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.

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.

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.

My recent article called “Why I Am Against Bipolar Meds” turned out to be less controversial than I expected. Some people refused to read past the title and that is unfortunate because the vast majority of those who commented said that it was a very fair assessment of both sides of the debate. There were several misconceptions, though, that need to be cleared up.

I mentioned the three stages of Bipolar Dis-Order and the three stages of Bipolar IN Order assuming most of the readers are familiar with the terms and my work. Unfortunately, that was not the case for many readers. In trying to keep the article to under 1000 words, I did not go into detail regarding the stages and what I mean by Bipolar IN Order.

This caused confusion for several Psychiatrists who assumed that Self-Mastery means remission. At the other end of the scale were several people with Bipolar Dis-Order who declared that they were in Self-Mastery when their statements seemed to contradict their self-assessment. It seems greater detail of the Bipolar IN Order concept is warranted.

The primary objective for someone with Bipolar Dis-Order is to lower the intensity of mania and depression and move away from Crisis toward Recovery. Bipolar IN Order is about becoming more functional in an expanding range of intensity and moving from Recovery toward Self-Mastery.

Many people say you should not discuss politics or religion with your friends because you might not be friends much longer. If your friends are Bipolar or associated with it in any way you might want to add meds to the list. The extremes both for and against meds give new meaning to the word Bipolar. The poles often seem further apart than the most intense debates in politics or religion.

I have been speaking with groups about Bipolar for almost ten years now and have tried my best to stay out of the debate. But many in the audience won’t let me. At the end of my talks I am frequently accosted by members of one camp or both. It is pretty clear that neither side even heard what I said and the only thing they listened for is whether I took their side in the only thing that matters to them. I didn’t validate their extreme point of view and they are furious with me.

In his song The Boxer, Paul Simon said, “Still, a man hears what he wants to hear and disregards the rest.” In my case they often hear things that were not even said. In their minds I gave a talk siding with the enemy.

I have always pretty much ignored the med controversy because it is not central to my message. Until now. I heard something recently that made me want to take a stand.

One of the many traits of being bipolar is the ability to see the world in a different way. Many might say it is a curse, but it can also be a gift when looked at from a positive perspective. This change in perspective can literally help you to see with greater clarity.

From early childhood, we have been taking tests to assess our understanding of the world. These tests have had a profound impact on us in ways that we are often unaware. They have created a world view that places too much importance on passing the test and not enough on learning more about ourselves. In some ways, the tests themselves have gotten in the way of what the goal was in the first place.

I have been wearing glasses for almost thirty years. Every year or so I take a new exam to make sure my prescription is still the same. The test seems simple enough: the clinician shows me letters at different sizes and asks me to identify what letters I see. Anyone who has a driver’s license has taken a similar test as has anyone who wears glasses or contact lenses.

A few years ago I discovered a major breakthrough that has completely changed my life. It has brought my life into focus in many ways. I share it with you in hope that it will help you to see better too.

“You don’t know the half of it” is a once-common phrase that is generally applied to negative things. It usually means that you don’t really know how bad it is. It is easy to see how bipolar people can use the phrase to describe how horrible bipolar disorder is to someone who does not experience it.

image by John Forward

I imagine many people would expect this article to be a rant on how people without bipolar disorder have no idea how bad we have it. I am sorry. It is not. It is for those who already know how bad it can be. They may not know the half of it, either.

I often joke that depression is so terrible that we sometimes wish we were dead and we act so badly during mania that everyone else wishes we were. It is good for a laugh, because we all know it has some truth in it. The horrible symptoms of depression and mania that can occur when an individual is in a disordered state are well known. They include physical, mental, emotional, spiritual, social and career/financial dysfunction.

Funded massively by the pharmaceutical industry, partly because it is one of their biggest profit centers, there have been countless studies about bipolar disorder and how to move people from crisis through managed stage to recovery. There are many who argue over the choice of tools to address depression and bipolar, but nearly everyone agrees on one thing: depression and bipolar are horrible mental illnesses that need to be removed from our lives. They don’t know the half of it.

Depressed individuals have a shorter life expectancy than those without depression, in part because depressed patients are at risk of dying by suicide.1 However, we also have a higher rate of dying from other causes.2 Some researchers conclude that we may be more susceptible to medical conditions such as heart disease.3 I had an experience that might point to another cause that we need to address: we don’t treat many health issues because we think they are just symptoms of depression.

Last winter, I went through one of the deepest depressions of my life. It was very intense physically, mentally, emotionally, and spiritually. It was a beautiful experience, but that is for another article. The physical aspect is what I want to focus on here.

My physical experience this time was far more intense than any other depression. I was in tremendous pain throughout my body, but especially in my digestive track and chest. I was also completely drained of energy. It took a tremendous act of will just to get out of bed. It was so intense that I found myself reviewing my life in search of any other time that I had similar experiences.