In an earlier series of blogs, I described how I wound up having dinner with Robert Spitzer MD, the man responsible for the ground-breaking DSM-III of 1980, and its successor, the DSM-III-R of 1987. You may recall that Dr Spitzer seemed to be somewhat overprotective of his baby. Following Dr Spitzer, Michael Frist MD of Columbia University was asked to head up the task force for the DSM-IV of 1994.
There is now a new boss of the DSM. He is David Kupfer MD, chair of the department of psychiatry at the University of Pittsburgh, an expert on bipolar and sleep disorders. His brief is to chair the task force for the fifth revision of the DSM, due out in 2011. I have met Dr Kupfer on a number of occasions, and I’m very happy to report that my brief encounters have been positive (last year I gave him a “McMan – Knowledge is Necessity” pen).
So do I have any inside knowledge on what’s in store? The short answer is no. But when I talk to the experts, they tell me not to expect any earth-shaking changes to the bipolar diagnosis. Why? Because the DSM, by its nature, is a conservative document, and we have the entire health industry invested in the status quo. Further, should we expand the bipolar diagnosis to include much of the unipolar population, as some experts are advocating, well, think of stretching a rubber band past its breaking point. Finally, five years may seem like a long time, but when we are talking about as complex an illness as ours the last thing we want is to go flying 200 miles per hour in the wrong direction.
Various work groups will be created in 2007 to whip specific sections of the DSM-V into shape, which means a panel of experts will be recruited for the bipolar (or perhaps the entire mood disorders) assignment. So, you may ask, if nothing much is going to change then what will these learned individuals be doing? Well, for one, they will be listening to you.
The American Psychiatric Association, which publishes the DSM, has set up a special DSM website which encourages individuals to submit suggestions. According to the website: "All suggestions will be entered into the DSM-V Prelude data base for eventual referral to the future relevant DSM-V Work Groups.”
Consider: If the bipolar work group likes your suggestions, you may get to write the whole bipolar section yourself, only they won’t pay you. Be assured, I will be making my suggestions, and I encourage you to do the same. Following are some bullet points I have put together:
• The mood spectrum. Should depression and bipolar be regarded as part of a continuous spectrum rather than separate illnesses? Should the bipolar II diagnosis be expanded to include mixed or highly-recurrent depressions? Should mixed or highly recurrent depressions be accorded special DSM status?
• Mixed states: Too much confusion over mixed mania? Why the DSM’s silence concerning mixed hypomania and mixed depressive states?
• Hypomania: Legitimate baseline for some or pathology – where do we draw the line? What about dysphoric hypomania?
• Depression in bipolar: Why are the DSM criteria for bipolar depression exactly the same as the DSM criteria for unipolar depression?
• Cognition: A core feature of mood disorders?
• Anger: Why is this not mentioned as part of mania?
• Length of episode: Why two weeks for depression, one week for mania, and four days for hypomania?
• Early onset: Different manifestations of bipolar disorder, or different illnesses entirely? How do you separate out early onset bipolar from ADHD and conduct disorder?
Past blogs have already investigated some of these issues, and there will be lots more in blogs to come. I urge you to read these blogs, do your own research, then give yourself lots of time for ideas to germinate. You may not be an expert, but you are a patient, which is all the qualification you need. Simply by living with your illness you have earned the right to join the conversation. When you are ready, three months from now, four, five, please go to www.dsm5.org and give the experts the benefit of your wisdom.
Maybe the new DSM bipolar diagnosis won’t look an awful lot different than the old one, but you never know, one of the new changes could be yours.
Share your thoughts on what the new DSM should include in the message boards.
Published On: June 07, 2006
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