Fun with the DSM-5: Bipolar Edition

In the last 15 years or so, one of the major trends in the treatment of children and adolescents is the increased prevalence of being diagnosed with Bipolar II Disorder. There has been significant speculation regarding the reasons. Among the concern is the problem of diagnostic creep, which means that the criteria required by the diagnosis becomes much more diffuse and non-specific. As a result, more people are identified with these vague sets of criteria.

Bipolar II is susceptible to diagnostic creep because there is a level of vagueness to its diagnostic categories as opposed to Bipolar I. Namely, the difference between hypomania and mania (an episode of mania will automatically result in a Bipolar I diagnosis) is enormous, particularly as hypomanic people still have insight and can be engaged in treatment, they just have a significant elevation in mood that can result in some impulsive or dangerous behavior (or they can also be wildly creative and productive).

Why is this diagnostic creep problematic? It is because psychiatrists and other clinicians are not able to have any reliable indicators of prognosis or best practices if more and more people are captured under the Bipolar II umbrella, particularly during development. It also prevents the adequate focus and development of treatment protocols for youth whose symptoms actually meet the criteria for bipolar II disorder and whose prognosis worsens each year they are not treated (indicating the need for psychiatric intervention). You end up capturing too many children with general mood dysregulation problems whose symptoms make be similar but not exactly meeting the criteria for diagnoses like ADHD, ODD, Bipolar II and PTSD (among others).

In response, the DSM-V has introduced a new disorder called Disruptive Mood Dysregulation Disorder.

Severe mood dysregulation is a syndrome defined to capture the symptomatology of children whose diagnostic status with respect to bipolar disorder is uncertain, that is, those who have severe, nonepisodic irritability and the hyperarousal symptoms characteristic of mania but who lack the well-demarcated periods of elevated or irritable mood characteristic of bipolar disorder. Levels of impairment are comparable between youths with bipolar disorder and those with severe mood dysregulation. An emerging literature compares children with severe mood dysregulation and those with bipolar disorder in longitudinal course, family history, and pathophysiology.

Longitudinal data in both clinical and community samples indicate that nonepisodic irritability in youths is common and is associated with an elevated risk for anxiety and unipolar depressive disorders, but not bipolar disorder, in adulthood. Data also suggest that youths with severe mood dysregulation have lower familial rates of bipolar disorder than do those with bipolar disorder. While youths in both patient groups have deficits in face emotion labeling and experience more frustration than do normally developing children, the brain mechanisms mediating these pathophysiologic abnormalities appear to differ between the two patient groups. No specific treatment for severe mood dysregulation currently exists, but verification of its identity as a syndrome distinct from bipolar disorder by further research should include treatment trials.


Makes sense in many ways, right? Better diagnosis=better treatment. Better treatment in youth might also mean that there will be a better prognosis for these children, whose untreated (or poorly treated) symptoms might result in depression and an array of anxiety disorders.

But what I struggle with is what I've struggled with throughout my time treating adolescents and adults. Namely, when we formulate diagnostic categories, are we addressing problems or are we bringing problems into being? Are we looking at mood dysregulation and medicalizing it, resulting in research and patents for big pharma while conveniently ignoring other factors that result in mood dysregulation, like poverty, economic instability, community violence and overburdened schools (and a lack of attention to individual learning needs and styles)? Are we using drugs and illness to resolve social problems? And when one's illness stubbornly defies categorization as it becomes increasingly prevalent in the population, why is the answer always to create new diagnostic categorizations or do you ask yourself, "Is there something else going on" ?

I'd be interesting in your input, as I am not anti-psychiatry at all, believing that medication can be beneficial. However, I am skeptical, as many in the profession are.

picture from here