Diagnostic Issues in Hypomania



Diagnostic Issues in Hypomania





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



The initial assessment interview

With a thought toward avoiding these errors, specific methodologies are presented in Table 3.2 and elaborated in the ensuing text. Attention to these factors can lead to improved diagnostic success.


Increasing the odds for successful diagnosis

As with any psychiatric assessment, it is best to quickly identify the patient’s chief complaint and his or her reason for coming to the evaluative session. With elevated mood, two elements confound the diagnostic process.



  • Many patients present for conditions and chief complaints that do not specifically involve elevated mood; yet, elevated mood is an important component to correctly identify the ultimate diagnosis.


  • When patients with bipolar disorder or cycling moods do complain of mood problems, the complaint is most often depression, not elevated mood.

It is, therefore, crucial for the clinician to understand bipolar disorder as a multifaceted illness that can present to the clinician with many different faces. These presentations may overtly involve mood symptoms including depression, mania, mixed states, and rapid cycling moods. There are, however, many other presentations that initially do not have mood as an obvious core element. As can be seen in Table 3.3, there is a wide variety of presenting complaints that do not readily relate to mood.


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



































Mania


Depression


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


Attention/concentration problems


Disordered intrafamily, interpersonal, or marital relationship


Substance abuse and its sequelae


Disordered sleep


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


High energy


Irritability


Extroverted


Reckless


Increased plans/activities


Overtalkative


Creative


Intrusive


Self-confident


Poor judgment


Self-directed


Lack of awareness of consequences of behavior


Contagious humor


Unstable relationships


Novelty seeking


Disorderly


Consistently high output or productivity


Scattered—may start many tasks but follow through erratically


Business or financial success


Functional inconsistencies



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











• Productivity


• Positivity


• Predictability


• 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.


Depression and elevated mood

As will be seen in Chapter 4, depression is by far the most common presenting complaint in cycling mood disorders. This is not unexpected, given that for most patients, depression is much more emotionally painful and debilitating than hypomania. Patients with bipolar II disorder also spend much more of their time in the depressed phase of the illness than they do in asymptomatic or hypomanic stages.

Lish et al. (1) demonstrated that early diagnosis of elevated mood is a difficult task, given our current diagnostic acumen and patient presentation. In a survey involving members of the Depressive and Manic-Depressive Association, three fourths the number of those surveyed had given an alternative explanation for their symptoms (i.e., not a mood disorder). One fourth to one third the number of patients were misdiagnosed as having unipolar depression. More than one third of the patients took >10 years to receive an accurate diagnosis. This issue is common and sufficiently significant to merit a separate chapter on the topic.


One symptom does not a diagnosis make

There is no single symptom that is pathognomonic of hypomania. For example, isolated episodes of increased energy alone, decreased sleep alone, rapid speech, impulsivity, or any one symptom is not sufficient, in and of itself, to make a diagnosis of hypomania. To establish a diagnosis, it is important to
identify a constellation of symptoms that, together, point to the likelihood of hypomania. In addition to the classic symptoms of elevated mood, the clinician needs to be familiar with the most common symptoms of hypomania that are shown in Table 3.6.








TABLE 3.6 Most common manifestations of hypomania





























Increased activity


97%


Increased energy


96%


Increased plans and ideas


91%


Increased self-confidence


86%


Decreased sleep


84%


Increased talkativeness


72%


Decreased inhibition


71%


Increased optimism


68%


From Wicki W, Angst J. The Zurich Study. X hypomania in a 28- to 30-year-old cohort. Eur Arch Psychiatry Clin Neurosci. 1991;240(6):339-348, (2).


Another way to remember these components is the useful mnemonic DIGFAST, which stands for the elements that, in addition to irritability, can be used to diagnose bipolar disorder. As shown in Table 3.7, DIGFAST stands
for Distractibility, Insomnia, Grandiosity, Flight of ideas/racing thoughts, increased Activities, rapid Speech, and Thoughtlessness.








TABLE 3.7 The elements of DIGFAST



















Distractibility


Insomnia


Grandiosity


Flight of ideas/racing thought


Activities


Speech


Thoughtlessness


From Ghaemi SN. Mood disorders. Philadelphia: Lippincott Williams & Wilkins; 2003:13-14, originally developed by William Falk, MD, (3).









TABLE 3.8 Screening questions for elevated mood























Have ever had a time when you …



Were feeling so good or so “up” that people around you thought you were not your usual self?



Were so energetic that you acted in a way to get yourself in trouble?



Were overly active and felt like you could do much more than you are usually capable of?



Were irritable to the point of shouting, starting fights or arguments, or yelling at inappropriate times?



Received feedback that you were hyperactive or “manic”?



Had periods without the need for sleep?

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Jul 29, 2016 | Posted by in GENERAL | Comments Off on Diagnostic Issues in Hypomania
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