DSM-5 Report Card - Grading Bipolar: Part I
Are we asking too much for psychiatry to get it right? Yes, apparently.
The DSM-5 and bipolar disorder. In February 2010, the DSM-5 Task Force turned in its homework regarding proposed revisions to the DSM. Soon after, I started grading its efforts. In another article here, 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.”
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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 ...
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.
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?
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.
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 said no to both.
Just say no to the DSM-5.
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 may 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.
Dysphoric and Euphoric Hypomania
The same arguments that apply to mania apply here.
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 first several times, the person you entrust your life to is not about to pick it up, either.
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 mania (with a capital M) and depression (with a capital D) rear their ugly heads together. Thus: MD.
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 manic and hypomanic states to include at least three depressive symptoms inside (hypo)mania. Thus, your (hypo)mania may come pre-loaded with "a little bit" of depression.
Thus, as well as MD, there is also Md.
Presumably, this translates into symptoms strong enough to turn “euphoric” manias “dysphoric.” 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?
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. These mixed states would be defined as "specifiers" to depressive and manic episodes rather than as mixed episodes in their own right.
The catch is for the specifier to kick in, first there most be evidence of a full-blown episode. But why? 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?
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.
At least give the DSM credit for considering lowering the time and symptom thresholds for a hypomanic episode for bipolar II. On the the other hand, let's not. The DSM-5 recognized the problem, but did nothing to fix it.
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 ...
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?
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.
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.”
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.
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.
Where there’s smoke there’s fire. A smoke detector would not be difficult to devise. Another extra credit project.
No grade.Go to Part II
Published as a serieis of blogs April 2010, reworked into two articles Jan 3, 2011.
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