Q: Questions Regarding the DSM-V
Hello Dr. Phelps!
Even though my wonderful and patient psychiatrist often reminds me, "It's not
the diagnosis that counts but the treatment and the patient's response" I am
curious about what YOU think and hope will appear in the DSM, fifth addition due
out in 2012 regarding Bipolar Disorder.
Will the DSM recognize bipolar disorder as a spectrum disorder?
Will anxiety symptoms/disorders be in the mix?
How about the differences seen in sleep patterns, expand on the differences
between unipolar depression and bipolar depression, well you get my drift.
Besides expanding the disorder for clinical reasons my hope is that it might
help people with their insurance coverage-- but as a nurse, please don't get me
started on the American Health Care system.
Dear Barbara --
As you may know, the committees which will be
writing the criteria for diagnoses in the DSM-V are already underway. And
already the issue has arisen as to whether a "spectrum" point of view should be
incorporated in their system somehow (i.e. some of the principal players
involved have already expressed views on this issue, in print.)
So one might say that in some respects, the idea of
a "spectrum" has already been validated by the DSM- V. That is overstating it a
bit, or rather, the committee would probably say so anyway. As you also may
know, the international Society for bipolar disorders as already effectively
endorsed the concept of a bipolar spectrum perspective, in terms of its clinical
utility as well as descriptive validity (Phelps
They actually face a really painful challenge this
time around. More and more genetic data suggest that the conditions we treat
are truly spread out across a very broad spectrum (not infinite, but far broader
than our current categories allow). So the more we learn, the more
inappropriate it seems to have narrow diagnostic categories anymore. On the
other hand, as one of my colleagues put it, "it's not good to change your entire
diagnostic system too many times in one century".
In other words, even though they might recognize
the need for a rather massive change, there is definitely a downside to even
considering such a thing. For example, lots of data tracking is based on our
current system of discrete categories (for good health purposes such as
epidemiology; as well as some perhaps not so good purposes, like insurance
company databases). What would happen to our ability to track conditions if we
admit that there are myriad variations? A certain amount of "lumping" is
necessary to keep some "big picture view" intact.
As for anxiety symptoms being recognized as part of
"bipolar disorder", I don't know what they are thinking. I find a genetic
perspective progressively more useful, the more we learn. For example, I used
to use a rubber chicken to illustrate the concept of a bipolar spectrum (there
is no place at which to "cut at the joints" if it is a continuum, a truly
rubber chicken). Now I use a bicycle combination lock instead: many possible
combinations, but not an infinite number.
And as for the American healthcare system? You're
right, let's not get started on that. What an instrument of discrimination we
have managed to craft, perhaps inadvertently, perhaps not so inadvertently.
Thanks for your question.
Published November, 2008