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DSM V - What would your BP classification recommendations be?


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I for one get incredibly irritated with DSMIV's classifications for bipolar disorder.

My first recommendation would be get rid of the stupid, erroneous label. Rename it to Manic Depressive Illness (MDI). Aside from not having two poles, I don't have a disorder, I have an illness, a disease, a medical problem that just happens to be handled under psychiatry.

Either add BPIII in the BP section, or add it to MDD since there are people who present mostly as depressed, do not respond to ADs but do to stabilizers.

Expand BPII, or more specifically reclassify to include all bipolar except psychotic. Recognize BPIIs experience mixed states, and possibly recognize that there are more than one type of mixed state. Add some classes for degrees of hypo/mania (see next point). Add something on inter-episode symptoms. Re-evaluate if four switches a year is the right number for rapid cycling (dunno on that one).

Reserve BPI for manic psychosis. Consider putting PB depression psychosis there, too, if there's science to indicate that psychosis in either state share the same or similar brain dysfunction. (Exactly what is the purpose of 'most recent episode whatever'? Really, what purpose does that really have? Hallucinates w/o meds - hmm, that might have research relevance.)

Basically, let the science dictate the categories as much as possible. Descriptions can be developed to guide clinicians. Right now the basis for classifications is backwards.

Yes, I really like spectrum theory as well. I'm also big on THE manual providing direction to research. Why? It helps increase the odds that research will break down what's studied in ways more apt to yield better understanding and better meds. Personally, I get a bit ticked that no meds are researched and developed specifically for this illness. The med development is primarily for epilepsy or schizophrenia. We're just lucky when they work for BP, too. In a nut shell... where the hell are antidepressants that I can take?

Enough of my thoughts.... What are your DSM-V recommendations.

Btw, here's the portal to actually make your thoughts known to those updating the manual.

[link=http://dsm5.org/suggestions.cfm" target="_blank][link=http://dsm5.org/suggestions.cfm" target="_blank][link=http://dsm5.org/suggestions.cfm" target="_blank]http://dsm5.org/suggestions.cfm[/link][/link][/link]

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i wouldn't rename it, for the reason that it used to be called manic depression, but the name was changed to bipolar affective disorder to avoid stigma. i'd like to avoid as much stigma as possible!

i'm all about the spectrum theory, but i have a problem with it too. it basically is dividing types of bp based on certain criteria, however we know that people can have milder manias but throw in mixed states, and milder manias but throw in psychosis (especially in the depressive phase), massive manias but no/hardly any depression, etc, and be treated wtih the same meds and in the same way. how many people with bp2 take what i do? i've come across more than 1 CBer who takes lamictal for bp1 and some for bp2, WB for both, Abilify for both, etc.

since pdocs basically treat to symptoms, what does that mean? to me, it means that there are too many variables in the presentation of bp to divide it into 1, 2, 3, whatever.

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Hmm.

I admit I hate the term "bipolar disorder" too and think a return to "manic-depressive illness" makes a lot more sense.

However I am actually not a huge fan of the spectrum theory or of broadening the definition to include everyone who .... doesn't respond to antidepressants, got hypomanic from antidepressants, periodically shops impulsively, or so on. Diagnoses get looser and looser and eventually they don't mean anything at all, which I find kind of annoying. I could see maybe further breaking down Major Depressive Disorder, to have a single subcategory for a recurrent type of depression, maybe seasonal, with atypical features (think bipolar II without the hypomania.) I don't think that entity should be categorized under bipolar disorder (or MDI), though.

You say

Expand BPII, or more specifically reclassify to include all bipolar except psychotic

but that IS the current bipolar II definition, no? All features of bipolar I without manic psychosis? (well, okay, there is that thing about no "severe impairment" or whatever, but since that's so vague I think psychiatrists generally use psychosis as the cutoff.) However, I'm not sure that's a good definition of bipolar II, since bipolar II is usually different from bipolar I in other ways besides not having psychosis. (And furthermore, the presence or absence of psychosis is not really sufficient to define to separate syndromes. Major depressive disorder with or without psychosis is still major depressive disorder, right?) BPII, as you mentioned ususally has significant inter-episode symptoms and often doesn't have the same kind of super-clear-cut episodicity as BPI. Plus depressive symptoms are heavily leaned toward the atypical, which they aren't necessarily in BPI. So maybe the criteria for BPII should take those things into account.

That is, in practice BPI and BPII are very different entities, but in the DSM it looks like BPII is "bipolar lite." Which is totally wrong. So I think the focus on differentiating the two should be (in addition to the absence of psychotic mania) clear episodicity and inter-episode remission, as well as the nature and chronicity of depressive symptoms.

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I understand, and probably share, the preference for "manic depressive" over "bipolar." It's more reflective of my experience too.

It's the preference for "illness" over "disorder", that I have some trouble with. I think because illness suggests something cureable, for one thing, something short term maybe, I'm not sure exactly what it is.

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How about "bipolar that responds to antipsychotics", and "bipolar that gets worse with antipsychotics due to akathisia".

I'm the latter.

And FWIW, I just randomly threw that one out, it's past 6PM and my mind's not functioning anyways, as usual.

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Good points, Sorrel. I think we are saying the same thing in a lot of areas, my choice of words was a bit confusing.

However I am actually not a huge fan of the spectrum theory or of broadening the definition to include everyone who .... doesn't respond to antidepressants, got hypomanic from antidepressants, periodically shops impulsively, or so on.

I don't believe spectrum theory has to place those with the above symptoms in BP. I do, however, believe that there are a couple of significant groups that should be categorized discretely based on probable physiological differences. Those w/major depression who don't respond to ADs but do to something else most likely have a different physiology than those who do. That type of thing is important for research. Build it and they will come... give it a label and it'll be researched.

Diagnoses get looser and looser and eventually they don't mean anything at all, which I find kind of annoying. I could see maybe further breaking down Major Depressive Disorder, to have a single subcategory for a recurrent type of depression, maybe seasonal, with atypical features (think bipolar II without the hypomania.) I don't think that entity should be categorized under bipolar disorder (or MDI), though.

Completely agree. That's the point I was trying to make. I guess I'm just a little more open to it being under BP if it is clearly defined as, hmmm, not really BP. ;)

You say
Expand BPII, or more specifically reclassify to include all bipolar except psychotic

but that IS the current bipolar II definition, no? All features of bipolar I without manic psychosis? (well, okay, there is that thing about no "severe impairment" or whatever, but since that's so vague I think psychiatrists generally use psychosis as the cutoff.)

Here's where I was not at all clear. I meant drop "BPII" and add categories. I didn't want to start creating new nomenclature, but was thinking something like MDIa, MDIb, MDIc, MDId, etc. MDIa = has experienced psychosis. MDIb = has experienced severe impairment, minor delusions only, etc, MDIc = has experienced significant mixed states, but not a or b. Et cetera. Most of this stuff is lumped together either under the most eloquently and clearly defined NOS category or BPII. Btw, I'm not attempting to identify the categories, just to illustrate. That said, I feel pretty strongly that the groupings should be by behavior that appears to link to a biological variation in the illness, which again is about prodding researchers (and most likely making dx'ing more meaningful to clinicians).

However, I'm not sure that's a good definition of bipolar II, since bipolar II is usually different from bipolar I in other ways besides not having psychosis. (And furthermore, the presence or absence of psychosis is not really sufficient to define to separate syndromes. Major depressive disorder with or without psychosis is still major depressive disorder, right?) BPII, as you mentioned ususally has significant inter-episode symptoms and often doesn't have the same kind of super-clear-cut episodicity as BPI. Plus depressive symptoms are heavily leaned toward the atypical, which they aren't necessarily in BPI. So maybe the criteria for BPII should take those things into account.

That's a huge point. And, yes, it is almost like two different syndromes. The thing I'd add is that psychosis does not necessarily preclude inter-episode symptoms. Since I really do not get why there are all those "last episode whatever" subcategories, I'd make something like inter-episode experience the subcategory instead. (I really believe that any competent pdoc notes mood when patients are seen. Map it, chart it, don't stick in a manual.

That is, in practice BPI and BPII are very different entities, but in the DSM it looks like BPII is "bipolar lite." Which is totally wrong. So I think the focus on differentiating the two should be (in addition to the absence of psychotic mania) clear episodicity and inter-episode remission, as well as the nature and chronicity of depressive symptoms.

Yep.

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I understand, and probably share, the preference for "manic depressive" over "bipolar." It's more reflective of my experience too.

It's the preference for "illness" over "disorder", that I have some trouble with. I think because illness suggests something cureable, for one thing, something short term maybe, I'm not sure exactly what it is.

Since MDD is taken, Manic Depression can't have disorder. That's the obvious that I'm sure you already got. To me 'illness' means disease, biological condition. 'Disorder' implies more of a psychological thing. Think PDs. No one calls allergies a disorder, no one says I have Hodgkin's Disorder. Makes sense?

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Since it's looking like recurrent depression and atypical depression could be closer to BD than to normal depressive disorder, mania as a diagnostic requirement needs to be ditched. Likewise, manic depression in the name is misleading. The classification needs to include everything that's cyclic, pretty much. It looks like a lot of textbooks, Jamison, for example, are already doing this.

I question if sczitzoaffective disorder as a thing that actually exists as something other than a catchall classification. It can probably be folded into bipolar and sczitzophrenia in a lot of cases.

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I question if sczitzoaffective disorder as a thing that actually exists as something other than a catchall classification. It can probably be folded into bipolar and sczitzophrenia in a lot of cases.

I've seen different mood component definitions. Some where depression is all that's necessary to qualify a schizophrenic as schizo-affective and others where some hypo or mania is required as well. I'm not that versed on the Schizos, but suspect this is more grey territory.

Interesting that you put the emphasis on the cyclical. The door that seems to open is anyone with a disorder that manifests in cycles would hall into the group... heheh (tongue in cheek)... holiday over-eating syndrome for example. ;) I do think there is something to the approach. I just need to see where the parameters are laid before jumping on the bandwagon. I haven't read much on it, so freely admit some ignorance. Off-hand I'd think it require a complete overhaul of DSM organization structure (which might not be a bad thing).

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Since it's looking like recurrent depression and atypical depression could be closer to BD than to normal depressive disorder, mania as a diagnostic requirement needs to be ditched. Likewise, manic depression in the name is misleading. The classification needs to include everything that's cyclic, pretty much.

Interesting that you put the emphasis on the cyclical. The door that seems to open is anyone with a disorder that manifests in cycles would hall into the group... heheh (tongue in cheek)... holiday over-eating syndrome for example. :)

Well, in this case it would be cyclic moods. ;) Which has been presented to me as something that;

a) Cycles from the same (or in the case of Depression - lowering) points on a scale that has a high point as Mania, and a low point as really severe depression.

b) You go between the moods without any other known cause. (Meaning it does it on its own without meds or life events directly causing it)

Part (b) was really the key part, and cause, of the conversation..

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I think (not that it really matters what I personally think) we should have related but separate classification schemes for etiology, for symptoms, and for treatment, and that the DSM should focus on the latter.

Confusing how something is caused with how it should be treated nets us the fake categories of "situational" and "biological" depression, and the notion that someone who's been depressed and suicidal for months following a really bad life event shouldn't get medication.

Confusing symptoms with treatment means that you give antidepressants to both people who are likely to go manic on them and people who are actually helped by them. (To get around this, clinicians and researchers look at family history, past response to medications, etc.) But you still want to know what the symptoms are because in terms of life stuff, people with major depression + anxiety are going to have similar problems to people with bipolar disorder where hypomania looks like anxiety.

Focusing on treatment for a lot of mental illnesses often means treating to the available medications, plus some kind of therapy (probably usually CBT, but maybe something else). This would be really unpopular with people who would feel it's pandering to drug companies, and it would be hard to entirely avoid that, but it would also be super-pragmatic. Plus it would get the notion of different kinds of therapy for different things more visible on the map.

It would also go out of date more quickly. But if they put it online and keep it more current... Like a DSMpedia, where you have to have high credentials to update stuff, and it would have to be approved.

Ideally these are all really the same thing - you know what specific causal factors make something to present the way it is and how different treatment will affect causation. But we just don't have that now; knowing what something really is (whether you think that's how it's caused or how it's presented) is intellectually interesting but only relevant to treatment when it translates well into specific recommendations.

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Confusing how something is caused with how it should be treated nets us the fake categories of "situational" and "biological" depression, and the notion that someone who's been depressed and suicidal for months following a really bad life event shouldn't get medication.

That's interesting. I didn't know that that is the common perception. I was diagnosed with "situational" depression when I was younger and still in my parent's house - and it really was. However, my treatment was the same. It was more semantics than anything..

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Guest ClaudiaP

In addition to changing back to manic depression (more poetic, more descriptive, more accurate, and more inclusive... plus, what stigma? There's no stigma any more, or at least it's not worse than bipolar), I'd like them to tighten up the discussion of "childhood onset" vs. adult-onset bipolar. I was a textbook case as a child for child bipolar, and I'm now, in my 40s, STILL a textbook case for child bipolar. Rapic cycling, mixed state, rage-dominated. Why distinguish this form of BP as being particular to childhood, when we know that many people experience it as adults?

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  • 3 weeks later...

i'm no expert and am not quite sure what changes should be made, but all i know is that personally i don't really seem to fit fully into any specific dsm category, yet i don't seem to be so symptomatically dissimilar to a lot of people roaming around on these boards (that is, the bipolar-esque, a lot of anxiety, mostly depressed, moody, no mania, but still know how to have a fucken good time types).

i think maybe we need our own little category and that lumping it in with bipolar disorder is just confusing the issue. and the same goes if it were to be thrown in with MDD too.

i say this mainly because i've seen people with full blown mania and i feel like their illness is miles away from mine. i feel stupid saying i'm bipolar because i have never experienced anything like this, and don't see how treatment that works for them is going to work for me (admittedly i haven't tried them all so i may be speaking too soon).

likewise with your run of the mill unipolar depression. i certainly have features, but then there's all this other stuff on top or that doesn't quite fit. and the many variety of treatments out there for this definitely don't work (eg AD's, psychotherapy, exercise, diet, etc etc). some are valuable, but as times goes by my illness gets worse, even if i cope a little better.

i assume this type of mood disorder originally got lumped into the bipolar category because of some evidence it responds better to mood stabilizers than ADs?? i'm not convinced that makes it the same illness - especially if you think about, for instance, how mood stabilizers were actually developed for epilepsy. different illness, same medication. get my drift?

and i'd be really keen to see a bunch of research done on this bipolar-esque depression that isn't clouded by what is already known about bipolar and unipolar depression. maybe it's a different beast and something new might be discovered? maybe if there was a different name for it i wouldn't get so bloody confused when reading about clinical trials and which illness category i actually fit into. it seems pretty hit or miss as to whether a bipolar treatment may or may not work for me.

most importantly i just think there needs to be something that lists all the possible symptoms more clearly. there's lots of stuff i never told my doctors about because i never thought they may be indicative of a more complex illness that depression.

as for the illness vs. disorder thing - it's kind of much of a muchness, but disorder seems pretty appropriate to me as it suggests a long term affliction that requires long term management, as well as reflects its distinction from a persons usual state. a disorder is as much of a disease as an illness is, but it's connotation is that it'll recur, and there is a potential for returning to normal between episodes. illness' are more something that either passes and you're better, or you die from. of course, there are exceptions to these rules. i guess to me disorder seems like more of a life sentence and that's kinda what i feel like i've got. but then again i use the word illness all the time, so what do i know?!

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i don't really seem to fit fully into any specific dsm category, yet i don't seem to be so symptomatically dissimilar to a lot of people roaming around on these boards (that is, the bipolar-esque, a lot of anxiety, mostly depressed, moody, no mania, but still know how to have a fucken good time types).

You are far from alone.

i think maybe we need our own little category and that lumping it in with bipolar disorder is just confusing the issue. and the same goes if it were to be thrown in with MDD too.

I agree. BPII already is crowded. At least the working dx assignment seems to be psychosis and complete mania are BPI while all else bipolar is BPII. Some pdocs will place more significant mixed states under BPI, but you get the idea. Adding in recurring depression and depression that doesn't respond to ADs seems like stuffing different illnesses into one already full category to marginal utility.

i say this mainly because i've seen people with full blown mania and i feel like their illness is miles away from mine. i feel stupid saying i'm bipolar because i have never experienced anything like this, and don't see how treatment that works for them is going to work for me (admittedly i haven't tried them all so i may be speaking too soon).

That may or may not be true. Using Lithium to supplement an AD has had success for years. Lamictal seems to work with some serious depression. Same story with Abilify and Geodon.

i assume this type of mood disorder originally got lumped into the bipolar category because of some evidence it responds better to mood stabilizers than ADs?? i'm not convinced that makes it the same illness - especially if you think about, for instance, how mood stabilizers were actually developed for epilepsy. different illness, same medication. get my drift?

I too question whether all these flavors of bipolar are the same illness. Different people respond to different meds. Periods between episodes vary. Degree of episodes varies. Dominant disordered affect state varies. Etc. At the same time, the main purpose for a med's development is almost irrelavent if it works for your particular brain cooties. (Ha, that said, I too feel like BP gets the left overs from epilepsy and schizophrenia.)

most importantly i just think there needs to be something that lists all the possible symptoms more clearly. there's lots of stuff i never told my doctors about because i never thought they may be indicative of a more complex illness that depression.

That would be useful beyond your brand of depression.

as for the illness vs. disorder thing - it's kind of much of a muchness, but disorder seems pretty appropriate to me as it suggests a long term affliction that requires long term management, as well as reflects its distinction from a persons usual state. a disorder is as much of a disease as an illness is, but it's connotation is that it'll recur, and there is a potential for returning to normal between episodes. illness' are more something that either passes and you're better, or you die from. of course, there are exceptions to these rules. i guess to me disorder seems like more of a life sentence and that's kinda what i feel like i've got. but then again i use the word illness all the time, so what do i know?!

Mostly, I would like to see the name go back to Manic Depression. MDD is taken, so Illness in next best.

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What's interesting to me is that the DSM started out as a research project to determine the percentages of people affected by certain types of neuroses/psychoses... particularly men people enlisting in the military who may be 'unfit' for duty.

While I agree that it's helpful to have names and taxonomy for the clusters of symptoms that get in the way of us having full, healthy, happy, productive lives, I also believe that the DSM creates more problems than it solves. I'm more of a Szaz kinda gal myself... let's talk about the problems in living that you experience.

But the DSM itself, while full of overlapping categories and incomplete symptom lists, isn't as much the problem (IMHO) as the paternalistic attitudes of folks with the MD and PhD etc behind their names who treat us as the illness (ie clusters of symptoms or "the bipolar in room 2") instead of whole human beings with factors that enhance our risk, resiliency, and overall functioning.

ETA: Yes, I know the DSM isn't going away anytime soon. I just like to fantasize. But what would make it better is to move toward more concrete and mutually exclusive diagnostic categories.

Peace,

Wooster (who clearly lives in her own little utopia in her head, but if the delusion keeps you sane...???)

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