DIAGNOSING BIPHASIC MOOD DYSFUNCTION

The expressions "feeling high" and "depressed" have come into common use, and as descriptions of Bipolar Disorder are readily available in the public domain, it is essential to distinguish a disorder with mood swings from ordinary mood fluctuations. To be called a "disorder" a condition should, ideally, fulfill the "4D’s": sufficient duration of difficulties (not needed in acute or crisis situations, e.g.. mania) significant distress to self or others, feeling despondent (as in depression) or being driven (as in mania), and evidence of significant dysfunction.

Hypomania, in particular, because it can present with a low-grade severity, is frequently missed without particular screening and specific criteria being explored. However, the overzealous clinician can easily overdiagnose hypomania by assuming that "feeling high" is the single most common symptom in the condition. In the ECA Study it was demonstrated that a decreased need for sleep, increased energy and racing thoughts are more commonly reported than feeling high or elated. Hypomania may be missed in the presence of certain adolescent behaviours and lifestyles, but one should take care not to overdiagnose hypomania in adolescence as some ordinary adolescent behaviours can sometimes be mistaken for hypomania.

Mania is more readily diagnosed than a hypomania using standard DSM IV criteria. However, mania can, occasionally, go unnoticed or be masked due to the extreme demands of a subject’s work or life situation, during which changes in sleep, energy, drive and activity, aggression, etc. may well be required or be a consequence of the situation.

Irritable mood is much more common in Major Depression than previously realised, and can occur without a miserable or depressed mood, although almost always accompanied with depressed thinking and cognitions. This is particularly so in adolescence and in the elderly. Early onset depression with psychotic features should alert the clinician to the risk of future bipolar disorder. Not every episode of depression in a bipolar disorder may meet the full criteria for a major depression. However, the subject should have at least one episode of major depression and one episode of either hypomania or mania, or one episode of clear hypomania or mania alone.

Rapid cycling can often present as turbulent and chaotic behaviour and relationship functioning, and be missed or misdiagnosed. Mixed states are more common than previously thought, particularly in young people. Mania with dysphoric features has been reported in 5-70% of different samples (McElroy et al, 1992). Depressive mixed states, where depression is more predominant but with many features of a hypomania or mania being present, are now being increasingly recognised and may be more common than previously thought (Akiskal, 1996).

References
Akiskal HS. 1996. The Prevalent Clinical Spectrum of Bipolar Disorders: Beyond DSM-IV. J Clin Psychopharmacology. 16:2. Suppl 1 4S-14S

McElroy SL, Keck PE, Pope HG, Hudson JI, Faedda GL, Swann AC. 1992. Clinical and Research Implications of the Diagnosis of Dysphoric or Mixed Mania or Hypomania. Am J Psychiatry. 149: 12. 1633-1644.