Taking it Personally: The DSM-5 and the Narcissism Controversy

I'm back into mucking out my Augean Stables, otherwise known as updating my mcmanweb site. I have a number of great pieces (at least I think they're great) lined up for this blog, but, in the meantime, from the vaults of "Knowledge is Necessity" (Dec, 2010) ...

A few weeks ago, the NY Times featured a piece by psychologist Charles Zanor entitled, A Fate Narcissists Will Hate: Being Ignored. The long and short of it is that narcissistic personality disorder will be axed from the DSM when the next edition is published in 2013. Imagine how your average narcissist must feel.

The article mentions that retiring the diagnosis has drawn the wrath of clinicians, who view the various committees of the DSM-5 as dominated by academics out of touch with reality. John Gunderson of Harvard, one of the leading authorities on personality disorders, called the decision “unenlightened.”

Actually, overhauling the entire field of personality disorders is probably the only thing those charged with the DSM-5 did right, though with reservations. A little background:

In this post-Freud era of biological psychiatry, “Axis II” personality disorders have been accorded a lot less respect than “Axis I” disorders such as depression, bipolar, anxiety, or schizophrenia. A cynic would say that is because there are no meds for Axis II disorders and they would be one hundred percent right. The upside to this is there has been no big pharma to call the shots. It is no coincidence that the only major reforms to the next DSM occurred in the one realm where pharma is conspicuously absent.

The first obvious change is no Axis I/Axis II distinction. Personality disorders will get the same billing as mood disorders and anxiety disorders and all the rest. The next obvious change is a new “dimensional” component to complement the “categorical” classification of personality disorders, something that should have been done with mood disorders and arguably the whole rest of the DSM.

In its background papers and rationale, the APA and the DSM-5 group note that separating out personality into discrete illnesses has generated no end of end of clinical confusion. Is someone who abruptly breaks off a friendship, for instance, an “antisocial” with no remorse, a “borderline” who can’t cope, or a “narcissist” who cares only about him or herself?

Clinicians typically hedge their bets by choosing more than one, or by tacking on the NOS (not otherwise specified) qualifier.

The dimensional view acknowledges the complexity and subtlety of personality. Instead of asking “which one?” at the expense of ignoring whatever else may be going on, a clinician would be asking “how much” and “how severe?” In a sense, psychiatry is bringing back neurosis, but with some important refinements.

The personality disorders we are most familiar with are grouped into “Cluster B” in the current DSM. They include borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, and histrionic personality disorder. The next edition of the DSM will give narcissistic personality disorder and histrionic personality disorder the boot, and prune out a number of other disorders from clusters A and C as well, leaving us with five “personality disorder types,” including antisocial/psychopathic, borderline, avoidant, obsessive-compulsive, and schizotypal.

According to the rationale provided in the draft DSM-5, three of these types have the “most extensive empirical evidence of validity and clinical utility.”

Here’s where the dimensional component would come in. The draft DSM-5 proposes testing for six “trait domains” that would include:

1. Negative Emotionality (such as depression or anxiety).
2. Introversion (such as social withdrawal and intimacy avoidance).
3. Antagonism (such as callousness, manipulativeness, narcissism, histrionism, hostility, aggression, oppositionality, and deceitfulness).
4. Disinhibition (such as impulsivity).
5. Compulsivity (such as risk aversion).
6. Schizotypy (involving odd behaviors and cognitions).

These trait domains are based on well-established personality tests such as the five-factor model and Cloninger’s psychobiological model, and would seek answers (note the plural) to such life mysteries as why an individual would abruptly break off a friendship.

Sounds good in theory, but are clinicians too set in their old ways? As the NY Times notes:

Clinicians like types. The idea of replacing the prototypic diagnosis of narcissistic personality disorder with a dimensional diagnosis like “personality disorder with narcissistic and manipulative traits” just doesn’t cut it.

Sounds a bit narcissistic to me, wait, I mean - uh - never mind.

Much more to come ...

Personality Disorder: Decisions, Decisions ...

The story so far:

In the one thing those charged with the DSM-5 did right, personality disorders will receive a major overhaul. Five of the ten current personality disorders will be axed and the current “categorical” system will be supplemented by a “dimensional” model.

Let’s look at the categorical reforms. The wisdom of the DSM-5 is readily apparent in relieving clinicians of the agony of having to decide between the likes of “schizotypal” and “schizoid” (schizotypal makes the cut, schizoid gets the axe). Similarly, only those prone to histrionic displays are shedding crocodile tears over the demise of “histrionic,” which is way too easy to confuse with “narcissism,” which will - Wait! What the f...? - you mean narcissism goes too?

Okay, we’ll get to the issue of narcissism later. In the meantime, sayonara, as well, to “paranoid” and “dependent.” And in a Nobel-worthy gesture (medicine or peace, take your pick), the foul and malignant NOS (“personality disorder not otherwise specified”) gets the deep-six. Clinicians will actually have to decide between the disorders left standing ("antisocial/psychopathy", "avoidant", "borderline", "obsessive-compulsive", "schizotypal"). But will they be happy making their choices? Let’s use the new borderline and antisocial/psychopathy as our examples:

The first thing readers will notice in the new borderline diagnosis is a lengthy narrative description of the illness. Thus:

Individuals who match this personality disorder type have an extremely fragile self-concept that is easily disrupted and fragmented under stress and results in the experience of a lack of identity or chronic feelings of emptiness.  As a result, they have an impoverished and/or unstable self structure and difficulty maintaining enduring intimate relationships. ...

And so on and so on. The checklist that follows roughly corresponds to the one in the DSM-IV, but looks a lot different. The following, for instance, is symptom #6 from the old checklist:

Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

Here’s how that same symptom (#1) in its new form will appear:

Negative Emotionality: Emotional Lability
Having unstable emotional experiences and mood changes; having emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.

“Negative emotionality” is what the DSM-5 calls a “trait domain,” one of six for the five personality "types". (“Introversion”, “antagonism”, “disinhibition”, “compulsivity”, and “schizotypy” are the others.) Every symptom includes a trait domain, further modified by “trait facets,” such as “emotional lability.”

Borderline comes heavily loaded with negative emotionality, six symptoms of 10 in all involving, besides emotional lability, “self harm”, “separation insecurity”, “anxiousness”, “low self-esteem”, and “depressivity”. There are two “antagonism” domains (with “hostility” and aggression” as facets) to borderline, plus a “disinhibition” domain (“impulsivity” as a facet), and one “schizotypy” domain (with “dissociation proneness” as a facet).

A quick comparison to the new version of antisocial/psychopathic shows a very different loading, with six antagonism traits and zero negative emotionality traits. Right off the bat, clinicians are put on notice that they are dealing with two entirely different species of personality. The narrative highlights the contrast:

Individuals who match this personality disorder type are arrogant and self-centered, and feel privileged and entitled.  They have a grandiose, exaggerated sense of self-importance and they are primarily motivated by self-serving goals.  They seek power over others and will manipulate, exploit, deceive, con, or otherwise take advantage of others, in order to inflict harm or to achieve their goals. ...

In addition to hostility and aggression, the antisocial/psychopathic symptom list includes the antagonism traits of “callousness”, “manipulativeness”, “deceitfulness”, and “narcissism”. Intriguingly, hostility and aggression are word-for-word replicas of what appears in the borderline list. But the symptom overlap comes across as deliberate and in context rather than random and coincidental. In other words, in constructing the various categorical diagnoses, we appear to be looking at an ordered modular system with interchangeable parts.

(We see another interchangeable part in antisocial/psychopathy with “disinhibition-impulsivity”, but with the further emphasis of “irresponsibility” and  “recklessness”.)

Here’s where the DSM-5 personality symptom lists radically differ from those in the DSM-IV. Instead of just checking off the relevant symptoms and counting them to arrive at an arbitrary diagnostic threshold (such as five out of nine symptoms), the clinician rates each symptom on a five-point scale, from “very good match” to “no match”. Thus, from a severity perspective, a pair of fives may trump several threes. The current draft offers no magic threshold numbers, which suggests that in making the final call the clinician will be accorded a lot more discretion. Presumably, this works when when the clinician has clear guidelines.

Sounds good in theory.

Much more to come ...

Recent Personality Disorder Blog Pieces

Taking It Personally: The DSM-5 and the Narcissism Controversy

Let's Play Spot the Personality Disorder 

Why is Spotting the Personality Disorder So Damned Hard?

Taking it Personally: The DSM-5 and the Narcissism Controversy

A few weeks ago, the NY Times featured a piece by psychologist Charles Zanor entitled, A Fate Narcissists Will Hate: Being Ignored. The long and short of it is that narcissistic personality disorder will be axed from the DSM when the next edition is published in 2013. Imagine how your average narcissist must feel.

The article mentions that retiring the diagnosis has drawn the wrath of clinicians, who view the various committees of the DSM-5 as dominated by academics out of touch with reality. John Gunderson of Harvard, one of the leading authorities on personality disorders, called the decision “unenlightened.”

Actually, overhauling the entire field of personality disorders is probably the only thing those charged with the DSM-5 did right, though with reservations. A little background:

In this post-Freud era of biological psychiatry, “Axis II” personality disorders have been accorded a lot less respect than “Axis I” disorders such as depression, bipolar, anxiety, or schizophrenia. A cynic would say that is because there are no meds for Axis II disorders and they would be one hundred percent right. The upside to this is there has been no big pharma to call the shots. It is no coincidence that the only major reforms to the next DSM occurred in the one realm where pharma is conspicuously absent.

The first obvious change is no Axis I/Axis II distinction. Personality disorders will get the same billing as mood disorders and anxiety disorders and all the rest. The next obvious change is a new “dimensional” component to complement the “categorical” classification of personality disorders, something that should have been done with mood disorders and arguably the whole rest of the DSM.

In its background papers and rationale, the APA and the DSM-5 group note that separating out personality into discrete illnesses has generated no end of end of clinical confusion. Is someone who abruptly breaks off a friendship, for instance, an “antisocial” with no remorse, a “borderline” who can’t cope, or a “narcissist” who cares only about him or herself?

Clinicians typically hedge their bets by choosing more than one, or by tacking on the NOS (not otherwise specified) qualifier.

The dimensional view acknowledges the complexity and subtlety of personality. Instead of asking “which one?” at the expense of ignoring whatever else may be going on, a clinician would be asking “how much” and “how severe?” In a sense, psychiatry is bringing back neurosis, but with some important refinements.

The personality disorders we are most familiar with are grouped into “Cluster B” in the current DSM. They include borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, and histrionic personality disorder. The next edition of the DSM will give narcissistic personality disorder and histrionic personality disorder the boot, and prune out a number of other disorders from clusters A and C as well, leaving us with five “personality disorder types,” including antisocial/psychopathic, borderline, avoidant, obsessive-compulsive, and schizotypal.

According to the rationale provided in the draft DSM-5, three of these types have the “most extensive empirical evidence of validity and clinical utility.”

Here’s where the dimensional component would come in. The draft DSM-5 proposes testing for six “trait domains” that would include:

1. Negative Emotionality (such as depression or anxiety).
2. Introversion (such as social withdrawal and intimacy avoidance).
3. Antagonism (such as callousness, manipulativeness, narcissism, histrionism, hostility, aggression, oppositionality, and deceitfulness).
4. Disinhibition (such as impulsivity).
5. Compulsivity (such as risk aversion).
6. Schizotypy (involving odd behaviors and cognitions).

These trait domains are based on well-established personality tests such as the five-factor model and Cloninger’s psychobiological model, and would seek answers (note the plural) to such life mysteries as why an individual would abruptly break off a friendship.

Sounds good in theory, but are clinicians too set in their old ways? As the NY Times notes:

Clinicians like types. The idea of replacing the prototypic diagnosis of narcissistic personality disorder with a dimensional diagnosis like “personality disorder with narcissistic and manipulative traits” just doesn’t cut it.

Sounds a bit narcissistic to me, wait, I mean - uh - never mind.

Much more to come ...

Grading Depression

I recently posted a five-part (and counting) series, Are Antidepressants Bad for You? For a good many, the answer is yes. A lot of it has to do with our antiquated diagnostic criteria for depression, which treats virtually all depressions as the same. This encourages one-size-fits all treatments that turn out to fit very few and harm a good many.

In Feb, the American Psychiatric Association released a draft of an updated DSM, which would perpetrate the mistakes of the past. In light of my most recent series, it's appropriate here to re-run three of my critiques in this one post. Without further ado ...

Grading Depression - Part I

This is the first in a series of report cards that grades the homework turned in last week by the DSM-5 Task Force. Our first assignment: Depression.

First, some background ...

According to statistics cited on the NIMH website, major depression is the leading cause of disability in the US and affects 6.7 percent of Americans in any given year. Plus major depression is a major component to bipolar disorder, affecting another 2.6 percent of the US population each year. In addition, dysthymia (major depression lite) accounts for an additional 1.5 percent.

An illness of this dimension literally comes equipped with its own gravitational field. Thus, few psychiatric diagnoses make sense without some reference to depression, be it anxiety or schizophrenia or borderline personality disorder.

This means that if the people responsible for coming up with a new version of DSM depression get it wrong, then the whole document - together with the whole field of diagnostic psychiatry - is going to be out of alignment.

Fortunately, everyone knows what depression is, right? Um, not exactly. Early versions of the DSM recognized the highly complex nature of the illness at the expense of confusing just about everyone and thus influencing no one. The DSM-III of 1980 and its successors (the DSM-III-R, the DSM-IV, and the DSM-IV-TR) went for simplicity and clarity, which seemed to please just about everyone, except maybe patients.

The major knock on depression as we know it is that it is a catch-all diagnosis for all manner of things going wrong. But this is its major appeal, as well. One one hand, not enough patients are getting better on meds and therapies designed to combat this simultaneously mysterious and obvious entity called depression. On the other hand, just enough are.

At issue for the DSM-5’s Mood Disorders Work Group is how these major contradictions can be reconciled.

Time to start grading ...

The symptom checklist

This was a masterstroke from those who brought us the DSM-III. So much so, that we tend to think of the checklist as something that existed since before the dawn of time and that is based on pure science rather than being pulled out of thin air. Even though the current DSM recognizes several different forms of depression, everything originates from this (five of) nine-item menu.

Critics have identified a number of major problems with the list, namely:

• It is biased toward identifying depression in women rather than men (such as “appears tearful”).
• It fails to identify the patient’s predominant state of mind. For instance, it is possible to check off “feeling depressed,” followed by “significant weight loss,” “insomnia,” “psychomotor agitation,” and “fatigue.” Voila! Major depression, but what does that tell us? Is one vague mental symptom followed by four physical ones truly depression?
• It fails to identify the patient’s predominant state of mind (again). Sad? Agitated? Unmotivated? Feeling hopeless? Overthinking things? Excruciating psychic pain? Yes, we know it’s depression. But what is really going on?

On the other hand, the list has been in service for 30 years. It may not be perfect, but it does give us a reasonable approximation of a condition that so profoundly lays waste to so many. So why change it? This was the approach adopted by the workgroup.

Unfortunately, this was the safe option that gave us nothing to think about, that squelched a conversation that we badly need to be having, and that put the interests of monied stake-holders (such as the insurance industry) over the needs of patients.

Grade: F-minus.
      
Mixed Anxiety Depression

This is a wholly new and separate diagnosis, distinct from major depression. The workgroup recognized that nearly 60 percent of those with major depression also experience anxiety, which adversely affects patient outcomes.

The new diagnosis would acknowledge that one need not experience full-blown major depression or full-blown anxiety to wind up seriously distressed and incapacitated. A little bit of each will do. Thus, Mixed Anxiety Depression calls for just three or four depression symptoms (one which must include either feeling depressed or loss of pleasure), plus “anxious distress” which involves such things as “irrational worry.”

The recognition of anxious-depression is long-overdue, but since it was already listed in the DSM-IV appendix as deserving of future consideration, one cannot give the current workgroup credit for putting the issue on the table. Moreover, there is no mention of how “agitated depression” and other types of “mixed states” may fit into the picture.

Grade: C.

Mixed Episodes

The current DSM only recognizes mixed depression-mania states as occurring in bipolar I, and only in the ridiculously limited context of full-blown mania combined with full-blown depression. The DSM-5 would restore a measure of sanity by acknowledging that mixed states can occur in bipolar II, as well.

How this fits into unipolar depression is unclear. On one hand, the workgroup expressly rules out unipolar depression if the patient had ever experienced a mixed episode. On the other hand,
with no explanation, the workgroup adds the specifier, “with mixed features.” Huh?

There is good evidence that many individuals with unipolar depression experience mania/hypomania symptoms in their depressions, not enough to rate a diagnosis of bipolar, but enough to raise their levels of distress and make their depressions more difficult to treat.

On this very important issue, the DSM-5 workgroup has not handed in its homework.

Grade: Incomplete.

Grading Depression - Part II

Part I began issuing grades on the homework handed in last week by the DSM-5 Task Force concerning its proposed revisions to depression. To recap:

The symptom checklist - “So why change it? This was the approach adopted by the workgroup.” Grade: F-minus.

Mixed anxiety depression -  “The recognition of anxious-depression is long-overdue.” Grade: C.

Mixed depression-mania episodes - “On this very important issue, the DSM-5 workgroup has not handed in its homework.” Grade: Incomplete.

Moving on ...

Chronic and Recurrent Depression

These are two entirely different animals. For the first time, the DSM would fully acknowledge the chronic variety (“chronic depressive disorder” with an episode lasting at least two years). The new diagnosis would subsume dysthymia and change its threshold to include major depression as well as low grade depression.

Gone is the “chronic” specifier to a major depressive episode.

The DSM-IV criteria for recurrent depression would stand, namely two or more major depressive episodes (lasting at least two weeks) at least two months apart. No provision is made, however, for the reality of highly-recurrent depressions that come and go at a faster rate.

Recurrent depression - and the highly-recurrent variety in particular - may have more in common with bipolar depression than unipolar depression, or at least may occupy common ground in dire need of mapping. Somewhere, somehow, on some level, the rather obvious overlap between unipolar and bipolar needs to be recognized and dealt with. On this vital issue, the workgroup looked the other way.

Grade: F.

Severity

The DSM-5 Task Force mandated its various workgroups to come up with sophisticated severity measures analogous to assessing hypertension. This would obviate the rather arbitrary and clumsy distinction the current DSM makes between major depression and dysthymia (which the workgroup proposes eliminating).

It also places less emphasis on the symptom checklist. Thus, someone with all nine depression symptoms who is nevertheless able to hold down a job and keep his or her marriage going is in much better shape than someone with only four symptoms who technically does not meet the threshold for major depression but hasn’t been able to get out of bed in six months.

The Mood Disorders  workgroup is currently investigating a variety of measures.

Grade: Incomplete.

The Specifiers

The current DSM uses these to parse out different types of major depression, thus major depression with: psychotic features, catatonic features, melancholic features, atypical features, postpartum onset.

The DSM-5 would leave this list intact with two exceptions. “Chronic” is removed as a specifier and upgraded to a diagnosis, and “mixed features” is added with no explanation. In addition some changes are added to the psychotic features specifier to account for severity as well as type (“congruent” or “incongruent”).

The problem with specifiers in this context is they are only as good as the symptom checklist they are supposed to be specifying. There must be a better way, for instance, of distinguishing an agitated depression from a vegetative one or a mainly sad state of mind from one characterized by the lack of ability to care.

Think of depression as too much emotion on one hand and not enough on the other. Factor in too much or not enough thinking, and you can see that the experts charged with this brief had their work cut out them. They didn’t put in the work.

Grade: F.

Reactive Depression

The DSM-II of 1968 distinguished between what it saw as biologically-based depression (endogenous) and depression seen as a reaction to stressful events (exogenous). The DSM-III and its successors wisely ditched speculating about cause and effect and stuck to categorizing observable symptoms.

Thirty years later, however, advances in brain science suggest some merit in going back to the future, but with this ironic twist: Although current brain science does not yet support diagnostic descriptions based on underlying biology, one can make a good biological case for supposedly non-biological reactive depression.

Not only that, we already know that managing stress is a key to managing one’s depression. Stress Junction is where Freud, brain science, and common sense meet. The DSM-5 workgroup missed the bus.

Grade: F-minus.

Personality

Can persistent and treatment-resistant depression be looked upon as a personality disorder? Consider this assignment extra credit. Neither the Mood Disorders nor the Personalities Disorders workgroups took up the challenge.

No grade.

Grading Depression - Part III

NOS

Is there a place in your house you dread looking into? The attic? The crawl space? A certain closet? The bottom of your refrigerator? The current DSM contains its own version of the dreaded place. It is called NOS - not otherwise specified - and accompanies 41 listed diagnoses.

The draft DSM-5 would continue the practice. I peeked in and, suffice to say, experienced every traumatic flashback involving attics, crawl spaces, closets, and refrigerators, and then some. Some background:

If you’re a DSM editor and don’t know what to do with a certain type of symptom or behavior, you create an NOS closet (or refrigerator) and stick the weird stuff in and close the door. Maybe you’ll figure out what to do with it later.

It you’re a doctor and don’t know how to diagnose a certain patient, you write up NOS and find the appropriate closet (or refrigerator), shut your eyes, stick it in, and close the door. Maybe you’ll come up with the correct diagnosis later.

The trouble is NOS is a black hole. What, for instance, does “Depression NOS” mean? Imagine “Cardiovascular NOS” and you can see that the practice is unacceptable, whether one is practicing medicine or writing a diagnostic manual. Moreover, the practice is highly abused. A background paper put out by the DSM-5 mood disorders workgroup cited an unpublished study that found that the specialist and nonspecialist clinicians in the sample employed “NOS” in 37-38 percent of their primary diagnoses for depression.

The DSM-5 would change NOS to CNEC (conditions not otherwise classified). I opened the freshly painted closet door to find ...

Subsyndromal depressive CNEC. This would include patients in obvious distress who somehow don’t meet the formal diagnostic criteria for depression. Given the extremely wide view of depression the DSM already employs and its generously low thresholds it’s hard to imagine such a group. Certainly there are those who must put up with residual symptoms once the worst is over, but can’t we find a better way of defining this category? Out in broad daylight?

Major depressive disorder superimposed on a psychotic disorder. What the hell is something this major doing buried away in a closet?

Recurrent brief depressive disorder. So THAT’s where they stuck highly recurrent depression! I was looking all over for it. Nope, not out with recurrent major depressive disorder, where it belongs. Nope, not red-flagged as a type of depression closely related to bipolar. Nope, stuck away in a closet.

PMDD. Are you kidding me? We still hide “women’s problems” in the closet?

The sad thing is the things lurking in the DSM-5 CNEC closet are nearly identical versions of those still gathering dust in the DSM-IV NOS refuse bin.

Grade: F-minus

To Sum Up

Thus concludes my three-part DSM-5 Depression Report Card. Here are the subjects and my grades:

• Symptom Checklist: F-minus
• Mixed Anxiety Depression: C
• Mixed Episodes: Incomplete
• Chronic and Recurrent Depression: F
• Severity: Incomplete
• The Specifiers: F
• Reactive Depression: F-minus
• Personality (extra credit): No grade
• NOS: F-minus

Overall grade: F

Concluding Remarks

One of the ironies in issuing this report card is that I owe much to virtually all of the members of the DSM-5 mood disorders workgroup. I have read their articles. I have heard them speak at conferences. I have asked them questions face-to-face. In some cases, I found myself seated at the same breakfast or luncheon or dinner table.

My dealings with these individuals have been extremely productive and beneficial. To a person, they are as dedicated to their work as they have been gracious to me. Moreover, a good deal of what I know about mood disorders can be attributed to them and their colleagues. Many of my key Aha! moments are a direct result of the wisdom they have shared with me, their professional colleagues, and with patients and family members.

So, what went wrong?

For one, DSM-5 operating parameters were far too restrictive, involving an onerous burden of proof for new inclusions. Too often, the necessary empirical data was lacking. We may “know” for instance that depression is bound up in personality, but can we “prove” it?

Scientists need to “validate” their claims with scientific evidence. But what if the picture they produce is inaccurate and misleading and leads to the kind of absurd results I've brought up this series? No acknowledgment of the obvious relation and overlap between depression and bipolar? C'mon!

My concern is with "credibility," which the DSM-5 sacrificed in its obsessive over-pursuit of "validity." As a result, the DSM-5 is failing in its key mission of aligning psychiatric authority to our clinical reality.

Nevertheless, everyone has a stake in the status quo - Pharma, the insurance companies, the clinical-research establishment, perhaps even patient advocacy groups. Credible or not, the DSM pays the bills. Thus, no one is about to stand up and say the DSM-5 is a piece of shit. Okay, I just did, but who listens to me?

The other main problem is “paradigm freeze,” which I will get to in a future blog piece.  

And Finally ...

I don’t want to come across as negative, but my next Report Card grades bipolar, which will also involve liberal use of the sixth letter of the alphabet.

The DSM-5: Science vs Scientism

Just a quick note before I start packing for Kansas. Nassir Ghaemi MD of Tufts (pictured here), who has helped me enormously in understanding the fine points of my illness over the years, has cited one of my blogs pieces here with approval.

In a blog post on Medscape, Dr Ghaemi neatly encapsulates the DSM-5 debate. To quote at length:

In recent months, there has been back-and-forth between the heads of DSM-III (Robert Spitzer) and DSM-IV (Allen Frances), on one side, and the leaders of DSM-V (David Kupfer and colleagues), on the other. Frances in particular has been vocal in articles in the Psychiatric Times and the British Journal of Psychiatry; his critique sums up this way: 

Changes in DSM-V should not be made unless strong scientific evidence exists to do so. A conservative baseline mind-set appears to exist such that revisions should always err on the side of not making a change unless notably strong evidence exists for change. The rationale, as Frances describes it, is partly so that the psychiatric profession is protected from rapid and unnecessary changes in nosology.

Dr. Frances does not seem to question the validity of his assumptions: Should we have a very high threshold for making changes? Should we be erring on the side of not making changes? 

As John McManamy notes, this would ensure that we would forever be mired in the "Groundhog Day of 1980", the last time anyone in psychiatry had the courage to structurally change our nosology.
Science, yes; scientism, no.  We should not let claims of science blind us to data that are good enough, or to current practice that has the virtue of not requiring change but the vice of being unscientific.  

As I noted in other pieces here, the DSM-5 is not a science project. Instead of an academic publication that maybe 30 people would read, the DSM is a real world document relied upon by millions. Ironically, in the name of science, the DSM-5 is leaving in place ancient diagnostic criteria the defies both science and reality (such as not acknowledging the depression-bipolar spectrum).

As Dr Ghaemi concludes:

Over time, revolutionaries tend to become conservatives, and reaction engenders counter-reaction. There is a psychological law of inertia, as the writer Henry Adams observed: What exists is valued simply because it exists, and much more effort is needed to push the boulder of dogma into motion than to leave it alone. Perhaps the physicist Max Planck is sadly all too right that new scientific truths are routinely resisted by prior generations, who are rarely convinced, and rather are only accepted by a changing of generations.

My DSM-5 Commentaries: In Search of Elephant, Willing to Settle for Hippopotamus

A quick update. In early February, the American Psychiatric Association's DSM-5 Task Force issued its Proposed Revisions to the next DSM, due out in 2013. Soon after, on this blog, I began writing some review pieces, which developed into Report Cards highly critical of the draft DSM-5's treatment of depression and bipolar.

This in turn led to my "People's DSM" with its own Alternative Depression Diagnosis and Alternative Bipolar Diagnosis.

The point of both exercises was to get us thinking about issues we tend to take for granted, but which have a profound impact on our well-being.

Needless to say, these are issues with a long shelf life. A blog, on the other hand, tends to be very ephemeral, based on what people do with yesterday's newspaper - namely, you wrap fish in it.

Consequently, I went over my DSM-5 pieces, worked them into article shape, then assembled them in a manner that allowed for coherent reading and review. Last night, I uploaded the effort to my website, McMan's Depression and Bipolar Web. My website is based on the concept of a reference library - information is stored there, in easy-to-find places, there when you need it.

Clicking on a link in the navigation bar on all 200 or so pages of the site takes you to a band new DSM-5 section with eight articles.

The Draft DSM-5: Rip it Up and Start Over is based on two or three blog pieces that first appeared here. The article gives historical background into mood disorders and how Freud and Kraepelin and their followers set the tone for DSMs I through IV. The article also details what went wrong with the draft DSM-5.

My Report Cards set out the issues the various DSM-5 working groups needed to consider, but failed to do, such as clarifying the relationship between unipolar depression and bipolar, rethinking bipolar as a cycling illness, doing something about the schizoaffective diagnosis, making symptom criteria gender-neutral, and so on. Thus:

Grading Depression
Grading Bipolar - Part I
Grading Bipolar - Part II

Think of my Report Cards as the background commentary to my People's DSM, in which I offer an alternative reality to the one imposed on us by the official DSM. Thus:

My Alternative Depression Diagnosis - Part I
My Alternative Depression Diagnosis - Part II
My Alternative Bipolar (Cycling) Diagnosis - Part I
My Alternative Bipolar (Cycling) Diagnosis - Part II

I make no claims to having a better view of reality. Reality is far too vast and elusive to stand still for our own convenience. Basically, we're the six blind men in search of the concept of "elephant." We're never going to achieve "elephant," but perhaps if we keep poking around long enough in the dark, we may come up with something that reasonably approximates elephant, such as "hippopotamus."

Anyway, I encourage you to visit my website, have a new look at points of view you first read about here, leave your comments, and come back here for who knows what we'll stumble upon next.

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

In the “rip it up and start over” spirit of this series, let’s replace the term “bipolar” with “cycling illness” to reflect the true nature of what we are dealing with. I know the name won’t fly - that we’re stuck with bipolar - but, hey, this is a rough draft where I get to say what I really think.

The term, “bipolar,” implies a static and symmetrical illness where the subject flips back and forth between two sharply contrasting (and “polar” opposite) mood “episodes” or “states” that bear no seeming relation.

“Cycling” acknowledges the reality of a dynamic and not necessarily symmetrical condition where one mood “phase” gives rise to another and perhaps yet another.

In addition, cycling acknowledges the likelihood of other cycle disturbances, such as sleep.

On with the show ...

Mood Disorders
Cycling Illness (all of the below must be met):

1. Evidence of a mood cycling pattern (through clinical observation, case history, or patient or witness reports), with discernible contrasting phases.
2. At least one phase (or the combined effect of more than one phase) must be a significant departure from baseline condition
3. At least one phase (or the the combined effect of more than one phase) must significantly impair ability to work, relate to others, and enjoy life.

A. Types: 

Cycling I: Subject experiences one or more mood cycles from depressive low or a non-manic low to manic high.

Cycling II: Subject experiences one or more mood cycles from depressive low to hypomanic high.

Cycling III: Subject experiences one or more mood cycles from depressive low to non-depressive high. 

Cyclothymia: Subject experiences one or more cycles from elements of depression to elements of hypomania.

B. Phases:

DEPRESSIVE PHASE

Subject may experience recurrent or highly recurrent or cycling depression (see My Alternative Depression Diagnosis - Part II).

MANIC PHASE (check one):

Euphoric

Subject may experience uncharacteristic feelings of extreme joy, superhuman positive abilities, and a sense of connectedness with the world, him or herself, and those around him or her. Subject may project a magnanimous “larger than life” presence.

Dysphoric

Subject may experience uncharacteristic feelings of extreme irritability, superhuman positive and negative abilities, and a sense of disconnectedness with the world, him or herself, and those around him or her. Subject may project a hostile menacing presence.

Domains (both must be checked):

Behavior:

Subject may display high energy, little need for sleep, pressured speech, a sense of impatience, an inability to control impulses, lack of judgment, and a need to satisfy cravings and indulge in projects or engage in risky behavior.

Behavior must be out of control to the point that subject can no longer responsibly manage his or her affairs or reasonably interact with others. 

Thinking:

Subject may experience racing thoughts, expansive thoughts, or disturbed thoughts. On one hand, subject may become easily distracted, on the other may be focused to the point of tuning out one’s surroundings or neglecting one’s responsibilities. On one hand, subject may experience a state of hyper-awareness; on the other may experience difficulties in basic cognitive tasks.

Thinking must be out of control to the point where subject has a grossly distorted perception of him or herself and his or her surroundings, and is no longer capable of making realistic or responsible decisions. 

Qualifying Criteria:

Mania lasts most of the day for at least two days and is not attributable to alcohol or drug use or a medications side effect (other than antidepressant medications).

HYPOMANIC PHASE (check one):

Euphoric

Subject may experience uncharacteristic feelings of joy, enhanced positive abilities, and a sense of ease with the world and those around him or her. Subject may project a sociable charismatic presence.

Dysphoric

Subject may experience uncharacteristic feelings of irritability, enhanced positive and negative abilities, and a sense of unease with the world, him or herself, and those around him or her. Subject may project an unpleasant mildly threatening presence. 

Domains (both must be checked):

Behavior:

Subject may display high energy, little need for sleep, pressured speech, feel a need to get things done or experience pleasurable activities, and not think through the consequence of his or her actions.

Subject may exhibit unusual or unexpected behavior, but is still capable of responsibly managing his or her affairs and interacting with others.

Thinking:

Subject may experience racing thoughts, expansive thoughts, or disturbed thoughts. On one hand, subject may become easily distracted, on the other may be focused to the point of tuning out one’s surroundings or neglecting one’s responsibilities. On one hand, subject may experience a state of hyper-awareness; on the other may experience difficulties in basic cognitive tasks.

Subject may have a mildly distorted perception of him or herself and his or her surroundings, but is still capable of making realistic and responsible decisions.

Qualifying Criteria

Hypomania lasts most of the day for at least one day and is not attributable to alcohol or drug use or a medications side effect (other than antidepressant medications).

NON-DEPRESSIVE HIGH PHASE

Subject may simply feel “normal” or “better than normal” and not feeling depressed, but does not cycle higher into hypomania or mania. Nevertheless, “normal” or “better than normal” stands in sharp contrast to depression and points to evidence of a cycling phenomenon.

Qualifying Criteria

Non-depressive high phase lasts most of the day for at least one day and is not attributable to alcohol or drug use or a medications side effect (other than  antidepressant medications).

NON-MANIC LOW PHASE

Subject may feel “normal” or “worse than normal” and not feeling manic, but does not cycle lower into depression. Nevertheless, “normal” or “worse than normal” stands in sharp contrast to mania and points to evidence of a cycling phenomenon.

Qualifying Criteria

Non-mania low phase lasts most of the day for at least one day and is not attributable to alcohol or drug use or a medications side effect.

***

Discussion Points

There is considerable overlap between “Cycling Depression” as part of my Alternative Depression Diagnosis and “Cycling III” as part of my Alternative Bipolar (Cycling) Diagnosis. I would submit the overlap far closer resembles reality than the artificial (and out of position) categorical gap imposed by the current (and future) DSM. Nevertheless, a differentiator or two would be helpful. Perhaps evidence of bipolar in a family member for a Cycling III diagnosis?

Your views?

Also, I can use some help on hypomania. Just because it is a deviation from a subject’s baseline condition doesn’t mean it has to be regarded as a pathology. Like any phase of a cycling illness, hypomania has to be looked at in terms of what is likely to come next in the cycle. A shift from euphoric to dysphoric hypomania? A swing up to mania? A steady slide down into something approaching normal? Or a precipitous crash into depression?

My view is that clinicians tend to treat hypomania as if it were mania and thus they err on the side of over-medicating us. Your views?

***

This is a lot more to come to my alternative bipolar (cycling) diagnosis, including mixed phases, rapid cycling, and dimensional and spectrum considerations. Stay tuned. In the meantime, your feedback is strongly encouraged. Fire away ...

Further Reading from Knowledge is Necessity 

Grading Bipolar - Stating What's Obvious


From BipolarConnect 

The Depression-Mania Two-Step
The Depression-Mania Two-Step - Part II
What It's Really All About is Cycling

The People’s DSM: My Alternative Depression Diagnosis - Part III

As you know from reading this blog, the people charged with coming up with the DSM-5 failed to turn in their homework. After handing out nine report cards with an average grade of F (I was way too generous), I decided to get crackin' on my own DSM, starting with depression.

My first installment recognizes the true complexity of depression by breaking the illness into six domains (such as “thinking” and “behavior”) which resolve into two types of depression: “Vegetative” and “Agitated,” plus an intermediate “Mixed” state.

My second installment adds a set of specifiers that would further break down depression according to variability, chronicity, dimensional, spectrum, severity, and suicidality considerations. Thus, “Agitated Depression, Highly Recurrent or Cycling,” “Mixed Depression with Anxiety,” and so on, plus a separate diagnosis of “Bipolar Spectrum Depression.”

Today, I drill deeper down to the “modifiers.” These involve environmental, lifetime, cultural, and gender issues that may either trigger or compound the course of an episode. Typically, we cannot prove cause and effect. Coincidence is our only clue.

On one hand, this kind of speculation may be a pointless exercise. On the other, careful attention to the modifying red flags may make all the difference in the world. To pick up where we left off ...

MODIFIERS:

A. Depression Coincident with Stress and Trauma:

Reactive

Depression that anticipates, coincides with, or follows soon after a major personal loss (such as of a loved one, a loving relationship, or employment), hardship (such as financial), interpersonal difficulties (such as a toxic family situation), or traumatic event (such as a danger to one’s physical safety or an extreme change in personal circumstances).

Reactive depression may also result from the culmination of negative personal events and circumstances over time.

The depression appears to bear a relationship to the coinciding event (such as evidence of a long period of high functionality followed by low functionality in the wake of a messy divorce).

The subject appears to display an inherent lack of resiliency, or of finding an adaptive response, to negative or stressful events in general, or a particular negative or stressful event.

The depression shows no sign of abating after four weeks or after the resolution of the coinciding event (such as finding new employment after being downsized).

Traumatic

Subject may appear overwhelmed or functionally impaired by unresolved trauma issues, such as early abuse or neglect.

The depression appears to bear a relationship to recollections of the traumatic event or events (such as evidence of flashbacks, nightmares, emotional triggers, or obsessive ruminations). 

Subject appears to display an inherent lack of resiliency, or of finding an adaptive response, to his or her traumatic recollections.

B. Depression Coinciding With Age (Check One):

Note: Age ranges are approximate and may overlap.

Child and Adolescent Onset

From early childhood to early teenhood (ages 5 to 15). Symptoms may be masked or exacerbated by developmental issues or hormonal changes, or life transitions particular to children and adolescents.

Youth Onset

From late teenhood to early adulthood (ages 15 to 25). Symptoms may be masked or exacerbated by developmental issues, hormonal changes, or life transitions particular to those entering adulthood.

Adult Onset

From young adulthood to middle age (ages 21 to 45). Symptoms may be masked or exacerbated by life transitions particular to those settling in to adulthood.

Mature Onset

From midlife to retirement age (ages 40 to 65). Symptoms may be masked or exacerbated by hormonal changes or life transitions particular to those in their middle years.

Late Onset

From retirement age upward (ages 60 and above). Symptoms may be masked or exacerbated by hormonal changes, life transitions, or medical and neurological conditions particular those in late life.

C. Depression Coincident with Female Hormonal Fluctuations

Postpartum Onset

The depression occurs within one year of childbirth.

The depression appears to bear some relationship to the childbirth (such as evidence of other emotional difficulties surrounding the birth).

The subject displays unexpected difficulty in adapting to the demands of the new child.

Premenstrual Onset

Depression coincides with the second half of a woman’s menstrual cycle, and ends when menstruation begins or soon after. Subject may also manifest difficulties in managing emotions, and may feel intense mental anguish and physical discomfort. The condition is far more severe than PMS.

D. Gender (Check one):

“Female” Features, Gender Congruent

Depression manifests in a way consistent with “western” social expectations or baseline behavior.

Female subject (or male who identifies as a female) may over-ruminate, may express emotional pain by appearing sad (such as breaking into tears), may seek out others, may see her condition as a situation of her own making and blame herself, may seek comfort in indulgences (such as satisfying a sweet tooth or impulse buying), may reach out for help in indirect ways (such as expressing a wish to die), or may engage in suicidal gestures (such as taking a non-fatal dose of pain-killers).


“Female” Features, Gender Incongruent

Depression manifests with a significant number of features that may run counter to “western” social expectations of female (or male identifying as female) behavior or out-of-character with baseline behavior (such as a male who cries).

“Male” Features, Gender Congruent

Depression manifests in a way consistent with “western” social expectations or baseline behavior.

Male subject (or female who identifies as a male) may lack the capacity for ruminative introspection, may express emotional pain by appearing angry and aggressive or sullen, may not seek out others, may deny anything is wrong and blame others, may seek comfort in alcohol or drugs or risk-taking activities (such as venturing into dangerous neighborhoods), may alienate those in a position to help, and may be planning a suicide attempt.

“Male” Features, Gender Incongruent

Depression manifests with a significant number of features that may run counter to “western” social expectations of male (or female acting as male) behavior or out-of-character with baseline behavior (such as a female who acts aggressively).

E. Cultural Identity

Within any given social or ethnic group regarded as a “minority,” depression features may be masked or exacerbated by cultural norms particular to that group (such as distrust in confiding to outsiders or an emphasis on keeping emotions in check), by language barriers, or by different ways of interpreting similar phenomena (such as seeing depression as a disease of the soul).

On the other side of the coin, behavior that perfectly accords with the cultural norms of a  particular social or ethnic “minority” group (such as demonstrable displays of grief or apparently submissive gestures) may be mistaken by western observers as signs of depression.

The People’s DSM: My Alternative Depression Diagnosis - Part I

If you want anything done right, you have to do it yourself. With the DSM-5 task force and its various work groups and study groups a virtual walking and talking “How many psychiatrists does it take to change a light bulb?” joke, it is time for me to take matters into my own hands.

Following is a very rough draft to the first installment of “The People’s DSM,” which I am dedicating to the pioneering spirit of Robert Spitzer and those who worked with him on the ground-breaking DSM-III of 1980. Spitzer and company essentially ripped up the DSM-II and started over. Something the DSM-5 people should have done to the DSM-IV.

Something I’m doing right now. But I need your help. Please give me your feedback and suggestions and we’ll keep reworking it together till we get it right. On with the show ...

Mood Disorders
Depression

Introduction

The current depression diagnosis, with its antiquated symptom checklist, does not adequately account for extreme variations in emotions, thoughts, and behavior. Below are six domains to depression (such as emotion and thinking), each domain arranged in two complementary pairs, each pair with contrasting characteristics (symptoms or sets of symptoms).

These six domains would replace the symptom checklist.

For the Alternative Depression Diagnosis, clinicians need to check at least one characteristic from each domain. All four characteristics from a particular domain may be checked, even if they are opposite. As opposed to the previous DSM, this is not an exercise in symptom counting. More symptoms do not equate to a more severe depression.

Rather, this is an exercise in spotting symptom (characteristic) patterns and anomalies. Clustering of certain characteristics tends to resolve into one of two types of contrasting depressions: “Vegetative” and “Agitated”. There is also an intermediate “Mixed” depression.

All three may be called depression, but they are likely to demand entirely different and extremely subtle treatment and therapeutic approaches, as if they were different diseases. Current diagnostic practice does not encourage this.

A final note: Suicidal ideation is not included as a characteristic (symptom) here. This will be dealt with in a future installment.

Depressive states (all of the below must be met):

1. Must last most of the day for two weeks or more, with no apparent sign of improvement.
2. Must be a significant departure from baseline condition.
3. Must significantly impair ability to work, relate to others, and enjoy life.

Domains (at least one from each of six):

A. Emotion (Too Much Feeling or Too Little):

1. Subject may feel overwhelmed, and express intense sadness or anger.
2. Subject may experience emotional numbness, such as loss of pleasure, inability to grieve, or feel motivated.
3. Subject may experience excessive guilt or irrationally worry about one’s self or others.
4. Subject may lack the capacity to feel guilt or display concern for one’s self or others.

B. Perception and Sense of Self (Wholly Negative or Some Positives):

1. Subject may experience exaggerated worthlessness, feel deserving of his or her fate, and undeserving of a better personal situation.
2. Subject may experience a sense of exaggerated bad luck, feel undeserving of his or her fate, and deserving of a better personal situation.
3. Subject may view events in a negative light, discount good news, and see one’s personal situation as hopeless.
4. Subject may view events in a temporarily positive light, react to good news, and may see ahead to the possibility of one’s personal situation improving.

C. Thinking (Overthinking or Underthinking):

1. Subject may obsessively ruminate on destructive or self-defeating thoughts.
2. Subject may report difficulty concentrating or trying to plan ahead.
3. Subject may exhibit difficultly in processing routine mental tasks, such as remembering a phone number.
4. Subject may experience anxious or racing thoughts.

D. Behavior (Wholly Passive or Some Active):

1. Subject may experience difficulty engaging in routine tasks (such as keeping appointments or personal hygiene), pleasurable activities (such as hobbies), and relating to others (as if a fish out of water).
2. Subject may engage inappropriately in routine tasks (such as messing up an easy  assignment), pleasurable activities (such as drug or alcohol use or reckless behavior), and relating to others (such as being argumentative and confrontational). 
3. Subject may passively withdraw from social contact and isolate.
4. Subject may aggressively withdraw from social contact and withhold his or her companionship.

E. Mental (Speeded Up or Slowed Down):

1. Subject may experience a deadening of the senses (such as loss of sex drive or inability to taste food).
2. Subject may experience a heightened sensitivity to unpleasant sensations (such as the sound of a person’s voice).
3. Subject may experience a subjective slowing of the brain (such as a feeling of being dead).
4. Subject may experience persistent psychic pain (such as a feeling of wanting to crawl out of one’s skin). 

F. Physical (High or Low):

1. Subject may display nervous energy (such as pacing and inability to sleep or not eating).
2. Subject may display loss of energy (such as psychomotor slowing, fatigue, need to sleep, or overeating).
3. Subject may experience unexplained pain.
4. Subject may feel beyond the ability to feel physical pain.

***

Depressive types

Vegetative depression (subject leans toward most of the following):

Too little emotion, Negative Perception, Tendency to underthink, Passive behavior, Slowed down mental state, and is Physically low. 

Agitated depression (subject leans toward most of the following):

Too much emotion, Some positives in perception, Tends to overthink, Some active behavior, Some speeded up mental states, Some physical heightening.

Mixed depression (subject displays roughly equal vegetative and agitated qualities)

***

Vegetative, agitated, and mixed depressions may bear a relationship. A subject may present first with agitation, as if struggling against his condition, then give in to a vegetative depression. Conversely, an agitated depression may signal progress from a vegetative state toward remission or a worsening of one’s condition.

Final Word (for now)

Replacing the classic symptom checklist helps address some major concerns, namely:

• “Male” traits are mentioned for the first time, such as anger, drug use, confrontation, and aggression (along with “female” traits such as rumination), which should help redress the gender imbalance in the depression diagnosis.
• It helps identify the subject’s predominant state of mind (other than just “depression”), as well as other states, which gives clinicians and patients something to work with.
• It acknowledges the complexity of depression and its infinite variations.

In addition, the vegetated/agitated distinction eliminates the current and confusing melancholic/atypical depression distinction. It also accounts for the “pleomorphic” nature of depression, where symptoms (characteristics) may present differently from depression to depression or even within the same depression.

Two important first principles: No two depressions are alike. Depressions cannot be treated as if they are all the same. The current DSM discourages both clinicians and patients from thinking this way. The People’s DSM is offered as an antidote to this practice.

***

This is a lot more to come to my alternative depression diagnosis, including chronicity, cycling, severity, dimensional concerns (such as anxiety, mania and temperament), suicidality, and relationship to stress. Stay tuned. In the meantime, your feedback is strongly encouraged. Fire away ...

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

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

Episodes

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.

Severity

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

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

The DSM-5 - What Went Wrong

I have now finished issuing my grades for the homework handed in by the DSM-5 Task Force concerning their proposed revisions to the depression and bipolar diagnoses. My two introductory articles included in the title, “Rip It Up and Start Over.” Then I issued nine report cards, three for depression and six for bipolar.

I handed out grades in a total of 39 assignments, including F-minus (at 17) and F (8), plus a “no-grade” in a case where an F-minus would have been far too generous. Throwing out my four incompletes and three “no-grades” for extra credit, the fail rate was a stunning 81 percent. A lone B was my highest grade.

So what went wrong?

In an earlier piece, I brought up that the fact that the DSM-5 operating parameters were far too restrictive, involving an impossible burden of proof for even minor changes. The DSM-5 operated under the mistaken assumption that they were drafting a research paper that would be read by maybe 30 people instead of putting together a real world manual that would be relied on by millions worldwide.

In short, the DSM was never meant to be a science project. In the real world, we proceed on the best information we have available to us. This information may not always be “scientifically valid,” but it does yield results that are both useful and credible.

Instead, we bore witness to DSM-5 work groups tripping over their own feet. For instance, the draft explicitly recognized that “the current DSM-IV-TR diagnosis schizoaffective disorder is unreliable,” yet did nothing to make it reliable.

This was repeated throughout, though usually implicitly. Thus 30-year errors that defied both science and common sense (such as artificially separating out unipolar from bipolar) were being perpetuated. Thus, easy fixes with at least some measure of validity, that would lead to more precise diagnoses and save lives, were being excluded.

Other factors were at play, too. Let’s discuss “paradigm freeze.” The DSM-5 pays homage to scientific validity, but thanks to Thomas Kuhn and others we know that the quest for knowledge is hardly governed by disinterested scientists rationally sifting through the facts. In reality they are operating within their own particular conceptual frameworks (paradigms) that govern how they think.

The various DSM-5 work groups drew from the top experts in the field, but this was a fairly homogenous bunch, working within the same specialty, with similar professional backgrounds, operating off the same set of beliefs, inclined to nitpick at best. The field’s notable boat-rockers, as it turned out, were conspicuously absent. (Why wasn’t Hagop Akiskal on the mood disorders work group? Or, at the very least, one of his Facebook friends?)

Thomas Kuhn emphasized that paradigm shifts are not initiated by science’s in-crowd. Rather, they are brought about by outsiders - young practitioners and those operating in different fields. That shift is only a decade or two off in psychiatry. What needs to happen is for our nascent brain science and its allied disciplines to mature, along with new ways to explain old behaviors.

Then, instead of depression or bipolar or schizophrenia, we’ll be treated for things like “surprachismatic nuclei disease” and - supreme irony - “neurosis.”

I have been to public forums where the DSM has been debated, and I know for a fact that those on its working groups are fully aware of the impending shift. Indeed, some are even leading it. But this awareness has only seemed to immobilize them. They see the car approaching, but are frozen in its headlights.

In the meantime, we with the most at stake can hardly afford to wait for the inevitable paradigm shift. Mental illness kills. Simple. Making the changes we need to the DSM right now will hardly satisfy the conceits of scientists (old paradigm or new), but it will save lives.

Can someone explain this simple fact to the DSM-5 people?

Previous 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
My DSM-5 Report Card: Grading Depression - Part III
My DSM-5 Report Card: Grading Depression - Part II
My DSM-5 Report Card: Grading Depression - Part I

Coming soon: Grading Personality Disorders

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:

• 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
• My DSM-5 Report Card: Grading Depression - Part III...
• My DSM-5 Report Card: Grading Depression - Part II...
• My DSM-5 Report Card: Grading Depression - Part I

More report cards to come ...