Duration Criteria and the DSM: Much Ado About Nothing?

John McManamy Health Guide February 23, 2013
  • If your mania lasts only six days instead of seven, is your condition normal? What about hypomania? Should three days be regarded as normal? A strict reading of the DSM-IV (psychiatry’s diagnostic bible) would be yes to both. But does this make sense?   Nearly two years ago, I attended the...

5 Comments
  • peachy
    Feb. 25, 2013

    I think that duration and function are intimately linked.

     

    Setting aside the researchers vs. clinicians issue (spot on with that John), it seems to me that language that makes this clearer and gives clinicians flexibility in assigning a diagnosis based on a combination of duratoin, function, presenting symptoms and history is the only thing that makes...

    RHMLucky777

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    I think that duration and function are intimately linked.

     

    Setting aside the researchers vs. clinicians issue (spot on with that John), it seems to me that language that makes this clearer and gives clinicians flexibility in assigning a diagnosis based on a combination of duratoin, function, presenting symptoms and history is the only thing that makes sense.

     

    What point is there in arguing over whether hypomania has to be 2 or 4 days if, as you pointed out, the degree of impaired function is significant within 2 hours? What the heck are these guys afraid of? That suddenly the clinicians are going to go hog wild diagnosing people with bipolar at some astounding rate if they just toss the stupid time limits?

     

    Surely there must be a way of using a combination of symptom presentation, severity of symptoms, relative functional impairment, history and disqualifiers such as being under the influence of drug/alcohol that would allow for a bipolar NOS diagnosis that does NOT require that symptoms exist for a set period of time.

     

    The enormous variation in symptom presentation, disease progression and response to treatment makes the diagnostic label of Bipolar nearly meaningless in reality. I completely agree with the comments about research vs. clinicians. I am enthusiastic about research, done a littile myself here and there. But there are some things that, by their nature, are nearly impossible to research or study in an experimental or traditional fashion. Bipolar is one of them IMHO.

     

    Bipolar is not the only disease where this kind of problem exists. Look at diseases like Inflammatory Bowel Disease or Lupus. The researchers need a way to make comparisons from one patient to another, one patient before and after, and from one group of patients to another. So they create what are truly arbitrary scales to measure response to treatment or degree of illness. In fact, those scales do not measure either of those things in a substantial minority of patients. yet they continue to be used because the disease presentation is so varied, response to treatment is unpredictable in onset, degree, and duration that devising a scale that could encompass all these issues would be both difficult and, frankly, make it a lot harder for them to give you an r or p value for their fiindings.

     

    But the clinicians need the researchers and vice versa, although I am pretty sure neither party would care to admit it.

     

    Here I am in the middle of the night talking in circles again. Well, I can tell you that my hypomania can last as little as 12 hours or as long as 3 months. Usually more like 2 - 3 days like the one I had Thursday and Friday. But the five days before that I was depressed, weepy, suicidal, irritable/enraged at times.

     

    I see my relatively new therapist Tuesdays and Fridays. Tuesday she ended the session asking me did I have "intent or plan?" code for was I going to actually kill myself. No I said, I am trapped here by the damage my death would bring to those who love me, especially my children. Good she said. 

     

    Friday I brought her the 4' high contraption/art I had made the day before (took me about 90 minutes). It included a tomato cage, an old grill top, twinkly lights, artificial flowers and pictures of galaxies all held together with 12 gauge wire and duct tape. "Oh my" I believe was her first response. I mentioned that I was a little hypomanic and she said "I can see that."

     

    I am still recovering from a 4 month long period of hypomania that evolved into mania then into a mixed episode with psychotic features. 7 days hospitalization (after I convinced them to take me) and nearly 3 months in step down intensive outpatient program. Seeing tdoc 2x week seeing pdoc every 2 to 4 weeks. The psychotic symptoms have mostly stopped but I think they may never go away completely now.

     

    I am so much better it is wonderful. And I am really scared that this is as good as it is going to get.

     

    And how in the he%% is anyone going to fit me into a category? I hear there are people with bipolar who do fit in those categories. I know that the NOS thing is supposed to be for people who don't fit the other two choices. I'm thinking maybe we need a fourth choice since NOS doesn't seem appropriate for someone who would fit into Bipolar 1 or 2 except that they don't meet the timetable rules. 

     

    Bipolar R? R= rebel? reject? racer? relative? ratio? 

    Bipolar M? M= messy? muddled? magnificent?

  • Clunk
    Feb. 23, 2013

    This discussion is very interesting to me.  I'd love to join it, and I certainly benefit from hearing anything anyone has to share about their experiences and opinions. 

     

    It's incredible how many individuals are out in the world trying to cope with an illness that manifests itself in so many ways....so many things we share in common and yet...

    RHMLucky777

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    This discussion is very interesting to me.  I'd love to join it, and I certainly benefit from hearing anything anyone has to share about their experiences and opinions. 

     

    It's incredible how many individuals are out in the world trying to cope with an illness that manifests itself in so many ways....so many things we share in common and yet so many variables as well.  Bipolar disorder is a label that is thrown around loosely sometimes, yet there is a huge spectrum of types of bipolar disorder experiences. 

     

    I've been through so many cycles and variations in episodes of depression and mania/hypomania  (and possible mixed states too I'm now realizing) over a period of about 30 years, it's hard to keep on top of it all and really be sure my doctors (a psychiatrist and a therapist) are getting the info they need to help me best. 

     

    Sometimes it seems to be so subtle that the way I describe it during appointments can potentially make a difference in how my mood and state are assessed.  Due to insurance costs I only see my psychiatrist about once a month, my therapist twice a month.  I wish I could afford to pay more copays and have the chance for them to witness my states in person more frequently.

     

    The attention being paid to the diagnostic criteria is important.  But I wonder how well it's being analyzed.  How in touch are the professionals with their patients?  How can changes in the healthcare system and insurance reforms be made to help patients and professionals to better be able to deal with such serious conditions?

    • Tabby
      Feb. 24, 2013

      Interesting... the "connection" between professional and patient to really assess what is happening... throw in possible continual disruption of care (or repeated changing of professionals) due to money/insurance issues...

       

      psych evals, for which pdocs diagnose and lay Bipolar upon folks... are generally (in my neck of the woods) done within 45 minutes...

      RHMLucky777

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      Interesting... the "connection" between professional and patient to really assess what is happening... throw in possible continual disruption of care (or repeated changing of professionals) due to money/insurance issues...

       

      psych evals, for which pdocs diagnose and lay Bipolar upon folks... are generally (in my neck of the woods) done within 45 minutes now

       

      the patient walks in, a few or several questions are asked... and in 45 minutes to a hour (at most)... the doc has him or her diagnosed

       

      could be the same as the 5 pdocs before... or could be something so completely different

       

      then the therapist may, or may not, see the patient and yet another diagnosis and or diagnosis change....

       

      meanwhile... NO ONE really gets to "see" the patient and NO ONE really gets to "know" the patient... only what the patient reports, each time he or she is seen for the 45 minutes - 1 hour (at best)...

       

      be it therapy or doc visit... every 6 weeks-3 months (in my neck of the woods and poverty population.. it's possible to have 1 therapy appointment every other month and 1 doc visit every 3 months).

       

      meanwhile... Bipolar and Schizoaffective Disorder (new flavor diagnosis) is tossed about

      in the agency that I work, as a admin... Bipolar II (that and Cyclothymia, but no other oddly) is very very popular a diagnosis... course, so is Alcohol and/or other substance Dependence... but who is counting and considering?

  • cathryne
    Feb. 23, 2013

    I wonder, sort of, what they all would do about me.  I have had chronic, treatment ressistant depression since I was 10  That's 53 years.  It is not the same as majore depressive disorder.  I have been majorly depressed, but the usual is not deep, it is quet, low level, sort of an "eh, who care" depression. People use to call me Eyore becasue...

    RHMLucky777

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    I wonder, sort of, what they all would do about me.  I have had chronic, treatment ressistant depression since I was 10  That's 53 years.  It is not the same as majore depressive disorder.  I have been majorly depressed, but the usual is not deep, it is quet, low level, sort of an "eh, who care" depression. People use to call me Eyore becasue I believed truly that nothing every really works out favorably.  I have changed that way of seeing the world slowly over the past ten years.  Conciously, proactively, on purpose.  When hypo-mania stikes it results in a mixed mood.  I don't really have mania unless it's irritable.   It's irritable, I believe, due to the underlying depression.  I've never been able to fit my symptoms into the DSM chriteria. or the silly decision tree.  They probably would not diagnose me as bi-polar.  Yet antileptics work.  So what does that tell them.

  • Tabby
    Feb. 23, 2013

    Hypomania is like, to me; you say potato, I say po-ta-o.  Again, with psychiatry... IN MY PERSONAL OPINION AS A PATIENT... no definition easily defined nor across the board consenually agreed upon.  Hell, not even mania is easily defined and even less, across the board consensually agreed upon.

     

    Right at this moment I am in what I refer to as...

    RHMLucky777

    Read More

    Hypomania is like, to me; you say potato, I say po-ta-o.  Again, with psychiatry... IN MY PERSONAL OPINION AS A PATIENT... no definition easily defined nor across the board consenually agreed upon.  Hell, not even mania is easily defined and even less, across the board consensually agreed upon.

     

    Right at this moment I am in what I refer to as a Mixed Episode; which, by the way, some clinicians I've dealt with both as patient and as co-worker (admin remember in a MH agency) would say really doesn't exist.  Anywhoo... I have a lot of energy just under the surface.  Just enough to make me want to stay awake on a computer for hours at a time (it's 4:26am where I am and I went to bed at 11pm, have been up since 3:02am).

     

    During the day; I am both exhausted and yet fully energized.  The Energizer bunny who desperately wants to lay down and die but just can't seem to STOP beating the damn drum, or moving.  This has been going on for about 3 weeks now.

     

    It was kinda fun, at the beginning.  I laughed, I giggled, I chuckled.  Up at work all joking and boisterous.  I balanced my much ignored and avoided checkbook, about 2 weeks ago, of which I found I had way NO money but couldn't really recall where it all went... I organized my desk at home and at work.   I even, at work, transitioned our work from an old database to a new database - which took me nearly a month to do.

     

    Now:  I still have the energy, I still laugh and giggle and chuckle.  I am still "up" at work and zipping about... but ANGER, IRRITATION, and huge agitation has kicked in.  I am quick now, without much filter or inhibition, to say what is on my mind regardless of appropriateness or "professionally" respectful.  My communication style, of recent, has been called into question.  Employer not so adoring of me, at the moment, as they were a week ago.

     

    Underneath; a horrendous dark depression is swimming.  You know; one of those really black sucking pit type depressions.  I "see" it and I "feel" it, swimming closer and closer to the surface.  Each hour of each day brings it even more closer in which to swallow me.  I feel it's breath upon my person, every second.

     

    It's kinda like in a horror film where you "hear" the pounding eery music and it is slowly rising in volume and speed... you see the woman, at first, stepping quickly in the half lit hallway... and as the music speeds up and volume rises and beat starts pounding... she starts to skip, then to run, then to run frantically... as the "unseen" horror is quickly approaching.  Suddenly, a darkened arm reaches towards her, it's right on her, she screams, turns - her face frozen in horrifying fright, she stumbles and falls backward, you hear the darkness giggling as it reaches down to grab her, ..........................

     

    It's how I feel about that black sucking depression.. that I "see" and "feel" is just on the cusp.

     

    Would you call this hypomania, dysphoric mania, dysphoric depression, or mania?

     

    Let's talk duration... This started, initially, 3 weeks ago and now it's "shifting" and "transitioning".  It's still there, just morphing.  Grant it, I had a "squirrely" spell, for about 2 weeks before this started that in "low functioning" individuals would've seen them in a hospital.

     

    Really... what would you call it?