The DSM-5 and Bipolar - A New Series

John McManamy Health Guide
  • As most of you know, in May this year, the American Psychiatric Association will publish a new edition to its psychiatric bible - the DSM. The DSM-5, which will supersede the current DSM-IV, represents the first significant update of the DSM in nearly two decades. Unfortunately, this hardly translates to better information based on what we have learned about mental illness over 20 years. Much less will the new version better assist clinicians in reaching an accurate diagnosis, or in improving understanding among the general public.


    Basically, bipolar as we are expected to know it in 2013 (and probably for the next ten years) will remain the bipolar we knew back in 1994. This translates to doctors continuing to misdiagnose bipolar patients with unipolar depression. You’ve been through it, I’ve been through it. We get put on destabilizing antidepressants and tend to get worse.

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    Trust me, nothing in the DSM-5 addresses this menace. 


    In the weeks ahead, I look forward to a series of in-depth critiques. In the meantime, this very quick historical overview:


    “Manic-depression” was coined in the early twentieth century by the pioneering diagnostician, Emil Kraepelin, who viewed the entire realm of mood as existing on the same continuum. Although he parsed out many clinical presentations, Kraepelin viewed both depression and mania as part of the same underlying phenomena. Later researchers separated out unipolar depression from manic-depression, but this applied to more infrequent cases of “chronic” depression. “Recurrent” depression continued to be seen as a close cousin of manic-depression.


    The DSMs I and II of 1952 and 1968 largely preserved Kraepelin’s conception of manic-depression (including a “depressive type” that consisted “exclusively of depressive episodes”). But then we had (in the DSM I) the Freudian “depressive reaction” under the heading of “psychoneurotic disorders.”


    An open-minded reading of these ancient DSMs reveals a highly nuanced and enlightening view of mood. But it was at once too naive (no true science to go on) and too sophisticated (attempting to reconcile Freud with Kraepelin) to be of any practical use. The ink was no sooner dry on the DSM-II when reformers looked ahead to a new DSM.


    A lot of this had to do with psychiatry weaning off its dependency on Freud. The advent of Thorazine and other first-generation psychiatric meds initiated a paradigm shift to biological psychiatry. The catch was the biology of the day told us very little about cause and effect. This was the same problem that Kraepelin had been faced with in his day. Kraepelin’s solution (which he did not view as a solution) was in meticulously cataloguing symptoms he observed in his patients, which was how he separated out manic-depression from schizophrenia.


    A new generation of “Neo-Kraepelinians,” largely centered at the University of Washington (St Louis) and Columbia University, sought to tease out different mental illnesses by similar methods, according to related clusters of symptoms, or “phenotype.” By way of analogy, a heart attack looks a lot different than a diabetic coma, which implies very different treatment. 


    So far, so good. The catch lies in where to carve nature at its joints. Can unipolar depression truly be separated from manic-depression? Can manic-depression be separated from schizophrenia? And how do you separate normal from abnormal? Where do you draw the line?


    Let’s give credit where it is due. The DSM-III of 1980 was a revolutionary document that brought psychiatry kicking and screaming into the twentieth century. Suddenly, doctors had more to go on than just “neurosis” or other Freudian gobbledegook. Suddenly, clinicians and patients worldwide could speak in a common language.

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    But the DSM-III was basically a work-in-progress, based on a lot of inspired guess-work and thus prone to considerable error. Continued new editions could have kept the original revolutionary spirit alive, with constant updates based on new knowledge and insights. Instead, the DSM became set in concrete, its inspired guess-work mistaken for received wisdom, its original errors entrenched for decades to come.


    With regard to the entirely new diagnosis of “bipolar,” the DSM-III egregiously erred in its task of carving nature at its joints by purporting to separate it out from unipolar depression. Gone was the all-inclusive “manic-depression.” This might have been fine if all unipolar depressions were either the same or related to one another, but the evidence is that “recurrent depression,” particularly the highly recurring type, is far more closely related to bipolar.


    Indeed, the definitive text on bipolar, “Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression,” by Goodwin and Jamison, takes precisely this view.


    The DSM-III of 1980 mandated a full-blown manic episode for bipolar. So what about those who merely cycled up to a light mania? Sorry, they were lumped with the unipolar depressives, to be put on antidepressants. It took another 14 years until the DSM got with the program by acknowledging Bipolar II and hypomania. Even so, a huge misconception remains: Commentators (particularly those aligned with the antipsychiatry movement) mistakenly believe that the DSM-III “bipolar disorder” of 1980 represents the pure and historical view of bipolar disorder.


    You can probably see where this line of reasoning goes, namely: Any attempt to stretch the “true” meaning of bipolar is seen as some reckless attempt to pathologize even normal behavior. Next thing, the whole population will be on bipolar meds.


    Wrong. Dead wrong. I cannot emphasize this enough. To the contrary, with a wider definition of bipolar, we would likely see fewer patients destabilized on antidepressants. (This assumes, of course, smart clinicians who actually pay attention.) And perhaps “softer” versions of bipolar wouldn’t involve meds at all (again, this assumes smart clinicians).


    Sad to say, the DSM-5 version of bipolar is an almost exact duplicate of the DSM-IV. Thus, when making the very tough diagnostic call between unipolar and bipolar, the DSM-5 offers clinicians no practical guidance. Back in 1994, there might have been an excuse for this. Today? Based on what we know? 


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    More to come ... 

Published On: January 13, 2013