This is the second (and final) of our look at the DSM-5, the latest version of psychiatry’s diagnostic bible, which has superseded the DSM-IV, dating from 1994. In case you’re wondering, the stylistic change from the Roman numeral IV to the modernistic 5 represents the DSM’s major innovation. Just about everything else is distressingly same-old, same-old.

Last week, in The DSM-5 Debacle, we looked at the failure of the DSM-5 to address the problem of clinicians who misdiagnose patients with depression. Except in cases where a patient is presenting in obvious mania, very few clinicians get the bipolar diagnosis right the first time around. The sad result is patients being prescribed the one drug that runs a strong risk of making their condition worse - antidepressants.

Perhaps you are wondering: Wouldn’t it be a good thing if we could clarify diagnostic criteria to reduce the risk of the suffering caused by misdiagnosis? The people responsible for the DSM-5 did not think so.

This week’s installment is far more bland and prosaic. It focuses on the changes the DSM-5 actually made to the bipolar diagnosis. This means a mercifully short post.

Mixed Episodes

The most significant change involves the widening of criteria for mixed episodes. Mixed episodes involve depressed symptoms and manic symptoms occurring at once. These typically involve agitated depressions or manias or hypomanias where you feel terrible (dysphoric) rather than euphoric. In my book "Living Well with Depression and Bipolar Disorder," I put it this way:

If one thinks of either pure or mild mania as the music of Duke Ellington and Louis Armstrong on a clear summer night, mixed mania is heavy metal and rap in a thunderstorm, the blast of jackhammers, the frizzle-frazzle of shorted-out power lines, and the elbows on the black keys of every neuron in the brain vibrating to extinction.

A similar description would apply to agitated depressions. We are talking extreme psychic distress.  

Under the old DSM, mixed episodes were unrealistically restricted to mania. As well as full-blown mania, one also had to simultaneously experience full-blown depression. The new DSM widens the criteria for mixed episodes in a number of ways:

• Manic episodes no longer have to include full-blown depression. Just three simultaneous DSM depressive symptoms will do.
• Mixed episodes may also include hypomanic states, again with the minimum of three simultaneous depression symptoms. Think of those times you experienced road rage while shopping in Walmart. 
• Mixed states may also occur in depressive episodes, with a minimum of three simultaneous (hypo)manic symptoms.

If this looks like a counting-angels-on-the-head-of-a-pin exercise, you are correct. There is little to distinguish an agitated depression from a dysphoric (hypo)mania other than, perhaps, a pure depression that grows more complex or a pure (hypo)mania that turns against itself. Inexplicably, the DSM-5 left out those states involving “a little bit” of (hypo)mania accompanied by a “little bit” of depression, but let’s not quibble.