The Danger of Broadening the "Bipolar" Diagnosis in the DSM V

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.

Does Lithium Work by Resetting the Body's Clock?

Biplolar Blog featured a really interesting story about a recent study of lithium.  Lithium, of course, is one of the go-to meds for bipolar disorder.  Scientists at Manchester University have discovered that the drug inhibits a "clock protein" called GSK3 (damn that GSK3!) which inhibits the the body's circadian rhythms.

This finding is interesting for a couple of reasons.  First, it suggests that bipolar disorder is due in part to a dysfunction in the body's natural wake-sleep cycle.  Second, it provides a refined target for possible new medications.  Potentially, these medications may lack the side-effects of lithium -- side effects that often cause people to give up on the drug entirely, triggering another bipolar cycle.  Finally, it sheds light on why so many people find light therapy, which also affects the body's rhythms, to be so effective at treating mood disorders.

Given all the problems I've had with my internal clock, and all the crazy shit I've had to do to regulate it, I gotta say this makes a hell of a lot of sense to me.  You can read the whole article here.

"Falling Back": SAD, The Return to Standard Time, and How I Survived It

On Sunday, the clocks officially got turned back by an hour.  On the plus side, an extra hour of sleep.  On the minus side, the sun sets an hour earlier.  And on the double-plus minus side (ha! see what I did there?), at this time last year is when I really began to lose it.

I was at home in Minnesota for a family wedding a year ago.  My visit had been great.  We'd had a lovely, late Indian Summer*.  The days were balmy -- I didn't even need a coat most of the time -- but the nights were cold enough that frost was forming on the ponds.  Since we've all grown up, the younger family members and friends have scattered all over the country, and all over the world.  Most of us (not me) have demanding careers.  We hadn't all been in one place since my brother graduated from high school ten years before.

After the wedding reception we set our clocks back (which, I'm just now realizing, means the happy couple added an hour to their wedding night ... clever!).  The next day we had a nice post-wedding brunch at one of the bride's parents homes.  And when we started home at around 4:30, and it was already dusk, I thought, bleahhh ...".

John McManamy and the People's DSM: Finally, some reality.

I've been reading John McManamy's site recently.  He's the author of Living Well with Depression and Bipolar Disorder, a highly regarded book that I haven't read yet.  He's a journalist, he lives with bipolar, and he's got a pretty good grasp of brain science.

He's also got a fascinating project going called The People's DSM.  The forthcoming revision of the DSM 5 has a ton of problems.  It contradicts itself, it ignores the role that stress plays in triggering mental illness, and it generally continues the fine DSM tradition of lacking real scientific basis.

The People's DSM is an effort to create a way of categorizing and diagnosing mental illness based on the actual realities of -- get this -- people who have actual mental illnesses.