Bipolar Blog posted an opinion piece today from a research psychiatrist, Mark Zimmerman, MD, who sees danger in expanding the definition of bipolar disorder in the DSM V. Some of you may already know that the DSM V is considering such diagnoses as "bipolar III" and "mood spectrum disorder" to describe those whose symptoms are "sub-threshold" for bipolar disorder, but are a little closer to bipolar than to unipolar depression.
This is a controversy in the psychiatric community, with some doctors, like Nassir Ghaemi, advocating for the expanded diagnosis.
I'm not sure what to think about this. My own official diagnosis is "depression with psychotic features". For whatever reason, my illness involves daily depressive mood swings that last from 3 pm until 7 pm. My illness cycles in a way that typical depression doesn't. While I don't have a bipolar diagnosis -- I've never had a hypomanic or manic episode -- I'm being treated in exactly the same way I would be if I were bipolar: I'm on a mood stabilizer instead of an antidepressant, with an antipsychotic thrown in for additional support. In my case, it doesn't matter what my diagnosis is called; the important thing is that I'm getting the treatment I need.
But it would be pretty easy for a pdoc to look at my symptoms and keep trying me on SSRI's, no matter that they sedate me. In that way I might be better off with some sort of expanded bipolar diagnosis.
On the other hand, as Zimmerman points out, there is a danger in expanding the definition of bipolar disorder to include people who've never had mania of any stripe but are considered "sub-threshold" in some way. There's no evidence that mood stabilizers are a better treatment for these folks, and mood stabilizers often have more unwanted side effects than SSRI's.
There's a bigger danger in misdiagnosing and medicating someone for bipolar disorder: some of these meds can actually cause the symptoms they're meant to alleviate. I've seen this first hand with my friend Anna.
Anna had been on SSRI's for years without really feeling an effect from them. Her depression worsened, and she was diagnosed as bipolar II based solely on the fact that over the years, she hadn't responded to trials of at least three antidepressants. So her pdoc tried a cocktail that involved a mood stabilizer, an SSRI, and an antipsychotic. At that point, she had her first hypomanic episode.
That was a year and a half ago. Since then her pdoc tried her on various combinations of meds in those categories. She wound up in the hospital several times. She had to deal with side effects like tremors, at which point her doctor put her on a beta blocker; then came the anxiety, for which her doctor put her on clonopin. She was finally able to talk her pdoc into giving her much lower doses of her meds.
She's finally stable, and no longer has to take other meds to treat side effects of the first ones. Needless to say, she resents losing a year of her life to the experimentations of her medical team.
In her case, it seems like the meds she's on actually induced her bipolar condition. Keep in mind that she'd never showsn symptoms of hypomania before her bipolar II diagnosis. In her case, it seems that an expanded definition of bipolar did not help to treat her illness.
I think the moral of the story is that whatever the DSM V committee decides to do with bipolar definitions, it would be nice if psychiatrists kept in mind that it's just a guideline. People do not fit neatly into their categories. When it comes to diagnosing a real, live, human being, the art, and not just the science, of medicine must come into play.
This is a controversy in the psychiatric community, with some doctors, like Nassir Ghaemi, advocating for the expanded diagnosis.
I'm not sure what to think about this. My own official diagnosis is "depression with psychotic features". For whatever reason, my illness involves daily depressive mood swings that last from 3 pm until 7 pm. My illness cycles in a way that typical depression doesn't. While I don't have a bipolar diagnosis -- I've never had a hypomanic or manic episode -- I'm being treated in exactly the same way I would be if I were bipolar: I'm on a mood stabilizer instead of an antidepressant, with an antipsychotic thrown in for additional support. In my case, it doesn't matter what my diagnosis is called; the important thing is that I'm getting the treatment I need.
But it would be pretty easy for a pdoc to look at my symptoms and keep trying me on SSRI's, no matter that they sedate me. In that way I might be better off with some sort of expanded bipolar diagnosis.
On the other hand, as Zimmerman points out, there is a danger in expanding the definition of bipolar disorder to include people who've never had mania of any stripe but are considered "sub-threshold" in some way. There's no evidence that mood stabilizers are a better treatment for these folks, and mood stabilizers often have more unwanted side effects than SSRI's.
There's a bigger danger in misdiagnosing and medicating someone for bipolar disorder: some of these meds can actually cause the symptoms they're meant to alleviate. I've seen this first hand with my friend Anna.
Anna had been on SSRI's for years without really feeling an effect from them. Her depression worsened, and she was diagnosed as bipolar II based solely on the fact that over the years, she hadn't responded to trials of at least three antidepressants. So her pdoc tried a cocktail that involved a mood stabilizer, an SSRI, and an antipsychotic. At that point, she had her first hypomanic episode.
That was a year and a half ago. Since then her pdoc tried her on various combinations of meds in those categories. She wound up in the hospital several times. She had to deal with side effects like tremors, at which point her doctor put her on a beta blocker; then came the anxiety, for which her doctor put her on clonopin. She was finally able to talk her pdoc into giving her much lower doses of her meds.
She's finally stable, and no longer has to take other meds to treat side effects of the first ones. Needless to say, she resents losing a year of her life to the experimentations of her medical team.
In her case, it seems like the meds she's on actually induced her bipolar condition. Keep in mind that she'd never showsn symptoms of hypomania before her bipolar II diagnosis. In her case, it seems that an expanded definition of bipolar did not help to treat her illness.
I think the moral of the story is that whatever the DSM V committee decides to do with bipolar definitions, it would be nice if psychiatrists kept in mind that it's just a guideline. People do not fit neatly into their categories. When it comes to diagnosing a real, live, human being, the art, and not just the science, of medicine must come into play.
I think the bottom line on the DSM V revision is that it is still working with "symptom silos," diagnosing on the basis of how an illness manifests itself, leading to treatments designed to eliminate symptoms. The conflicts about ANY of the proposed DSM changes are controversial because the whole concept of the DSM is becoming obsolete. We are at a tipping point, now that we (almost) have the tools to identify the underlying biological dysfunctions. Soon we will be able to develop treatments for a disregulated HPA axis, or weak pineal gland, or dietary gaba/glutamate imbalance -- any of which can result in the same symptoms, same (mis)diagnosis, same inappropriate treatment. Unfortunately for your friend Anna and a lot of us, not soon enough.
ReplyDelete"Symptom silos". What a great way of putting it. Your symptoms are mostly congruent with X Disorder, but there are a few here from Y Disorder ... well we'll just throw those in the X Disorder Silo and say that you have X. It will all work out, don't worry.
ReplyDeleteI can't wait for the day when we have tests that can reveal the underlying biological imbalances. I'm sure that (most) psychiatrists feel the same way.