Psychiatric Incompetence and the DSM - Big Problem

Patient Expert

Last week, in a post highly critical of the DSM-5 (due out in May) I wrote:

Basically, bipolar as we are expected to know it in 2013 (and probably for the next ten years) will remain the bipolar we knew back in 1994. This translates to doctors continuing to misdiagnose bipolar patients with unipolar depression. You've been through it, I've been through it. We get put on destabilizing antidepressants and tend to get worse.

Trust me, nothing in the DSM-5 addresses this menace.

In a Question of the Week, I asked you to tell me about your experiences having been diagnosed with depression. Your responses should be required reading in every medical school. It's going to take at least two posts to do justice to your comments. Let's get started. Tabby sets the scene:

I've been on MAOIs, Tricyclics, SSRIs and the newer non-SSRIs, and I've had NOT A SINGLE one do anything to benefit.I've had them to completely "POOP" out, run me manic, develop EPS symptoms, cause psychotic hallucinations, agitation and wild mood swings, and at the very worst - suicidal ideation and attempt.

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Guess what?I still get ADs when I see psychiatrists.In fact, many with Bipolar are prescribed a AD or two. When I've explained that I do NOT DO ADs, they smile, and write me a script anyway. Then assure me that everything will be fine and if not, they'll try something else.

Perhaps you see why we need to bring clarity to the DSM. Then again, this is a classic case of psychiatrists not listening, which will make a good topic for another series of posts. Okay, brace yourself. Tabby goes on to report that when she tells psychiatrists about her bipolar, they reply with "Do you believe that you have bipolar disorder?"

I had to close my eyes and hit my head several times to see if I had read that right. To illustrate just how totally bizarre this situation is, just imagine an oncologist asking his or her patient, "Do you believe you have cancer?" Then imagine the patient saying,   "No, I think this strange growth the size of an egg is a pimple." Now imagine the doc sending the patient out the door with a prescription for pimple cream.

If I am reading Tabby correctly, her doctors kept trying to convince her she had depression. After all, according to Tabby, her doctors have never seen her "fly off the building because you think you are Wonder Woman."

This is one of the major myths about bipolar disorder, namely that you have to be floridly manic to qualify for the diagnosis. It's one thing for the general public to believe this, but doctors or therapists have no excuse. In 1994, the DSM introduced "Bipolar II" with its threshold of "hypomania" (mania lite). Mania lite can be nothing more than an energized state, but doctors still mistakenly believe there has to be a Wonder Woman (or Superman) component to this, only perhaps we don't fly off of buildings.

But what if your "up" is simply higher than your "down"? Unfortunately, psychiatrists think that is normal and direct their focus exclusively to the down, which they assume has to be unipolar depression. But what if "up-higher-than-down" is not exactly normal? What if it is an indicator, instead, of an affective instability?

This is a subtle argument, so bear with me. With unipolar depression, we assume that a patient will eventually return to "normal," to a state before the depression set in. There is no underlying affective instability. Perhaps there will be a recurrence of the depression, but again the emphasis is on "back to normal."

With bipolar, we assume an underlying affective instability. This is our true normal. The patient may well settle into a state of "normal", but we can generally predict frequent returns back to depression. "Normal" is not normal for us. We cycle, from "down" to "up" and "up" to "down." Mistakenly, our doctors assume our "up" has to involve mania. So, again, I put it to you: What if our "ups" are merely higher than our "downs"?

Good luck with that. Willa, who went through years of going from bad to worse on antidepressants, reports of a doctor who decided to probe for bipolar. Willa had told the doctor that she had been writing "maniacally." Her doctor picked up on the cue. "Are you manic?" she asked. No, replied Willa. She was excited. Willa reports: "So the doctor moved on to the next antidepressant.

Again, I had to close my eyes and hit my head several times. Here's the problem, as Cathryne sees it: "Hardly anyone presents to their therapist or psychiatrist as manic because if you're feeling on top of the world why on earth would you go to a psychiatrist."

This, of course, places an extra burden on the doctor to probe for those "ups," for evidence of cycling up and down - for signs of affective instability rather than depression superimposed on "normal."

So here's Willa's doctor asking, "Are you manic?" and then moving on. No intelligent follow-up. Nothing along the lines of: "When you write, do you tend to stay up all night?" "Do you feel this driven with other projects?" "What does it feel like when you write maniacally? What's it like when you feel excited?" On and on and on.

It doesn't stop there, because once we have signs of "up," then "down" takes on an entirely different context. The follow-up questions would go something like this: "When you're excited, do you still feel depressed?" "When the excitement stops, do you go back to feeling depressed?" "So being excited happens in your life, is that right?" "So you get excited and also depressed, is that right?" "So when you're depressed, how do you feel? Not excited?" On and on and on.

Willa goes on to say that "six antidepressants, three psychiatrists and two psychologists later, I was the one who had to convince my pdoc that I had BPII." Cathryne makes the similar point that "I had to diagnose myself."

This should not be the case. A competent psychiatrist should be able to probe for signs of affective instability. More and more, I am believing that competence is a rare attribute in psychiatry. The DSM-IV, as I mentioned in my previous post, does not exactly encourage diagnostic competence. The DSM-5 could have addressed the problem. It didn't.

Excuse me while I close my eyes and hit my head several times.

More to come ...