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No need to soften criteria

Vol. 8, No. 9 / September 2009

I am concerned about the article on “soft bipolarity” and easing the diagnostic criteria for bipolar disorder (BP) II (“Soft bipolarity: How to recognize and treat bipolar II disorder,” Current Psychiatry, July 2009).

I’ve found no issue as vexing as that of dealing with the “soft” end of the so-called “bipolar spectrum.” At that end of the spectrum, it can be very difficult to determine whether my patient’s symptoms are most properly attributed to 1 or more of several other DSM-IV conditions, most notably attention-deficit/hyperactivity disorder (ADHD), posttraumatic stress disorder (PTSD), and borderline personality disorder. Including overactivity would sweep in a multitude of patients with other diagnoses, most notably ADHD. A number of psychiatric conditions can cause at least 1 night of not sleeping. Softening the diagnostic criteria for hypomania to include only 1 night of sleeplessness would capture a number of patients who do not have BP.

In my clinical practice, I routinely encounter patients who I believe have been misdiagnosed with BP II or BP not otherwise specified by clinicians who are using “soft” criteria such as those promoted by Dr. Daniel J. Smith. These patients often have been exposed to a number of psychiatric medications that have caused adverse effects and have not lead to significant benefits. Instead of using “soft” criteria for BP, I adhere to the “hard criteria” for BP II and other conditions in the DSM-IV when making diagnoses, and I utilize evidence-based treatments for these conditions. Supporting my skepticism is the fact that patients who would meet soft BP II criteria often experience excellent responses to treatments for conditions such as PTSD or ADHD, and ultimately never require treatment for BP.

I believe there is real potential for harm to our patients in softening current criteria:

  • Overdiagnosis of bipolar disorder in my experience leads to underdiagnosis and undertreatment of other psychiatric conditions.
  • Diagnosis naturally leads to treatment, often with drugs that do not have good data supporting their use for BP II, as Dr. Smith states in his article.
  • Medications for bipolar disorder are among the most toxic medications used in psychiatry, with serious side effects, including renal failure, weight gain, Stevens-Johnson syndrome, and hypercholesterolemia.

Exposing more patients to these treatments without clear evidence that softening the diagnostic criteria identifies those with true bipolar disorder is a frightening prospect.

Joseph Lasek, MD
Associate medical director
University of Vermont College of Medicine
Burlington, VT

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