Updating Diagnostic Language in Bipolar Disorder Treatment

In this video from on-site at Psych Congress 2023 in Nashville, Tennessee, Julie A. Carbray, PhD, PMHNP-BC, PMHCNS-BC, APRN, clinical professor at the University of Illinois at Chicago, and Jim Phelps, MD, emeritus psychiatrist at Samaritan Mental Health, navigate the complexities of diagnosing bipolar disorder and highlight the importance of comprehensive assessment beyond rigid classifications. Join Drs Carbray and Phelps as they explore the intersection of the traditional Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) framework and the emerging bipolar spectrum language and elucidate the concept of merging categorical diagnoses into a comprehensive continuum.

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Read the Transcript:

Julie Carbray, PhD: So Jim, I'm wondering, has the bipolar spectrum language really replaced the categorical DSM-5 kit diagnosis of bipolar disorder? What are your thoughts on this?

Jim Phelps, MD: Thanks for that question because as you know, this is an area of interest of mine for many years. If we replace the word replace with merged with, I think we could say yes, definitely. So the notion of mood disorders as a continuum from unipolar to bipolar with people all the way along in between a spectrum of mood disorders has been around for a long time. I've been touting this idea as an important clinical one for over 20 years. More recently, the DSM is moving in the direction of acknowledging spectral disorders like autism spectrum, for example. And so I think we're getting pretty close to having that for mood disorders. With the DSM-5, they didn't quite get there, but with the initiation of the mixed-state concept, we got closer. And a number of organizations, including the Australian and New Zealand Royal College of Psychiatry have announced that it is a mood spectrum.

In their most recent treatment guidelines, they even call it explicitly that, have a figure presenting it. If we think it has legitimacy and the DSM is still with us, and if we use the two together, the DSM works well for extremes, which makes the diagnostic criteria obviously met. But then there are so many people in between, and that's where I think we need to realize some data suggesting it's another half again, double the amount of people with bipolar 1 and 2 have sub-threshold bipolarity at least. There's that middle group that needs to be recognized with the spectrum concept, but we don't have to abandon the DSM. We can use them at the same time.

Dr Carbray: It really helps clinicians think a little bit more comprehensively around mood symptoms for our patients rather than having to pigeonhole into these buckets. It's not really buckets, it's more of the stream of different moods that we're really helping our patients.

Dr Phelps: It does make things more complex because you have to come up with sort of a probabilistic assessment. How probable is bipolar disorder? How much bipolarity does this patient have? Rather than a yes or no. So it's more challenging to kind of keep that in one's mind as you then progress to decisions about treatment and discussions with patients about treatment. But I think it's much more intellectually honest to the reality of the phenomenon of mood disorders as a spectrum.

Julie A. Carbray, PhD, PMHNP-BC, PMHCNS-BC, APRN, is a clinical professor of psychiatry and nursing at the University of Illinois at Chicago. Dr Carbray holds her PhD (93) and Master of Science (88) degrees from Rush University, Chicago, and her Bachelor of Science (87) degree from Purdue University in West Lafayette, Indiana. 

James (Jim) Phelps, MD, has worked in inpatient, outpatient, and primary care consultation and liaison programs for over 25 years, including private practice, while supporting a closet-academic’s habit of following the psychiatric literature. He is the author of A Spectrum Approach to Mood Disorders for professionals, and has written 2 other books on bipolar disorders for patients and families.