My Alternative Bipolar (Cycling) Diagnosis - I
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Let's start by changing the name.
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The Pepole's DSM. 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.
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In addition, cycling acknowledges the likelihood of other cycle disturbances, such as sleep.
On with the show ...
Cycling Illness
(All of the below must be met):
- Evidence of a mood cycling pattern (through clinical observation, case history, or patient or witness reports), with discernible contrasting phases.
- At least one phase (or the combined effect of more than one phase) must be a significant departure from baseline condition.
- At least one phase (or the combined effect of more than one phase) must significantly impair ability to work, relate to others, and enjoy life.
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.
Phases
DEPRESSIVE PHASE
Subject may experience recurrent or highly recurrent or cycling depression.
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?
As opposed to depression, a highly-complex illness that clinicians dangerously over-simplify, one can make a strong case that bipolar is far more simple than it looks. Change the name to “cycling illness” characterized by “phases” rather than “episodes” or “states,” borrow what’s relevant from what we already have for depression, fill in the blanks with a little bit about what “up” looks like, and stop right there.
When stripped to essentials, cycling illness is basically a pattern of down and up. And since we tend to be down way more than we are up, it’s fairly accurate to say that cycling illness is depression with speed bumps.
“Up” is anything that contrasts with down. You don’t have to be dancing on tables. “Normal” or “better than normal” will do, so long as it shows you have a depression that is not standing still.
Complex depression, simple illness. Simple, really.
Yes, Very Simple
Okay, “up” needs to be explained a lot better than what you find in the current and highly antiquated DSM mania/hypomania symptom list. You can have racing thoughts, grandiosity, pressured speech, and all the rest, but are you feeling great or feeling lousy?
The DSM doesn’t tell you. Can you believe it? Myth has it that we’re supposed to be feeling like Leonardo DiCaprio with Kate Winslet on the bow of the Titanic (or vice-versa), but too often we’re more like Kim Jong il on a bad hair day.
Depression with a power surge, in other words. “Dysphoric” mania/hypomania, as opposed to “euphoric.”
Mixed Phases
Another way of looking at it is our depressions and manias are mixed. Think of dysphoric mania/hypomania as the cycle gone crazy - out of phase, so to speak - with both up and down screaming for attention at once. One is crashing down the door while the other hasn’t yet left the building.
How much depression inside mania/hypomania do you need? Only enough to turn euphoric mania/hypomania dysphoric. No need to count symptoms. Simple. Do we even have to add the specifier, “mixed,” to dysphoric? No. It’s totally redundant. Then again, maybe we better, thus:
1. MANIC PHASE, DYSPHORIC (MIXED)
2. HYPOMANIC PHASE, DYSPHORIC (MIXED)
Meanwhile, over on the other side of the diagnostic divide, we already have “agitated (or mixed) depression with mania” (which we would include on this side of the divide, as well, without specifically having to spell it out). In some cases agitated depression may appear difficult to distinguish from dysphoric mania/hypomania, but, hey, this is life in the real world. Depression and mania co-exist on the same spectrum, and, contrary to what the current and future DSM would have you believe, the two overlap. One bleeds over into the other. They don’t separate for the convenience of clinicians in a hurry.
Finally, what about situations involving say just two symptoms of mania combined with just three symptoms of depression? Going by official DSM criteria, you are healthy. Except for the fact that you are feeling rotten. Fortunately, The People’s DSM is not anal about symptom counts. Problem solved.
Dare we get more complicated?
April 7, 2010, reviewed Jan 3, 2011
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