The Depression-Mania Two-Step - Part II

John McManamy Health Guide
  • Last week, in The Depression-Mania Two-Step, I referred to the Draft DSM-5, which drew 14 comments. Dysmystic took the words right out of my mouth with the observation that “I think DSM-5 got its info off a Wheaties packet.”

    My long version to this observation adds up to 11 blog pieces on my daily blog, Knowledge is Necessity. This includes seven report cards in which the average grade is an F. More pieces are in the works. (Links to the blog pieces are at the end of this sharepost.)

    As I stated here last week:

    What I would like to do here and in future shareposts is comment on some observations that jumped out and hit me in the face as I was “grading papers,” and in turn invite your feedback.

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    Part I dealt on how depression and mania/hypomania are linked via the cycling phenomenon that defines our illness. An astute clinician, through careful observation of anomalies within one’s present depression, may deduce a history of mania/hypomania. Then, by asking the right questions, may elicit confirmation from the patient.

    The psychiatrist who initially evaluated me failed to do this, and judging from your replies, neither did the ones who first evaluated you. As Survivor noted, part of why she was misdiagnosed with clinical depression ...

    ... was due to a psychiatrist who didn't know what he was doing. By then I had learned to my surprise that bipolar didn't mean spending your life savings on shoes or running around pulling off your clothes and screaming.

    Tabby, who finally found a psychiatrist who knew what he was doing, had this to report:

    He asked me to describe times when I felt mad for no reason or agitated. He asked how I felt about my assorted co-workers over the years and how I compared to them in doing the same work?  He asked a lot of very very very strange questions, questions no other pdoc had ever taken the time to actually ask me. ...

    He then looked at me, put his pen down, and said "Bipolar with Schizoaffective traits" and I sat stunned.  ... I asked why no one else had ever diagnosed me correctly with bipolar?  He asked: "Did you go to see [a doctor or psychiatrist] while you felt good and able to handle the world?" and I answered "of course not” ...  He leaned back in his chair, and nodded.

    The depression-mania two-step flows in two directions. Just as depression can point to mania/hypomania, so can mania/hypomania give us an insight into our depressions, namely by providing us with clear markers into how long they last and how fast they come and go.

    Literally everyone with bipolar experiences recurrent (as opposed to “chronic”) depression. In the fictitious world of the DSM, recurrent depression is classified as part of unipolar depression, but the classic view is that recurrent depression and bipolar are part of the same “manic-depressive” phenomenon.

    Indeed, that was the opinion of the pioneering diagnostician, Emil Kraepelin, who coined the term “manic-depression.” The DSM-III of 1980 replaced this wide view of manic-depression with an extremely narrow one of “bipolar,” replete with its ridiculously high diagnostic threshold of full-blown mania.

  • The DSM-IV of 1994 introduced “bipolar II” with its less stringent threshold of hypomania, which many would argue did not go nearly far enough.

    Those charged with working on the DSM-5 (due out in 2013) needed to consider expanding the bipolar II diagnosis to include less obvious expressions of hypomania (such as episodes lasting shorter than four days) or adding a “bipolar III” diagnosis to take into account more subtle ups.

    Another possibility was to work from the other side of the diagnostic divide by adding new versions of recurrent depression, such as “highly recurrent depression” or “cycling depression.”

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    It’s all about the cycle. Cycling depressions. We are depressed way more than we are manic/hypomanic. For those with bipolar I, the ratio is three to one. For bipolar II the ratio is way higher, in the neighborhood of 50 to I. In a psychiatric emergency, we need to treat the symptom du jour, but over the long haul we are talking about treating the cycle, smoothing it out, slowing it down.

    What the ups tell us is that we have a cycling depression going on, not a flat-line chronic depression. Even if we experience raging manias, in many ways it is more helpful to look upon our illness as a cycling depression.

    Let’s return to the first time I ever sought help for my depression. As you recall from Part I, all I talked about was my depression. Day in, day out, unremitting, years on end. Just to show him how depressed I was now (early Jan, 1999), I happened to volunteer that unlike previous Christmases, I had not even bothered to hand-craft gifts this time around for my niece and nephews.

    Can you spot a possible major contradiction to my account?

    Hmm, my psychiatrist might have responded, pondering the matter. Then, gathering his wits, he might have framed a question along these lines: “So you made Christmas gifts the year before, is that correct? And how did you feel when you were making those gifts?”

    Just fine, you idiot, I would have been thinking had he asked. “I really enjoyed doing it,” I probably would have replied, instead.

    Aha! A fairly recent time I had felt within some approximation of normal. A time when I was up, even if my version of up happened to be a long way from dancing on tables. A depression punctuated by at least one up.

    Further evaluation would have revealed more ups, clear evidence of a cycling depression. This alone should have put my psychiatrist on notice. Had the interview concluded at this stage with no further questions, the psychiatrist would have had ample reason to write down “depression NOS (not otherwise specified)” on my chart.

    Had the interview continued, he would have uncovered evidence of someone with full-on bipolar. But whether he viewed me as someone with depression NOS or bipolar I, the issue on his plate would have been the same: How to treat my depression without in some way accelerating or intensifying my cycle.

    You just wouldn’t send me out the door with an antidepressant and no mood stabilizer.

  • Okay, back in 1999, maybe. We know a lot more now. Clinical practice is changing, and the next DSM is bound to reflect those changes. Uh, don’t bet your life on it ...

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Published On: February 26, 2010