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

Okay, time for the boring stuff. In my alternative depression diagnosis, I sensibly restored complexity to an inexcusably oversimplified illness. Bipolar demands an opposite approach. Strip the illness to its essentials and we are talking about a cycle involving down and up, where up simply has to be higher than down.

Concentrate on the fact that we are dealing with a cycling phenomenon, and sensible treatment and illness-management is more likely to follow.

Nevertheless, it’s prudent to add shading and texture. Thus, Cycling I, II, and III, plus cyclothymia - plus (as specifiers) allowances for mixed phases (essentially out-of-phase cycles), plus (more specifiers) the reality of various psychosis complications. These were all dealt with in Part I, Part II, and Part III to my Alternative Bipolar Diagnosis.

In Part IV, I’m going with yet more specifiers (and modifiers), but in keeping with a rough draft (and to keep from boring you to tears) I’m just going with the bare bones, short and sweet.

Cycling Specifiers

Timing: Short phases or long? Undetermined? Short intervals of remission or long? Undetermined?

Rapid cycling, ultra-rapid cycling, and ultradian cycling would be included here. Important point: Here’s why “bipolar” is an erroneous name for what should more accurately be called cycling illness. Bipolar places priority on the episode over the cycle. So, technically, under the current DSM, someone who cycles up and down and back again in the course of a week is not in an episode (as the minimum is a week for mania) long enough to qualify for a bipolar diagnosis.

WTF? True, we don’t want to diagnose someone with a mental illness who is feeling out of sorts for just a day or two. But indisputable evidence of a cycle clearly trumps minor quibbles over length of episode (or, more accurately, cycle phase). Looking at it another way, if you’re cycling that fast you’re in a special kind of episode (phase) that is clearly playing havoc with your life.

Reducing mania and hypomania to a two-day minimum obviates a lot of these concerns. (Note to self: include an exception to the depression and mania and hypomania time minimums where there is clear evidence of ultra-rapid or ultradian cycling.)

Emphasis: Mostly depressed? Mostly manic? Mostly hypomanic? Mostly mixed? Undetermined?

People with “bipolar” tend to be depressed three times longer than they are manic or hypomanic, with residual symptoms persisting even longer. Individuals with bipolar II stay depressed for even longer. If that’s the case, this needs to be spelled out. Likewise if an individual is manic/hypomanic or in various mixed phases most of the time. It makes no sense to give individuals a vague diagnosis with no indication of what their particular version of crazy looks like.

Most recent phase: Depression? Up? Mixed?

This is straight out of the current DSM playbook.

Severity:

Particular phases of the cycle may be relatively benign, but the demands of adjusting to these phase changes may be too much to handle. Loving one day, hostile the next? Not a way to stay in a relationship or hold down a job.

Sleep Specifiers

Our next specifier would bring sleep into consideration, as disruptions to the sleep cycle and the mood cycle are strongly linked. Indeed, one can make a strong case that the mood disorder is the downstream effect of the sleep disorder. Another way of looking at it: Addressing the sleep issues resolves a lot of the mood issues.

We can make this as complicated as we like, but let’s opt for simplicity:

Sufficient consolidated and undisturbed night sleep: Yes? No?

Sufficient daytime wakefulness to meet work and personal obligations and self-enjoyment? Yes? No?

Sleep/wake phase delay/advancement: Yes? No?

Dimensional Specifiers

These cut across diagnostic categories and would be the same as for the Alternative Depression Diagnosis, only linked (if possible) to each phase. Otherwise, to the diagnosis as a whole. Thus:

... with anxiety.

... with personality complications.

(Note to self: the depression phase would also include suicidality and other specifiers from the Alternative Depression diagnosis.)

Severity Specifier

We mentioned severity in relation to the cycle. Normally, each phase would require its own severity specifiers, as well, but mission already accomplished for the up phases in the form of Cycling I, II, and III. For the depression phase, we copy and paste from the Alternative Depression diagnosis.)

Modifiers

I distinguish “modifier” from “specifier” by virtue of how gender, age, and cultural identity may affect the course and presentation of the illness. Depressed women, for instance, are more likely to act in accord with current DSM criteria (such as “appears tearful”) while men who express their psychic pain as anger are likely not to get diagnosed. I’m not sure how this plays out for mania, but let’s make room for discussion. 

Child and Adolescent onset deserves special consideration. The current DSM lacks an early-onset specifier for bipolar, which can be interpreted to mean that the illness manifests similarly in kids and adults. Except for the fact that this is not the case. Kids tend to cycle far more rapidly, often in the course of a day with a clear relation to sleep/wake cycle disturbances. Moreover, kids tend to experience mixed phases that are expressed as severe rages.

Thus, if we keep the criteria for cycling and mixed states (not to mention sleep) unrealistically narrow (as under the current DSM), both adults and kids are left out in the cold. The simple solution is to widen these criteria (as we have already done), and include the early onset modifier. This would keep the diagnosis consistent across the life-span, while allowing scope for differences in presentation.

Note the diagnosis remains sufficiently narrow to distinguish cycling from other forms of kid behavior. Nevertheless, there is considerable room for discussion in dealing with kids’ issues, so feel free to fire away.

Conclusion

This wraps up my Alternative Bipolar (Cycling) Diagnosis for now, but we’re by no means finished. Please feel free to join the conversation. Comments below ...