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.
TABLE 3.1 Diagnostic omissions in evaluating elevated mood
The clinician may do the following:
• Make an incomplete assessment that fails to include collateral sources of information
• Become blinded by the chief complaint
• Misattribute hypomanic traits to other causes
• Fail to obtain a family history
• Accept a previous erroneous or incomplete diagnosis
• Fail to evaluate a longitudinal history
• Fail to reassess the diagnosis during the course of treatment
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.
TABLE 3.2 Keys to diagnostic success with elevated mood
• Ask the appropriate questions
• Use information sources beyond the patient
• Determine family history and construct a genogram
• Use standardized screening tools
• Evaluate soft signs of elevated mood
• Use mood charting
• Review the diagnosis in light of treatment response and failure
• Reassess the diagnosis over time
Hyperthymia and hypomania
Not all behavioral elements that are energetic, highly active, or accelerated in pace are abnormal or require treatment. Both hyperthymic temperament and hypomania can present with a constellation of these behaviors at the time of evaluation or in the history.
TABLE 3.3 Variable presentations of bipolar illness
Mixed states (agitated depression or dysphoric mania)
Anxiety or agitation
Frequent mood changes or cycling
Psychotic thoughts or behavior
Consequences of impulsive behavior (financial troubles, promiscuity, physical injury)
Aggression, violence, or legal infractions
Disordered intrafamily, interpersonal, or marital relationship
Substance abuse and its sequelae
Anger or rage episodes
Suicidal ideation or behavior
Repeated employment failures
No complaints at all. The patient is brought in by another person.
Although most hyperthymic individuals do not present for evaluation or treatment for accelerated and elevated mood traits, when these are seen, the clinician must differentiate the truly hypomanic individual (who may need treatment) from the hyperthymic individual (who may not). Beyond the initial complaint, the patient with minor elevated mood will likely not have problematic behaviors consistently but only a few mild ones. These will be interspersed with many desirable, beneficial, or even exceptional behaviors. In general, individuals with hyperthymic temperament but not hypomania have the characteristics in the left-hand column of Table 3.4
but few, if any, of the symptoms in the right-hand column. The hypomanic individual, however, may show some of the items in the left-hand column but will also exhibit one or more pronounced behavioral symptoms in the right-hand column. As has been depicted in Figure 1.1
, a defined sharp line is not always present between what is positively perceived and what is problematic.
The four Ps of functionality
Another way to organize data so as to distinguish hyperthymia from true hypomania is to focus on the four Ps of functionality (Table 3.5
TABLE 3.4 The range of elevated mood symptoms
May be positively regarded by the patient—mildly elevated mood
Negative behavioral consequence— significantly elevated mood
Lack of awareness of consequences of behavior
Consistently high output or productivity
Scattered—may start many tasks but follow through erratically
Business or financial success
Increased substance use
Rationalizing negative behavior or consequences
Denial of need for help despite evidence of deficiencies
It is not only how a person feels, but also how they function on a day-to-day basis that may determine whether a psychiatric illness is present. These functional elements can be remembered as the four Ps—productivity, predictability, positivity, and people skills. Individuals with hyperthymic temperament may have appropriate functioning in each of these areas, but hypomanic persons will have exaggerated behaviors, often exhibiting deficits in one or more areas.
For example, with productivity,
the hyperthymic individual may be consistently active in a positive way and viewed by others as more productive that the average individual. In hypomania, however, persons may feel
productive, but objective measurements of their activity show scattered erratic performance. At times, the hypomanic individual may be productive, but this often fluctuates and does not last. Hyperthymic persons can be consistently and predictably highly active with constant output and production. With persons with hypomania, on the other hand, predictability
suffers and the person may have some periods of productivity, but is often erratic and unpredictable. This variability can be seen in areas such as work performance, academic success, and financial management.
TABLE 3.5 The four Ps of functionality
• People skills
With positivity, the hyperthymic person is found to be engaging, outgoing, and carrying a positive outlook on life. When exaggerated in hypomania, however, these criteria can yield excessive optimism, grandiosity, and poor decision making, often without regard to consequences.
Hyperthymic individuals usually have better-than-average people skills. They are jovial, engaging, and engender others’ admiration, attention, and friendship. They mix well in social situations. They are often effective public speakers. When exaggerated in hypomania, the same skills can show social intrusiveness, increased talkativeness, and increased self-absorption, without apparent awareness about others’ feelings and wishes. The hypomanic individual can be dominating and irritable, especially when his or her wishes are not met.