call for a diagnosis of major depression with mixed features.
✔ Major depression with hypomania that fails to meet the criteria for a hypomanic episode: An individual has experienced one or more major depressive episodes along with periods of hypomania that fall short of the symptoms required for a hypomanic episode. For example, the person may have an elevated or expansive mood for four consecutive days, but she has only two of the three other symptoms required to qualify as having had a hypomanic episode.
✔ Hypomanic episode without a major depressive or manic episode: This designation enables doctors to diagnose bipolar disorder in the absence of a full-blown major depressive episode (which would result in a diagnosis of bipolar II) or a manic episode (which would result in a diagnosis of bipolar I).
✔ Short-duration cyclothymia: An individual has experienced multiple periods of depression and hypomania that don’t meet the criteria for major depressive episode or hypomanic episode in the course of fewer than 24 months (or fewer than 12 months in children or adolescents).
The unspecified bipolar disorder designation is used to diagnose individuals who present with symptoms characteristic of bipolar disorder that cause clinically significant distress or functional impairment but don’t fully meet the diagnostic criteria for the other bipolar disorder diagnostic categories. This diagnosis is used instead of other specified bipolar and related disorder when a doctor, for whatever reason, doesn’t want to go into detail about why the criteria for a specific bipolar diagnosis hasn’t been met; for example, in emergency room settings by doctors who need to diagnose and treat the symptoms immediately and may not have the time or sufficient details to make a more specific diagnosis.
Your doctor doesn’t use bipolar disorder to label you or minimize your worth as a human being. The label provides a convenient way to refer to your condition among insurance and healthcare providers. It helps all the people involved in your treatment to quickly recognize the illness that afflicts you and to provide the appropriate medications and therapy. You aren’t bipolar disorder. Bipolar disorder is an illness you have, and you can manage it with the right treatments.
Digging Deeper with Bipolar Specifiers
The DSM provides specifiers to help doctors more fully describe a person’s condition. Think of specifiers as adjectives used to describe nouns, the noun being the primary diagnosis.
Specifiers indicate the nature of the person’s current or most recent episode, the severity of symptoms, the presence or absence of psychosis, the course of the illness, and other features of the illness, such as anxiety or a seasonal pattern. Specifiers serve two useful purposes:
✔ They allow for the subgrouping of individuals with bipolar disorder who share certain features, such as people who have bipolar disorder with anxious distress.
✔ They convey information that’s helpful and relevant to the treatment and management of a person’s condition. For example, someone who has bipolar with anxious distress likely needs treatment for both bipolar and anxiety.
In the following sections, we describe the bipolar specifiers in greater detail.
This specifier identifies the most active or recent phase of illness, with a primary goal of identifying the most appropriate treatment. These specifiers are coded in the patient’s medical record, where they’re also important for insurance reimbursement purposes:
✔ Manic: The current or most recent episode is primarily mania.
✔ Hypomanic: The most recent or current episode is primarily hypomania.
✔ Depressed: The most recent or current episode is primarily depression.
These specifiers have been part of the diagnostic system for a long time, and they continue to be part of the DSM-5. They assist in treatment planning and in following the course of illness; for example, a patient moving from severe to mild symptoms suggests that the acute episode is resolving. Historically the doctor making the diagnosis would use his clinical judgment and experience to estimate severity. DSM-5 strongly encourages the use of more objective data, particularly by using scales that patients or doctors fill out, to provide more consistent ratings across patients and across treatment providers.
Severity typically relates to the intensity and frequency of symptoms as well as the degree to which symptoms impair function:
✔ Mild: Symptoms are less frequent, milder in intensity (causing some distress), and sometimes affect function seriously.
✔ Moderate: Symptoms are more persistent and intense (causing more distress) and often affect function seriously.
✔ Severe: Symptoms are very persistent to continuous, very intense (causing high levels of distress), and often affect function seriously.
Perhaps the most frightening accompaniment to depression or mania is psychosis, which may include delusional thinking, paranoia, and hallucinations (typically auditory as opposed to visual). Although psychosis isn’t a necessary part of the bipolar diagnosis, it can accompany a mood episode. The extremes of depression and mania are sometimes associated with profound changes in the reality-testing system of the brain, which lead to severe distortions in perception and thinking. During a psychotic episode, you may experience any of the following symptoms:
✔ Feel as though you have special powers
✔ Hear voices that other people can’t hear and that make you believe they’re talking about you or instructing you to perform certain acts
✔ Believe that people can read your mind or put thoughts into your head
✔ Think that the television or radio is sending you special messages
✔ Think that people are following or trying to harm you when they’re not
✔ Believe that you can accomplish goals that are well beyond your abilities and means
This specifier overlaps with the presence or absence of psychosis when a diagnosis is coded. If the illness is active, the specifier notes whether or not psychosis is present.
If the illness is moving out of active phase, then one of the following specifiers is used:
✔ In partial
