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.
Tom Wootton is CEO of Bipolar Advantage. Along with experts in complementary fields, including doctors teaching the next generation of therapists, their mission is to help people with mental conditions shift their thinking and behavior so that they can lead extraordinary lives. Tom is the author of three books: The Bipolar Advantage, The Depression Advantage, and Bipolar In Order: Looking At Depression, Mania, Hallucination, And Delusion From The Other Side.
Editor: Nadeem Noor
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.
Most people new to the concepts of Bipolar IN Order do not recognize mania until it is too late. As illustrated in the above graph, they typically have as little as a week before 40% (hypo-mania) escalates into 80-90% (mania) where they often completely lose control within an hour or so.
At that point, who cares if the DSM wants to call it something else? The person is in extreme danger and so are the people he/she comes in contact with.
Depression, on the other hand, often has a much longer window of time at both ends of the intensity spectrum. Even beginners can hold on to a 40% depression for a month or more and can endure an 80-90% depression for a day or so. In both cases, this buys critical time to use interventions to lower the state.
The equations change dramatically when we factor in a properly designed psychoeducation program. The assessments mentioned above play an important part of such education, but are only the beginning. Advanced tools based on improving functionality include, among other things, the skills needed to recognize depression and mania at lower intensities where functionality is enhanced. Stage-specific plans round out the program by providing detailed steps to take according to one’s stage of growth.
As one learns to recognize depression and mania earlier, there is a much longer window of time before the intensity escalates. Combined with intensity reduction tools, students find that a 20% mania can remain stable for up to a month before escalating. Depression often can last even longer. Early recognition and reduction tools are the hallmark of a good managed stage plan.
Freedom stage is where one begins to focus on increasing functionality at intensities still below what is often labeled hypo-mania (40%). Although most people function very well at 20%, their skills are challenged when the intensity hits 30% for longer than a few hours. As they develop greater understanding and skills, the length of time when they can function highly increases to thirty days or more. This gives them plenty of time to moderate the intensity if necessary.
With enough training and practice, most people can learn to function highly during 30% depressions and manias. By then they have taken the first steps toward IN Order instead of leaving their condition in disorder. They recognize higher intensities, including 40%, are beyond their current understanding and abilities, but are afforded a normal life with highs and lows comparable to people without depression or bipolar disorder.
Along with such changes, the time they can be in the more intense states without completely losing control lengthens. Their awareness and understanding is such that they not only recognize it earlier, but take necessary interventions in time to keep it from turning into a crisis.
Some people are motivated to do the work it takes to function highly at 40% intensities or higher. They see benefits in these hypo-manic and hypo-depressed states and are willing to follow a process that enables them to safely expand their range. They find they are enhanced by the states when they understand each so well that they are able to function highly during all states of 40% intensity and below. They, and importantly the people around them, become very comfortable with such states as their behavior proves mastery over both depression and mania within the bounds of 40% intensity.
Those who master 40% intensities find that they can remain in such states for 30 or more days without losing high-functionality and without undue risk of the intensity escalating. Some of us have mastered even higher states that would normally be called fully manic or depressed (80-90%), yet since we are highly functional and in full control for up to a month in mania and for several months in depression, the definitions of depression and mania as defined by the DSM no longer apply.
This renders the DSM guidelines moot and illustrates the lack of understanding I mentioned at the beginning. Basing a diagnosis on an arbitrary number of days or a simple list of symptoms is neither accurate nor very useful. It is a foolish waste of time (pun intended) without accounting for intensity, awareness, understanding, functionality, comfort, value, and a proper understanding of time.
Depression and bipolar are much more complex than most people are aware of. It takes far better assessments, tools, and plans than are currently in vogue to understand enough to function highly during more intense experiences. The first step is to recognize the limitations of the currently popular assessments, tools, and plans. Supplementing, and in some cases replacing, them with better ones will bring us to a much needed revolution in the way we diagnose and treat those who are still experiencing depression and bipolar in disordered ways.