DSM-5 Report Card - Grading Bipolar Part II
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Kraepelin got it right the first time. Expect the DSM to get it wrong the fifth time.
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The DSM-5 and bipolar disorder. Part I 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.
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So, can the DSM-5 do better where bipolar bleeds over in the other direction into schizophrenia?
Also included is a consideration of bipolar as a cycling illness. First a little background ...
Psychosis, An Introduction
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.” One view of psychosis refers to hallucinations and delusions to which the patient lacks insight. Another view would incorporate patient insight. The DSM goes with symptoms listed for the positive symptoms of schizophrenia (same as for a brief psychotic episode), which might also embrace “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.
Cycling, An Introduction
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? Or is everything going to be okay?
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 ...
Published as a serieis of blogs April 2010, reworked into two articles Jan 3, 2011.
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