DSM-5 Changes to Mixed States - A Report from the 9th International Bipolar Conference

John McManamy Health Guide
  • I just arrived back from Pittsburgh, where every two years the International Conference on Bipolar Disorder is held. This year proved of particular interest. Since the last Conference in 2009, the American Psychiatric Association’s DSM-5 Task Force has released its draft DSM-5. By the time the next Conference rolls around in 2013, the DSM-5 will have replaced the DSM-IV as psychiatry’s  diagnostic bible.

    The Conference featured a special DSM-5 session involving a panel of heavy-hitters from the Mood Disorders Work Group, including the legendary Swiss diagnostician Jules Angst, Ellen Frank from UPitt, and Trisha Suppes from Stanford. All of the participants emphasized the fact that mood disorders exist on a “dimensional” spectrum, “analogous to blood pressure,” as Dr Angst described it, from depression to mania, normal to severe, with temperament also bleeding into it.

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    There is one extremely major catch. Although the reality is not “categorical,” nevertheless, Dr Frank told us, the DSM has to be in order to give names and provide cut-off points. Sounds reasonable, but this is where the conversation quickly went off-track. Instead of focusing on the big picture of clinical presentation (eg feeling sad vs feeling glad vs feeling grouchy), the panel got lost in the minutiae of numbers.

    As a couple of psychiatrists I later talked to told me, the discussion came across as counting angels on the head of a pin. The distinctions were way too subtle for the real world of clinical practice, they pointed out.

    One of the major issues the DSM Work Group faced concerned mixed states. Here’s the big picture Dr Frank presented, from Kay Jamison’s An Unquiet Mind:

    I felt infinitely worse, more dangerously depressed, during this first manic episode than when in the midst of my worst depressions.

    Think of an agitated depression or a dysphoric (hypo)mania. Instead of feeling sad or happy, one wants to grab the world by the throat and shake it. The DSM-IV only recognizes full-blown mania combined with full-blown depression. The DSM-5 would change this to “specifiers,” in other words full-blown depression combined with some mania features (“mixed depression”) or full-blown mania or full-blown hypomania combined with some depression features (mixed depression”).

    The magic number is three. Thus, full-blown depression (at least five of nine symptoms) combined with at three manic or hypomanic symptoms for mixed depression, and full-blown mania or hypomania combined with three depression symptoms. But not just any old three symptoms - the specifier symptoms have to be particular to a given pole rather than common to both (such as messed-up sleep). In other words, no double-counting of symptoms. 

    As you - my readers - have made very clear in your comments in my ongoing series on “Up,” mixed states are the bane of your life (and mine) and is indubitably the reality you deal with. Clearly, these specifiers represent a major leap forward. Significantly, a mixed state specifier to depression is a clear recognition that bipolar exists in unipolar depression. But is the DSM-5 sending a strong enough signal to clinicians?


  • This is perhaps the most important issue the DSM-5 Work Group had to face. In other words, if a clinician picks up signs of bipolarity in unipolar depression, should he or she prescribe a mood stabilizer instead of an antidepressant? We know an antidepressant runs a strong risk of destabilizing bipolar patients. What about those, in effect, with “a little” bipolar?

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    The panel felt confident they had sufficiently flagged the issue. I would have felt far more comfortable with a separate diagnosis, call it whatever you want - bipolar III, mixed depression-bipolar. But maybe it doesn’t matter. The participants at the conference, largely academic researchers, acknowledged to me in private that the DSM is basically a researcher’s document, for their purposes, not much use to clinicians. Or, at least, clinicians don’t rely on it much. Basically, one researcher told me, clinicians will still call depression or bipolar as they see it, with no reference to the DSM.

    In essence, all the changes in the world won’t make a difference.

    That’s right, I acknowledged. A lot of clinicians aren’t even aware of bipolar II (which has been in the DSM since 1994). How can we expect them to wrap their heads around something even more subtle?

    The researcher nodded his head knowingly.

    Next Week: Tell me what you want to do - pursue this DSM-5 discussion or return to my series on “Up”?    

Published On: June 12, 2011