrenia, not to mention the hybrid diagnosis of schizoaffective. In theory, clinicians have a rough guide to work with. In practice, uncertainty prevails, namely:

How, precisely, does psychosis tie in to mood? And, while we’re at it, is there actually one person in the whole wide world who can explain schizoaffective, much less the reason for its existence?

Brain science and genetics promise to yield far more definitive answers than we presently have, which may explain why the draft DSM-5 changed virtually nothing. My view is we need to do our best based on the knowledge we have now, even if future scientific discovery proves us wrong. Let’s get to work:

The current DSM treats “with psychotic features” as a specifier to bipolar rather than to depression or mania. Let’s keep the specifier approach, but find more precise applications, thus:

Euphoric Mania with Psychosis

Various euphoric mania characteristics (such as enhanced positive abilities) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself or his or her situation in a grossly exaggerated light (such as a superman on a special humanitarian mission).

Dysphoric Mania (Mixed) with Psychosis

Various dysphoric mania characteristics (such as enhanced negative abilities) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself or his or her situation in a grossly exaggerated light (such as the only one in the world aware of a vast conspiracy).

And a copy and paste from the Alternative Depression Diagnosis Part II:

Vegetative (or Mixed) Depression with Psychosis

Various vegetative domain characteristics (such as excessive guilt) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself as deserving of punishment (such as being tracked by agents for an imaginary crime).

Agitated (or Mixed) Depression with Psychosis

Various agitated domain characteristics (such as a sense of exaggerated bad luck) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself as the object of unwarranted harassment (such as being tracked by agents as a result of a frame-up).


Thus, in these situations, psychosis is strongly linked to different phases of the cycle in terms of both timing and congruency. When the mania recedes, for instance, so does the psychosis. This suggests mood stabilizers as a first option rather than an antipsychotic.

If, on the other hand, the psychosis appears have a life independent of the cycle, then the clinician needs to spell it out, such as: “Cycling l, with Co-Occurring Psychotic Disorder.” (The current DSM lists “Delusional Disorder” and “Brief Psychotic Disorder”.)

This suggests different treatment options, such as an antipsychotic for the psychosis plus a mood stabilizer for the cycle (with perhaps the antipsychotic serving double duty in lieu of a mood stabilizer).

It is important to emphasize that psychosis with a life of its own is not synonymous with schizophrenia. Generally, more is going on with schizophrenia than just psychosis. Nevertheless, a very compelling case can be made for an overlap between bipolar and schizophrenia. Unfortunately, the DSM’s ‘tweener diagnosis of schizoaffective is more of a problem than a solution. Thus:

Kill the Schizoaffective Diagnosis

The operative phrase to the schizoaffective diagnosis is: “There is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia.”

Criterion A lists other symptoms besides psychosis, and calls for a minimum time of one month. (There is a Criterion C for schizophrenia, which mandates a six-month minimum for “continuous signs of the disturbance,” but there is no reference to this in the schizoaffective diagnosis.)

Schizoaffective, then, is basically short-form schizophrenia punctuated by relatively brief overlays of depression or mania (the DSM minimum for mania, for instance, is one week). The assumption is that it is highly likely that there will be long periods when the schizophrenia symptoms manifest with no mood symptoms, and indeed this is a DSM requirement.

Thus, schizophrenia symptoms can appear without mood symptoms, but mood symptoms can’t appear without schizophrenia symptoms.

Does this sound like schizophrenia to you? Short form or not? Say, schizophrenia with mood symptoms? Is schizoaffective, then, a euphemism diagnosis for clinicians too chicken to tell their patients the truth? It appears that way.

Let’s kill the schizoaffective diagnosis, then. And while we’re at it, let’s rethink schizophrenia, complete with a name that accurately describes the illness. But that’s for later, along with a full review of psychosis. In the meantime, to sum up:
  1. When the psychosis can be linked to a phase of the cycle: Specify the phase within the cycling diagnosis.
  2. When the psychosis appears independent of the cycle but does not meet criteria for schizophrenia: Stick to cycling diagnosis, with a co-occurring psychotic disorder.
  3. When the psychosis appears related to schizophrenia: Go with a schizophrenia diagnosis, with a mood symptoms specifier.
Please note that I do not regard this draft as anything approaching the final word. If you have your own approach to breaking down psychosis, or can think of a hybrid bipolar-schizophrenia diagnosis that makes sense - or for that matter can make a good case for not fixing what ain’t broken - then, please, let’s hear from you.

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