09 juin 2008

La vie est une tragédie pour celui qui sent et une comédie pour celui qui pense.

Dante Gabriel Rossetti, The day dream, 1872.

Bipolar disorder was distinguished as a separate class by the occurrence of excitement, distractibility, agitation, and talkativeness in the patient’s life history. Parallel to the subtyping in the DSM category of major depression, the bipolar disorders weredivided into bipolar I with a single manic episode (with more recent episode mixedor depressed or unspecified), bipolar II (with hypomanic but not manic episodes), andcyclothymic disorder. The list of specifiers is similar to those in the major depressive category, with the addition of rapid cycling.

The new classification and specific criteria were quickly challenged by clinicians who could not fit their patients within the defined categories. In response, new diagnostic classes were included in the 1987 revision (DSM-IIIR) and again in the 1994 iteration (DSM-IV). The number of recognized diagnostic entities dramatically increased. The episodic nature of emotional illnesses was recognized in the definition of major depressive, manic, mixed, and hypomanic episodes that were combined into major depressive disorder (either single or recurrent), and further divided by the specifiers of chronic and severity/psychotic/remission and by the features of catatonia, melancholia, atypical, or postpartum onset. To the recurrent disorders, two additional specifiers of course and seasonal pattern were offered. This extended list of diagnoses was still considered insuYcient. Clinicians labeled variations in the duration of the illness, its seasonal features, diVerential response to medication, and mixtures of psychopathology as seasonal aVective disorder, atypical depression, double depression, brief recurrent depression, and endogenomorphic depression.

Mood disorders were separated by assumed precipitants and labeled major depression following childbirth (postpartum depression), in menopause (invonal depression), with aging (geriatric depression), and after the loss of a loved one (abnormal bereavement).

The labels were offered as if the psychopathology, course, outcome, or treatment of the condition was differentiable from other depressive disorders. In clinical practice, however, these situational precipitants do not define the presentation of the illness, the response to treatments, or the endocrine markers. The limitations of the present DSM classification are well recognized. The DSM-V iteration planned for the years 2007–2010 seeks a basis in experimental studies of genetic, neuroanatomic, neuroimaging, developmental science, and family criteria. Whether the neurosciences will oVer suYcient data to define a more useful classification is unpredictable.