As described in the previous two chapters, the detection of hypomania and elevated mood is crucial to appropriate diagnosis and management. Whether the chief complaint is elevated or (more likely) depressed mood, it is not hard to diagnose hypomania or a form of bipolar disorder when a patient acknowledges the classic symptoms of elevated mood. These classic symptoms can include lack of need to sleep, excess energy, impulsive spending, grandiose thoughts, increased talkativeness, or significantly inappropriate social and business judgments. Our diagnosis becomes much more difficult, however, when the patient presents depressed or, on direct questioning, does not clearly acknowledge hypomanic symptoms. It is most difficult, of course, if the practitioner never asks questions about elevated mood at all!

Given that hypomanic symptoms are often not the primary presenting complaints, how can we increase the odds of recognizing hypomania in the context of the myriad other psychiatric symptoms including depression, anxiety, substance abuse, and other behavioral disturbances? Until critical endophenotypic elements of elevated mood are elucidated as described in Chapter 2, we must use current phenomenologic measures to guide our
diagnosis. This chapter looks at the issue of recognition and diagnosis of elevated mood, hypomania, and bipolar disorder and provides symptom-based guidelines for the clinician.

To assist us in determining best practice techniques, it is first useful to understand the common ways that even astute clinicians may fail to diagnose hypomania. The seven most common failings of diagnosticians are listed in Table 3.1.

An incomplete assessment can result from many causes including a clinician in hurry or one who does not have a consistent system for assessing all aspects of a patient’s condition. Good practice is facilitated by maintaining a list of symptoms and behaviors that are routinely addressed in every diagnostic assessment. Virtually all patients should be asked specific screening questions about elevated mood during an initial evaluation. These questions will be specified later in the chapter.

If the clinician doing the screening becomes narrowly “locked on” to the chief complaint, exploring only the patient’s overt presenting problem, questioning may become unnecessarily circumscribed, and elevated mood may be left uninvestigated. This commonly occurs when depression or anxiety is the chief complaint. Under these circumstances, the clinician may perform a detailed evaluation of anxious or depressive symptoms, but fail to undertake an evaluation for the presence of elevated mood elements currently or in the past.

A corollary to becoming fixed on to the chief complaint is the failure to evaluate current complaints in the context of other symptoms and the long-term symptom pattern. For the most accurate diagnosis, it is important to assess the patient’s longitudinal history, including his or her underlying temperament or any previous history of mood symptoms—whether diagnosed or not.

When symptoms of elevated mood are described by the patient, the clinician may mistake “feeling good” as evidence of enthusiasm, passion, or
improvement from a previous depressed episode. It is critical that the period after a depression be carefully evaluated because hypomania may easily be mistaken as emergence from an episode of depressed mood.

Although not every evaluation can include information gathered from a family member or other knowledgeable person, when there is a suspicion of elevated mood, the assessment should include data from these additional sources. With every patient, inquiry should be made as to a history of psychiatric symptoms, diagnoses, or treatment in biologic relatives. Similarly, a family history of substance abuse may overlay a diagnosis of elevated mood disorder, and the clinician must be diligent in exploring this aspect of the family pedigree. Although individual patients may have limited or incomplete information about family members, an attempt should be made to obtain as much information as possible early in the process of evaluation. It may be necessary for a patient to contact relatives to obtain this information.

Routinely accepting a diagnosis made by another practitioner may point a clinician in the wrong direction, limiting his or her independent assessment of symptomatology. Many patients may present to a psychiatrist after having already been evaluated by primary care clinicians, nonpsychiatric mental health practitioners, or other mental health professionals. These clinicians may have had their own biases about diagnosis, may or may not have done a thorough evaluation, and may or may not have correctly included all symptoms in making their diagnosis. Childhood diagnoses (often made by pediatricians or non-medical therapists) can become confounding in correctly diagnosing elevated mood. Overactive or even flagrantly hypomanic symptoms may have been attributed to attention-deficit disorder (ADD)/attention-deficit hyperactivity disorder (ADHD), other developmental disorders, or “just a stage.” If the clinician accepts these assessments at face value, vital clues to the presence of hypomania may be missed. Similar caution should be exercised in automatically accepting a diagnosis of bipolar disorder made earlier. There are clinicians today who see bipolar disorder “around every corner” and label almost every instance of significant functional disturbance, substance abuse, or hyperactivity as bipolar in origin.

The clinician may fail to periodically reevaluate the initial diagnosis in light of treatment response or lack thereof. Commonly, a patient has been diagnosed as having a major depressive disorder but has failed several antidepressant trials, or obtained some transient relief, and then rapidly lost the symptomatic response. A diagnostic reconceptualization may reveal the diagnosis of recurrent depressive mood cycling with subsyndromal hypomanic symptomatology—a disorder that mimics the course of bipolar disorder and may be more appropriately treated with mood stabilizers.

A clinician may also fail to reassess the patient over time. This is the long-term variation of being overly focused on an initial diagnosis. The clinician may have first diagnosed the patient with unipolar depression or an anxiety disorder, but has kept “blinders on” with regard to other possible diagnoses including that of a cycling mood disorder.