My Alternative Bipolar (Cycling) Diagnosis - II
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Let's keep it simple.
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The People's DSM. Thus far (in Cycling Part I), I have kept what I refer to as “cycling illness” simple. As long as we appreciate that down and up are connected as different phases in the same cycle, there is little room for confusion. But there is a major complication called psychosis. If the psychosis is severe enough and prevalent enough, suddenly clinicians are faced with some very tricky diagnostic calls.
The current DSM recognizes psychosis as an illness in its own right and acknowledges its occurrence in other illnesses, including depression, bipolar, and schizophrenia, not to mention the hybrid diagnosis of schizoaffective. In theory, clinicians have a rough guide to work with. In practice, uncertainty prevails, namely:
How, precisely, does psychosis tie in to mood? And, while we’re at it, is there actually one person in the whole wide world who can explain schizoaffective, much less the reason for its existence?
Brain science and genetics promise to yield far more definitive answers than we presently have, which may explain why the draft DSM-5 changed virtually nothing. My view is we need to do our best based on the knowledge we have now, even if future scientific discovery proves us wrong. Let’s get to work:
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Psychosis
The current DSM treats “with psychotic features” as a specifier to bipolar rather than to depression or mania. Let’s keep the specifier approach, but find more precise applications, thus:
Euphoric Mania with Psychosis
Various euphoric mania characteristics (such as enhanced positive abilities) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself or his or her situation in a grossly exaggerated light (such as a superman on a special humanitarian mission).
Dysphoric Mania (Mixed) with Psychosis
Various dysphoric mania characteristics (such as enhanced negative abilities) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself or his or her situation in a grossly exaggerated light (such as the only one in the world aware of a vast conspiracy).
And a copy and paste from the Alternative Depression Diagnosis:
Vegetative (or Mixed) Depression with Psychosis
Various vegetative domain characteristics (such as excessive guilt) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself as deserving of punishment (such as being tracked by agents for an imaginary crime).
Agitated (or Mixed) Depression with Psychosis
Various agitated domain characteristics (such as a sense of exaggerated bad luck) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself as the object of unwarranted harassment (such as being tracked by agents as a result of a frame-up).
***
Thus, in these situations, psychosis is strongly linked to different phases of the cycle in terms of both timing and congruency. When the mania recedes, for instance, so does the psychosis. This suggests mood stabilizers as a first option rather than an antipsychotic.
If, on the other hand, the psychosis appears have a life independent of the cycle, then the clinician needs to spell it out, such as: “Cycling l, with Co-Occurring Psychotic Disorder.” (The current DSM lists “Delusional Disorder” and “Brief Psychotic Disorder”.)
This suggests different treatment options, such as an antipsychotic for the psychosis plus a mood stabilizer for the cycle (with perhaps the antipsychotic serving double duty in lieu of a mood stabilizer).
It is important to emphasize that psychosis with a life of its own is not synonymous with schizophrenia. Generally, more is going on with schizophrenia than just psychosis. Nevertheless, a very compelling case can be made for an overlap between bipolar and schizophrenia. Unfortunately, the DSM’s ‘tweener diagnosis of schizoaffective is more of a problem than a solution. Thus:
Kill the Schizoaffective Diagnosis
The operative phrase to the DSM-IV schizoaffective diagnosis is:
There is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia.
Criterion A lists other symptoms besides psychosis, and calls for a minimum time of one month. (There is a Criterion C for schizophrenia, which mandates a six-month minimum for “continuous signs of the disturbance,” but there is no reference to this in the schizoaffective diagnosis.)
Schizoaffective, then, is basically short-form schizophrenia punctuated by relatively brief overlays of depression or mania (the DSM minimum for mania, for instance, is one week). The assumption is that it is highly likely that there will be long periods when the schizophrenia symptoms manifest with no mood symptoms, and indeed this is a DSM requirement.
Thus, schizophrenia symptoms can appear without mood symptoms, but mood symptoms can’t appear without schizophrenia symptoms.
Does this sound like schizophrenia to you? Short form or not? Say, schizophrenia with mood symptoms? Is schizoaffective, then, a euphemism diagnosis for clinicians too chicken to tell their patients the truth? It appears that way.
Let’s kill the schizoaffective diagnosis, then. And while we’re at it, let’s rethink schizophrenia, complete with a name that accurately describes the illness. But that’s for later, along with a full review of psychosis. In the meantime, to sum up:
- When the psychosis can be linked to a phase of the cycle: Specify the phase within the cycling diagnosis.
- When the psychosis appears independent of the cycle but does not meet criteria for schizophrenia: Stick to cycling diagnosis, with a co-occurring psychotic disorder.
- When the psychosis appears related to schizophrenia: Go with a schizophrenia diagnosis, with a mood symptoms specifier.
Okay, Time for the Boring Stuff
In my alternative depression diagnosis, I sensibly restored complexity to an inexcusably oversimplified illness. Bipolar demands an opposite approach. Strip the illness to its essentials and we are talking about a cycle involving down and up, where up simply has to be higher than down.
Concentrate on the fact that we are dealing with a cycling phenomenon, and sensible treatment and illness-management is more likely to follow.
Nevertheless, it’s prudent to add shading and texture. Thus, Cycling I, II, and III, plus cyclothymia - plus (as specifiers) allowances for mixed phases (essentially out-of-phase cycles), plus (more specifiers) the reality of various psychosis complications.
Now its time for yet more specifiers (and modifiers), but in keeping with a rough draft (and to keep from boring you to tears) I’m just going with the bare bones, short and sweet.
Cycling Specifiers
Timing: Short phases or long? Undetermined? Short intervals of remission or long? Undetermined?
Rapid cycling, ultra-rapid cycling, and ultradian cycling would be included here. Important point: Here’s why “bipolar” is an erroneous name for what should more accurately be called cycling illness. Bipolar places priority on the episode over the cycle. So, technically, under the current DSM, someone who cycles up and down and back again in the course of a week is not in an episode (as the minimum is a week for mania) long enough to qualify for a bipolar diagnosis.
WTF? True, we don’t want to diagnose someone with a mental illness who is feeling out of sorts for just a day or two. But indisputable evidence of a cycle clearly trumps minor quibbles over length of episode (or, more accurately, cycle phase). Looking at it another way, if you’re cycling that fast you’re in a special kind of episode (phase) that is clearly playing havoc with your life.
Reducing mania and hypomania to a two-day minimum obviates a lot of these concerns. (Note to self: include an exception to the depression and mania and hypomania time minimums where there is clear evidence of ultra-rapid or ultradian cycling.)
Emphasis: Mostly depressed? Mostly manic? Mostly hypomanic? Mostly mixed? Undetermined?
People with “bipolar” tend to be depressed three times longer than they are manic or hypomanic, with residual symptoms persisting even longer. Individuals with bipolar II stay depressed for even longer. If that’s the case, this needs to be spelled out. Likewise if an individual is manic/hypomanic or in various mixed phases most of the time. It makes no sense to give individuals a vague diagnosis with no indication of what their particular version of crazy looks like.
Most recent phase: Depression? Up? Mixed?
This is straight out of the current DSM playbook.
Severity:
Particular phases of the cycle may be relatively benign, but the demands of adjusting to these phase changes may be too much to handle. Loving one day, hostile the next? Not a way to stay in a relationship or hold down a job.
Sleep Specifiers
Our next specifier would bring sleep into consideration, as disruptions to the sleep cycle and the mood cycle are strongly linked. Indeed, one can make a strong case that the mood disorder is the downstream effect of the sleep disorder. Another way of looking at it: Addressing the sleep issues resolves a lot of the mood issues.
We can make this as complicated as we like, but let’s opt for simplicity:
Sufficient consolidated and undisturbed night sleep: Yes? No?
Sufficient daytime wakefulness to meet work and personal obligations and self-enjoyment: Yes? No?
Sleep/wake phase delay/advancement: Yes? No?
Dimensional Specifiers
These cut across diagnostic categories and would be the same as for the Alternative Depression Diagnosis, only linked (if possible) to each phase. Otherwise, to the diagnosis as a whole. Thus:
... with anxiety.
... with personality complications.
(Note to self: the depression phase would also include suicidality and other specifiers from the Alternative Depression diagnosis.)
Severity Specifier
We mentioned severity in relation to the cycle. Normally, each phase would require its own severity specifiers, as well, but mission already accomplished for the up phases in the form of Cycling I, II, and III. For the depression phase, we copy and paste from the Alternative Depression diagnosis.)
Modifiers
I distinguish “modifier” from “specifier” by virtue of how gender, age, and cultural identity may affect the course and presentation of the illness. Depressed women, for instance, are more likely to act in accord with current DSM criteria (such as “appears tearful”) while men who express their psychic pain as anger are likely not to get diagnosed. I’m not sure how this plays out for mania, but let’s make room for discussion.
Child and Adolescent Onset deserves special consideration. The current DSM lacks an early-onset specifier for bipolar, which can be interpreted to mean that the illness manifests similarly in kids and adults. Except for the fact that this is not the case. Kids tend to cycle far more rapidly, often in the course of a day with a clear relation to sleep/wake cycle disturbances. Moreover, kids tend to experience mixed phases that are expressed as severe rages.
Thus, if we keep the criteria for cycling and mixed states (not to mention sleep) unrealistically narrow (as under the current DSM), both adults and kids are left out in the cold. The simple solution is to widen these criteria (as we have already done), and include the early onset modifier. This would keep the diagnosis consistent across the life-span, while allowing scope for differences in presentation.
Note the diagnosis remains sufficiently narrow to distinguish cycling from other forms of kid behavior. Nevertheless, there is considerable room for discussion in dealing with kids’ issues, so feel free to fire away.
Conclusion
This wraps up my Alternative Bipolar (Cycling) Diagnosis for now, but we’re by no means finished. Please feel free to join the conversation.
April 7, 2010, reviewed Jan 3, 2011
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