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Diagnosing Bipolar Disorder: Signs and Symptoms

Alan Podawiltz, DO, MS, FAPA

Department of Psychiatry, University of North Texas Health Science Center, Fort Worth

In everyday speech, words like mania or depression are ubiquitous. For example, people who say they are depressed after a bad day may merely mean that they feel disappointed or demoralized. People may say they are manic if they simply feel happy and full of energy. However, when used in psychiatry, these words convey the presence of clinical syndromes. The clinical diagnosis of bipolar disorder, including mnemonics for identifying manic and depressive episodes, is described in this activity.

Epidemiology of Bipolar Disorder

In the community, the prevalence varies from 0.4% to 1.6% for bipolar I disorder and is about 0.5% for bipolar II disorder.1 The average age at onset is 20 years.2 Bipolar I disorder occurs equally in men and women, although bipolar II disorder is more common in women.1 Having a first-degree biological relative with bipolar disorder increases the risk of having the condition; 4% to 24% of relatives have bipolar I disorder and 1% to 5% have bipolar II disorder.2 Studies3 of twins have confirmed the high heritability of bipolar disorder: concordance rates are 65% to 100% in monozygotic twins and 10% to 33% in dizygotic twins.

Diagnosis of Bipolar Disorder

In the DSM-IV-TR,2 bipolar I disorder is characterized by the presence of at least 1 manic or mixed episode in the patient's history. Major depressive episodes have usually occurred as well but are not required for the diagnosis. Patients with bipolar II disorder have a current or past major depressive episode but have never had a manic episode; instead, they have a current or past hypomanic episode. Clinicians will not find bipolar II disorder in most electronic medical record systems but can use the category "bipolar disorder NOS" instead.

Besides the affective features of bipolar disorder, which can include depression, anxiety, euphoria, and irritability, clinical features of bipolar disorder can include behavioral, psychotic, and cognitive symptoms, as well as suicidal thoughts or actions. Suicide is more likely to occur during depressive or mixed episodes and is completed in 10% to 15% of patients with bipolar I disorder.2

Bipolar disorder usually has a relapsing and remitting course, and patients' functioning during episodes clearly differs from interepisode functioning in which patients are often well, or much improved. Tools such as the MDQ can help screen patients for bipolar disorders.

Manic episode. Mania is a state of elevated, expansive, or irritable mood that is severe enough to either impair functioning or lead to hospitalization, or that has psychotic features. Psychosis occurs in over 50% of patients with manic episodes.4

AV 1. Symptoms of a Manic Episode: DeTeR the HIGH (00:49)

Adapted with permission from Caplan and Stern, created by Gross5

To identify a manic episode, clinicians can use the following mnemonic: DeTeR the HIGH (AV 1).5 To meet DSM-IV-TR2 criteria for a manic episode, patients must have had an elevated or expansive mood plus 3 symptoms of mania or an irritable mood plus 4 symptoms of mania for at least 1 week. The duration requirement can be less than 1 week if symptoms cause hospitalization.

The differential diagnosis for mania includes substance use and general medical conditions, as well as treatments such as ECT or light therapy. Substances that can induce mania include corticosteroids, levodopa, antidepressants, and stimulants (eg, amphetamines, cocaine, ephedrine). Drug or alcohol withdrawal syndromes can also induce mania. General medical conditions that can cause mania include head trauma, mass lesions, stroke, multiple sclerosis, hyperthyroidism, Cushing’s disease, Huntington’s disease, and complex partial seizures.

More

Additionally, a differential diagnosis should be made between bipolar mania and other psychiatric disorders, such as schizophrenia, schizoaffective disorder, and borderline personality disorder.2 In schizophrenia or schizoaffective disorder, psychotic symptoms occur in the absence of mood symptoms. Similarities between bipolar and borderline personality disorders include impulsivity, suicidal behavior, irritability, and paranoid ideation. Borderline personality disorder has a long-standing course, and patients have pervasive but transient symptoms that usually last hours to a few days but that do not endure as long as those of bipolar episodes, they fear abandonment, and they tend to idealize and then unexpectedly devalue others. These patients also experience uncertain identity and a feeling of emptiness. Clinicians should avoid over diagnosing personality disorders, especially when patients are simply noncompliant with treatment recommendations. If you suspect a personality disorder, have the patient evaluated by a psychologist or psychiatrist.

Major depressive episode. Almost all patients with bipolar disorder have a major depressive episode, and this episode is what usually leads them to seek treatment. Because people are less likely to seek medical help during manic episodes than depressive ones, anyone who presents with depression should be evaluated for a history of mania and the possibility of bipolar disorder before antidepressant treatment is started.

AV 2. Symptoms of a Major Depressive Episode: SIG E CAPS (00:43)

Adapted with permission from Caplan and Stern, created by Gross5

Clinicians can use the following mnemonic to remember symptoms of a major depressive episode: SIG E CAPS (AV 2).5,6 (This mnemonic refers to a prescription [SIG] for Energy CAPSules to combat the vegetative symptoms of depression.) To meet DSM-IV-TR criteria for a major depressive episode, 5 or more symptoms (1 of which is depressed mood or anhedonia) must have been present for 2 weeks or longer. The symptoms can be described by the patient or by an observer but must have caused the patient significant distress or impairment in functioning at work, home, or elsewhere. A major depressive episode should be distinguished from other psychiatric conditions such as adjustment disorder and bereavement; general medical conditions such as hypothyroidism, anemia, postcerebrovascular accident, postmyocardial infarction, and pancreatic cancer; and substance-related problems with steroids, β-blockers, α-methyldopa, alcohol, benzodiazepines, or cocaine or amphetamine withdrawal.

Mixed episode. Patients in a mixed episode have symptoms of mania and of depression at the same time. Criteria for both a manic episode and a major depressive episode must be met nearly every day for at least 1 week.2 Symptoms must be severe enough to cause marked impairment in functioning or result in hospitalization, or must include psychosis.

Hypomanic episode. Criteria for a hypomanic episode are having an elevated or irritable mood for 4 days plus 3 or more manic symptoms (see AV 1).2 Delusions or hallucinations (ie, psychosis) cannot be present. Symptoms, although not severe enough to cause marked impairment in functioning, must cause clinically significant distress or impairment in functioning, must be uncharacteristic, and must be observable to others. Hypomania should be differentiated from anxiety disorders and ADHD. Patients with ADHD have excessive energy, act as if “driven,” do not focus well, may be impulsive, and may appear disruptive in some settings and relationships; however, while these behaviors are lifelong for most individuals with ADHD, they are episodic for people with bipolar disorder.

Rapid cycling. Patients who have rapid cycling experience 4 or more mood episodes in 12 months, whether major depressive, manic, mixed, or hypomanic, that are separated by remission for 2 months or a switch to the opposite polarity.2 These patients should be referred to a psychiatrist.

Comorbid Psychiatric Conditions

AV 3. Bipolar Disorder: Making a Differential Diagnosis (03:07)

Alcohol or drug abuse or dependence is the most common comorbidity with bipolar disorder. Because an active substance use disorder can worsen the prognosis for bipolar disorder, the disorders should be treated concurrently. Other frequent comorbidities are personality disorders, anxiety disorders, and ADHD (AV 3).

Summary

While diagnosing a major depressive episode is fairly straightforward, physicians should check for a history of mania or hypomania, which is indicative of bipolar disorder rather than major depressive disorder. Mnemonic devices such as DeTeR the HIGH and SIG E CAPS may aid diagnosis. Clinicians must also rule out general medical conditions, substance use, and other psychiatric conditions before finalizing the diagnosis and initiating treatment. Comorbidities must also be identified and managed concurrently.

For Clinical Use

 

  • Always ask about mania before treating depression
  • Rule out medical conditions, other psychiatric disorders, and substance use
  • Use mnemonic devices to identify symptoms, such as DeTeR the HIGH for mania and SIG E CAPS for depression, when evaluating patients for bipolar disorder

 

Abbreviations

ADHD = attention-deficit/hyperactivity disorder
DSM-IV-TR = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
ECT = electroconvulsive therapy
MDQ = Mood Disorder Questionnaire
NOS = not otherwise specified

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References

  1. American Psychiatric Association. Practice guideline: treatment of patients with bipolar disorder, 2nd ed. http://psychiatryonline.org/content.aspx?bookid=28&8523;sectionid=1669577#50051. Published 2002. Accessed November 30, 2011.
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.
  3. Sadock BJ, Sadock VA, Ruiz PE. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.
  4. Canuso CM, Bossie CA, Zhu Y, et al. Psychotic symptoms in patients with bipolar mania. J Affect Disord. 2008;111(2–3):164–169. PubMed
  5. Caplan JP, Stern TA. Mnemonics in a nutshell: 32 aids to psychiatric diagnosis. Curr Psychiatry Online. 2008;7(10):27–33.
  6. Carlat D. The psychiatric review of symptoms: a screening tool for family physicians. Am Fam Physician. 1998;58(7):1617–1624. PubMed
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