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.