Alan "Tony" Amberg, MSN, APRN, PMHNP-BC discusses making the DSM-5 criteria for manic and hypomanic episodes in bipolar disorder more digestible for providers utilizing clinical patient probes.

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Hi, my name is Tony Amberg and I am a psychiatric nurse practitioner. Today I will be speaking about how to screen for bipolar disorder using the DSM-5. We’ll unpack the criteria set forth in the guidelines in a more digestible manner and use patient probes to better understand how to use these criteria in a clinical setting.

Now let’s turn our attention to screening for a manic or hypomanic episode.

Again, we’ve already said, patients typically do not present for hypomania or mania-- they’re feeling great! Or if they’re feeling irritable, it’s not because they feel irritable or angry, it’s because other people have a problem. These are not symptoms that typically bring people into the office. So mania may not “look like” a serious episode. And I want you to think about it from the patient’s POV. If much of their life they’re in depressive episodes, why would they want to get treated for mania? They may take umbrage at the idea that you’re saying something wrong with them when they feel so great. And then of course, there’s the issue of a mixed episode. We’ll touch on that in a moment.

So, Let’s first review the DSM-5 criteria for a manic or hypomanic episode.

As you can see listed in the DSM-5 criteria, a manic or hypomanic episode is defined as a distinct period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased activity or energy. This must last for at least 1 week and be present most of the day, AND cause a significant change in functioning.

[01:52] Now, you may have some people who regularly feel they are a gift to the world, or very powerful or very important beyond what one might expect from their actual role in life. That’s a different diagnosis. You’re looking for somebody who has had a CHANGE into an episode that is distinctly different from how they’ve been. And now they see themselves as big, as important, as incredibly creative, as able to solve amazing problems.

During the period of mood disturbance, the patient must have experienced three or more symptoms, or all four if the mood is only irritable; and as we said, symptoms must represent a significant change from usual behavior. And again, we could have changes like this that are related to medication or substance use or a physical condition.

So be sure to keep your antenna up for these other things that may be happening that could explain this kind of behavior.

So just like we did when screening for depression, let’s talk about clinical probes for bipolar disorder.

I may start the conversation by asking if they’ve ever experienced an overly excited or energetic mood and, you know what? Patients don’t always know what you mean by this so after I screen for depression, I might say to them, “Okay we talked about depression so let’s talk about the opposite. Have you ever had a time where you felt great? And I don’t mean great, I mean GREAT, you might have felt superhuman! And you might’ve felt this way for a while. You feel like you can do anything. Anything like that ever happen?” And when you’ve had that mood, did, others notice this change?

On the other side of elevated mood, I may also inquire about irritability or overly angry behavior, and again if others noted this change.

[03:57] Once you have established mood changes, you should go on further to evaluate self-esteem and how their altered mood affected their sense of self.

It’s common for people to feel the need for less sleep or to stay up all night. Gauging how much sleep your patient usually needs may help determine the extent of the change.

Now, one of the places where I’d like you to pay particular attention are times when people are forced into periods where they’re not able to get sleep. This may trigger a manic episode. A common example that I’ve seen are college students, typically toward the end of the semester when they’re studying for exams and papers are due. And remember, it doesn’t have to happen regularly. It only needs to happen once in a person’s lifetime to give you the diagnosis of bipolar disorder.

So let’s talk about increased energy or goal-directed behavior. Some people are naturally energetic. You’re looking for a change. You may inquire if the patient feels their productivity levels have changed or if they feel restless. Have they suddenly felt like they have all kinds of energy to do all kinds of things? Now remember, to the person who’s manic or hypomanic—this may feel good to them.

Cognitive function is also affected during a manic or hypomanic episode. You can ask your patient if they felt their mind was full of overcrowded or racing thoughts that were difficult to organize.

Patients may also be more prone to distraction. Find out if a lack of focus has been a problem in the past, again go all the way back to childhood, or if this emerged only while experiencing an altered mood.

Both racing thoughts and distractibility may cause increased talkativeness. You can probe into the frequency of speech and determine if others observed that they spoke much faster than usual.

Now, if you’re meeting a patient in a hypomanic or manic phase, you will observe all of these things. The patient will be talking very rapidly. They will be filled with great ideas. They will be very excited about what is going on. They may seem very grandiose, or very irritable, and by the way, remember, when you see that, it’s generally always someone else’s fault. It couldn’t have anything to do with their mood, now could it?

So the speech will feel like it’s pressured, like they can’t get it out fast enough. When the patient has these kinds of presentations, especially being hyperverbal and rapid speech, be sure to probe that.

Because they may also just be so excited to meet you and tell you know what’s going on, that they want you to know their entire life story right away, and they can’t wait to tell you all of it! So, make sure this is a change that has chronicity and is causing functional impairment.

[06:51] Finally, something that’s very important to assess for is loss of impulse control and changes in judgment. See if they can provide details about how risky behavior has affected their life as a whole, as well as the potential consequences of these actions that could cause harm to themselves or others.

Now, very important, remember that for the person who is hypomanic or manic, they might not recognize that their behavior is risky or may have poor consequences that impact them.

So one of the things you want to do is listen, nonjudgmentally, not jump to a conclusion really quickly, and tease out what this loss of impulse control looked like. Tease out what the change in judgment and what the harm was about. And again, does this represent a change in their behavior? At the end, you may actually ask open-ended or reflective questions about their behavior to see if they perceive they were putting themselves in risky situations. That’s an important clue.

While these clinical probes can be very helpful, the answers provided may not lead to a clear-cut diagnosis right away. As you can see listed in the DSM-5 criteria, there’s one more thing you should consider.

Suppose the patient gives you all the symptoms of mania or hypomania and at the same time, they’re still horribly depressed. That’s the specifier you use for a mixed episode.

[08:25] Mixed episodes are harder to treat. You should pay particular attention to treatment strategies for this, you may need to get an additional consult to help out, and these patients will often need more frequent monitoring. Make sure you review the mixed features specifier in the DSM-5 and ensure that your patient’s symptoms do indeed fit the profile of a manic or hypomanic episode rather than unipolar depression with some other comorbid condition going on.

The DSM-5 criteria can feel a bit daunting and difficult to apply in a clinical setting. What we’ve tried to help you do is convert these to simple questions and a more naturalistic conversation that may feel more practical both the provider and patient.

Differential diagnosis is challenging, sometimes patients go years without finding the right diagnosis. So, comprehensive screening, a good history, and collateral is critically important to determine the right treatment. 

Always evaluate your patients for both unipolar depression and bipolar disorder when they present, so that we can improve their course of care from the get-go.

I’m Tony Amberg, I want to thank you so much for joining us in this discussion of clinical probes and keep looking around the Navigator. You’ll find other items that will be helpful too. Take care.

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