Bipolar Disorder For Dummies. Joe Kraynak

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      ✔ With anxious distress: Anxiety commonly co-occurs with bipolar disorder even in the absence of a full-blown anxiety disorder and the presence of this anxiety may influence treatment decisions.

      ✔ With mixed features: Mood episodes in bipolar disorder often aren’t completely clear-cut. People with mostly manic symptoms may still express symptoms of depression, such as guilt and hopelessness or suicidal thoughts. Or someone who is primarily depressed may have a lot of physical agitation and racing thoughts characteristic of mania. This specifier accounts for these types of presentations, which may affect treatment planning.

      ✔ With rapid cycling: Rapid cycling is a specifier that identifies bipolar disorder that presents with four or more mood episodes in a 12-month period. This subtype is thought to be more severe and often doesn’t respond as well to medications.

      ✔ With melancholic features: This subtype of depression is quite severe. It includes features such as very low mood that shows little or no response to improved external circumstance, very low energy, almost no interest in or response to pleasurable stimuli, agitation or slowing of movements, diurnal variation (mood and energy worse in the morning), sleep interruptions including early morning awakening, impaired thinking and concentration, and loss of appetite. It’s really the most extreme presentation of most or all of the symptoms of a major depressive episode.

      ✔ With atypical features: This specifier describes a pattern of depression symptoms that used to be considered less typical of depression, but are now recognized as a frequent feature of depression. The name has stuck though. Symptoms include responsiveness to changes in external stimuli – feeling better if things improve or worse if something bad is going on, increased appetite or weight gain, excessive sleep and severe fatigue, feelings of leaden paralysis (heaviness in the limbs), and longstanding patterns of sensitivity to interpersonal rejection.

      ✔ With mood-congruent psychotic features: This label is used when psychosis is present and the hallucinations and delusions are similar to the mood episode – delusions of grandiosity and power in mania or delusions of guilt and hurting other people in depressed periods.

      ✔ With mood-incongruent psychotic features: This label is used when the hallucinations or delusions don’t match the mood episode.

      ✔ With catatonia: Catatonia is a state of minimal responsiveness to the environment and abnormal movement. Symptoms can include stupor, immobility, rigid muscles or movements, very slowed or very fast movements, repetitive movements or speech, mutism (not speaking at all), odd mannerisms or postures, staring, unusual muscle responses when someone moves her limbs, negativism (oppositional or no response to external stimuli), and echolalia and echopraxia (repeating other people’s language or movements). Catatonia can be present in many psychiatric conditions, and it can occur with either depressive or manic poles of bipolar disorder.

      ✔ With peripartum onset: This specifier is used when the onset of the bipolar mood episode is any time during pregnancy or in the four weeks after delivery, which is important because pregnancy and childbirth influence treatment decisions. (See Chapter 10 for details.)

      ✔ With seasonal pattern: This label indicates a well-established pattern of mood episodes that start and end at specific times of the year.

      ✔ Unipolar depression: A major depressive episode without a history of mania or hypomania doesn’t qualify as bipolar disorder. However, if you experience depression and you have a history of bipolar disorder in any first-degree relatives (parent, sibling, or child), your doctor may want to monitor you closely if she starts treatment with an antidepressant, because of the increased risk that you may have bipolar disorder that hasn’t shown its manic pole yet. Additionally, the differentiation between unipolar and bipolar depression can be quite difficult. If a symptom such as agitation is present, it can be part of a mixed-mood episode of bipolar disorder, but it can also just be part of unipolar depression. Another difficult diagnostic situation is when during recovery from depression a person has periods of feeling particularly well. Are these periods symptomatic of hypomania or simply a strong recovery from a depressive episode?

      ✔ Anxiety: Anxiety may make you feel wired or tired with racing thoughts, poor sleep, and irritability, all of which overlap with symptoms characteristic of depression and mania. Many people with bipolar disorder also have an anxiety disorder, so they can happen together, but determining whether anxiety is the primary disorder rather than bipolar is important.

      ✔ Attention deficit hyperactivity disorder (ADHD): ADHD and mania are both characterized by impaired concentration and attention, impulsivity, high energy levels, and problems with organization and planning. However, for those with bipolar disorder, these symptoms are present only during a manic episode, not all the time. In addition, diagnostic criteria for hypomania or mania include an increase in goal-directed behavior, a decreased need for sleep, and grandiose thinking; ADHD doesn’t include any of these. The pattern of symptoms, especially the episodic nature of mood episodes, is a key way to distinguish bipolar disorder from ADHD.

      ✔ Schizophrenia and schizoaffective disorders: Schizophrenia and schizoaffective disorders are thought disorders characterized by psychosis – delusional thinking, paranoia, and auditory or visual hallucinations. Although psychosis may accompany mania and depression, the bipolar psychosis is present only during an acute mood episode and goes away during times of normal mood. In schizoaffective disorders, psychosis occurs for at least some period of time separate from the mood episodes. Schizophrenia and related disorders are persistent and severe disruptions of thinking and reality testing unrelated to mood episodes.

      ✔ Borderline personality disorder (BPD): BPD shares a few characteristics with bipolar. For instance, someone with BPD may be impulsive, irritable, and argumentative much like someone who’s experiencing a manic episode. However, BPD mood shifts are typically abrupt, short-lived, and in response to an external trigger, such as a conflict with another person; bipolar mood shifts are slower to develop, last longer, and may not appear to be in response to anything external. The rages that often characterize BPD aren’t equivalent to mania. BPD symptoms are chronic, representing the person’s baseline behaviors, whereas bipolar symptoms are episodic and different from the person’s usual behavior patterns.

      ✔ Other medical conditions: Many medical conditions – including brain tumors, meningitis, encephalitis, seizure disorders, brain injury, hormone imbalances, anxiety disorders, autism, and pervasive developmental disorder (PDD) – can produce symptoms similar to those of bipolar mania or depression.

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