Mood

What's In Your Diagnosis?

Confused about your illness? So are the experts.

What is wrong with the bipolar diagnosis?

The third chapter of Goodwin and Jamison’s recently-published second edition to their landmark "Manic Depressive Illness: Bipolar Disorders and Recurrent Depression," wastes no time getting to the point. The chapter is entitled, "Diagnosis," and the first sentence reads:

"The history of psychiatric diagnosis has been notable for the confusion reflected in the myriad overlapping systems for classifying and subdividing depressive disorders."

A little further along, the authors inform us:

"The organization of both DSM-III and DSM-IV implies that bipolar disorder is distinct from all forms of major depression. This division discourages consideration of underlying unifying relationships between bipolar and the more highly recurrent forms of unipolar disorder, including the possibility that they fall along a spectrum."

The authors also contend that this confusion results in patients being misdiagnosed with unipolar depression. The authors further identify other major weaknesses in the DSM, including:

* Emphasis on episode rather than disorder, with no consideration of natural course, longitudinal patterns, and family history.
* Weighting all criteria equally (a la checklist).
* Narrow criteria for mixed episodes (that exclude many dysphoric manias and agitated depression).
* Over-focus on euphoria in mania and hypomania.
* Arbitrary length for manic and hypomanic episodes.
* Lack of satisfactory boundaries for cyclothymia.
* Lack of clarity concerning whether various clinical conditions may be a distinct disorder, two or more co-occurring disorders, or some kind of diagnostic hybrid.
* Problems with differential diagnoses (especially regarding borderline personality disorder and, in kids, ADHD).
* Schizoaffective disorder: Schizophrenia lite, BP heavy, a separate illness, two co-occurring illnesses, or something occupying the psychosis spectrum?

Intriguingly, references to the DSM virtually disappear after the third chapter. It’s as if the authors have decided that psychiatry’s diagnostic bible is irrelevant to clinical reality, let alone to brain science and genetics.

Unfortunately, patients (and their clinicians) are not likely to read Goodwin and Jamison. Far more likely, patients will develop their understanding of their illness from various websites, books, and pamphlets, not to mention quickie explanations from their clinicians, virtually all of it derivative of the DSM. As an article in the Jan 3, 2005 New Yorker explains, in reference to the breakthrough third edition of the DSM in 1980:

"Almost immediately, the book started to turn up everywhere. It was translated into thirteen languages. Insurance companies, which expanded their coverage as psychotherapy became more widespread in the nineteen-seventies, welcomed the DSM-III as a standard. But it was more than that: the DSM had become a cultural phenomenon."

In other words, the DSM has set the tone not only for the information we read, but the advice and treatment and therapy we receive or may be denied from receiving. Its surprise runaway success more than a quarter century ago moved psychiatry into a more modern age, but a strong case can now be made that in its present – and essentially unchanged – form it is impeding progress.

Which begs the obvious question: If the DSM leaves so much to be desired, yet remains uncritically accepted by the professionals we entrust our lives to, what does this say for our prospects of recovery?

It also begs this slightly less obvious question: If the DSM is so firmly entrenched in medical, insurance, and other circles, what are our chances that those responsible for the DSM-V will place our needs above those who make money off our illness?

Take the DSM – Please!

First an explanation: The term nosology refers to the systematic classification of illnesses.

Now the good news. At a symposium at the American Psychiatric Association’s Annual meeting in May 2007 entitled, "The Controversy over Lumping vs Splitting in Psychiatric Nosology" (seriously, this word has to go), four speakers demonstrated that at least some psychiatrists are encouraging some serious thinking outside the DSM box.

The bad news is the symposium was sparsely-attended.

Ahmed Okasha MD of Ain Shams University (Cairo) pointed out that psychiatry has no gold standard for identifying disorders. The DSM-IV has parsed out 284 psychiatric disorders. Rare is the patient diagnosed with just one of these disorders. Further diagnostic confusion is evidenced in the lack of treatments specific to a particular diagnosis. For instance, antidepressants are "misnomers," as they treat many other illnesses aside from depression.

G Scott Waterman MD of the University of Vermont argued that the DSM system, with its emphasis on subjective experiences, "separates us from the rest of medicine." Further, the DSM’s tendency to set symptom lists in stone "retards development of understanding."

Juan Lopez-Ibor PhD of Complutense University (Madrid) attacked the DSM’s arbitrary splitting of illnesses by category, pointing out that even the pioneering diagnostician, Emil Kraepelin, expressed second thoughts in his last writings over the dividing line he drew between what he called manic-depression (now bipolar and recurrent depression) and dementia praecox (now schizophrenia).

Hagop Akiskal MD of the University of California, San Diego was his usual reserved and diplomatic self. "The emperor has no clothes," he thundered. Referring to the disconnect between the DSM and what he sees as clinical reality, Dr Akiskal informed his audience that "our patients are violating our nosology every day."

For instance, limbic hyperactivity (ie how our brains react to the environment and life experience) appears to confound diagnostic categories.

Making his case for a spectrum approach that would include a range of disorders and behaviors within the bipolar umbrella, Dr Akiskal argued that "these are the type of patients that I see, and that my residents see."

Bad for Your Health?

Criticism of the DSM comes from surprising sources. In a 2002 white paper published by the American Psychiatric Association, entitled, "A Research Agenda for DSM-V," Dennis Charney MD, then chief of the Mood and Anxiety Disorders at the NIMH, and his colleagues wrote:

"The descriptive approach adopted by the DSM allowed for the development of a classification system that met the field’s need for a common language, without being mired in ideological hypotheses about the causes of psychiatric illness. Questions have been raised by many critics that the DSM’s descriptive approach may have outlived its usefulness and is in fact potentially misleading."

Significantly, the white paper was edited by Michael First MD, David Kupfer MD, and Darrell Regier MD, PhD. Dr First headed up the APA task force responsible for the DSM-IV. Drs Kupfer and Regier were appointed last year to head up the DSM-V.

Setting the DSM-V Agenda

The DSM-V is due out in 2012. At a symposium at the Seventh International Conference on Bipolar Disorder, hosted by the University of Pittsburgh and the Western Psychiatric Institute in Pittsburgh in early June 2007, Darrel Regier MD, PhD, Director of Research of the American Psychiatric Association and vice chair of the APA’s DSM-V Task Force, turned in his progress report.

The DSM-V, Dr Regier said, began in 1999. David Kupfer MD, chair of the Department of Psychiatry at the University of Pittsburgh and chair of the APA committee on Psychiatric Diagnosis and Assessment, along with then-director of the NIMH Steve Hyman MD and Steve Marinen, Medical Director of the APA, concluded that growing concern about the DSM-IV justified getting started about thinking about the DSM-V. Soon after, a planning group was established to start reviewing broad areas of research.

These areas included nomenclature, the underlying neuroscience, developmental perspectives (which acknowledges that mental illness does not just emerge fully-formed in adulthood), dimensional issues (especially in personality disorders), how functional impairment and disability fits in, and culture and gender issues.

Out of this emerged the APA’s 2002 "A Research Agenda for DSM-V". Subsequent papers will include topics on infancy and childhood, sex and gender, the elderly, and the role of religious beliefs and spirituality.

There have also been ongoing conferences with representatives of the World Health Organization and other bodies aimed at harmonizing the next editions of the DSM and the ICD. Topics include cultural issues, substance use disorders and co-occurring substance use, methodology, the dimensional modes of personality disorders, dementia, and "stress-induced fear circuitry disorders."

Stress-induced fear circuitry disorders (the "limbic hyperactivity" cited by Dr Akiskal at the APA) was a clear reference to the Hariri-Caspi studies and related findings, frequently mentioned in this Website, and cited by Science magazine as the second-biggest scientific breakthrough of 2003. The studies point to a predisposition in certain individuals to over-react to stressful situations in ways that manifest in a variety of moods, emotions, behaviors, and thinking.

As Dr Regier explained, the purpose was "to get people thinking about some of the pathophysiology and commonalities that might exist across diagnostic boundaries."

The conferences also looked at breaking down diagnostic barriers by focusing on "deconstructing psychosis," "obsessive-compulsive behavior spectrum conditions" (including impulse control and addictive disorders), "dimensional approaches to diagnosis" (such as is biology an appropriate measure of severity or symptoms?), "somatic presentations of mental disorders" (focusing on the interface of other organ systems).

With reference to the latter Dr Regier remarked: "Our whole concept of somatoform disorder, I think, is one this group almost uniformly said we need to completely reconsider."

In addition, "Externalizing disorders in childhood" looked across a whole range of illnesses ad behaviors and their overlap.

At the time of his talk, a conference on "depression and generalized anxiety disorder" was two weeks away. Dr Regier referred to a number of studies showing a common genetic predisposition for these conditions, plus a hypothesis that various environmental exposures may influence whether this tracks out into a prominent mood condition or a generalized anxiety condition.

The final conference in September focused on the public health considerations of psychiatric classification (such as impacts on reimbursement, forensics, disability assessments, prevention implications, and primary healthcare practice).

In 2006, the APA appointed David Kupfer MD, chair of the University of Pittsburgh department of psychiatry, as chair of the DSM-V Task Force and Dr Regier as co-chair. The task force, comprising about 25 people, will oversee various workgroups, with a brief to incorporate biological measures and dimensional approaches.

Dimensional vs Categorical

The dimensional approach recognizes that having "a little bit" of an illness may be clinically significant, and that a decent measure for "severity" would also be useful. The refined calibrations of the dimensional approach have been proposed as an antidote to the DSM’s all-or-nothing categorical system. As described by Oregon psychiatrist Jim Phelps MD in his book, "Why Am I Still Depressed," in the context of the mood spectrum:

"Instead of saying ‘yes’ or ‘no’ as to whether you might have a mood disorder, [psychiatrists] try to determine how much bipolarity you have."

On his website, Dr Phelps relates how this approach is used in clinical practice at Harvard’s Bipolar Clinic:

"The system considers five ‘dimensions’ of bipolarity. Note that the presence of hypomania or mania is only one of the five dimensions. All the others receive equal weight …

1. Hypomania or mania
2. Age of onset of first mood symptoms
3. Illness course and other features generally only visible over time
4. Response to medications (antidepressants and mood stabilizers)
5. Family history of mood and substance use problems."

(When discussing polarity, depression is a given.)

One of the authors of this system is S Nassir Ghaemi MD, formerly of Harvard and now at Emory University. Dr Ghaemi has headed up a 30-member Diagnostic Guidelines Task Force of the International Society of Bipolar Disorders, an organization of leading researchers and clinicians. According to the Task Force:

"We expect the impact of this work to be a significant contribution to the ongoing debate and to have some resonance with the DSM-V research group …"

As well as Dr Ghaemi, the committee has included outspoken spectrum advocates such Frederick Goodwin MD, Franco Benazzi MD, and Dr Phelps, plus a host of other leading lights who have shaped the conversation. So going with a dimensional system was a foregone conclusion with this committee, right?

Well, uh, not exactly. As Lakshmi Yatham MD of the University of British Columbia and President of the International Society for Bipolar Disorders (ISBD) explained at the Seventh International Conference on Bipolar Disorder held in June:

"Rightly or wrongly our committee decided that for the time being it’s perhaps better to stick with the categorical system and … make refinements so that they become much more useful."

Whoa! What happened?

Walk, Do Not Run

Question time at the DSM symposium indicated that it may be prudent to exercise caution. As Nick Craddock MD, PhD of Cardiff University, who has made breakthrough genetic findings demonstrating an overlap between bipolar and schizophrenia, related: "We’re in the pickle we’re in at the moment because we have arrived at things through opinion and expert ideas rather than solid data." In light of the fact that a better biological understanding of what’s going on is years away, "it would be incredibly unfortunate if we set up an edifice of dubious categories."

This thinking is reflected in the Dr Charney’s section of the APA’s 2002 white paper:

"Current classification in psychiatry therefore resembles the medicine of 50–100 years ago, before the underlying pathophysiology of many disease processes was understood."

Dr Charney et al write that it will be years, "and possibly decades," before a suitable match between diagnostics and science is possible, and when it occurs it is highly likely that "current symptom clusters of DSM will ultimately not map onto distinct disease states."

In other words, today’s psychiatry may be to tomorrow’s psychiatry what astrology is to astronomy. We may be on the cusp of paradigm-rocking new insights, but we are not there yet. Before we start realigning our diagnostic universe, perhaps it would be advisable first to come to grips with the psychiatric equivalent of gravity.

So What Kind of Changes Are We Looking At?

In mood disorders, prudence is likely to translate into some fairly significant categorical clean-ups, but with no one from the Department of Nosology and Abominable Terminology wheeling in their heavy machinery and knocking down walls.

Various DSM-V workgroups will soon begin thrashing out the issues in anticipation of publication in 2012, but a taste of the future was offered in Dr Yatham’s presentation at the Seventh International Conference on Bipolar Disorders. His ISBD organization has no connection to the APA’s DSM-V Task Force, but it is difficult to imagine the respective conversations will be radically different.

At the conference, Dr Yatham informed his audience that the ISBD’s Diagnostic Guidelines Task Force has recommend no change to the current diagnostic criteria for pure mania. Mixed episodes are another matter. The DSM-IV recognizes only mixed states in bipolar mania. The ISBD committee wants to break mixed states into both mixed mania (full mania plus at least three depression symptoms) and mixed depression (full depression plus at least two depression symptoms).

Other recommendations:

* New criteria for bipolar depression, emphasizing hypersomnia and daytime napping, hyperphagia or increased weight, other atypical symptoms such as leaden paralysis, psychomotor retardation, psychotic features or pathological guilt, and lability of mood/manic symptoms. Other considerations include early onset of first depression, multiple prior episodes of depression, and family history of bipolar. (The DSM-IV criteria for bipolar depression is a mere copy and paste of its criteria for unipolar depression.)
* Hypomania would be modified to include mixed hypomania (with depressive symptoms) and reducing the four-day episode threshold to two days. Bipolar NOS would catch "unipolar hypomanics" and other diagnostic oddities.
* A new diagnostic category of "Bipolar Spectrum Disorder" would recognize recurrent depression without spontaneous mania or hypomania as a bipolar phenomenon, provided certain criteria are met. These might include at least six of the following: hyperthymic personality, at least three recurrent depressive episodes, brief depressive episodes (less than three months) atypical depressive symptoms, psychosis during depression, early age onset, postpartum depression, and lack of response to at least three antidepressants.
* Pediatric bipolar would require the presence of mania, hypomania, or mixed episodes, plus (if only irritable symptoms were present) evidence of decreased need for sleep.
* Schizoaffective disorder would include a bipolar type, depressed type, and schizophrenia type.
* Bipolar would include "longitudinal course specifiers" that would zero in on the dominant pole of one’s illness (depressive, hypomanic, manic), as well as recognize cognitive impairment during symptom-free states. The specifiers would also account for inter-episode recovery, seasonal pattern, and rapid cycling.

Significantly, the ISBD committee addressed, at least in part, nearly all of the issues detailed in Goodwin and Jamison’s Third Edition, listed at the beginning of this article.

The ISBD is scheduled to publish its final recommendations in early 2008.