On Wednesday, the American Psychiatric Association’s DSM-5 Task Force released the draft to the new DSM, available for viewing and comment on the APA website.
The new version of the DSM, scheduled for publication in 2013, would supersede the current DSM-IV, in effect since 1994 but little changed from the ground-breaking DSM-III of 1980.
A little background. A strong body of expert opinion views bipolar as occupying a broad band in a unifying spectrum, with at least three ways of mixing the primary colors:
1. Recurrent depression at one end, bipolar at the other. Think of manic-depression as a much wider term than bipolar. Instead of static poles, we are looking at an illness defined by cycles, and not ncessarily from one extreme to the other. Thus we see a continuum with bipolar I and II involving clearly observable upswings bleeding over into recurrent depression with its barely discernible swings to feeling better. Chronic depression is seen as a different phenomenon altogether.
Why this is important: If your so-called “unipolar” depression has much in common with the cycling of bipolar, then it may be wise to consider treating it with bipolar meds rather than an antidepressant.
2. “Pure” depression at one end, “pure” mania at the other. Occupying the middle ground, depression and mania converge into various mixed states. Think agitated and energized depression or dysphoric mania (euphoria gone sour), different ways of saying road rage, even if you don't drive.
Why this is important: Pure states tend to be easier to treat than mixed states. Different meds and therapy strategies may be called for.
3. Personality at one end of a severity scale, pathology at the other. Personality is your natural “trait,” which may be depressive, exuberant, cyclothymic, or anxious, but nevertheless falling within “normal” and “functional.” As opposed to “trait,” pathology is identified as a “state,” but the two tend to overlap.
Why this is important: We want our doctors to treat our illness, not medicate the personality out of us.
How has the DSM-5 Task Force addressed these concerns?
For Number 1: The Task Force could have added something along the lines of “bipolar III” to embrace certain forms of recurrent depression. Think of “bipolar III” as an extension of bipolar II (which was added to the DSM in 1994). Alternatively, the Task Force could have flagged recurrent depression in a way to suggest a possible relationship to bipolar. Perhaps the Task Force could have judiciously deployed elements of both. Instead, it did nothing.
For Number 2: The Task Force proposes a much wider version of “mixed episode.” Currently, the DSM recognizes mixed states when both major depression and mania appear fully loaded at the same time. The expanded version acknowledges the reality that mixed states also occur when a patient is “predominantly manic or hypomanic” (full-on mania or hypomania with two or three depression symptoms) or when “predominantly depressed” (full-on depression, two or three mania/hypomania symptoms.
This would rectify the current DSM's non-acknowledgement of mixed states occurring in bipolar II. But what about the reality of mixed episodes occuring in unipolar depression? The draft DSM-5 is insisting that if the depression is mixed, then it is not unipolar depression. Bipolar depression then? Only if there is a different episode involving pure depression. Confused? So is the Task Force's thinking on this issue.
The Task Force deserves credit for acknowledging the reality of mixed states, but needs to put more work into refining the concept. Speaking of which, what about a state involving both minor depression plus minor mania? Cannot two minors together incapacitate us as badly as one lone major? Ah, questions, questions.
For Number 3: The Task Force reports that it “is proposing several options for severity.” On one scale, 1 would be normal, 2 borderline ill, and on to 7 extremely ill. But what is normal? Just as your version of bipolar differs from my version of bipolar, so do our respective normals. Don’t expect the DSM-5 to address this concern.
Much more on the DSM-5 later. In the meantime, I urge you to go to the APA’s DSM-5 website and share your impressions. Comments below ...
Published On: February 12, 2010
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