As most of you know, the DSM-5 - psychiatry’s diagnostic bible - is due out next month. This latest edition will supersede the current DSM-IV that has governed our modern conception of mental illness since 1994 and arguably (through the DSM-III) since 1980. You can now pre-order the DSM-5 on Amazon, which will be available for shipping on May 22.
Earlier this year, we took an extensive look at how the DSM-5 will affect how doctors diagnose bipolar. The short answer is not much at all. In brief:
- The DSM-5 sticks to the view that bipolar is “episodic” rather than “cyclic.” True, we do experience episodes, but this view encourages us to look at our depressions and manias in isolation, as static states, rather than as part of a dynamic cycle. Why this is important is that doctors frequently treat the “episode,” with no regard to the underlying cycle that drives these episodes.
- The episodes themselves - mania, hypomania, and depression - are presented in the same checklist format as the DSM-IV, with virtually no changes. This would be fine if the current symptom lists were not seriously flawed. Alas, what are we to make of symptom 1 from the DSM-IV and DSM-5, where a depressive episode is defined as “depressed mood”?
- Symptom lists do not tell the whole picture. The DSM-5 could have addressed this problem by showing how symptoms impact mood, behavior, perception, thinking, and physical function, but this would have meant a thorough rewrite of the symptom checklists.
- The definition for mixed episodes (simultaneous depressive and manic symptoms) has been considerably expanded, but there is no attempt to describe what a mixed episode looks like.
- There is no attempt to connect bipolar (or any other condition) to biology. A good case can be made that this would have been premature, but this underscores the fundamental flaw of the DSM, namely it is based on an outdated 1980 view of reality, with no reference to more than 30 years of brain science.
- There is no acknowledgement of the causal relationship of stress and trauma to depression and mania (or other conditions). Why this is important is that the DSM encourages clinicians to focus exclusively on the episode rather than treat the underlying stress or trauma.
- DSM-5 bipolar remains boxed into a diagnostic category. The alternative - supported by Goodwin, Ghaemi, Akiskal, and numerous others - is to view bipolar as existing on a overlapping spectrum occupied by other conditions and personality traits, as well as in terms of severity. In other words, a “little bit” of bipolar can still be clinically significant. Why this is important is that those who do not technically meet strict DSM criteria for hypomania are likely to be misdiagnosed with depression, with often catastrophic results. Likewise, the DSM’s categorical view encourages clinicians to overlook personality (such as a depressive temperament vs a clinically depressed state).
- No attempt has been made to clarify the schizoaffective diagnosis. Schizoaffective is seen as where bipolar and schizophrenia overlap. A DSM workforce described the classification as “unreliable,” then made only one minor change.
- No attempt was made to clarify early-onset bipolar. A new diagnosis of Disruptive Mood Dysregulation Disorder only confuses a very confusing situation.
In an article in last week’s Huffington Post, Allen Francis - who headed up the DSM-IV of 1994 - urges clinicians, insurance companies, educators, and policy makers “simply to ignore DSM-5.” (Note that Dr Francis left patients off his list.)
I would urge the very opposite. Pay very close attention to the DSM-5. Play your own game of spotting the weaknesses. You will gain much better insight into how you tick and tock (or not) as a result.
Finally, keep in mind that the DSM-5 was already outdated as soon as the American Psychiatric Association appointed a task force to work on it. Brain science is overtaking it as we speak. One day in the future, armed with brain scans and other results, our treatment and recovery may focus on modifying how our brain responds to stress or in regulating our sleep cycles rather than in generic “bipolar” interventions. But that day is not here.
Even the best DSM-5 in the world would have been inadequate. Nevertheless, it would have been a lot more useful than what we have now.
Update: The DSM-5 Debacle
Published On: April 22, 2013
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