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The Debate Goes On

Bipolar Spectrum Disorders in DSM-V

By Rakesh Jain, MD, MPH
Posted on
September 01, 2010

"What will be the representation of the Bipolar Spectrum Disorders in DSM-V?"
There is no doubt that the single most discussed, argued over, and controversial topic is what you are alluding to—What will DSM-V do with the Bipolar Spectrum Disorders!
This question was asked at the recent Treating the Whole Patient: The Mind Body Connection in Psychiatric Disorders all day CME meeting in Newport Beach, Calif. If you were there, you received exposure to a tremendous amount of cutting edge, practical information. And if you were not there, fret not—we are going to conduct an even more expanded CME program at the 23rd Annual U.S. Psychiatric and Mental Health Congress in Orlando, Fla., from November 18th to the 21st. I hope you will come attend.

Why this controversy? The reason is simply: we clinicians are seeing a very significant number of patients who clearly have mood symptoms that do not fit either major depression, nor DSM-IV-defined Bipolar I or II Disorders. These patients also often do poorly on antidepressants. So what do we call them? A search of DSM-IV leaves many of these patients without a “diagnostic home.” This is not just an academic matter where we clinicians feel compelled to label patients correctly—the diagnosis we give our patients often has profound short- and long-term implications. An error can have significant negative implications, such as incorrect medication choices, treatment misadventures, loss of patient confidence in the psychiatric profession, and worse.
Therefore, we are often forced to use terminology such as “Bipolar Spectrum Disorder” to label these patients who have some symptoms from the mood disorder criteria, but not enough to be fully inclusive. What is not in doubt is that these patients are suffering from their symptoms. The problem is that DSM-IV is completely silent on the spectrum issue: each clinician creates their own definition of what is a spectrum and what isn’t. Speaking for myself, my acceptance of the spectrum concept of bipolar disorder has lead to significantly better treatment outcomes for many of my patients. My treatment choices are better and more effective now that I am willing to accept that many patients will not neatly fit any categories, but I still have an obligation to help them.
Let’s quickly examine a recent article by Angst and colleagues.1 These data are from the National Comorbidity Survey Replication study (NCS-R), which finds a whopping 40% of patients with major depression have subthreshold hypomanic symptoms. An amazing 40%! This is not, therefore, a rare event. What would we call these patients—bipolar? Well, we can’t if we stick to DSM-IV criteria, so we end up using the amorphous phrase: Bipolar Spectrum Disorder.
This categorical/dimensional split is vexing to both clinicians and researchers. Vieta and Phillips, in a recent article, have tackled this topic head on and I recommend reading their article.2
DSM-V, expected to come to life in the next few years, has indeed taken an interest in this issue. While the American Psychiatric Association is (APA) at the point of gathering feedback, it has put out some suggested criteria. While one cannot predict what the ultimate shape of DSM-V will be in regards to this issue, one thing appears to be clear—it will have a more dimensional approach to diagnosis, in contrast to just a categorical approach. I see both advantages and disadvantages to this changed approach, but mostly advantages.
The advantages: the dimensional approach will be a far better way to diagnose nearly all patients we see in our practices. For example, new research studies will look at treatment outcomes in dimensionally ill patients, and not just the categorically defined patients; and patients with both mild and severe illnesses will justifiably be given psychiatric attention. The downside is the backlash one can expect from the lay public and the press. They might raise objections such as: Is Psychiatry trying to say everyone has mental illness? If everyone has some symptoms, does it mean everyone is ill and therefore should take medications? Is the APA trying to be a marketing tool for pharmaceutical companies in order to sell more medications? While these points are false and without merit, we mental health clinicians will have to deal with these questions if and when the dimensional approach to making a diagnosis becomes part of DSM-V.
If you wish to read more on this issue straight from the DSM-V committee, check out this link:

As the host for the 2010 Psych Congress, I will have a face-to-face, live interview with Dr. Alan Schatzberg. As you know, he is the past president of the APA and has played a significant role in DSM-V’s creation. This question regarding Bipolar Spectrum Disorders will be one of the hot topics that I will discuss with him. Please come to the 2010 Psych Congress to watch and hear this event live! You are also welcome to write to me here at our Community Forum and suggest questions I should ask Dr. Schatzberg!
Rakesh Jain, MD, MPH

  1. Angst J, Cui L, Swendsen J, et al. Major depressive disorder with subthreshold bipolarity in the National Comorbidity Survey Replication. Am J Psychiatry. 2010;[Epub ahead of print].
  2. Vieta E, Phillips ML. Deconstructing bipolar disorder: a critical review of its diagnostic validity and a proposal for DSM-V and ICD-11. Schizophr Bull. 2007;33(4):886-892.

As usual, Dr. Jain, you are right on target and I am particularly grateful because a voice with your specific weight is putting this neglected topic on a public forum.
A decade ago the creator of the term Bipolar Spectrum Disorders, professor Akiskal, wrote in the Journal of Affective Disorders:
“The patients seen today in psychiatric practice deviate considerably from such a classical prototype. The rubric classical bipolar disorder is generally reserved for non-mixed euphoric mania that alternates with depression in a cyclical, episodic fashion. I haven’t seen such patients in this strict sense for a long time. Most patients have rather subtle presentation.”
In my experience this is a reality that can no longer be ignored by the APA. Just today I evaluated a patient who was talking of a sister with a "serious case of bipolar disorder…in and out of the psych ward." After listening to her concerns about the severity of her sibling it would ill-advised to say, "by the way, you also have bipolar disorder."
My patient is high functioning professional with severe insomnia due to a racing mind, unstable relationships mostly because of impulsive decisions and a person who "gets irritated by little things." I was able to sell the concept of Cyclothymic Disorder as a "mild form of mood disorder which is treated with the same medications used for bipolar disorder but at lower doses."
In the somatic medicine with make the distinction between Insulin-dependent diabetes and Type II diabetes because these illnesses have the same "last name" but they are very different.

Finally, I also want to congratulate you for highlighting the fact of a poor response to antidepressants. I strongly believe that those patients with "Treatment-Resistant Depression" are in fact cases of bipolar spectrum disorders who fail every known antidepressant because they don't have "depression" but mood swings. To my critics I always ask: give me a pharmacological explanation that could justify the depression of a person on 3 drugs that (combined) bind with every receptor associated with depression.
See you at the Psychiatric Congress in Orlando.

Manuel Mota-Castillo, M.D.
Lake Mary, Florida
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