Thomas R. Insel, M.D., Director of the National Institute of Mental Health, has issued a sharply worded condemnation of the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5).  The DSM has long been considered the “Bible” of Psychiatry and has recently been under attack from many angles, but this announcement might be a game changer. It will be interesting to watch how it all plays out.

According to Dr. Insel, “it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.”

When I look at how they account for time in the DSM-V, I wonder if they know anything about depression or bipolar. They know time plays an important role, but they don’t seem to understand the role that time plays whatsoever. By the way they define it, you can have a very low intensity depression for 14 days and it’s called depression, yet an intense depression for 13 days doesn’t count. This makes no sense at all, yet is the only accounting for time they provide.

Properly accounting for time takes an understanding of the relationship between time and intensity. You cannot learn that relationship by asking people a brief checklist of common symptoms as is done in the currently popular assessments. You need to know the right questions to ask.

I learned the right questions by doing more accurate assessments that include asking about the relationship at different intensities between awareness, understanding, functionality, comfort, and value mentioned in the previous articles in this series. This led to a deeper understanding of how to ask about time.

The most important question to ask about time is how long before each level of intensity causes one to lose functionality. When we base the answer on a thorough functionality assessment, we understand the relationship between time and intensity in ways the authors of the DSM completely miss.

Although intensity is a major factor in predicting how long one can remain highly functional, there are many others equally important. If one is not aware of the lowest intensities of depression or mania until functionality has already been lost, for example, there is very little time to do something about it and avoid another crisis.

Many bipolar people say they are “high-functioning,” but most of them mean they function OK when in remission and cannot function when things get too intense. How well one functions DURING depression or mania defines the difference between Bipolar Disorder and Bipolar IN Order. At every intensity, functionality influences the comfort of everyone involved and whether they see value in the experience. Functionality should be the central focus of any approach to bipolar instead of simply trying to make it go away.

Many think intensity of depressive or manic episodes is the determining factor in functionality, but evidence contradicts such belief. Far more important are awareness and right understanding as outlined in the previous articles in this series. With enough education and practice, intensity becomes far less relevant to functionality than most people believe.

Functionality does not mean driving as fast as your car will go or talking so much you take over the conversation. It must include the ability to do the things necessary to function in society. Measurements for physical, mental, emotional, spiritual, social, and career/financial productivity need to be part of the analysis. Real functionality includes the ability to get along with others and for them to be comfortable with your behavior.

The functionality scale, like the other items in the graph, runs from zero to one hundred percent in increments of ten. Fifty is a normal person during normal times. Less than fifty means that depression or mania is causing one to function less well than normal, whereas above fifty means functionality is enhanced.

When I first started putting together the protocol for assessing depression and bipolar disorder, I was working with a professor of Psychiatry to make sure the ideas were sound. His advice was to combine both awareness and understanding in the graph to keep it simpler. I am glad that I did not take the advice.

Awareness and understanding are different in ways that matter. Expertise might help someone understand why things happen, but does not necessarily lead to increased awareness. An expert on sex, for example, may be totally unaware that his wife is having an affair. It takes awareness (covered in the first article of the series) to know what is going on whether you understand the phenomenon or not.

It turns out that understanding is more related to functionality (covered in the next article) than awareness. You may be completely aware that you are sitting in a car, but unless you understand how to operate it you cannot drive.

Understanding is not just about knowing the physical, mental, emotional, spiritual, social, and career/financial aspects and their implications, it also includes knowing about the tools. You need to know how the tools work, have proficiency in using them, and understand which ones to use at each stage of bipolar – the disordered stages of Crisis, Managed, and Recovery, and the IN Order stages of Freedom, Stability, and Self-Mastery. I call this functionality-based understanding.

Too many people are holding out those who cannot function as the ones we should be listening to. Those who only know bipolar disorder and have not created Bipolar IN Order in themselves or others have no understanding of what it takes to make it happen. They can learn, but many times their beliefs limit their willingness to do so. They keep insisting it is not possible to be highly functional with bipolar and refuse to consider the evidence that contradicts such beliefs.

You can live in the same neighborhood for thirty years and still have little idea of what is going on there. You can shop in the stores, eat in the restaurants, talk with the neighbors, and feel that you know the community very well. But there are still more things going on than you know about. You simply never knew to look for them or were never taught how.

The police that work in the area know about crimes that go on right in front of you. The pest control people see things in the restaurants that might shock you if you knew they were there. Everyone from the woman in the plumbing shop to the guy selling pot (maybe even out of your own house) see things going on that you do not. The preacher knows about the spiritual goings on and the neighborhood doctor sees all of the injuries and illnesses.

When a thief sees a saint all he notices is his pockets. We all only see the things we have been trained to look for. As Paul Simon famously sang, “We all see what we want to see and disregard the rest.”

The same thing is happening in the depression and bipolar worlds. Many doctors and therapists only see it as a disease, family members see behaviors, and people with depression only see pain and suffering. There is so much more going on that none of them have been taught how to see. I have been teaching all three groups for ten years and am amazed how little awareness there is about very important details until I show them were to look.

This video is from a public television program called “Moving From Bipolar Disorder To Bipolar IN Order.” It explains what bipolar is and the difference between disorder and IN Order by detailing the six stages that one goes through as understanding and functionality improves. It outlines more complete assessments geared toward success, advanced tools that supplement existing tools, and stage specific plans that accommodate the needs of each of the six stages. It builds on the previous article called The Six Stages Of Bipolar And Depression.

The direct link to youtube for the video is http://www.youtube.com/BipolarAdvantage and http://www.bipolaradvantage.com goes into more detail about it. I would love to hear your feedback on it and where on the scale you think you might be at.

Moving From Bipolar Disorder To Bipolar IN Order

Everyone has up and down times. It is a natural part of life. If we observe our lives over time we might say there are two poles that we have; some days we feel on top of the world and other days perhaps on the bottom. That is the basis for the word bipolar and the reason I say that everyone is bipolar. Some may argue that there are people who are unipolar and only experience the up or down side, but even they have a range of experience with a “pole” on each end.

Unfortunately, the word bipolar is generally used to describe a subset of people who have adverse reactions when they go to far toward the high and low poles. Although related to how far from center one is, there is no distance from center that guarantees one would necessarily react to it in an adverse way. It really depends on how far we are from our comfort zone. One person might be perfectly comfortable and highly functional at a certain point from center while another could be so uncomfortable that he/she is literally in danger of suicide. I see the comfortable person as keeping life in-order, while the person in danger of suicide has lost control and is in dis-order. Using bipolar as a term to describe the dis-ordered person is an over-simplification that goes too far. We should at least distinguish the difference between having Bipolar Dis-Order or Bipolar In-Order.

But life is not even that simple. If I just won a marathon, for example, I might be very high emotionally yet completely drained and low physically. To really see where we are on the spectrum from high to low we need to consider all of the aspects of our lives: physical, mental, emotional, spiritual, social, and career/financial. It is probably more accurate at any given time to say that we are really in a “mixed state” instead of somewhere on a straight line between the two poles, so we must see even the expansion of bipolar to Bipolar Disorder and Bipolar IN Order as just a convenient simplification of a much more complex topic.

The Experts Are Asking The Wrong Questions About Depression And Bipolar Disorder.

Over the last ten years I have spoken with thousands of people diagnosed with bipolar disorder. When I ask them to relate their story of how they were diagnosed, a troubling pattern is pretty evident; the diagnosis was very brief and largely irrelevant in regards to bringing any hope to the situation.

Most people I have talked with see the assessment as a life sentence with no path for making life work the way they had hoped for. I wonder where they got that idea?

For the last five years I have been speaking to groups of therapists and doctors. When I tell them assessments are not thorough enough they are often in agreement about others, but believe their own assessments are very thorough and use the best evidence-based tools available.

What tools? The Beck Depression Inventory (BDI) takes about 10 to 15 minutes to complete the 21 questions in a self-report format including the items intended to measure symptoms of severe depression that would require hospitalization. The BDI has been used for 35 years and is reported as being highly reliable regardless of the population. The Hamilton Depression Scale asks only 17 questions. There are others, of course, but none provide the insight needed to achieve Depression IN Order or Bipolar IN Order.

http://jonathanwallacestudio.com/

I have been meditating for over 50 years. I started when, at five years old, I became fascinated with watching my breath go in and out. I intuitively knew that this and other meditative practices would bring me to a state of ecstasy. It didn’t take long before pursuing that state became the most important thing in my life.

Although I got incredibly close through my efforts in meditation, it wasn’t until I looked for ecstasy in depression that I truly found it. Once I found ecstasy in depression I found it everywhere. My hope is that sharing my experience might help others to find the same insights that I have.

As I watched my breath go in and out I found some dramatic changes in my state of consciousness. I would detach from my body and find myself floating above and looking down at myself sitting there. It was a very pleasurable state, but also very profound in how I viewed the world. I believed that part of me was untouched by the physical world; the part that I now call my soul.

It wasn’t long before my soul separations started encroaching on my waking states. I would often find myself turning the corner and suddenly being in a long tunnel with a light at the end of it. During those experiences time would stand still or at least slow down dramatically. I interpreted these experiences as seeing God.

Stigma, medication, treatment options, recovery, patient rights and physiological basis are some of the most discussed topics regarding bipolar. There are, of course, many other interesting aspects to debate, but it is hard to find any discussions about bipolar that do not include one or more of these central topics.

While it has been very healthy to debate all of them, there is an underlying assumption that must be addressed too.

The paradigm that all of the above topics are based on is that we are incapable of remaining in control when mania and depression reach a certain intensity.

We are therefor not responsible for our behaviors when manic or depressed because it is not possible in those states to choose better ones. This creates the goal of removing bipolar from our lives (at least at higher intensities) and the debate is about how it is best done. Much of the debate about medication, for example, is about alternative methods to achieve the same goal of reducing intensities of mania and depression.

But, what if we could be highly functional while manic or depressed? This idea has so many repercussions that people are afraid to even think about it. Consider what is at stake: If we cannot choose how to respond to the different states because it is impossible for anyone to, in-ability becomes central to the arguments in each of the above topics.

If anyone can choose, the impossibility argument is removed and the discussion becomes either how to function in mania and depression or why some cannot.