
Clinical Conundrum: Approaching Bipolar Diagnosis Four Ways
We are using 4 different approaches to bipolar diagnosis, according to the author of this commentary.
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According to our informal
Our 4 different approaches may explain a similar wide difference in practitioners’ estimates of the prevalence of bipolar disorder. In an
Categorical or dimensional? (DSM or spectrum)
Note that one-third of practitioners endorsed the pure DSM-based categorical approach (option A in Figure 1). Technically correct. Efficient. And utterly at odds with bipolar phenomenology. Yes, the DSM operates this way, but even the DSM-5 chairman suggested that mood disorders “might be better represented as an affective disorders continuum, with variable expressions of bipolarity representing dimensions of underlying pathophysiologic processes” (emphases mine).
In 2008 the International Society for Bipolar Disorders, recognizing the chaos still evident in Figure 1, convened a group of bipolar specialists to review the available literature and make recommendations on how to approach bipolar diagnosis. The
Fortunately, “categorical or dimensional” is itself a false dichotomy. One need not abandon the DSM to incorporate a spectrum view. Patients whose symptoms are near the extremes-either in their presence or their complete absence-can be handled with the DSM approach, yes or no. Patients whose bipolar markers are less numerous or prominent warrant examination using a dimensional approach.
Gathering all the relevant data
The key to a fully informed approach to bipolar diagnosis is to gather all the relevant data. You take a family history, regardless of the presence or absence of DSM A criteria? Right, sure you do, we all do. But if that behavior is logical, then it is also logical to gather similarly clinically relevant data on other
Or you could just routinely administer a questionnaire to gather these strong markers and a few weaker markers as well, using the 2-page MoodCheck questionnaire (detailed in
Imagine the uniformity that would result if we all began our diagnostic assessment with the same database. Not just McBurney’s sign, or just an ultrasound or CBC, but all the relevant data on every patient. We might differ in our interpretation of those data and how to vary treatment accordingly. Indeed, surely we would, because we have almost no research to guide us when treating a patient with “subthreshold bipolarity” (the group whose numbers swell bipolar prevalence from 1.1% [BP I plus BP II] to 3.3% of the general population, and as much as 47% of all patients with depression according to one
(Does that 47% figure disturb you? Please see the abstract, and note the author list, all highly respected members of the
To move away from an embarrassing diversity of diagnostic approaches, now, Step One would be to decrease the diversity in the questions we ask of patients to detect bipolarity. We should gather all the relevant data, every new patient, every time. The DSM A criteria are no defense: a full understanding of bipolar phenomena dictates a more comprehensive approach. No more “I just look for McBurney’s sign”!
References:
1. Vieta E, Suppes T. Bipolar II disorder: arguments for and against a distinct diagnostic entity. Bipolar Disord. 2008;10(1 Pt 2):163-178.
2. Phelps J, Angst J, Katzow J, Sadler J. Validity and utility of bipolar spectrum models. Bipolar Disord. 2008;10(1 Pt 2):179-193.
3. Angst J, Azorin JM, Bowden CL, et al; BRIDGE Study Group. Prevalence and characteristics of undiagnosed bipolar disorders in patients with a major depressive episode: the BRIDGE study. Arch Gen Psychiatry. 2011;68:791-798.
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