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A study found that exercising and playing online games were the most common means of addressing mental health issues during the COVID-19 pandemic.

The international study, conducted by digital board game publisher Marmalade Game Studio, highlighted the mental health issues individuals have experienced during the pandemic and the steps these individuals have taken to address the issues. The study included adults from across France, Germany, Hong Kong, Singapore, and the United States. Nearly 6 out of 10 (57%) of all participating individuals reported experiencing mental health issues, with individuals in Singapore (65%) and Hong Kong (64%) the most affected, followed by France (57%), Germany (56%), and the United States (52%). The most commonly cited mental health issues were stress (38%), anxiety (30%), and depression (22%), with 4% of individuals reporting that they have had suicidal thoughts.

In order to address these issues, 38% of individuals reported exercising more, and 30% reported playing online games, with 29% visiting with friends and family more often, 27% seeking help from a doctor, 26% speaking to their loved ones, and 25% seeking help from mental health professionals. The study also found that 42% of gamers from the European Union said playing multiplayer games during lockdown made them happier, while 16% said that playing games online and connecting with others—particularly family—helped them during lockdown.

“The pandemic has had a huge effect on mental health globally, and millions have at points suffered from a range of conditions caused by worries about their own and others physical health as well as financial worries,” said Cristina Mereuta, Marmalade Game Studio co-CEO, in a press release. “Many people are clearly taking action, with increased exercise and online gaming appearing to be the most popular ways of relieving stress and anxiety. It is important, however, that people seek professional help where appropriate.”

Exercise and online gaming are helping beat mental health issues.

 News release. The Worldliness. April 6, 2022. Accessed April 21, 2022.

The most common issues during the COVID-19 pandemic included stress, anxiety.

Individuals Cite Exercise, Gaming as Top Ways to Address Mental Health Issues

, we connected with experts from across psychiatry to bring you thoughtful articles about a wide variety of psychiatric issues, including the latest in psychedelics; the relationship between neuroplasticity and smart phones; malingering in the COVID-19 era; and ethical considerations for vaccine mandates. Here are some highlights from the issue:

Psychedelics and the Future of Psychiatry

Over the past several years, we have witnessed a psychedelic renaissance, and a growing body of evidence suggests that several psychedelic compounds hold strong therapeutic potential for a wide array of mental health conditions.

Once dismissed as dangerous and having little therapeutic potential, 

 are gaining mainstream acceptance. Research data continue to demonstrate that, on the whole, these medicines are not only safe, but mostly well tolerated. Although more research is needed to better understand safety, especially in the context of at-risk conditions, these favorable safety profiles are enabling deeper exploration of these medicines. 

One of my favorite quotes from philosopher Jiddu Krishnamurti is, “Consciousness is its content.” It makes perfect sense. After reading a book, watching a movie, traveling to Italy, visiting with family over the holidays, finishing a grueling day at work, or surviving a traumatic experience, our mind retains the memories of these experiences in varying regions of our brain. If we ensure a 

, the memories of the previous day will be stored for long-term recall in various brain structures during the night by our hippocampus, along with neuronal connections that will allow us to reconstruct all these memory fragments to recreate the experience. 

Vaccine Mandate Exemptions for Anxiety: Ethical and Practical Considerations

Lauren T. Edwards, MD; Margaret Emerson, DNP, APRN, PMHNP-BC; David Cates, PhD; and Robert Steel, PhD

Many US health care institutions have established mandatory 

 vaccination policies to protect employees, patients, and the community, as well as to comply with the Occupational Safety and Health Administration’s anticipated emergency temporary standard requiring health care providers with 100 or more employees to ensure that staff are vaccinated.

 In response, some health care workers are submitting vaccine exemption requests for religious, medical, and mental health reasons, and organizations are challenged with determining the validity of these requests with little precedent to inform current policy. The purpose of this article is to discuss how behavioral health (BH) experts in one organization conceptualized anxiety-related medical exemption requests for the COVID-19 vaccine, in an effort to inform others confronted with similar circumstances. 

Malingering as a Maladaptive Pattern of Survival During the Pandemic

Teofilo Matos Santana, MD; Matthew N. Goldenberg, MD, MSc; and Seth Powsner, MD

 is a common challenge for emergency department (ED) clinicians, and disasters such as the COVID-19 pandemic tip more people into such dysfunctional adaptations. We present 3 cases of COVID-19–induced malingering. 

. And be sure to stay up-to-date by subscribing to the 

Do you have a comment on any of these or other articles? Have a good idea for an article and want to write? Interested in sharing your perspectives? Write to us at 

The experts weighed in on a wide variety of psychiatric issues for the Psychiatric Times February 2022 issue.

From the Pages of Psychiatric Times: February 2022

Everyone has experienced moments when one bad outcome convinces us we are doomed to a life of failure. These catastrophic thoughts are akin to making a proverbial mountain out of a mole hill. It is why after a breakup, we think no one will ever love us. It is that seizing fear when waiting on a doctor’s report. It is that gnawing feeling when someone vaguely texts “we need to talk.”

This exaggerated expectation that only the worst possible outcome will occur can exert a powerful and debilitating influence over our lives. Left unchecked, these catastrophic thoughts can set dangerous patterns that prohibit us from taking reasonable chances, following inspiration, or recognizing life’s silver linings.

As psychiatrists, we often encounter catastrophic thinking in our patients. We understand how difficult it can be to change these patterns, even with professional help. And while it is often easier to see this in others, the demands of our profession make us susceptible to falling into these very same traps. Tasked with supporting our patients’ well-being, psychiatrists—and physicians in general—feel enormous pressure to produce positive changes in their lives. When our patients suffer setbacks, it is hard to not take it personally. And it can cast a strong and deeply personal shadow of doubt on our abilities.

Then there are the traps of burnout that can lead to catastrophic thinking: regulatory hoops, the ever-increasing bureaucracy and paperwork, clinician shortages, training mandates, the threat of 

. Like a hamster on a treadmill, it is easy to feel that there is never enough time and no end in sight.

Getting out of a catastrophic funk requires following the same treatment and advice we might give our patients. This means asking for help when we need it—something many physicians find difficult to do. Our jobs require us to be stalwart and seemingly infallible, but without balance and mindfulness, we continue to walk a dangerous razor’s edge of catastrophic thinking.

Catastrophic thinking, also known as magnifying, is a kind of cognitive distortion—a thought pattern that is irrational or exaggerated. Psychologist Albert Ellis, PhD, first coined the phrase in 1957 as he was developing his rational-emotive behavior therapy, a precursor to modern-day 

. His ABC model involved an activating event, beliefs that were irrational, and the consequences of those beliefs. His theory was that our emotions and perceptions are not formed by an event—rather, how we think about the event directs how we feel.

Catastrophic thinking can be triggered by one’s perception of what is happening at present or what they anticipate will happen in the future. Situations that trigger magnifying usually fall into 3 categories: how we interpret vague or ambiguous information, how we cope with the loss of someone or something valuable, and fear—especially irrational fear.

Catastrophic thinking shares some similarities with 

. The difference is that anxiety may serve a purpose, such as justified fear, while catastrophizing involves irrational magnification. It is also linked to depression, where feelings of unhappiness and helplessness can trigger an avalanche of catastrophic thoughts. Catastrophizing is common among those who have experienced traumatic events, or anything that threatens their safety and security or shatters their sense of control. It is common among those suffering from 

 (PTSD), depression, and anxiety. Among combat military troops, those with high levels of catastrophic thinking were 29% more likely to develop PTSD. Additionally, those who experienced high levels of catastrophic thinking coupled with higher combat intensity were 274% more likely to develop PTSD.

Ironically, catastrophic thinking can serve as a dysfunctional coping mechanism. After all, if you are always expecting the worst, you will rarely be disappointed. But this comfort can come at a steep price—one that can increase debilitating feelings of anxiety, avoidance, and isolation.

Magnifying can also affect and intensify how we experience pain. This is especially true with those suffering from chronic 

. Pain catastrophizing can feed on the memory and 

 of past events, which can influence how patients perceive future pain. Additionally, it can cause patients to ruminate on it and ultimately feel helpless against the idea of it. Pain symptoms account for 80% of physician visits and $100 billion a year in health care expenditures and lost productivity.

 Because of this, it is essential for physicians to gauge patterns of catastrophic thinking in their patients—not just to recognize the exaggerations, but to notice symptoms of other potential problems. Patients suffering from painful medical disorders in particular report high levels of catastrophic thoughts, along with self-reported pain, disability, and fear-avoidance behaviors.

 In a worst-case situation, catastrophic pain is a risk factor for suicidal ideation in those suffering from chronic pain.

 is a leading cause of catastrophic thinking. Defined as emotional and physical exhaustion brought on by prolonged stress, burnout has been noted in 50% of physicians-in-training and practicing physicians.

 It is generally attributed to work environments rooted in excessive workloads, inefficient work processes, clerical burdens, work-home conflicts, and a lack of input or control, leadership culture, or organizational support. Female and younger physicians are more likely to report higher rates of burnout.

 can reduce one’s sense of effectiveness and personal accomplishment, leaving a person feeling emotionally drained. At worst, depersonalization associated with burnout can lead some to regard patients as objects rather than human beings.

 Physical symptoms include fatigue, body aches, 

, gastrointestinal effects, increased susceptibility to common infections, and disrupted sleep patterns.

Physician burnout is a common problem that has far-reaching effects. For patients, it can result in lower-quality care, medical errors, longer recovery times, and lower patient satisfaction. Physicians are more likely to experience substance abuse problems, depressive and 

, and motor vehicle crashes. The health care industry suffers at large due to reduced physician productivity, turnover, and less access for patients. All of this has resulted in $4.6 billion a year in costs.

The pandemic has created its own unique breeding ground for burnout, with 53% of health care workers reporting high levels. Heading into its third year, the rebounding pandemic and its relentless pressure on the health care system creates an environment ripe for catastrophic thinking. Rather than succumb to its pitfalls, awareness is the first step in fortifying our mental defenses.

Psychiatrists are particularly susceptible to burnout, more so than surgeons and other physicians. In some ways, the stakes are higher, as our patients are more prone to violence and suicide. Because we use ourselves as tools to treat patients, we are vulnerable to a powerful range of emotions. These include feeling powerless against illness, fear of becoming ill, and the obsessive need to rescue patients.

Ellis did more than identify catastrophic thinking. He highlighted a way out of it by expanding the original ABC model to include ABCDE. The “D” refers to the disputation of beliefs, which calls for irrational thoughts to be converted into rational ones. And the “E” represents the effects these new and healthier thoughts might have on a person’s well-being. One of the best ways to counteract catastrophic thinking is by challenging it. Ellis’ method of decatastrophizing involves posing rational questions,

-What is the worst thing that can happen?

Sometimes, saying “stop” out loud can help disrupt the pattern of repetitive negative thoughts. In the heat of the moment, it can be difficult to recognize catastrophic thinking as it is happening. The help of a clinician can clearly define these patterns and use a cognitive-behavioral approach to decatastrophizing. In some situations, clinicians may prescribe antidepressants or other medications to address the root causes of catastrophic thinking.

Over time, this hard work of observing patterns and reframing our reaction pays off in the form of hard-earned 

. Resilience is measured by our ability to quickly recover from stress. It is a way of building mental fortitude despite—and because of—life’s hardships. Another benefit is that it can drown out catastrophic thoughts by interpreting failures as opportunities to learn and grow. Techniques to build resilience include taking on challenges where the risks are reasonable, discovering one’s personal meaning of life, and being surrounded by people who believe in you. Other methods to build resilience include:

TM is a meditation technique that involves silently repeated mantras to help reduce stress and promote a relaxed state of awareness. In one of the author’s studies, health care workers during the pandemic who practiced TM for 3 months showed significantly improved symptoms of emotional exhaustion, anxiety, and 

 over time when compared to a control group.

 In another pandemic study, emergency clinicians who practiced TM experienced significant reductions in burnout, along with fewer symptoms of depression, anxiety, stress, and sleep disturbances.

 This practice turns down the volume of mental chatter by engaging full attention on our daily and mundane tasks. By focusing on the here and now, mindfulness can help practitioners gain broader awareness of cognitive patterns and better control over irrational thoughts. One study found mindfulness was predictive of lower levels of disability, anxiety, 

, and catastrophizing in patients suffering from chronic back pain.

Through structured body postures, breathing exercises, and cognitive-behavioral processes, practitioners learn relaxation and stress-management techniques. Studies indicate that SKY offers a therapeutic option capable of reducing symptoms of depression and anxiety.

 Exercise, healthy eating, and getting enough sleep all help shore up our defenses against catastrophic thinking. Being kind and tending to one’s needs can have a calming effect on our tendency to dwell on the negative.

 Web- and phone-based apps provide quick, anonymous options to those hesitant about seeking mental health treatment. This technology helps users track moods, learn mindfulness techniques and exercises, and keep catastrophic moods in check. One study found that online tools helped reluctant health care workers reduce stress, burnout, depression, and suicidal ideation.

 Provides daily games tasked with increasing happiness, reducing stress, and overcoming negative thought patterns.

 Provides mindfulness and meditative tools designed to reduce stress and improve focus and sleep.

 Helps users track moods with guided journaling, coping techniques, check-ins, and positive affirmations.

They say physicians make the worst patients. Our need to display strength and dependability can prevent us from seeking help when we need it. As a result, many of us would prefer to cope alone rather than admit weakness and face the silent judgement of our peers. But this thinking runs counter to what motivated us to pursue a career in mental health in the first place. We often preach that our overall health is deeply grounded in mental health. Physicians can improve overall patient care by identifying situations that lead to catastrophizing and burnout and taking measures to correct it.

Catastrophizing can be catastrophic, but it can be managed by building resilience. As physicians, we need to apply this to ourselves just as we do our patients. As the saying goes, “Physician, heal thyself.” Never has this been more apt than in the current pandemic.

is a neuropsychiatrist, cognitive neuroscientist, adjunct associate in the department of medicine at Duke University,

1. Selva J. Albert Ellis’ ABC model in the cognitive behavioral therapy spotlight. Positive Psychology. December 13, 2021. Accessed February 2, 2022. 

https://positivepsychology.com/albert-ellis-abc-model-rebt-cbt/

2. Seligman MEP, Allen AR, Vie LL, et al. 

PTSD: catastrophizing in combat as risk and protection.

3. Lonczak HS. Catastrophizing and decatastrophizing: a PositivePsychology.com guide. Positive Psychology. December 7, 2021. Accessed February 2, 2022. 

https://positivepsychology.com/catastrophizing/

4. Quartana PJ, Campbell CM, Edwards RR. 

5. Gatchel RJ, Neblett R. Pain catastrophizing: what clinicians need to know. Practical Pain Management. Accessed February 2, 2022. 

https://www.practicalpainmanagement.com/pain/other/co-morbidities/pain-catastrophizing-what-clinicians-need-know

Physician burnout: contributors, consequences and solutions.

Societal pandemic burnout: a COVID legacy.

Physician burnout: contributors, consequences and solutions

10. Joshi S, Vaishnavi S, Brucker A, et al. Targeting healthcare provider burnout during the COVID-19 pandemic. 2022 ATS (American Thoracic Society) International Conference, May 13-18, 2022.

11. Azizoddin DR, Kvaternik N, Beck M, et al. 

Heal the healers: a pilot study evaluating the feasibility, acceptability, and exploratory efficacy of a transcendental meditation intervention for emergency clinicians during the coronavirus disease 2019 pandemic.

12. Cassidy EL, Atherton RJ, Robertson N, et al. 

Mindfulness, functioning and catastrophizing after multidisciplinary pain management for chronic low back pain. 

13. Hamilton-West K, Pellatt-Higgins T, Sharief F. 

Evaluation of a Sudarshan Kriya yoga (SKY) based breath intervention for patients with mild-to-moderate depression and anxiety disorders.

Web-based tools and mobile applications to mitigate burnout, depression, and suicidality among healthcare students and professionals: a systematic review.

Here’s how to help patients—and ourselves—recognize cognitive distortions.

Defusing Catastrophe

(This is the second of a 2-part series. The first article discussed how categorization bias favors the DSM, and how to avoid the consequent narrowing of treatment options.—Ed.)

In part 1 of this series, I discussed cognitive biases related to inaccuracies in the DSM and some solutions for improving the process of shared treatment decision-making with patients. I noted that categorical DSM diagnosis and dimensional spectrum-based diagnosis can be used simultaneously, depending on which is most useful. 

Sometimes categorical diagnosis is better—eg, for legal purposes or for communication with other medical colleagues. Dimensional assessment more closely matches mood phenomena (see 

). But is dimensional assessment difficult for clinicians to use? Are binary diagnoses necessary for binary treatment decisions?

No. Treatment decisions are often not binary, but instead lie on a continuum themselves. Here are 3 treatment-decision spectra:

1. Degree of certainty regarding a patient’s position on the mood spectrum

2. Number of previous treatments, and response thereto

3. Acuity versus chronicity and impact on long-term risk preference

Take Ms Smith, who presented in Part 1 with depression, anxiety, and a history of trauma. After consideration of thyroid, other medical issues, and substance use, the categorical differential for a mixture of depression and anxiety symptoms includes posttraumatic stress disorder (PTSD); major depression with mixed features (or comorbid generalized anxiety disorder); bipolar II; and borderline personality disorder. These diagnoses can be extremely difficult to differentiate, as suggested by the overlapping symptoms shown in the 

What is a clinician to do? Likely what many readers have been doing for years: Choose treatment options by 

. Let’s examine this process using the hypothetical Ms Smith as an example.

If Ms Smith describes intrusive reexperience and avoidance, and if a PTSD-specific psychotherapy (eg, cognitive processing therapy or eye movement desensitization and reprocessing) is available to her, then your PAR (procedures, alternatives, and risks) discussion would emphasize these specialized therapies. But if PTSD is not clearly the basis of her depression and anxiety (her trauma might be predisposing, but not causative), then antidepressants and more widely available therapies would become more prominent in your PAR. As your certainty about the role of trauma in her presentation shifts, so do your treatment recommendations: not from black to white, but gradually from a strong preference for one treatment option toward another.

If Ms Smith’s history includes cutting behavior, suicidal ideation, and dramatic interpersonal chaos, dialectic behavior therapy is an obvious treatment option. If Ms Smith meets full DSM criteria for borderline personality disorder, then antidepressants are unlikely to be of significant benefit.

 But to the extent that borderlinity is not certain, an antidepressant becomes a more prominent option and psychotherapy options broaden; perhaps cognitive behavioral therapy (CBT) would have more value than dialectical behavior therapy (DBT). Your shared decision-making would be strongly influenced by how Ms Smith reacts to your description of antidepressants’ risk/benefit ratios, and the 2 psychotherapies’ relative strengths—a reaction that itself lies on a continuum from strongly favoring one treatment to strongly favoring another.

If borderlinity is not prominent, then the decision-making focus shifts to Ms Smith’s depression and anxiety symptoms. Your PAR discussion would include a comparison of psychotherapies:

CBT for depression, or a transdiagnostic CBT

 that can address her anxiety as well. The strength of her anxiety symptoms relative to her depression symptoms, which also lies on a continuum, would determine your emphasis.

Finally, if a history of hypomania/mania is obvious, then one would target Ms Smith’s depression using a mood stabilizer with antidepressant effects (MSAE): interpersonal and social rhythm therapy (IP/SRT)

; and/or lamotrigine, lithium, quetiapine, olanzapine, or lurasidone. But if her bipolarity is uncertain, then antidepressants and a more standard psychotherapy—CBT or interpersonal therapy—become options. The choice would depend on the question, “how bipolar is she?”—just the question advocated years ago by the STEP-BD research program’s principal investigator.

Is this process really any different from just making a DSM diagnosis and recommending the appropriate treatments? Yes. At minimum, one approaches one’s patients differently—not saying, “this is what you have, and this is the treatment for it,” Rather, one is in a humbler position vis-à-vis the patient, and vis-à-vis what we really know about psychiatric diagnoses. To Ms Smith, for example, you might say: “We cannot know for sure where on the mood spectrum you are, or how much your awful experiences account for the symptoms you have. But the treatment options are much the same: psychotherapy (not Freud, not about your parents, no couch), and/or a medication for the mood part. We can start with either or both. May I tell you more?”

In shared decision-making, one would then contrast the forms of psychotherapy to be considered and the medication options. As you know from experience, this choice becomes particularly complex around 1 variable: bipolarity. Will you suggest an antidepressant or an MSAE? This thorny decision is strongly influenced by a second continuum: your patient’s previous treatments and responses.

Many patients who come to see you with depression and anxiety will have already seen their primary care provider and been given a prescription for an antidepressant, or several, and sometimes even an atypical antipsychotic. Or you may have tried these medications and now must follow the old dictum: “When your treatment’s not working, reconsider your diagnosis.” Your next recommendation depends on the number of previous treatments and response thereto.

Consider Ms Smith again. If she is “treatment naïve,” many symptoms or markers of bipolarity would be needed to justify using an MSAE instead of an antidepressant. One might even require that she meet DSM criteria for bipolar II. But if she has had 2 antidepressants without sustained benefit, an MSAE is more worthy of consideration. And if she has had 3 or more antidepressants, and perhaps a reliable course of CBT, and is still coming to you for help, then you might consider an MSAE as one of her best options even if she has very few bipolar markers. This continuum is shown schematically in 

(Lamotrigine is a first-line option for bipolar depression in 2 guidelines, from the Royal Australian and New Zealand College of Psychiatrists,

 and from the Canadian Network for Mood and Anxiety Treatments and the International Society for Bipolar Disorders (CANMAT-ISBD).

 Lithium is also first-line in these guidelines. The logic behind the positioning of these 2 medications is summarized on page 18 of the latter guidelines.)

A third continuum: If Ms Smith has been experiencing depression (perhaps in episodes) for years, she is more likely to accept that her treatment may also need to go on for a long time, for the prevention of recurrence. For many patients, this long-view perspective increases their preference for treatments with very low risk and very few side effects.

Conversely, a very acute or very severe episode may prompt a wish for a treatment with the strongest evidence for benefit, even if side effects or risks or costs are high. This continuum is shown schematically in 

inherently difficult for clinicians, because clinicians are not making binary treatment decisions. Rather, their treatment recommendations lie on at least 3 continua. Categorical diagnosis is not required to guide treatment.

In this series, I have used the example of a patient with depression, anxiety, and trauma to examine 1) the cognitive biases that sustain the DSM and 2) the dimensional nature of treatment decision-making. I chose a mood disorder case to illustrate these ideas because that is the field I know best. But I believe the logic presented here applies across almost all psychiatric illnesses. Most are better discerned using a dimensional perspective as well as categorical one, and treatment decisions are better understood as continua than as binary choices.

We need not abandon the DSM to move forward—we simply need to add a dimensional view of psychiatric illness alongside our categorical system. Use the one that most helps you help your patient.

is research editor at the Psychopharmacology Institute, emeritus faculty at Samaritan Mental Health in Corvallis, Oregon, and founder of 

. He is the bipolar disorder section editor for 

Mixed features in patients with a major depressive episode: the BRIDGE-II-MIX study

Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials

3. Barlow DH, Farchione TJ, Bullis JR, et al. 

The unified protocol for transdiagnostic treatment of emotional disorders compared with diagnosis-specific protocols for anxiety disorders: a randomized clinical trial

4. Interpersonal and social rhythm therapy. 

Depression and Bipolar Workbook: 30 Ways to Lift Your Mood & Strengthen the Brain

The Bipolarity Index as a tool for assessment and creating rapport: an expert interview with Gary Sachs, MD

The 2020 Royal Australian and New Zealand College of psychiatrists clinical practice guidelines for mood disorders: Bipolar disorder summary. 

8. Yatham LN, Kennedy SH, Parikh SV, et al. 

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

Treatment decisions lie on a continuum—befitting a dimensional approach to diagnosis.

Depression/Anxiety: Dimensional Treatment Decisions

(This is the first of a 2-part series. The next article will discuss the spectrum nature of treatment decisions and how this can improve the process of shared decision-making with patients—Ed.)

Bipolar disorder (BD) is a categorical diagnosis according to the DSM—

. But bipolarity is increasingly recognized to be a spectrum phenomenon that warrants dimensional diagnosis—eg, per the chairman of the DSM-5,

 the patient has bipolar disorder, the head of the STEP-BD research program suggested in 2005 that we should ask, “

 Why then are we still using the DSM as though it were the only way to think diagnostically? Here is 1 reason: categorization bias.

 presents an example of bipolarity as a spectrum phenomenon. It includes structured interview results from 641 primary care patients referred for psychiatric consultation,

 using the CIDI 3.0—a bipolar assessment tool

 from the World Health Organization that has been used in primary care research.

The CIDI asks 2 questions about euphoria and irritability. If either is endorsed, another screening question asks whether this is episodic. If that too is endorsed, the full questionnaire

 is administered, containing additional questions about manic symptoms. The 

 shows the frequency of each score, from 0 to 9.

As you can see, among these patients—who were referred primarily for depression or anxiety problems—most scored 0 on the CIDI. But among the rest of the patients, scores created a bell-shaped curve. In this study, the same phenomenon was seen

 with additional questions about bipolar markers: family history, age of onset of depression, course of illness, and response to previous treatments. All these indicators of bipolarity lie on a spectrum from absent to fully present. There is no step-up—no obvious place to put a categorical diagnostic cut-off (including at 7 

 responses, which is the criterion used in previous research

Likewise, in clinical experience, hypomania/mania is also dimensional. Manic symptoms can present at any intensity. Some patients have the full experience, for which DSM criteria work well: That is bipolar I. Some patients have obvious hypomania that is observable to others: That is DSM-level bipolar II. But patients describe myriad variations of “up” symptoms.

If you have seen lots of patients with depression, you will have also observed the subtle forms of hypomania: a little more talkative than usual, a little more flamboyant, enthusiastic, confident. Needing less sleep, more motivated, energized. More willing to spend money. This state can accelerate into overt hypomania or mania, or just subside—or collapse into depression or become admixed with it. There are no cut-offs between such states in clinical experience—nor in patients’ experience. A brilliant example is presented in a newly published memoir, 

BrainStorm: From Broken to Blessed on the Bipolar Spectrum

 a bipolar II parallel to Kay Jamison, PhD’s, descriptions of the full manic-depressive experience.

If bipolarity is a dimensional phenomenon, why is the DSM still our primary diagnostic approach to mood disorders? Categorical and dimensional approaches can be used simultaneously,

 but multiple cognitive biases incline psychiatry toward the DSM (

recently examined another that is relevant to psychiatric diagnosis: categorization bias.

 (This analysis is replete with examples of the serious costs associated with this bias in the financial world.)

According to 2 marketing professors, our natural tendency to draw lines and create categories has 4 downsides:

1. Compression: One can lose sight of the many variations that exist within the category.

2. Amplification: One can exaggerate differences across category boundaries.

3. Discrimination: One can favor certain categories over others, insufficiently attending to other categories.

4. Fossilization: To quote John Maynard Keynes, “The difficulty lies not in the new ideas, but in escaping from the old ones.”

To these we should add 1 more crucial downside of categorization bias: 

, or the tendency to make a thing out of a label. As Kenneth S. Kendler, MD, a scholar of psychiatric diagnosis, put it, “our field has undergone a ‘conceptual creep’ in which our criteria have mistakenly become our disorder.”

 In his article entitled “The Problem of Reification,” former National Institute of Mental Health (NIMH) Director Steven E. Hyman, MD, suggested that categorization creates “epistemic blinders” that impede progress toward valid diagnoses.

An article in the American Medical Association’s 

 asserts that, like all humans, health professionals are subject to cognitive biases, and we must recognize the costs of these cognitive biases and the potential benefits of combating them.

 The article cites a clinical decision-making specialist who has suggested using “cognitive forcing” to reduce errors.

 means conscious consideration of an alternative diagnosis—or, in this context, an alternative diagnostic perspective (eg, dimensional in addition to categorical).

For example, suppose your next patient, Ms Smith, presents with depression, anxiety, and a history of trauma. Posttraumatic stress disorder (PTSD) is an obvious potential diagnosis. Diagnostic forcing would entail consideration of alternative diagnoses, such as major depression with mixed features. Nosologic forcing would invite letting go of distinctions between trauma, mood, and anxiety disorders. 

Does this mean “farewell to differential diagnosis,” as one expert lamented

 following a description of the complexity of mixed states?

 Not entirely. One can think both categorically 

dimensionally (perhaps not at the same moment):

a) What is the diagnosis? Does the patient meet DSM criteria for PTSD?

b) How mixed is this depression? How traumatic was the experience?

Perhaps the latter questions will not help a busy clinician. Aren’t categories better for guiding clinical decisions? As a clinician myself, I strongly disagree, but we can all easily agree that we want what is best for Ms Smith. If it helps her to say yes or no to a diagnosis of PTSD, fine. For example, a formal diagnosis might make it easier to strongly recommend psychotherapy as first-line treatment for PTSD, rather than an antidepressant. On the other hand, if Ms Smith struggles with the label; if her trauma was not profound and she does not have pronounced avoidance and intrusive recall; and if she has a first-degree relative with a clearly established diagnosis of bipolar I—then perhaps then perhaps inviting her to learn more about subthreshold bipolarity and its treatment options is the next step. I created a series of 6 5-minute videos for this purpose.

In the next segment of this 2-part series on psychiatric diagnosis, I will suggest that treatment decisions lie on a continuum just as psychiatric diagnoses do. Contriving diagnostic cut-offs does not facilitate these decisions—indeed, it can interfere with them. Instead, acknowledging the spectrum nature of treatment decisions can improve the process of shared decision-making with patients. I suspect this is what many of us are really doing even while operating under the DSM roof.

is research editor at the Psychopharmacology Institute; emeritus faculty at Samaritan Mental Health in Corvallis, Oregon; and founder of 

Bipolar disorder diagnosis: challenges and future directions

2. Angst J, Merikangas KR, Cui L, et al. 

Bipolar spectrum in major depressive disorders

Bipolar spectrum disorder masquerading as treatment resistant unipolar depression

5. Phelps J, Bale J, Squires III K, et al. 

Bipolarity in a collaborative care model variation: detection, prevalence, and outcomes

6. Kessler RC, Akiskal HS, Angst J, et al. 

Validity of the assessment of bipolar spectrum disorders in the WHO CIDI 3.0

7. Cerimele JM, Chan YF, Chwastiak LA, et al. 

Bipolar disorder in primary care: clinical characteristics of 740 primary care patients with bipolar disorder

ased Screening Scale for Bipolar Spectrum Disorders

Exploring cognitive biases toward the DSM and their avoidable effects on treatment decisions.

Anxiety & Stress Disorders

Individuals Cite Exercise, Gaming as Top Ways to Address Mental Health Issues

From the Pages of Psychiatric Times: February 2022

Defusing Catastrophe

Depression/Anxiety: Dimensional Treatment Decisions

Why Use the DSM When It Is Inaccurate? Cognitive Biases and Solutions

Higher Rates of Anxiety, Depression Reported Among Minority Children

ADHD and Generalized Anxiety Disorder: Hand in Hand?

Helping Patients Thrive This Holiday Season

My Life is Hell, Doc. Please Help Me!

The Unimaginable: Pregnancy and Infant Loss in Psychiatric Practice