The DSM Bipolar Diagnosis - A Clear Case of Not Valid

John McManamy Health Guide
  • Last week, in a piece on the bipolar diagnosis, I asked, how reliable is reliable? My answer, in effect, amounted to “not nearly reliable enough.” This is based on the DSM-5’s own reliability data. In a commentary in the American Journal of Psychiatry, the authors of the DSM-5 are far more charitable in their assessment. (For more on the reliability controversy, please check out my earlier piece.) 


    Moving on ...


    “Reliability” is technically an indicator of clinician agreement. Thus, two clinicians - whether viewing the same mammogram or interviewing the same psychiatric patient - should be able to reach the same diagnostic conclusion at least most of the time. The catch is they may be 100 percent in agreement on a wrong answer. 

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    This raises the issue of “validity.” This explains why, according to two DBSA surveys, 69 percent of those with bipolar were misdiagnosed initially and more than a third remained misdiagnosed ten years later. Two other studies indicate that 40 percent of us were misdiagnosed with unipolar depression. Heaven help if you have bipolar II, without its tell-tale full-blown manias. (Check out a review article here.)


    In his Director’s Blog in April this year, Thomas Insel, head of the NIMH, straight out declared war on the DSM. In his own words:


    The weakness [of the DSM] is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.


    Accordingly, the NIMH is orienting its research away from DSM criteria and coming up with its own ways of assessing human biology and behavior. (I have written extensively about this in previous posts. Go here for the introductory article.) 


    Let me leave you with this:  On my website, mcmanweb, I give the hypothetical example of someone talking loud and fast with grandiose ideas and who can’t sleep. But is this mania?


    Talking loud and fast could also be a sign of anxiety or it could mean the person is from the east coast. Grandiosity is also a feature of narcissism. Plus your “normal” stuck-in-the-muds find it very difficult to distinguish grandiosity from visionary. And maybe if you are excited about your visionary idea you will almost certainly be talking faster than usual and not getting as much sleep.


    Surely, the DSM can separate out the founder of the next Facebook from the King of Antarctica. Not so fast. The DSM-5 lists seven symptoms for mania. For a bipolar diagnosis, a clinician only has to check off three. “Grandiosity,” “decreased need for sleep,” “more talkative than usual” will do just fine. 


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    That’s right, just three symptoms. Get excited and talkative over a cool idea of yours, lose a little sleep, and you have met the DSM-5 criteria for mania. Yes, a good psychiatrist should be concerned, especially if you have had a prior manic episode, a real one. That psychiatrist will be checking to see that you are on the safe side of normal and that you are not a 911 case waiting to happen.


    But that same psychiatrist will be using her own clinical judgment, shaped by her own experience observing patients, certainly not the DSM.

Published On: December 21, 2013