Part One of Bipolar and Related Disorders
Part One of Bipolar and Related Disorders covers specifiers. Specifiers are used to further define the characteristics that accompany a mental health diagnosis. Due to the polar nature (depression and mania) of Bipolar and Related Disorders, there are several options to specify an individual’s diagnosis. These specifiers are important because diagnosis determines the course of treatment. The following specifiers are defined below: anxious distress, atypical features, catatonia, melancholic features, mixed features, peripartum onset, psychotic features, rapid cycling, and seasonal pattern.
Bipolar and Related Disorders is the third diagnostic class being covered in the Mental Health Diagnosis! blog series. If you missed the introduction to the series click HERE to learn how the Diagnostic and Statistical Manual-5 works. Click HERE to read the introduction to Bipolar and Related Disorders where we cover important concepts such as mania, hypomania, and depression!
Specifiers for Bipolar and Related Disorders
The anxious distress specifier is added to a diagnosis if the individual experiences two or more ‘anxious’ features during their most recent manic, hypomanic, or depressive episode. The number of symptoms experienced determines the severity of the distress. Experiencing two symptoms is considered mild; three symptoms is moderate; four or five symptoms is moderate to severe; and, experiencing four to five symptoms with motor agitation (involuntary and meaningless movement) is classified as severe. The Fifth Edition of the Diagnostic and Statistical Manual (DSM-5) outlines anxious features as follows: tension, restlessness, worry that makes concentration difficult, fear something horrible will occur, and feeling as though they may lose control.
The atypical features specifier is added to a diagnosis when the following features are prevalent during the most current major depressive episode. The first necessary feature is mood reactivity which describes how an individual’s “mood brightens in response to actual or potential positive events” (Diagnostic and Statistical Manual of Mental Disorders, 2013). Secondly, the individual experiences two or more of the following features: “significant weight gain or increase in appetite; hypersomnia; leaden paralysis, [or a heavy feeling in the limbs]; and a long-standing pattern of interpersonal rejection sensitivity that results in significant social or occupational impairment” (Diagnostic and Statistical Manual of Mental Disorders, 2013). Finally, the individual must not meet the criteria for the “with melancholic features” or “with catatonia” specifiers, which are described below, during the same depressive episode.
Catatonia or catatonic behavior is a noticeable decrease in the level and intensity of which an individual interacts with or responds to their environment. The catatonia specifier is applied to a Bipolar and Related Disorders diagnosis when catatonic features are present during the individual’s manic or depressive episode. Details about catatonia can be found in Part Three of Schizophrenia Spectrum and Other Psychotic Disorders.
There are two criteria for meeting the melancholia features specifier. Criterion A requires that the individual experience either loss of pleasure in the majority of their activities or a “lack of reactivity to usually pleasurable stimuli” (Diagnostic and Statistical Manual of Mental Disorders, 2013). Criterion B requires that the individual experience three or more of the following features:
- “A distinct quality of depressed mood or so-called empty mood
- Depression that is regularly worse in the morning
- Early-morning awakening (i.e., at least 2 hours before usual awakening)
- [Noticeable] psychomotor agitation or retardation
- Significant anorexia or weight loss
- Excessive or inappropriate guilt”
(Diagnostic and Statistical Manual of Mental Disorders, 2013).
The psychotic features specifier is added to a diagnosis when the individual experiences delusions and hallucinations during a manic, hypomanic, or depressive episode. Delusions are beliefs that remain even when there is evidence that is contrary. Hallucinations occur when an individual involuntarily perceives an experience without any external stimuli. Details regarding delusions and hallucinations are described in the Introduction to Schizophrenia Spectrum and Other Psychotic Disorders.
The seasonal pattern specifier is used to describe the “lifetime pattern of mood episodes” (Diagnostic and Statistical Manual of Mental Disorders, 2013). A mood episode is a phrase used when generalizing manic, hypomanic, and depressive episodes. The seasonal pattern specifier is added to a diagnosis when the mood episode occurs during the same time of year. The DSM-5 outlines four criteria that qualify symptoms for the seasonal pattern specifier.
One, the relationship between the change of temporal season and the change in mood from depression to mania, depression to hypomania, and/or vice versa occurs regularly and during the same time of year. Two, the individual goes into full remission with the change of temporal season or at a particular time of year. An example of this is when depression lifts in the spring. Three, the individual’s mood episodes do not have non-seasonal changes. Four, seasonal mood episodes significantly outnumber any non-seasonal mood episodes during the individual’s lifetime.
Specifiers for Bipolar I and Bipolar II Disorders
The following specifiers are applied to Bipolar I and Bipolar II Disorders. We will compare and contrast Bipolar I and Bipolar II Disorders in part two of this series.
There are two subcategories for the mixed features specifier: “manic or hypomanic episode, with mixed features” and “depressive episode, with mixed features”. They each have four criterions, which are listed as A through D. Criterions B through D are the same for both specifiers, while Criterion A differs.
Criterion A for “manic or hypomanic episode, with mixed features” necessitates that the individual meet the full requirements for a manic or hypomanic episode and that the individual have at least three symptoms of depression.
Criterion A for “depressive episode, with mixed features” necessitates that the individual meet the full requirements for a major depressive episode and that the individual have at least three manic and hypomanic symptoms.
Criterion B requires that the symptoms of depression, mania and/or hypomanic are a change from the person’s typical behavior and that the changes are observable by others. Criterion C dictates that the diagnosis “manic episode, with mixed features” is used specifically for persons whose symptoms meet full criteria for mania and depression. Criterion D states that the “symptoms are not attributable to the physiological effects of a substance” (Diagnostic and Statistical Manual of Mental Disorders, 2013).
Specifying a disorder as rapid cycling requires that the individual experience at least four mood episodes within a twelve-month period. The mood episodes must meet the minimum criteria for mania, hypomania, or depression.
The peripartum onset specifier is reserved for describing the symptoms of a manic, hypomanic, or major depressive episode that began during pregnancy or within four weeks of delivery (Diagnostic and Statistical Manual of Mental Disorders, 2013).
Stay Tuned for Part Two where we cover Bipolar I and Bipolar II Disorders!
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Web. [access date: 21 March 2018]. dsm.psychiatryonline.org