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.

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 ...

My DSM-5 Report Card: Grading Bipolar - Part V, Child Bipolar

Ten years ago, virtually everyone thought you had to be of voting age to qualify for a bipolar diagnosis. Thankfully that has changed. In a post here last May, I placed recognition of child bipolar at the top of my list of mental health stories over the past decade. The draft DSM-5, unfortunately, is poised to reverse a decade of progress.

Some background ...

Back in the 1990s, Joseph Biederman and his colleagues at Harvard separated out a population of troubled kids whose behavior could not be entirely accounted for by ADHD or various conduct disorders. To Dr Biederman, plus investigators at other centers, the behavior looked a lot more like bipolar disorder.

Mood swings proved a key separator from ADHD, with grandiosity a major giveaway, but the manias these kids experienced were rarely euphoric, more like mixed raging states that literally held entire families hostage. Because these kids tended to cycle in and out of these states at least once a day (rather than the one-week minimum) technically they did not meet the DSM criteria for bipolar.

This was not a case of kids merely acting out, nor of bad parenting. Parents reported horror stories of their very young kids wanting to die and impulsively jumping out of moving cars and a lot more.

Although there was no precise agreement among researchers on the fine points of what a child bipolar diagnosis would look like, there was a strong general consensus that the phenomenon of raging kids with out-of-control moods was indeed real and needed to be included in the next DSM. 

As awareness grew, so did the rates of kids being diagnosed with bipolar. This resulted in an inevitable backlash, not only among the general public, but among psychiatrists and other professionals. The issue was further complicated by turf wars involving ADHD specialists and child therapists.

In the meantime, the tragic death in 2007 of four-year-old Rebecca Riley on a medications overdose set off a feeding frenzy of hysterical and uninformed commentary.  Soon after, it was discovered that Dr Biederman had neglected to disclose his financial ties to Johnson&Johnson, makers of Risperdal, a drug used for treating bipolar. This resulted in yet another feeding frenzy.

The unenviable task for those working on the DSM-5 was to sort out competing scientific claims, rise above petty professional turf issues, pay no attention to the crazy talk inside and outside psychiatry, and arrive at a diagnosis (perhaps more than one) wide enough to identify kids in need but sufficiently narrow to avoid pathologizing normal child behavior.

On with the grading ...

Narrow, Intermediate, and Broad Views

In 2003, Ellen Leibenluft of the NIMH proposed three “phenotypes” of “juvenile mania.” The “narrow phenotype” would strictly adhere to adult criteria. Two “intermediate phenotypes” would lower the criteria (to shorter episodes featuring tantrums and rages), while the “broad phenotype” would recognize a raging and aroused population without classic mood episodes.

As long as “narrow” and “intermediate” accompanied “broad,” these classifications showed promise. Unfortunately, the draft DSM-5 picked just one. Think of “The One Musketeer” or an eskimo with just one word for snow.

Grade: F-minus.

Pediatric (or Early Onset) Bipolar Disorder

Despite the claims of naysayers, the case for DSM pediatric bipolar is well-established. Dr Leibenluft’s “narrow” view (with identical pediatric and adult versions) would work, provided that first the criteria for the adult version is slightly widened. (This would account for clinical realities occurring within the adult population, as well.)

The draft DSM-5 for adult bipolar is arguably half-way there with a widened view of mixed states, but appears incapable of making a decision concerning extreme rapid-cycling.

An “intermediate” view would acknowledge that kids may present somewhat differently than adults, but that their behavior can nonetheless be attributed to bipolar. The tip-off is episodic states. The pediatric version would stress the mixed state rages and extreme rapid cycling.

The DSM need not include both views (though it would be helpful), provided one of them employs a name that acknowledges both the illness and the population it preys upon. Thus: “Pediatric Bipolar Disorder,” “Child and Adolescent Bipolar Disorder,” “Juvenile Bipolar Disorder,” or “Early Onset Bipolar Disorder.”

In a pinch, something like “early onset” could be employed as a specifier under the standard bipolar diagnosis. The point is the DSM-5 needs to send a clear signal to clinicians and the general public that bipolar in kids is very real.

Suffice to say, the draft DSM-5 chose not to send that signal. Why are we not surprised?

Grade: No grade. This is unforgivable.

Temper Dysregulation Disorder with Dysphoria - Credibility

In light of the failure of the draft DSM-5 to include a diagnosis along the lines of pediatric bipolar, everything else its two relevant workgroups may come up with is highly suspect. This is unfortunate, as the new diagnosis of “temper dysregulation disorder with dysphoria” (TDDD) deserves a fair hearing. But in the present context, TDDD comes across as “anything but bipolar.”

Grade: F-minus.

TDDD, Scare Tactics

The DSM-5 Child and Adolescent Disorders Workgroup (which collaborated with the Mood Disorders Workgroup) served up a background paper detailing its reasons for this new diagnosis. The first paragraph cites a study that “found a 40-fold increase between 1994 and 2003 in the number of outpatient pediatric psychiatry visits associated with the diagnosis of BD.”

But, when starting from a baseline of zero, any increase cited in percentages is highly suspect. A 2007 study found that youth released from the hospital with a primary diagnosis of bipolar amounted to less than one in a thousand.

True, misdiagnosis and overdiagnosis is always a danger. But clinicians finally waking up to reality can be regarded as a cautiously encouraging sign. Meanwhile, arguments employing selective science in pursuit of an agenda are best suited to talk radio.

Grade: F-minus.

TDDD - Justification

An earlier version of TDDD was “severe mood dysregulation” (SMD), a term coined by Dr Leibenluft to define her “broad phenotype.” These are kids who experience down moods and rage in a manner similar to those with bipolar, but not in episodes. This may be the tip-off that TDDD is a separate phenomenon entirely from child bipolar, or, if related, nonetheless needs to be separated out.

The background paper cited an NIMH study which found that, unlike kids with narrow bipolar symptoms, minors with SMD failed to develop classic mania/hypomanic episodes when followed over time. Less reliable data suggest that kids with SMD are more likely to be at risk for unipolar than bipolar as young adults.

What’s missing from the analysis is the fact that the current DSM does not recognize a wide variety of depressions and hypomanias as part of bipolar (namely mixed states and very rapid cycling). So SMD kids may very well experience mania/hypomania episodes and grow into adults whose moods more resemble bipolar than unipolar.

Again, SMD/TDDD may be valid (the background paper also cited preliminary brain scan studies), but when the yardstick is crooked so are any measures and conclusions based on those measures.

In any other context, the inclusion of an entirely new diagnosis based on the best knowledge we have at the time may have been justified. But not when the Mood Disorders Workgroup deliberately and obstinately shunned the “best knowledge” criterion for all the rest of mood disorders, even when clinical reality screamed for such changes.

Another way of putting it: Extreme double standards are in force here.

Grade: F-minus.

TDDD - A Catch-all Diagnosis?

At least the term bipolar was sufficiently frightening to make clinicians think twice before diagnosing kids. But a diagnosis that comes across as a euphemism? And one sufficiently broad to embrace normal kids going through bad phases?

Yes, the background paper cautions that kids with TDDD are as badly off as those with bipolar, but who (besides me) reads background papers?

What is going on here? Has the draft DSM-5 come up with a new diagnosis to make it safe for clinicians to diagnose problem kids with bipolar without calling it bipolar? In which case, we may find overdiagnosis in abundance, along with inappropriate treatments.

We wouldn’t be asking these questions if those working on the draft DSM-5 possessed the common sense to issue a clear and unambiguous “pediatric bipolar” diagnosis. Then there would have been an acceptable context for TDDD. This would have accorded with the original intention of Dr Leibenluft when she came up with SMD as one of three child bipolar phenotypes.

Leave it to the DSM-5 people to mess it up entirely.

Grade: F-minus.

Summing Up

Coming up with criteria for child bipolar was supposed to be a collaborative effort between two of the DSM-5’s workgroups. Judging by how the Mood Disorders Workgroup passed on all but one opportunity to make substantial changes to the rest of mood disorders, it is fairly apparent that they caved into the demands of the Child and Adolescent Workgroup.

No recognition of some form of child bipolar at all? No attempt to provide the necessary context for a new TDDD diagnosis? Clearly, the child psych people, with an agenda of their own, ran roughshod over the mood disorders people, a fight that never should have been allowed to break out.

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.

More DSM-5 report cards to come ...

Previous report cards:

• 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

My DSM-5 Report Card: Grading Bipolar - Part IV

Part I, Part II, and Part III to Grading Bipolar placed heavy emphasis on that largely unmapped middle ground where bipolar bleeds over into clinical depression. Why this is critically important is that clinical ignorance leads to misdiagnosis and wrong treatments, which translates into years and even decades of unnecessary suffering.

The current DSM abets numerous opportunities for bad psychiatric practice, which the DSM-5 was supposed to redress. Unfortunately, the Task Force and its various workgroups suffered an extreme outbreak of dereliction of duty.

So, can the DSM-5 do better where bipolar bleeds over in the other direction into schizophrenia? First a little background ...

Back in the early twentieth century, the pioneering diagnostician Emil Kraepelin separated out “manic depression” (bipolar and recurrent depression) from “dementia praecox” (schizophrenia). This distinction provided psychiatry with its first real navigational aid, which continues to guide diagnostic practice to this very day.

But Kraepelin also recognized the limits to making a clear categorical split, and recent genetic findings are backing his reservations. Virtually all the leading candidate genes for bipolar happen to be leading candidate genes for schizophrenia, as well.

The current DSM recognizes some of the crucial fine shadings. Thus we have “with psychotic features” as specifiers to both major depressive disorder and bipolar disorder. In addition, there exists the separate diagnosis of “schizoaffective disorder” that is widely interpreted as a hybrid between bipolar and schizophrenia.

The issue: Should those charged with the DSM-5 attempt to fix what doesn’t appear to be broken? Or is there considerable room for improvement?

On with the grading ...

Psychosis, a Clear Definition

The current DSM makes various references to psychotic features, but what precisely is “psychotic”? To find out, one needs to flip the pages to the rather obscure diagnosis of “brief psychotic disorder,” which mandates one or more of the following symptoms:

Delusions; hallucinations; disorganized speech; psychomotor symptoms, including catatonic behavior.

The DSM-5 would leave this unchanged.

Fine, that provides a breakdown of the component parts to psychosis, but what is psychosis? The glossary to the DSM-IV concedes that none of the historic definitions “has achieved universal acceptance.” Narrowly viewed, psychosis refers to hallucinations and delusions to which the patient lacks insight. A wider view would incorporate patient insight. Still wider are the symptoms listed for the positive symptoms of schizophrenia (same as for a brief psychotic episode) and wider still would incorporate “loss of ego boundaries or gross impairment in reality testing.”

The current DSM punted in coming up with an authoritative definition and set of distinctions. It appears the DSM-5 is similarly opting out.

Grade: F.

With Psychotic Features

Psychosis looms large in mania and less so in depression. The DSM-IV operative term is “with psychotic features,” which the DSM-5 would leave unchanged. Presumably, a “feature” is less intense than a “symptom,” but it would be helpful to see this spelled out. Is this asking too much? Apparently yes.

Grade: F.

Mood Congruent/Incongruent

When adding a “with psychotic features” specifier to depression or mania, the DSM-5 would mandate clinicians to differentiate “mood congruent” from “mood incongruent.” In a depression context, mood congruent psychosis might translate to, say, irrational feelings of deserved punishment. A manic context might involve delusions of a special relationship to a deity.

Mood incongruent, by contrast, involves no apparent linkage between mood and disordered thinking.

The current DSM buries this distinction way back in Appendix C. Moving this up front and center is a major step forward. But will clinicians have to flip to the back pages to find the definitions?

Grade: B.

How Psychotic is Psychotic?

We know we can have a mood disorder “with psychotic features.” What is unclear is whether we can have a mood disorder with full-blown psychosis. Or is that something else? Say schizophrenia or schizoaffective disorder?

Misinterpreting psychosis leaves no room for error, as a diagnosis of schizophrenia sends (very wrongly) a clear message to abandon all hope.

Grade: F.

Schizoaffective Disorder

The DSM-5 spells it out: “The current DSM-IV-TR diagnosis schizoaffective disorder is unreliable.”

To start, the current DSM classifies schizoaffective under “Schizophrenia and Other Psychotic Disorders,” but is this the right place to put it?

Too often, schizoaffective is employed as a glorified NOS diagnosis by clinicians who can’t decide whether their patient has bipolar or schizophrenia. As Goodwin and Jamison and others point out, the current DSM leaves wide room for mutually exclusive interpretations, such as:

A form of bipolar with psychosis, a form of schizophrenia with mood swings, co-occurring schizophrenia and bipolar, a separate illness, or a different phenomenon entirely occupying the psychosis spectrum.

Just to make things more confusing, a patient may appear to have schizophrenia during one phase of his or her life and bipolar in another.

So how would the DSM-5 fix a diagnosis it regards as “unreliable”?

“We recommend the following, minor change in the text ..."

A MINOR textual change? Is that it? Yes, apparently.

Grade: F-minus.

More to come ...

My DSM-5 Report Card: Grading Bipolar - Part III

Today’s grading assignment began with an apparently niggly issue that suddenly turned severe. Severity is the topic. Let’s get into it ...

Severity, Mania/Hypomania

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.

It’s too bad this message got lost in the mail.

Until someone comes up with a foolproof diagnostic test, severity is the only way of separating out mania from hypomania (and thus bipolar I from bipolar II). Indeed, the current DSM already red flags severity (“not severe enough to cause marked impairment”) to distinguish hypomania from mania.

What we need now are some precise measures that would aid clinicians in dialing in the diagnosis, plus perhaps detect the types of subtle “ups” that signal there is more to many depressions than simply depression. A lot of deep thinking is required to come up with the right indicator. Expect, instead, to find a last minute generic patch along the lines of the CGI.

Grade: F-minus.

Severity, General

The workgroup indicated it is considering various standard measures (such as the CGI) for severity for the bipolar diagnosis. One problem is these measures don’t seem to apply to episodes. Thus, for mania, the workgroup notes: “This is not a codeable disorder; therefore, there are no severity criteria proposed.”

Huh?

Grade: F-minus.

Severity, Cycling

What sets bipolar (including cyclothymia and recurrent depression) apart from other ills is that it is essentially a cycling illness. Thus, “feeling better” may actually be a sign of trouble, of the cycle about to ramp up or change course.

It’s all about the cycle. Fast or slow, extreme or subtle. Without an accurate read, we are literally flying in the dark. Does the workgroup have something in mind? If so, they haven’t told us.

Grade: F-minus.

Severity, Context

Perhaps you are feeling okay now, but you know if you went back to work or had to deal with some troublesome family issues you would fall apart. Is there a severity indicator for that? Consider this assignment extra credit.

No grade.

Severity, Stress

Where there’s smoke there’s fire. A smoke detector would not be difficult to devise. Another extra credit project.

No grade.

The Bipolar Report Card So Far ...

• Depression: F-minus
• Euphoric and Dysphoric Mania: F
• The Mania Minimum Time Limit: D
• Hypomania as a Marker for Depression: Incomplete
• Hypomania as a Marker for Mania: F
• Dysphoric and Euphoric Hypomania: F
• Antidepressant-Induced Mania/Hypomania: C-minus.
• Mixed Episodes, Symptoms: C-minus.
• Mixed Episodes, Spectrum Considerations: C-plus.
• Bipolar III: D
• Recurrent Depression: F-minus.
• Rapid cycling: Incomplete

More to come ...

My DSM-5 Report Card: Grading Bipolar - Part II

Part I began issuing grades on the homework handed in nearly two weeks ago by the DSM-5 Task Force concerning its proposed revisions to bipolar. To recap:

Depression - “What were these people thinking? They weren’t.” Grade: F-minus.

Euphoric and Dysphoric Mania - “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.

The Mania Minimum Time Limit - “Why seven days? Why not four? Who is truly counting the days when our life is in ruins? Don’t make me answer that.” Grade: D.

Hypomania as a Marker for Depression - “A very strong case can be made for lowering the diagnostic thresholds for hypomania.” Grade: Incomplete.

Hypomania as a Marker for Mania - “One simple adjustment. Are we asking for too much? Yes, apparently.” Grade: F.
   
Dysphoric and Euphoric Hypomania - “The same arguments that apply to mania apply here.” Grade: F.

Moving on ...

Antidepressant-Induced Mania/Hypomania

The DSM-5 would recognize that flipping into mania or hypomania as the result of an antidepressant or ECT or other depression treatment  “is sufficient evidence for a manic or a hypomanic episode diagnosis,” but cautions that a mere one or two symptoms (such as irritability) should not be taken as evidence of an episode.

For a change, the DSM-5 Mood Disorders workgroup actually made what would amount to a significant change to the bipolar diagnosis. The catch is they buried it in the usual standard boilerplate which is suddenly not so standard. Trust me, if I failed to pick it up, the person you entrust your life to is not about to pick it up, either.

Grade: C-minus.

Mixed Episodes, Symptoms

In real life there are “pure” depressions and “mixed” depressions, “pure” manias and “mixed” manias. Successfully differentiating one from the other is crucial to treatment success. The current DSM recognizes mixed states only in bipolar I, when depression (with a capital D) and mania (with a capital M) rear their ugly heads together. Thus: DM.

Your best source of finding out what a mixed episode is like is listening to a patient who has been through it. Unbelievably, the DSM never bothered to turn in a description. (Short description: various forms of energized psychic distress, such as road rage, even when not driving.)

In by far the most significant change to the bipolar diagnosis, the DSM-5 would widen mixed states to include two or three mania symptoms (m) inside depression (D) or two or three depression symptoms (d) inside mania/hypomania (M). Thus: Dm or Md.

Presumably, this translates into symptoms strong enough to turn “euphoric” manias “dysphoric” and mind-numbing depressions “agitated.” The problem is the DSM leaves us presuming. Once again, what does a mixed state look like? Do we have to Google the answers, ourselves?

Grade: C-minus.

Mixed Episodes, Spectrum Considerations

The DSM-5 would acknowledge two types of mixed episodes: Predominately depressed and predominately manic/hypomanic, which would include for the first time those with bipolar II. The DSM-5 workgroup is undecided whether to include mixed states as episodes in their own right or as specifiers to depressive and manic episodes.

Inexcusably undecided is the workgroup’s position on mixed states in unipolar depression (see Part I to Grading Depression). Why would mixed depressions somehow be regarded as exclusive to the bipolar diagnosis?

Last but not least, why should a mixed depression or mania/hypomania require a full-blown episode? Think: how well are you truly when you have elements of both depression (d) and mania/hypomania (m) going on at once (dm)? Or, to put it another way, when is counting symptoms a substitute for evaluating functional impairments?

Grade: C-plus.

Bipolar III

Should the threshold for bipolar II be lowered to include patients with so-called “soft” bipolar? These are individuals whose depressions have far more in common with bipolar than unipolar and who do cycle “up,” though not necessarily as high or as long.

Or should a new category by created for them, such as bipolar III?

In other words, why should those who don’t dance on tables be overlooked? Especially if they continue to lead miserable lives treated as if for unipolar depression.

The DSM is considering reducing the time criteria for a hypomanic episode for bipolar II, but is holding the line on the symptom minimum.

Grade: D.

Recurrent Depression

As opposed to chronic depression, recurrent depressions come and go, typically in an up and down pattern. The current DSM includes recurrent depression as part unipolar depression and the DSM-5 would preserve the status quo.

Here’s the issue: If no expanded bipolar II diagnosis or no bipolar III, then why not put recurrent depression into service? Perhaps add new criteria as part of a new “highly recurrent depression” or “cycling depression” diagnosis. There are at least three advantages to this:

• This would recognize the bipolar nature of these depressions without necessarily acknowledging them as part of the bipolar diagnosis. Clinicians would be encouraged to investigate more closely for these type of depressions before indiscriminately prescribing antidepressants.
• Since this type of cycling depression would not be regarded as part of the bipolar diagnosis, a clinician need not find evidence of hypomania or mania to make the right call.
• A cycling depression diagnosis would avoid the stigma of a bipolar diagnosis.

Mind you, for this to happen, the DSM-5 workgroup would have to put the interests of the patient above those who manufacture antidepressants or clinicians too lazy to ask the right questions or insurance companies who refuse to give clinicians time to do their job. I can well imagine the workgroup's deliberations: Explain the concept of patient interest to me ...

Grade: F-minus.

Rapid-Cycling

Strangely enough, true rapid-cyclers ride the roller coaster far too fast to be considered DSM-eligible as a rapid-cyclers, much less rate a bipolar diagnosis. Blame the current DSM for this mess, which demands the same “duration criteria” for episodes from everyone (two weeks for depression, one for mania, four days for hypomania).

According to an article in Psychiatric Times, even those responsible for the DSM-IV recognized the absurdity in their thinking. The question remains - can the DSM-5?

Grade: Incomplete.

Much more to come. Stay tuned for Part III ...

The Draft DSM-5 - Another Blogger Speaks Out

I'll be quick: Blogger comrade-in-arms Willa Goodfellow (pictured here) of Prozac Monologues has written a terrific critique of the Draft DSM-5. Sample:

Particularly disturbing is the failure to include new knowledge about Bipolar II.  The proposed revisions do not even keep pace with practice among psychiatrists who do listen to their patients' experience.  The evidence for a link between antidepressants and suicide is most compelling for those who are diagnosed with Bipolar II or those who could be diagnosed with Bipolar II, if the criteria shifted to include them.  The continued narrow definition leads to inappropriate treatment with antidepressants (translation: more sales of antidepressants), and deterioration, including a tripled risk of suicide. 

Say no more. Check it out ...

My DSM-5 Report Card: Grading Bipolar - Part I

Last week, the DSM-5 Task Force turned in its homework regarding proposed revisions to the DSM. This week, I started grading its efforts. In my last three pieces, I broke down Team Depression’s term paper and issued the overall grade of F. Can Team Bipolar rise to the challenge?

First, some background:

Before there was bipolar, there was DSM-II manic-depression, which - believe it or not - included a “depressive type” that consisted “exclusively of depressive episodes.”

Bipolar made its official debut as a “mood disorder” in the DSM-III of 1980, with the diagnostic threshold set to full-blown mania. The DSM-IV of 1994 modified its restrictive stance with the inclusion of “bipolar II” and its less stringent “hypomania” threshold. But this failed to satisfy critics, who to this day contend that the DSM-II view of manic-depression was a lot closer to reality.

So, after all these years, are we finally going to witness the unveiling of “bipolar III?”

In the meantime, experts woke up to the fact that bipolar depressions could be very different from unipolar depressions. Plus there was a growing realization that bipolar had more in common with schizophrenia than once thought.

Now that we have set the scene, on with the grading ...

Depression

Mania gets all the attention, but depression is what clinicians need to be closely scrutinizing. The DSM calls for evidence of a previous manic or hypomanic episode to diagnose a depressed patient with bipolar, but what if the patient is unable to recall ever feeling good or feeling too good for his or her own good?

The current DSM criteria for a bipolar depressive episode is a straight copy-and-paste from unipolar depressive episode. We now know that patients with bipolar tend to manifest different features to their depressions and react far differently to antidepressants. Some clear red flags in the next DSM would put clinicians on notice.

Gary Sachs MD of Harvard likens depression to the pointer stars of the Big Dipper, offering navigational clues to the North Star that is mania and hypomania. Clinicians would still require evidence of mania or hypomania, but spotting anomalies within depression would help them with their detective work. The DSM-5 workgroup had no shortage of clear pointers to work with. Instead, the workgroup stuck with the copy-and-paste option.

Needless to say, this decision absolutely guarantees that the current unacceptably high rates of misdiagnosis (along the terrible suffering that involves) will continue unabated. What were these people thinking? They weren’t.

Grade: F-minus.

Euphoric and Dysphoric Mania

We tend to think of mania as feeling way too good for our own good. In reality, mania also has a way of manifesting as euphoria’s diametric opposite. These are your road rage states, your crawling out of your skin states. The DSM does acknowledge that mania can involve irritable mood, but this is nowhere near close to delineating night from day.

The DSM also recognizes mixed episodes, which the DSM-5 would widely expand, but even then there is no indication as to what mixed depression-mania actually looks like. Perhaps dysphoric?

All which makes you wonder. 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.

The Mania Minimum Time Limit

Why seven days? Why not four? Who is truly counting the days when our life is in ruins? Don’t make me answer that.

Grade: D.

Hypomania as a Marker for Depression

Patients typically do not want to be cured of hypomania, but what does frighten them is what is likely to come next, such as crashing into depression. In this context, hypomania is more of a “marker” pointing to pathology rather than a pathology in its own right.

Why this is important is that depressions that cycle in and out (and up and down) are different animals than depressions that don’t. Often they need to be treated differently (such as going with a mood stabilizer rather than an antidepressant).

So, if all we are looking for is evidence of “up,” how high does up need to be? When triangulating depression, not high at all. Thus, a very strong case can be made for lowering the diagnostic thresholds for hypomania (say to two symptoms lasting two days). The DSM-5 says no to the former, but, pending further analysis, may say yes to the latter.

Grade: Incomplete.

Hypomania as a Marker for Mania

What separates hypomania from “normal” behavior is the individual’s own baseline. The operative DSM word is “uncharacteristic.”  Nevertheless, the individual’s functioning is not impaired. Turn up the heat to mania, however, and the picture is far different.

But 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. Needless to say, clinicians get it wrong a good deal of the time. It certainly doesn’t help that the symptom list for both hypomania and mania is exactly the same.

Consider: if the DSM does not regard hypomania as an impairment that interferes with normal functioning, then what is the justification for retaining the following symptom?

Excessive involvement in pleasurable activities that have a high potential for painful consequences ... (The DSM-5 would remove the modifier, pleasurable.)

As a symptom for mania, however, this could be a key differentiator. One simple adjustment. Are we asking for too much? Yes, apparently.

Grade: F.

Dysphoric and Euphoric Hypomania

The same arguments that apply to mania apply here.

Grade: F.

Much more to come. Stay tuned for Part II ...

My DSM-5 Report Card: Grading Depression - Part III

This concludes my three-part DSM-5 Depression report card, my answer to the DSM-5 draft proposals issued last week ...

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. But after that, I will move straight to personality disorders, where I foresee much higher marks.

Coming up: My DSM-5 Bipolar Report Card ...

From the My Report Card series

• My DSM-5 Report Card: Grading Depression - Part II...
• My DSM-5 Report Card: Grading Depression - Part I
• My Draft DSM-5 Report Card: Hint - Don't Expect Li...

My DSM-5 Report Card: 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.

We’re not finished. Stay tuned for Part III ...