Bipolar Disorder - What It's Really All About is Cycling

John McManamy Health Guide
  • As you know from reading my recent shareposts, last month the DSM-5 Task Force released for public comment its proposed revisions to the DSM. The current DSM - the DSM-IV - has been around since 1994, which in turn is a direct descendant of the ground-breaking DSM-III of 1980. The DSM-5 is due for publication in 2013 and, with the exception of widening the criteria for mixed states, would leave the bipolar diagnosis virtually unchanged.

    In my daily blog, Knowledge is Necessity , I detailed my criticisms to the draft DSM-5 (see links at the end of this piece). Here at BipolarConnect, I have a different focus. The exercise of reviewing both the current DSM and its would be successor has served up a number of insights that I have been sharing. For this week, first let me serve up a trick question: What, in your opinion, is the cardinal symptom of bipolar?

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    (Final Jeopardy music here ...)

    Grandiosity? Racing thoughts? Feeling depressed?

    TIme’s up. The answer is cycling. Let me explain ...

    Strip bipolar to its bare essentials and we are left with cycling. Up-down, up-down. The episodes we experience make no sense without taking the cycling that drives them into consideration. I touched on this in my previous two pieces on the draft DSM-5. Anomalies in a present depression point the way to a past history of mania, and future ones, too, if we merely treat the episode rather than the cycle.

    Likewise, evidence of up indicates that depression doesn’t simply lie still. It is a moving target. It slithers, it crawls. It goes up, it goes down. Often, antidepressants don’t work against this moving target. Too often, antidepressants make this kind of depression worse, much worse.

    So how high, then, does up have to be? Only higher than down. Only high enough to get a read on what is going on with the depression. This is way I would scrap the term, “bipolar,” entirely and replace it with something like “cycling illness.” Bipolar creates the highly misleading impression that we simply flip - not necessarily cycle - from pole to pole, from one extreme to the other. Depression to mania and back again.

    The DSM-III of 1980 essentially legalized this misperception. You had to have severe depression. You had to have full-on mania. “Bipolar” made its official debut in this edition of the DSM. Prior to that, it was “manic-depression.”

    It took 14 years for the DSM to ease up, or, ease up on up. In 1994, “bipolar II” was introduced, with its lower threshold of hypomania. “Up” didn’t have to go all the way up. We didn’t have to flip all the way from one pole to the other. The introduction of bipolar II gave rise to the possibility of bipolar III. Maybe up could be even lower. But even this is missing the point.

    As long as there is bipolar I or II, or even bipolar III or IV, both clinicians and patients are misdirected into seeking out episodes. A subtle hypomanic episode is virtually impossible to tease out, and even its high-flying versions are difficult to distinguish from perfectly normal exuberant behavior.

  • So, if a clinician finds no evidence of mania or hypomania, then he is supposed to diagnose you with unipolar depression and prescribe an antidepressant? Even if your depression is cycling? As I asked earlier: How high does up have to be? Merely higher than down.

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    There are a few other aspects to cycling worth touching on briefly. First, our episodes make no sense without reference to the underlying cycle. Mania essentially predicts depression. Depressions, as we know, simply don’t lie still, not “recurrent” ones, anyway. Episodes are simply part and parcel of the cycle We need to know where the wheel will turn next, how long and how severe.

    Another way of saying this is that depression and mania are the same animal. The cycle is essentially a shape-shifter, depression at one point in time, mania (or simply up) during another.

    And moods aren’t the only things that cycle. Our sleep cycles (in fact, you might think of bipolar as “sleep dysregulation syndrome with mood effects”). Our thoughts cycle. Our physical activities cycle. And all of these don’t necessarily cycle in sync. That’s why we end up in mixed states - agitated depressions, dysphoric manias - energized psychic pain.

    I’ve been referring to the DSM-IV for more than a decade, but only in my most recent exercise did the following revelation jump out and hit me in the face: Except for a brief reference to rapid-cycling, neither the current DSM nor its would-be successor mentions cycling at all. Is this crazy or what?


    My DSM-5 bipolar report cards from Knowledge is Necessity :


    My DSM-5 Report Card: Grading Bipolar - Part VI
    My DSM-5 Report Card: Grading Bipolar - Part V
    My DSM-5 Report Card: Grading Bipolar - Part IV
    My DSM-5 Report Card: Grading Bipolar - Part III
    My DSM-5 Report Card: Grading Bipolar - Part II
    My DSM-5 Report Card: Grading Bipolar - Part I

Published On: March 13, 2010