As you may know, the DSM-IV, the fourth edition to psychiatry’s diagnostic bible dating from 1994, has just been superseded by the DSM-5. I just received my 800-plus pages copy, which has that intoxicating new book smell. The content, however, is the same-old same-old, as if we have learned absolutely nothing about bipolar and other mental illnesses in the last two decades.
The challenge for the academic experts charged with bringing the DSM into the current millennium was to reconcile the “categorical” approach to diagnostic psychiatry with the “dimensional” approach. The categorical approach rigidly separates out mental illness according to defined criteria. Thus, you either have bipolar or you don’t. The dimensional approach, by contrast, sees a lot of overlap between various mental illnesses as well as between mental illness and “normal.” Thus, the appropriate question to ask is not “whether or not” you may have bipolar, but “how much” bipolar you may have.
This is no mere esoteric debate. Our very lives depend on psychiatry getting this right. If you are like me, you were probably first misdiagnosed with depression before you received a bipolar diagnosis. Chances are you were put on an antidepressant, with disastrous results. If you weren’t displaying classic bipolar symptoms before you sought treatment, you certainly were afterwards.
Back in 1980, when the first “modern” DSM (the DSM-III) was published, before the advent of SSRI antidepressants, this was hardly a major concern. Nor was it in 1987 with the DSM-III-R. In 1994, with the DSM-IV, we had SSRIs on the scene, but this was during the honeymoon wonder drug phase of Prozac and its copycats.
Two decades later, however, with the destabilizing effects of antidepressants well-known and with physicians handing out these pills like candy, there is no excuse. If the diagnosis is wrong, the treatment will be wrong. Not only wrong, possibly catastrophic.
Essentially, the DSM-5 has failed to recognize the existence of a “bipolar spectrum,” where unipolar depression bleeds into bipolar. The spectrum concept dates as far back as 1921, with Emil Kraepelin’s classic “Manic-Depressive Insanity and Paranoia.” Kraepelin viewed what we now call unipolar depression and bipolar disorder as part of the same phenomenon. To the horror of a good many experts (including Frederick Goodwin, co-author of the authoritative “Manic-Depressive Illness”), the DSM-III not only separated out bipolar from unipolar depression but very narrowly defined it by insisting on a full-mania threshold.
Thanks to the influence of Dr Goodwin and others, the DSM-IV widened bipolar to include hypomania (mania lite). For the first time, we had bipolar I and bipolar II. In theory, this meant that many of those who would have been diagnosed with unipolar depression would now be classified as having bipolar II. The catch is that hypomania is notoriously difficult to spot and separate out from “normal.”
It gets more complicated. Many individuals may not even experience hypomania. Wait, you may say. Surely, these are your classic unipolar depression cases. Are you sure? Does NOT experiencing hypomania automatically mean these people have unipolar depression? Sure, they are depressed. But what happens when you give them an antidepressant?
Here is the situation: Never mind mania or hypomania. These depressions really belong in the bipolar spectrum and need to be treated accordingly. We don’t want to see these individuals getting worse on antidepressants (typically for years on end) before our doctors finally see the light. Fine, but how do you identify this group at the outset? We really don’t want doctors to be hunting around for some kind of sub-hypomania when they can’t even find hypomania.
The key to the riddle is not the mania side of the equation. It is the depression side of the equation. To understand this, we need to think of bipolar as a “cycling” illness (the term dates back to 1851) rather than an “episodic” illness. A very good account of this dynamic is provided in Jim Phelps’ “Why Am I Still Depressed?”, which in turn is based on the work of Frederick Goodwin, Nassir Ghaemi (of Tufts), Gary Sachs (of Harvard), and others.
Suppose, for instance, we cycle in and out of our depressions, with periods of “normal” or “less depressed” in between. Our cycles may not take us up into hypomania or mania, but up we do go. Is this unipolar depression or bipolar? There are no easy answers. But we do know this: If we treat the situation as unipolar depression, there is a significant risk that antidepressant treatment will induce true bipolar.
There are other anomalies in our depressions to consider, such as various mixed states, where we may simultaneously experience various (hypo)manic symptoms inside our depressions. How much (hypo)mania inside our depressions is too much?
Okay, so what do we call these cycling and mixed depressions? Anomalous depressive disorder? Bipolar III? It really doesn’t matter, so long as the people we entrust our lives to are put on notice to investigate our depressions more closely.
If you’re like me, you will recall the first time you sought treatment. Your psychiatrist most likely saw you in a state of depression. He or she may have asked if you could recall any states where you felt normal or even better than normal, but of course you couldn’t. You remember what it was like. You remember walking out the office with a prescription or with some drug samples. You remember what happened.
Those were the days of the DSM-IV. The days of the DSM-5 will remain exactly the same.
Published On: June 01, 2013
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