Questions Regarding the DSM-V
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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 et al).

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.

Jim Phelps

Published November, 2008

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