Hi John, thanks for this important topic. Here is what I posted on the DSM website:
Hello, this comment covers all bipolar diagnostic groups. I suggest you include, to enable faster diagnosis of new patients, the following: "When considering past episodes to verify a diagnosis in this category, history alone may be used and examination (of a past episode) need not be necessary." This will mean that by giving a history the patient & caregiver will get a diagnosis immediately and not have to wait until a further episode brings them back to the doctor (or a new doctor, in which case they would start again).
I think they're getting their knickers in a knot as they try to divvy up depression from mixed states from mania. I guess my diagnosis will change with every episode depending on the previous episode. Nuts! I do not think these categories will be useful for researchers either for the same reason that people's diagnosis will change over the course of their illness.
Keep up the good work John
My first hospitalization and resulting dx came from the barely off the press DSM-IV. It was Major Depression, Recurrent, Severe -- in words as I don't know the numbers. Then, several years ago, I entered a long lasting full blown manic state that changed my dx to Bipolar, Mixed States. After finding in Kay Redfield's med school text, a description which totally fit me on my first hospitalization, i.e., depressive stupor, I am left with the following questions:
1) I think my family history was asked about and told them that my older brother was manic depressive. Was this not a possible clue towards my dx?
2) Given the above, was I asked (memories are very fuzzy when existent from this period) if I had ever experienced times of mania based on an accurate description as simplified as, "have you ever stayed awake for 3 days straight?"
3) Would I have been able to recall such an experience if I had been asked (though my husband could have easilty provided the info)?
4) Would my depression have been treated differently knowing the great possibility that I might be bi- instead of uni-?
I ask because, when well enough to concentrate a bit, I read William Styron's excellent book describing his experience of depression. While other people seemed to benefit greatly from his insights, to me it came across as a walk in the park -- something I never understood until learning that bipolar depression goes down deeper than unipolar depression.
So...is it only psych doctors and therapists who have been exposed to the Redfield (with apologies to her co-editor whose name I don't remember) that even have a clue as to the reality of this difference and will it be addressed in the new DSM?
I know that the DSM-5 is not the kind of topic that inspires comments. Diagnostics tends to be esoteric, so many thanks for recognizing this is an issue that strikes close to home and is so vital to our community.
Also, many thanks, Geekstyle and Madeline, for having the courage to jump in. We tend to get intimidated by academic researchers and defer to them when we really need to be speaking out, instead. Yes, they can teach us a lot, but it is your direct experience that counts.
Don't feel you have to do a ton of research to join the discussion here. Simply go with your experience. We're so used to having academics tell us what OUR bipolar is supposed to look like that we forget - we're the ones who are supposed to be telling them what our bipolar REALLY looks like.
Yes, I love engaging in an esoteric discussion on Kraepelin as much as the next psycho-wonk, but you will note from my posts here that I value your real world insights just as much, if not more. If I were to gather your insights posted in response to my shareposts here and put them between two covers, I guarantee, we would have a book that tells us far more about our illness than the DSM or any text or book you can buy on Amazon (including mine).
I struggle more with the tormenting Bipolar depressions than I do the full on Bipolar Mania. Yet, I've had 2 documented episodes of High Mixed Mania which has landed me the Bipolar I rung on the ladder by the old book of psychiatry.
Growing up, and going to school for a career in the health field, back in the mid 80s... Bipolar was Bipolar I with full on mania and very little depressive episodes. If you struggled with prolonged periods of severe depression... you had Recurring Severe Depression. When you had periods in between of feeling good OR feeling REALLY good.. it was termed Dysthymic Disorder (at least in my case).
No pdoc or general doc ever really took into account my feeling good or feeling REALLY good periods... I had them and they did as much, if not as equal the amount of damage and dysfunction as the depressions, but were much shorter lived. To them, along with not having the "hypersexuality" symptom... I could not possibly have Bipolar... for the most longest of years and I was treated solely for unipolar depression.
Even today... with several pdocs now agreeing on the Bipolar diagnosis... my last therapist refused to believe it. She went by the old thought... if you don't have more mania than depression... you simply don't have Bipolar.
By the way... though I know "kindling" is a controversial theory... I do know that my illness, having not been properly diagnosed and/or treated when younger... has manifested now that I'm older in a much more severe way.
Is there a chance this might be considered a bit more closely by someone?
We have been trying for years to get the mental health professionals to see consumers as individuals(people)instead of a diagnosis (label). This new argument seems to constitute new and more complex labeling. How about forgetting about what to call the disorder and concentrate on how to treat the disorder. I believe we should spend money on training the mental health professionals with people skills. There should be training in compassion, language skills, ethnic and cultural diversity. Money should be spent on making the enviroment in these mental health facilities more inviting and conducive to treatment. These facilities are often times messy, stinky, cluttered, unorganized and/or institutional looking. The individual is already in a crisis, pre-crisis and/or post crisis. The unskilled in compassion, language skills, cultural and ethnic diversity and gloomy institutionalized enviroment creates yet another disorder for the consumer. With all the statistical mental healtlh training in the world is of no avail if one is not able to meet the consumer where he or she is.
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I am a therapist working with adults in an outpatient facility at acommunity mental health center in a large metropolitan area. I am also successfully living with bipolar disorder. I have been awaiting the DSM-V eagerly, and have been to the official website repeatedly over the last year to follow the research process that has resulted in the recently posted recommended changes.
I am delighted in the recommended changes. The research teams for the DSM-V (comprised of the foremost experts divided into ten different categories) was given the liberty to closely examine current diagnoses and aggressively pursue clarifications and/or changes based on new and existing research. The researchers have spent years and years following studies done by clinicians (the DSM-V was initially aimed to be published years ago but has been pushed back to allow for more study), and were told by the APA (American Psychiatric Association) to make as many changes as necessary, per the research, and so were not bound to stick with current diagnoses.
The recommended changes reflect the continued discoveries made by extensive research. Psychology and psychiatry are still very new sciences, relatively speaking, and the current diagnoses have long been considered imperfect by clinicians.
For example, in 1921 theorist Emil Kraepelin identified multiple types of mixed states associated with bipolar disorder, including "depressive or anxious mania," "excited depression," "manic stupor," and "depression with flight of ideas." Emil Kraepelin was the first to distinguish schizophrenia from bipolar disorder, and his research continues to influence psychiatry today. However, the DSM-IV currently reflects only one type of mixed episode, and has long been criticized for this. The DSM-V proposed changes are much more in keeping with Kraeplin's identified mixed states. This change alone will be immensely helpful for clinicians to more clearly identify presenting problems for both therapy and medication purposes.
The DSM-V proposed changes are not final. They have been presented to the APA and are now requesting participation throughout the county for field trials to evaluate the validity of the possible changes. Extensive research lies ahead for clinicians throughout the country. Furthermore, once the research results from the field trials have been submitted, the research teams will again have to revisit their hypotheses, contrasting the proposed changes with the field results.
The DSM-V will be monumental in the fields of psychiatry and psychology. Clinicians thorughout the country are looking forward to improved understanding and clarification of current diagnoses to improve both prognosis and quality of life for the millions of individuals who struggle with mental health conditions.
Apparently, they will not be using Roman numerals for this edition. It will be the DSM-5.
I have had my dx changed (for example, for a long time after a 5-month hypo mania episode, then a quick drop into depression that lead to a suicide attempt) I was 296.62 which meant most recent episode mixed--moderate. It was like getting a report card! For quite awhile I got the designation "in full remission." A+ & gold stars during those times.
Hey, KMarie. Many thanks for bringing up Kraepelin. I'm a huge fan. A lot of what I've learned about Kraepelin is via Akiskal and Goodwin and the various researchers that they mentored. If the DSM-5 were to simply summarize Kraepelin into bullet points we would have a much improved diagnostic manual.
Widening mixed states is a huge advance in the back to Kraepelin movement. Unfortunately the DSM dropped the ball bigtime concerning the Kraepelin's true meaning of manic-depression, which incorporates recurrent depression, which is still regarded by the DSM-5 as unipolar depression. I would argue that this is a fatal flaw.
Re scientific validity: I'm a huge fan of science, but the standards set by the Task Force turned out to be a recipe for doing nothing. The DSM is meant to guide clinicians in the real world, never to be a research document. In their quest for validity, they sacrificed "credibility" and reached a lot of absurd conclusions. I've documented these in a series of blog posts on my other blog, Knowledge is Necessity:
http://knowledgeisnecessity.blogspot.com/
My point is that in guiding clinicians and the wider community in the real world we need to go with the best knowledge we have, even if it doesn't always come up to rigorous scientific standards.
But the real reason I'm answering this is I would love to have your input, even if it turns out you strongly disagree with me. The topic is way too important not to have a spirited conversation. So, I urge you to go to Knowledge is Necessity and post comments. Rip me apart, if you have to. Let's get the discussion going.
Also, I will be doing posts here at BipolarConnect, so please keep commenting here.