Akiskal Unplugged

Hagop Akiskal of UCSD is bipolar’s ultimate insider-outsider, at once the field’s elder statesman and enfant terrible, the best-known name in an establishment that would often rather not know him, and vice-versa. “I have no use for the DSM,” he told me as I greeted him last evening at a talk he was about to deliver to the San Diego chapter of DBSA.

And he was only just getting warmed up.

Dr Akiskal’s presentation was more in the nature of a conversation, with revealing tangents that allowed his audience rare glimpses into the mind of a visionary-at-work. A lot of what you read here on "Knowledge is Necessity" is highly derivative of Akiskal, and for good reason. Basically, if you want to know about bipolar, you read the usual literature. If you want to know what is really going on, you read Akiskal (and Frederick Goodwin, and Robert Post and a few others).

“Most depressions are at some level bipolar,” Dr Akiskal told his audience. Akiskal literally owns the terms “bipolar spectrum” and “mood spectrum,” which view both mood and temperament as blended shades of the same phenomenon rather than separate entities. Thus depression typically has elements of mania or hypomania, and vice-versa. Agitated depressions, if you like, or dysphoric manias. Think road rage, even if you don’t drive.

Just to make things interesting: Imagine if you have an upbeat (what Akiskal calls “hyperthymic”) temperament. You get depressed - “state,” in effect, superimposed over “trait.” It doesn’t take a rocket scientist to realize that your depression is likely to look quite a bit different than that of the melancholic type sitting next to you. But until Akiskal arrived on the scene no one in psychiatry even came close to thinking this way.

Okay, maybe Emil Kraepelin, a name Akiskal drops every chance he gets, including at least three or four times last night. Kraepelin, who was born the same year as Freud, coined the term, “manic-depression.” What Kraepelin meant by manic-depression embraced recurrent depression as well as bipolar. The DSM-III of 1980 missed this completely, as did the DSM-III-R of 1987 as did the DSM-IV of 1994 as did the DSM-5 (due out in 2013).

See why Akiskal has no use for the DSM?

“They are spending millions of dollars on the DSM-5,” Akiskal thundered. “I refuse to be part of it.” The DSM, he says, lists “five hundred ways to lose your sanity.” It could be simplified, he said, to about five or ten or fifteen.

“I don’t believe in borderline,” he threw in for good measure.

Ah, vintage Akiskal.

Much more to come ...

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More Akiskal on mcmanweb:

The Mood Spectrum
Multipolar Depression
The Fear and Anger Equation