Duration Criteria and the DSM: Much Ado About Nothing?
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 Ninth International Conference on Bipolar Disorder, put on by the Western Psychiatric Institute and the University of Pittsburgh. A panel from the mood disorders working group of the DSM-5 task force was presenting.
This is going to be interesting, I thought. After all, here were the world’s foremost academic experts about to engage in a thoughtful discussion on an illness that defines a large part of who I am.
If only. The panel discussed but one thing: whether the time period for a hypomanic episode should be shortened from its current cut-off of at least four days to at least two days. “Duration criteria” clearly matters. For instance, being wildly excited about something for one day doesn’t tell us much. Four days gives us something to go on.
For mania, the duration criteria is seven days, for depression two weeks. To give you a personal example, one I have related a number of times here before: The 2004 election didn’t turn out the way I anticipated. I immediately fell into a depression. If one were to merely run through the symptom checklist and start counting, I was clearly a walking-talking psychiatric basket case.
But did I really have clinical depression (or to be more precise, a depressive episode in bipolar disorder)?
Well, to start, nearly half the people who voted, if not depressed as I was, weren’t feeling so hot, either. From our point of view, depression was the normal response. We’re supposed to have feelings, remember? But then, after a reasonable period of time, we’re supposed to pull out of it. Staying depressed for say two weeks is worrying, to say the least.
So here I was, at the International Bipolar Conference, slowly being bludgeoned into a thudding coma from a panel of experts discussing the relative merits of two days vs four days for hypomania. The members of the panel confessed to leaning toward two days back when they first met as a DSM-5 working group. But then they all found themselves persuaded by the research of Jules Angst, emeritus professor at Zurich University.
The term, formidable, hardly does justice to Dr Angst. Over a long and distinguished career, he has very much shaped our modern conception of depression and bipolar. Dr Angst’s findings on the two vs four day criteria were a total surprise. Previous studies of his strongly suggested adopting “softer” criteria for bipolar, which would have meant, among other things, shortening the duration criteria.
So, here was Dr Angst, a “soft” proponent, acting as an advisor to the DSM working group, bringing around the other softies to an unexpected “hard” view. If you’re an academic researcher, this is something to be wildly excited about. There is one major catch: The DSM is a real-world document that impacts millions of lives. It is not an academic paper that maybe 30 people will read.
When I later asked a couple of clinical psychiatrists what they thought of the session, one of them remarked that it amounted to counting angels on the head of a pin. I got similar opinions from the other real-word psychiatrists I talked to. Indeed, to a person, they had little use for the DSM.
An article I came across in the Feb 2012 World Psychiatry, Prototype Diagnosis of Psychiatric Syndromes, by Drew Weston of Emory University, sums it up this way: “The assumption of the framers of subsequent editions of the DSM has been that clinicians need to change their ways and start diagnosing patients the way researchers do.”
The catch, he goes onto say, is that researchers have entirely different agendas than clinicians. Indeed, the patients researchers recruit into their studies bear at best a superficial semblance to the people clinicians see daily. These are your rare magic specimens who neatly fit into one diagnostic category, meeting the requisite symptom and other criteria, with nothing else going on.
The world of the clinician, by contrast, is far more messy and chaotic. Instead of studying the situation, the clinician needs to solve the problem, especially if his or her patient’s condition represents a ticking bomb that needs dismantling. Two days vs four days is harldy going to affect the diagnostic and treatment call.
Let’s consider two contrasting scenarios:
George has been hypomanic for two weeks. He had been highly productive at work and, as a result, has drawn praise from his boss. If past experience is anything to go by, he will slide into a moderate but not disabling depression. His output may slow, but he makes up for that by coming across as diligent and thoughtful, traits his boss also appreciates.
Cynthia has been hypomanic for two hours. She is feeling on top of the world. In ten minutes she will walk out the door with a stranger and contract an STD.
Take home message: In real life there are no easy answers. Don’t expect to find them in the DSM.
This piece was inspired by the comments to a recent piece of mine on functionality. I had expected to continue along the direction of the comments, but wound up taking the track in a different direction. Please feel free to take this track wherever you want go. Comments below ...