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In this podcast, Kate Sullivan, MSN, APN, share important considerations for understanding mixed affective states in bipolar disorder and how those states affect diagnosis.

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[0:00] Hello, I’m Kate Sullivan, and I’m a psychiatric nurse practitioner at Knoxville Behavioral in Tennessee.

Recognizing and accurately diagnosing bipolar disorder requires knowing how to identify both affective states that define bipolar disorder: elevated or irritable mood, known as mania or hypomania, as well as depressed mood states. As I will discuss in this podcast, one of the reasons why this can be so tricky is the complexity and diversity of elevated and depressed mood symptoms that a patient might present with, which may make them difficult to recognize.

Furthermore, some people exhibit what the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, calls “bipolar disorder with mixed features.” Although some people with bipolar will experience “pure” manic/hypomanic or depressive episodes, others will experience episodes that are a combination of both affective states. Yet, this is critical to making the right diagnosis for the patient by distinguishing bipolar disorder from major depressive disorder.

[1:29] We first need to set the stage by clarifying how depressive episodes and manic episodes are defined according to the DSM-5 criteria.

A major depressive episode occurs when a person experiences, for at least 2 weeks, excessively sad mood or a lack of interest in or pleasure from activities that they normally enjoy. In addition, the person must meet at least 4 of the following criteria, nearly every day, in the same 2-week period:

  • Significant change in weight or appetite
  • Sleeping excessively or having insomnia
  • Psychomotor agitation or retardation
  • Fatigue or loss of energy
  • Feelings of worthlessness or guilt
  • Difficulty concentrating or making decisions
  • Persistent thoughts of death or self-harm

DSM-5 defines a manic episode as a period of unusually elevated or irritable mood that lasts at least 1 week and is persistent throughout the day, nearly every day. During this period, the person meets at least 3 of 7 symptoms. These include:

  • Having an inflated or grandiose sense of self
  • Sleeping significantly less than usual
  • Being more talkative or experiencing pressured speech
  • Having racing thoughts
  • Feeling easily distracted
  • Being more active at work or school or perhaps more active socially
  • Engaging in activities with a high risk of self-harm, like having risky sex or going on extravagant spending sprees

As you might guess by its name, hypomania is like a “sub” form of mania in which many of the same symptoms are present but not enough to meet criteria for a full manic episode. Hypomanic episodes are also less persistent than mania, lasting at least 4 days rather than at least 1 week. However, you should not disregard hypomania as a milder or less serious form of mania. Hypomanic symptoms in some people can be associated with significant functional impairment.

As previously mentioned, some people exhibit what DSM-5 calls “bipolar disorder with mixed features.” This “mixed features specifier” is one of the main changes that was adopted when the previous version, DSM-IV, was revised as DSM-5. Those with mixed features will experience episodes that are a combination of both manic and depressed affective states, rather than “pure” manic/hypomanic or depressive episodes. The criteria for bipolar with mixed features are that a person currently in a manic or hypomanic state also exhibits at least 3 symptoms of depression at the same time. Alternatively, a person currently in a depressive state would exhibit at least 3 symptoms of mania or hypomania at the same time.

Identifying when a person has bipolar disorder with mixed features is critical, because these cases tend to be more complex, they can be especially difficult to treat, and tend to have poorer outcomes. In some studies, people with bipolar disorder with mixed features have also demonstrated an earlier age of onset, a greater number of mood episodes, and a longer duration of illness. Other evidence suggests these patients are at an even higher risk for suicide than people with bipolar disorder who experience “pure” mood episodes or non-mixed states.

[5:52] A mixed features episode can be tricky to recognize because of its murky combination of affective states. During a manic episode with mixed features, the individual may appear more irritable than euphoric or grandiose. But they also may exhibit anxiety, feelings of guilt, dysphoria, prolonged emotional instability, less involvement in pleasurable activities, less of a decreased need for sleep, and suicidal depressive symptoms. During a depressive episode with mixed features, the person may seem emotionally labile, irritable, easily distracted, restless, talkative, and impulsive.

Consequently, you may need to rely on more than just clinical presentation to determine whether bipolar is present and whether it is pure affective bipolar or mixed features bipolar. Unfortunately, patients may not openly talk about manic or hypomanic symptoms unless asked about them specifically, because they may not realize these symptoms are part of an illness. They may even find aspects of these symptoms, such as elevated mood, to be normal or enjoyable.

This underscores how critically important it is to obtain a detailed history from the patient. Even if you uncover what seems to be a history of mania or hypomania, be careful not to mistake these for other mental disorders. For instance, other psychiatric disorders that can appear similarly include schizophrenia, severe anxiety or obsessive-compulsive disorder, substance use disorders—especially stimulant intoxication and hallucinogen use, major depression accompanied by psychotic features, major neurocognitive disorder, and delirium.

There are several ways mental health care providers can better identify the mixed affective states that characterize bipolar. One, when a patient exhibits symptoms of depression that should automatically prompt further exploration of a possible bipolar diagnosis. Using a validated screening tool—such as the Mood Disorder Questionnaire, Bipolar Spectrum Diagnostic Scale, or Bipolar Disorder Screening Scale—can also be helpful, but screening tools are not diagnostic instruments.

It is important to also take a thorough patient history, including general medical and psychiatric assessment and family psychiatric history. If needed, family members can serve as useful sources of information.

Finally, use clinical probes based on the DSM-5 criteria to help you assess the patient’s history of mania or hypomania. You can ask questions such as, “Have you ever had a time in your life where your mood was so excited, energized, or ‘high’ that others said you were not acting like your normal self?” Or, “When your mood was abnormally elevated or irritable, did you ever feel rested or even more energized than usual despite getting very little sleep?”

I hope this episode has been helpful to you and demonstrates the importance of being well-informed about the different affective states of bipolar disorder as well as the potential presence of mixed features mood episodes. I look forward to speaking with you again.

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