One example (or perhaps counter example to your argument) is Premenstrual Dysphoric Disorder (PMDD). Its inclusion in DSM-5 and ICD-11 has given the diagnosis more credibility among researchers and clinicians. It may be coincidental, and is based purely on vibes, but I feel the inclusion gives impetus to improving clinical care for women with this disorder. It has also helped draw attention from media, the public and hopefully research funders.
It definitely helps to have a condition formally included. FDA approved Fluoxetine for PMDD before it was officially added to DSM-5 but formal inclusion has helped bring more attention to it. I don’t think folks are wrong to seek formal inclusion. I’m more frustrated that the medical and clinical communities give so much weight to the DSM in this regard considering how imperfect and fickle the process is.
"The way I see it, there are 3 separate questions:..."
One thing I always appreciate about your pieces, Awais, is the format. It makes it much easier for me to locate where, within the arguments you're engaging, my own disagreements actually sit (although in this piece I have none).
Part of the problem is it doesn't sit within DSM bipolar. Strictly speaking its a steroid psychosis. What I get from Brockington is that it falls under the bipolar "rubric" but Brockington's way of thinking about bipolar isn't quite like Akiskal’s "spectrum", it's more a diathesis concept which might seem like splitting hairs but somehow Brockington almost manages to create something with words like "rubric" and "diathesis" that both sides of the pond might almost be able to agree on. Then there is Brockington's "third pole", which sure as he'll isn't on the bipolar spectrum. So, much like Leonhard's bipolar wasn't Kraepelin's manic depression, so too Brockington's tripolar isn't really much like anything.
As David Healy pointed out, its a steroid psychosis, and if we want a biological psychiatry that has some merit. Better phenotype for research. Even if you think its the same fundamental diathesis, the course and picture are not bipolar 1, so it makes sense to study it as a separate phenotype. And anyone who really wants to crack the riddle of bipolar should understand that it's got exactly the sort of biological wedge needed to crack the case.
Just to explain why I think a diathesis model is not the same as spectrum model is that it opens the way for more distinctive syndromes to arise out of the same diathesis or type of fundamental weakness. You can technically do the same thing with a spectrum but it just not the same, a spectrum implies a different kind of overlap that I can't quite articulate, there is a difference, a spectrum places the overlap at the top, a diathesis places it more at the pathogenesis. It feels more like the way ataxia or epilepsy is classified. We don't talk about ataxia spectrums. The best part is a diathesis doesn't specify a single exact genotype, it suggests a similarity in the type of weakness that is recognisable. Similar pathways, similar points of failure. Its more like a small family of tightly related diseases with very similar pathology. You could say a spectrum is the same but I just don't think it gets the right idea across.
I find it interesting that the first 3 commenters are men.
I have a hard time seeing post-partum depression/psychosis as bipolar or even on a depressive spectrum if the woman has shown no symptoms of either illness prior to the post partum period. Of course, it could be that the pregnancy and/or delivery triggered the development of these illnesses. I don’t think enough is known about the vagaries of bipolar illness to make the assumption that one necessarily predicts the other.
How the pt. does after the post-partum period would be a stronger indicator of her overall mental health than a possible one-off episode in the post-partum period.
I’d be in favor of establishing post-partum issues as a separate entity in the DSM, at least until more is known about the true nature of bipolarity. Post-partum psychosis looks different from schizophrenic and other types of psychoses. Too soon to lump all psychoses together.
I appreciate this point, but I don’t know that it aligns with the meaning of the bipolar and depressive disorder categories. I think the closest analogy js Substance/Medication-Induced conditions, which are usually categorized with the symptoms observed -- for example Substance/Medication-Induced Bipolar and Related Disorders falls within the Bipolar and Related Disorders category. This doesn’t mean that people with steroid-induced mania had a biological predisposition, or are likely to go on to develop lasting bipolar disorder. Peripartum symptoms could easily be categorized in the same way; it wouldn’t imply the woman previously had an undiagnosed bipolar disorder, just that the acute peripartum period brought out a brief period of symptoms highly similar to a manic episode in presentation, course, and treatment response.
Thank you for an excellent article on two subjects that, for my entire career (over 30 years), have been the bane of attempts to formulate a decent system of psychiatry
As a male and a non-specialist in terms of post-partum issues, I feel more qualified to comment on your opening about the DSM (with the excellent cartoons and illustrations and with the acerbity that topic deserves) than on the equally good material on postpartum psychosis.
THE PROBLEMS WITH THE DSM ARE NOT LIMITED TO PSYCHIATRY, IN FACT THEY ARE NOT REALLY LIMITED TO ANY PARTICULAR PROFESSION, AS THEIR EFFECTS EXTEND THROUGHOUT SOCIETY.
In the crucial legal profession, there is almost no understanding or wish to understand the subtleties and controversies outlined in your post. Typically, legal professionals simply want a cut-and-dried “thing”, so that judges and prosecutors can say, “he did have that ‘diagnosis’ (actually syndrome) or she did not have that ‘diagnosis’ (actually syndrome).”
They like that because then one or the other or both can say, “That doctor was NOT within the bounds of ‘usual professional practice’ ”, which comes down to saying she or he violated the law.
I know from hard experience that in a recent courtroom proceeding, the DSM was the only psychiatric document actually to be found and referred to in the courtroom. It was treated as gospel, and in my opinion that is even worse than physicians treating it as gospel, because judges and lawyers have far more power.
A document flawed in the very serious, almost crippling ways that you outline so well does not deserve such power. I hope that you and other commentators on the DSM can either force enough improvement that it deserves any power it retains, or attain a true revision (instead of a performative revision), that will result in something that the profession can actually take pride in and genuinely value.
One example (or perhaps counter example to your argument) is Premenstrual Dysphoric Disorder (PMDD). Its inclusion in DSM-5 and ICD-11 has given the diagnosis more credibility among researchers and clinicians. It may be coincidental, and is based purely on vibes, but I feel the inclusion gives impetus to improving clinical care for women with this disorder. It has also helped draw attention from media, the public and hopefully research funders.
It definitely helps to have a condition formally included. FDA approved Fluoxetine for PMDD before it was officially added to DSM-5 but formal inclusion has helped bring more attention to it. I don’t think folks are wrong to seek formal inclusion. I’m more frustrated that the medical and clinical communities give so much weight to the DSM in this regard considering how imperfect and fickle the process is.
"The way I see it, there are 3 separate questions:..."
One thing I always appreciate about your pieces, Awais, is the format. It makes it much easier for me to locate where, within the arguments you're engaging, my own disagreements actually sit (although in this piece I have none).
Part of the problem is it doesn't sit within DSM bipolar. Strictly speaking its a steroid psychosis. What I get from Brockington is that it falls under the bipolar "rubric" but Brockington's way of thinking about bipolar isn't quite like Akiskal’s "spectrum", it's more a diathesis concept which might seem like splitting hairs but somehow Brockington almost manages to create something with words like "rubric" and "diathesis" that both sides of the pond might almost be able to agree on. Then there is Brockington's "third pole", which sure as he'll isn't on the bipolar spectrum. So, much like Leonhard's bipolar wasn't Kraepelin's manic depression, so too Brockington's tripolar isn't really much like anything.
As David Healy pointed out, its a steroid psychosis, and if we want a biological psychiatry that has some merit. Better phenotype for research. Even if you think its the same fundamental diathesis, the course and picture are not bipolar 1, so it makes sense to study it as a separate phenotype. And anyone who really wants to crack the riddle of bipolar should understand that it's got exactly the sort of biological wedge needed to crack the case.
Just to explain why I think a diathesis model is not the same as spectrum model is that it opens the way for more distinctive syndromes to arise out of the same diathesis or type of fundamental weakness. You can technically do the same thing with a spectrum but it just not the same, a spectrum implies a different kind of overlap that I can't quite articulate, there is a difference, a spectrum places the overlap at the top, a diathesis places it more at the pathogenesis. It feels more like the way ataxia or epilepsy is classified. We don't talk about ataxia spectrums. The best part is a diathesis doesn't specify a single exact genotype, it suggests a similarity in the type of weakness that is recognisable. Similar pathways, similar points of failure. Its more like a small family of tightly related diseases with very similar pathology. You could say a spectrum is the same but I just don't think it gets the right idea across.
I find it interesting that the first 3 commenters are men.
I have a hard time seeing post-partum depression/psychosis as bipolar or even on a depressive spectrum if the woman has shown no symptoms of either illness prior to the post partum period. Of course, it could be that the pregnancy and/or delivery triggered the development of these illnesses. I don’t think enough is known about the vagaries of bipolar illness to make the assumption that one necessarily predicts the other.
How the pt. does after the post-partum period would be a stronger indicator of her overall mental health than a possible one-off episode in the post-partum period.
I’d be in favor of establishing post-partum issues as a separate entity in the DSM, at least until more is known about the true nature of bipolarity. Post-partum psychosis looks different from schizophrenic and other types of psychoses. Too soon to lump all psychoses together.
I appreciate this point, but I don’t know that it aligns with the meaning of the bipolar and depressive disorder categories. I think the closest analogy js Substance/Medication-Induced conditions, which are usually categorized with the symptoms observed -- for example Substance/Medication-Induced Bipolar and Related Disorders falls within the Bipolar and Related Disorders category. This doesn’t mean that people with steroid-induced mania had a biological predisposition, or are likely to go on to develop lasting bipolar disorder. Peripartum symptoms could easily be categorized in the same way; it wouldn’t imply the woman previously had an undiagnosed bipolar disorder, just that the acute peripartum period brought out a brief period of symptoms highly similar to a manic episode in presentation, course, and treatment response.
Dear Awais,
Thank you for an excellent article on two subjects that, for my entire career (over 30 years), have been the bane of attempts to formulate a decent system of psychiatry
As a male and a non-specialist in terms of post-partum issues, I feel more qualified to comment on your opening about the DSM (with the excellent cartoons and illustrations and with the acerbity that topic deserves) than on the equally good material on postpartum psychosis.
THE PROBLEMS WITH THE DSM ARE NOT LIMITED TO PSYCHIATRY, IN FACT THEY ARE NOT REALLY LIMITED TO ANY PARTICULAR PROFESSION, AS THEIR EFFECTS EXTEND THROUGHOUT SOCIETY.
In the crucial legal profession, there is almost no understanding or wish to understand the subtleties and controversies outlined in your post. Typically, legal professionals simply want a cut-and-dried “thing”, so that judges and prosecutors can say, “he did have that ‘diagnosis’ (actually syndrome) or she did not have that ‘diagnosis’ (actually syndrome).”
They like that because then one or the other or both can say, “That doctor was NOT within the bounds of ‘usual professional practice’ ”, which comes down to saying she or he violated the law.
I know from hard experience that in a recent courtroom proceeding, the DSM was the only psychiatric document actually to be found and referred to in the courtroom. It was treated as gospel, and in my opinion that is even worse than physicians treating it as gospel, because judges and lawyers have far more power.
A document flawed in the very serious, almost crippling ways that you outline so well does not deserve such power. I hope that you and other commentators on the DSM can either force enough improvement that it deserves any power it retains, or attain a true revision (instead of a performative revision), that will result in something that the profession can actually take pride in and genuinely value.