Risk/Benefit Ratio for Further Expanding Bipolar Disorder
Psychiatric Times
By Allen Frances, MD
March 27, 2012
… Across the board, DSM-5 proposals consistently fail on 4 counts:
There has been a doubling in the ratio of bipolar to unipolar depression since DSM-IV. Some of this growth was the anticipated result of our introducing Bipolar II as a new diagnosis in DSM-IV. Some was caused by massive drug company marketing with resulting loose diagnostic and prescription habits—especially in primary care practice. DSM-5 should be promoting more careful diagnosis of Bipolar Disorder, not a further reckless expansion.
5. if a change results in more medication, they support it if at all possible.
I doubt that members of the Task Force would admit the truth of my number 5. if asked, or even to themselves. They just find themselves following that path over and over. I expect it’s downright Freudian, as in unconscious. Maybe a better term would be Harry Stack Sullivan’s term, "selective inattention." They just don’t notice that it’s happening. To admit the truth of number 5. would be personally painful, so the mind just goes around full awareness. Each of the changes has a rationalization attached that they believe. And if any of them were to read this, they would likely say, "See, those psychoanalysts make up stuff like that all the time" without giving it much thought.
But that’s the way my mind and the minds of the people I’m around work. When I write a prescription I don’t really want to write, I always have my reason, but there’s a discomfort. One has to learn to catch that discomfort before it evaporates, because if you don’t, you’ll develop a pattern of overlooking it, and do the same not right thing again and again. We’re told that if we insisted on having a Task Force without drug company connections, we wouldn’t have any experts at all. The obvious response would be to forget the revision altogether until that situation is rectified – because if that’s true, we already don’t have any experts. People who do the Frances four and the 1boringoldman number 5. aren’t running on expertise in the first place.
In the Voir Dire process in a courtroom, opposing lawyers don’t get to pick the jurors they want, they only get to eliminate the jurors they think are biased against their case. Maybe that’s the way we ought to pick our Task Force. And if a fair group can’t be found, there’s no real trial to be had. So move the trial or declare a mistrial. Barreling ahead just isn’t a reasonable option. If you think about it, the notion that we have to have a biased group is in·sane…
What makes the bipolar diagnosis so captivating is that not wanting to take what you’re prescribed is another “symptom” of your “illness”. It’s cruel. And every little oddity or non-oddity that is something other than evidence that the patient is fully embracing the bipolar diagnosis and medication for life as the answer is a “symptom”.
It has long been my understanding that the “pressured speech” of a manic episode is so intense and relentless that it’s difficult for the best actors to imitate. Now, it appears that speaking quickly is “pressured speech” which makes almost everyone in Manhattan bipolar.
Any statement of disagreement with psychiatrists and their minions can be labeled “grandiose” even when it’s a simple statement of fact that contradicts the conclusions of mental health professionals who think they’ve summed you up in 15 minutes.
And PTSD has all but disappeared because, I think, it is primarily pscyhological and moral. Once you’be been diagnosed as Bipolar II, talk of hyper-vigilance and triggers is “tangential” because all the patient needs to know is that he/she is “bipolar” and needs to stay on medication for life. The field has become “mindless” indeed. And cruel. And toxic. And incapacitating.
For people who are genuinely manic-depressive, there may be much good in proper medication at times, in the right measure; but still people with a severe mental illness also suffer from other problems that should be dealt with in their own right and not explained away as another symptom.