I commend Drs. Lake and Hurwitz for their out-of-the-box thinking about bipolar disorder (Current Psychiatry, March 2006), but their argument is the weakest I have seen in a scholarly article. One misdiagnosis does not prove that every patient labeled as schizophrenic has been misdiagnosed.
The authors describe Mr. C’s initial presentation but offer few details on his behavior and symptoms, saying only, “within 2 weeks, Mr. C. switches from depression to a mixed, dysphoric mania.” What does that mean? What signs and symptoms were present?
The only evidence the authors present to support their conclusion is Pope and Lipinski’s 1978 paper.1 Drs. Lake and Hurwitz barely address the controversy surrounding these findings, saying, “We concur…that psychotic bipolar disorder includes patient populations typically diagnosed as having schizophrenia and schizoaffective disorder.”
Note that the authors did not write, “We believe that these findings indicate that patients who meet DSM-IV-TR criteria for schizophrenia really have a form of bipolar disorder.” This reversal is merely sleight of hand.
Worse, Drs. Lake and Hurwitz fail to note that a set of diagnostic labels and criteria such as DSM-IV-TR facilitates communication among clinicians and researchers. This way, when a new patient’s chart indicates a schizophrenia diagnosis, you know what to expect (psychotic symptoms, auditory hallucinations, downward spiral, etc.).
In practice, however, I have seen patients with nearly every psychiatric disorder who have been misdiagnosed with bipolar disorder, usually with little or no evidence of past hypomania or mania. One provider closed his clinic and referred his patients to me; each came with an (incorrect) bipolar disorder diagnosis.
I no longer know what to expect when I see a patient who has been labeled as “bipolar,” “manic,” or “mixed manic.” The diagnosis has been distorted to the point of clinical uselessness.
Lumping schizophrenia into this rubric would further cloud bipolar disorder diagnosis. Should we next lump in panic disorder? Social phobia? Vascular dementia? Cocaine dependence? While these suggestions are patently ridiculous, I have seen patients with each of these diagnoses labeled by another clinician as “bipolar.”
Maybe DSM-V should list a separate axis for mood dysfunction, which would fit the construct of a “bipolar spectrum.”
Mark P. Snyder, MD
Pinehurst, NC