Bipolar ii disorder dsm 5 code

CHAPTER 3

Prior to beginning work on this discussion, please read Chapters 3, 4, and 17 in DSM-5 Made Easy: The Clinician’s Guide to Diagnosis; Case 20 from Case Studies in Abnormal Psychology; and Chapter 1 in Psychopathology: History, Diagnosis, and Empirical Foundations. It is recommended that you read Chapter 1 in Turning Points in Dynamic Psychotherapy: Initial Assessment, Boundaries, Money, Disruptions and Suicidal Crises.

For this discussion, you will choose a case study included in Case Studies in Abnormal Psychology.

In your initial post, you will take on the persona of the patient from the case study you have chosen in order to create an initial call to a mental health professional from the patient’s point of view. In order to create your initial call, evaluate the symptoms and presenting problems from the case study, and then determine how the patient would approach the first call.

Create a document that includes a transcript of a call from the patient’s point of view based on the information in the case study including basic personal information and reasons for seeking out psychotherapy. The call may be no more than 5 minutes in length. Once you have created your transcript you will create a screencast recording of the transcript using the patient’s voice. Based on the information from the case study, consider the following questions as you create your recording:

· What would the patient say?

· What tone of voice might he or she use?

· How fast would the patient speak?

· Would the message be understandable (e.g., would it be muffled, circumstantial, tangential, rambling, mumbled, pressured, etc.)?

You may use any screencasting software you choose. Quick-Start Guides are available Screencast-O-Matic (Links to an external site.)Links to an external site. for your convenience. Once you have created your screencast, include the link and the name of the case study you chose in your initial post and attach your transcript document prior to submitting it.

Resources:

Gorenstein, E., & Comer, J. (2015). Case studies in abnormal psychology (2nd ed.). New York, NY: Worth Publishers. ISBN: 9780716772736

Morrison, J. (2014). DSM-5 made easy: The clinician’s guide to diagnosis. New York, NY: The Guilford Press.

Craighead, W. E., Miklowitz, D. J., & Craighead, L. W. (2013). Psychopathology: History, diagnosis, and empirical foundations (2nd ed.). Hoboken, NJ: John Wiley & Sons. Retrieved from http://www.ebrary.com

Akhtar, S. (2009). Turning points in dynamic psychotherapy: Initial assessment, boundaries, money, disruptions and suicidal crises. London, England: Karnac Books. Retrieved from http://www.ebrary.com

Mood Disorders

DSM-5 notes that issues related to genetics and symptoms locate bipolar disorders as a sort of bridge between mood disorders and schizophrenia. That’s why DSM-5 separated the deeply intertwined chapters on bipolar and depressive disorders. However, to explain mood disorders as clearly and concisely as possible, I’ve reunited them.

Quick Guide to the Mood Disorders

DSM-5 uses three groups of criteria sets to diagnose mental problems related to mood: (1) mood episodes, (2) mood disorders, and (3) specifiers describing most recent episode and recurrent course. I’ll cover each of them in this Quick Guide. As usual, the link refers to the point where a more detailed discussion begins.

Mood Episodes

Simply expressed, a mood episode refers to any period of time when a patient feels abnormally happy or sad. Mood episodes are the building blocks from which many of the codable mood disorders are constructed. Most patients with mood disorders (though not the majority of mood disorder types) will have one or more of these three episodes: major depressive, manic, and hypomanic. Without additional information, none of these mood episodes is a codable diagnosis.

Major depressive episode . For at least 2 weeks, the patient feels depressed (or cannot enjoy life) and has problems with eating and sleeping, guilt feelings, low energy, trouble concentrating, and thoughts about death.

Manic episode . For at least 1 week, the patient feels elated (or sometimes only irritable) and may be grandiose, talkative, hyperactive, and distractible. Bad judgment leads to marked social or work impairment; often patients must be hospitalized.

Hypomanic episode . This is much like a manic episode, but it is briefer and less severe. Hospitalization is not required.

Mood Disorders

A mood disorder is a pattern of illness due to an abnormal mood. Nearly every patient who has a mood disorder experiences depression at some time, but some also have highs of mood. Many, but not all, mood disorders are diagnosed on the basis of a mood episode. Most patients with mood disorders will fit into one of the codable categories listed below.

DEPRESSIVE DISORDERS

Major depressive disorder . These patients have had no manic or hypomanic episodes, but have had one or more major depressive episodes. Major depressive disorder will be either recurrent or single episode.

Persistent depressive disorder (dysthymia) . There are no high phases, and it lasts much longer than typical major depressive disorder. This type of depression is not usually severe enough to be called an episode of major depression (though chronic major depression is now included here).

Disruptive mood dysregulation disorder . A child’s mood is persistently negative between frequent, severe explosions of temper.

Premenstrual dysphoric disorder . A few days before her menses, a woman experiences symptoms of depression and anxiety.

Depressive disorder due to another medical condition . A variety of medical and neurological conditions can produce depressive symptoms; these need not meet criteria for any of the conditions above.

Substance/medication-induced depressive disorder . Alcohol or other substances (intoxication or withdrawal) can cause depressive symptoms; these need not meet criteria for any of the conditions above.

Other specified, or unspecified, depressive disorder . Use one of these categories when a patient has depressive symptoms that do not meet the criteria for the depressive diagnoses above or for any other diagnosis in which depression is a feature.

BIPOLAR AND RELATED DISORDERS

Approximately 25% of patients with mood disorders experience manic or hypomanic episodes. Nearly all of these patients will also have episodes of depression. The severity and duration of the highs and lows determine the specific bipolar disorder.

Bipolar I disorder . There must be at least one manic episode; most patients with bipolar I have also had a major depressive episode.

Bipolar II disorder . This diagnosis requires at least one hypomanic episode plus at least one major depressive episode.

Cyclothymic disorder . These patients have had repeated mood swings, but none that are severe enough to be called major depressive episodes or manic episodes.

Substance/medication-induced bipolar disorder . Alcohol or other substances (intoxication or withdrawal) can cause manic or hypomanic symptoms; these need not meet criteria for any of the conditions above.

Bipolar disorder due to another medical condition . A variety of medical and neurological conditions can produce manic or hypomanic symptoms; these need not meet criteria for any of the conditions above.

Other specified, or unspecified, bipolar disorder . Use one of these categories when a patient has bipolar symptoms that do not meet the criteria for the bipolar diagnoses above.

Other Causes of Depressive and Manic Symptoms

Schizoaffective disorder . In these patients, symptoms suggestive of schizophrenia coexist with a major depressive or a manic episode.

Major and mild neurocognitive disorders with behavioral disturbance . The qualifier with behavioral disturbance can be coded into the diagnosis of major or mild neurocognitive disorder. OK, so mood symptoms don’t sound all that behavioral, but that’s how DSM-5 elects to indicate the cognitive disorders with depression.

Adjustment disorder with depressed mood . This term codes one way of adapting to a life stress.

Personality disorders . Dysphoric mood is specifically mentioned in the criteria for borderline personality disorder, but depressed mood commonly accompanies avoidant, dependent, and histrionic personality disorders.

Uncomplicated bereavement . Sadness at the death of a relative or friend is a common experience. Because uncomplicated bereavement is a normal reaction to a particular type of stressor, it is recorded not as a disorder, but as a Z-code [V-code]. See Z63.4 [V62.82] Uncomplicated Bereavement.

Other disorders. Depression can accompany many other mental disorders, including schizophrenia, the eating disorders, somatic symptom disorder, sexual dysfunctions, and gender dysphorias. Mood symptoms are likely in patients with an anxiety disorder (especially panic disorder and the phobic disorders), obsessive–compulsive disorder, and posttraumatic stress disorder.

Specifiers

Two special sets of descriptions can be applied to a number of the mood episodes and mood disorders.

SPECIFIERS DESCRIBING CURRENT OR MOST RECENT EPISODE

These descriptors help characterize the most recent major depressive episode; all but the first two can also apply to a manic episode. (Note that the specifiers for severity and remission are described later.)

With atypical features . These depressed patients eat a lot and gain weight, sleep excessively, and have a feeling of being sluggish or paralyzed. They are often excessively sensitive to rejection.

With melancholic features . This term applies to major depressive episodes characterized by some of the “classic” symptoms of severe depression. These patients awaken early, feeling worse than they do later in the day. They lose appetite and weight, feel guilty, are either slowed down or agitated, and do not feel better when something happens that they would normally like.

With anxious distress . A patient has symptoms of anxiety, tension, restlessness, worry, or fear that accompanies a mood episode.

With catatonic features . There are features of either motor hyperactivity or inactivity. Catatonic features can apply to major depressive episodes and to manic episodes.

With mixed features . Manic, hypomanic, and major depressive episodes may have mixtures of manic and depressive symptoms.

With peripartum onset . A manic, hypomanic, or major depressive episode (or a brief psychotic disorder) can occur in a woman during pregnancy or within a month of having a baby.

With psychotic features . Manic and major depressive episodes can be accompanied by delusions, which can be mood-congruent or -incongruent.

SPECIFIERS DESCRIBING COURSE OF RECURRING EPISODES

These specifiers describe the overall course of a mood disorder, not just the form of an individual episode.

With rapid cycling . Within 1 year, the patient has had at least four episodes (in any combination) fulfilling criteria for major depressive, manic, or hypomanic episodes.

With seasonal pattern . These patients regularly become ill at a certain time of the year, such as fall or winter.

INTRODUCTION TO MOOD EPISODES

Mood refers to a sustained emotion that colors the way we view life. Recognizing when mood is disordered is extremely important, because as many as 20% of adult women and 10% of adult men may have the experience at some time during their lives. The prevalence of mood disorders seems to be increasing in both sexes, accounting for half or more of a mental health practice. Mood disorders can occur in people of any race or socioeconomic status, but they are more common among those who are single and who have no “significant other.” A mood disorder is also more likely in someone who has relatives with similar problems.

The mood disorders encompass many diagnoses, qualifiers, and levels of severity. Although they may seem complicated, they can be reduced to a few main principles.

Years ago, the mood disorders were called affective disorders; many clinicians still use the older term, which is also entrenched in the name seasonal affective disorder. Note, by the way, that the term affect covers more than just a patient’s statement of emotion. It also encompasses how the patient appears to be feeling, as shown by physical clues such as facial expression, posture, eye contact, and tearfulness. Emphasis on the actual mood experience of the patient, rather than the sometimes fuzzy concept of affect, dictates the current use of mood.

In this section, I’ll describe three types of mood episodes. You will find case vignettes illustrating each one in the sections on the mood disorders themselves, which follow.

Major Depressive Episode

Major depressive episode is one of the building blocks of the mood disorders, but it’s not a codable diagnosis. You will use it often—it is one of the most common problems for which patients seek help. Apply it carefully after considering a patient’s full history and mental status exam. (Of course, we should be careful in using every label and every diagnosis.) I mention this caution here because some clinicians tend to use the major depressive episode label almost as a reflex, without really considering the evidence. Once it gets applied, too often there is a reflexive reaching for the prescription pad.

A major depressive episode must meet five major requirements. There must be (1) a quality of depressed mood (or loss of interest or pleasure) that (2) has existed for a minimum period of time, (3) is accompanied by a required number of symptoms, (4) has resulted in distress or disability, and (5) violates none of the listed exclusions.

Quality of Mood

Depression is usually experienced as a mood lower than normal; patients may describe it as feeling “unhappy,” “downhearted,” “bummed,” “blue,” or many other terms expressing sadness. Several issues can interfere with the recognition of depression:

• Not all patients can recognize or accurately describe how they feel.

• Clinicians and patients who come from different cultural backgrounds may have difficulty agreeing that the problem is depression.

• The presenting symptoms of depression can vary greatly from one patient to another. One patient may be slowed down and crying; another will smile and deny that anything is wrong. Some sleep and eat too much; others complain of insomnia and anorexia.

• Some patients don’t really feel depressed; rather, they experience depression as a loss of pleasure or reduced interest in their usual activities, including sex.

• Crucial to diagnosis is that the episode must represent a noticeable change from the patient’s usual level of functioning. If the patient does not notice it (some are too ill to pay attention or too apathetic to care), family or friends may report that there has been such a change.

Duration

The patient must have felt bad most of the day, almost every day, for at least 2 weeks. This requirement is included to ensure that major depressive episodes are differentiated from the transient “down” spells that most of us sometimes feel.

Symptoms

During the 2 weeks just mentioned, the patient must have at least five of the italicized symptoms below. Those five must include either depressed mood or loss of pleasure, and the symptoms must overall indicate that the person is performing at a lower level than before. Depressed mood is self-explanatory; loss of pleasure is nearly universal among depressed patients. These symptoms can be counted either if the patient reports them or if others observe that they occur.

Many patients lose appetite and weight. More than three-fourths report trouble with sleep. Typically, they awaken early in the morning, long before it is time to arise. However, some patients eat and sleep more than usual; most of these patients will qualify for the atypical featuresspecifier.

Depressed patients will usually complain of fatigue, which they may express as tiredness or low energy. Their speech or physical movements may be slowed; sometimes there is a marked pause before answering a question or initiating an action. This is called psychomotor retardation. Speech may be very quiet, sometimes inaudible. Some patients simply stop talking completely, except in response to a direct question. At the extreme, complete muteness may occur.

At the other extreme, some depressed patients feel so anxious that they become agitated. Agitation may be expressed as hand wringing, pacing, or an inability to sit still. The ability of depressed patients to evaluate themselves objectively plummets; this shows up as low self-esteem or guilt. Some patients develop trouble with concentration (real or perceived) so severe that sometimes a misdiagnosis of dementia may be made. Thoughts of death, death wishes, and suicidal ideas are the most serious depressive symptoms of all, because there is a real risk that the patient will successfully act upon them.

To count as a DSM-5 symptom for major depressive episode, the behaviors listed above must occur nearly every day. However, thoughts about death or suicide need only be “recurrent.” A single suicide attempt or a specific suicide plan will also qualify.

In general, the more closely a patient resembles this outline, the more reliable will be the diagnosis of major depressive episode. We should note, however, that depressed patients can have many symptoms besides those listed in the DSM-5 criteria. They can include crying spells, phobias, obsessions, and compulsions. Patients may admit to feeling hopeless, helpless, or worthless. Anxiety symptoms, especially panic attacks, can be so prominent that they blind clinicians to the underlying depression.

Many patients drink more (occasionally, less) alcohol when they become depressed. This can lead to difficulty in sorting out the differential diagnosis: Which should be treated first, the depression or the drinking? (Hint: Usually, both at once.)

A small minority of patients lose contact with reality and develop delusions or hallucinations. These psychotic features can be either mood-congruent (for example, a depressed man feels so guilty that he imagines he has committed some awful sin) or mood-incongruent (a depressed person who imagines persecution by the FBI is not experiencing a typical theme of depression). Psychotic symptoms are indicated in the severity indicator (it’s verbiage you add to the diagnosis, and the final number in either the ICD-9 or ICD-10 code, as discussed later in this chapter). The case vignette of Brian Murphy includes an example.

There are three situations in which you should not count a symptom toward a diagnosis of major depressive episode:

1. A symptom is fully explained by another medical condition. For example, you wouldn’t count fatigue in a patient who is recovering from major surgery; in that situation, you expect fatigue.

2. A symptom results from mood-incongruent delusions or hallucinations. For example, don’t count insomnia that is a response to hallucinated voices that keep the patient awake throughout the night.

3. Feelings of guilt or worthlessness that occur because the patient is too depressed to fulfill responsibilities. Such feelings are too common in depression to carry any diagnostic weight. Rather, look for guilt feelings that are way outside the boundaries of what’s reasonable. An extreme example: A woman believes that her wickedness caused the tragedies of 9/11.

Impairment

The episode must be serious enough to cause material distress or to impair the patient’s work (or school) performance, social life (withdrawal or discord), or some other area of functioning, including sex. Of the various consequences of mental illness, the effect on work may the hardest to detect. Perhaps this is because earning a livelihood is so important that most people will go to great lengths to hide symptoms that could threaten their employment.

Exclusions

Regardless of the severity or duration of symptoms, major depressive episode usually should not be diagnosed in the face of clinically important substance use or a general medical disorder that could cause the symptoms.

Essential Features of Major Depressive Episode

These people are miserable. Most feel sad, down, depressed, or some equivalent; however, some few will instead insist that they’ve only lost interest in nearly all their once-loved activities. All will admit to varying numbers of other symptoms—such as fatigue, inability to concentrate, feeling worthless or guilty, and wishes for death or thoughts of suicide. In addition, three symptom areas may show either an increase or a decrease from normal: sleep, appetite/weight, and psychomotor activity. (For each of these, the classic picture is a decrease from normal—in appetite, for example—but some “atypical” patients will report an increase.)

The Fine Print

Also, children or adolescents may only feel or seem irritable, not depressed.

Don’t disregard the D’s: • Duration (most of nearly every day, 2+ weeks) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders)

Coding Notes

No code alert: Major depressive episode is not a diagnosable illness; it is a building block of major depressive, bipolar I, and bipolar II disorders. It may also be found in persistent depressive disorder (dysthymia). However, certain specifier codes apply to major depressive episodes—though you tack them on only after you’ve decided on the actual mood disorder diagnosis. Relax; this will all become clear as we proceed.

The bereavement exclusion that was used through DSM-IV is not to be found in DSM-5, because recent research has determined that depressions closely preceded by the death or loss of a loved one do not differ substantially from depressions preceded by other stressors (or possibly by none at all). There’s been a lot of breast beating over this move, or rather removal. Some claim that it places patients at risk for diagnosis of a mood disorder when context renders symptoms understandable; a substantial expansion in the number of people we regard as mentally ill could result.

I see the situation a little differently: We clinicians now have one fewer artificial barriers to diagnosis and treatment. However, as with any other freedom, we must use it responsibly. Evaluate the whole situation, especially the severity of symptoms, any previous history of mood disorder, the timing and severity of putative precipitant (bereavement plus other forms of loss), and the trajectory of the syndrome (is it getting worse or better?). And reevaluate frequently.

I’ve included examples of major depressive episode in the following vignettes: Brian Murphy, Elizabeth Jacks, Winona Fisk, Iris McMaster, Noah Sanders, Sal Camozzi, and Aileen Parmeter. In addition, there may be some examples in Chapter 20, “Patients and Diagnoses”—but you’ll have to find them for yourself.

Manic Episode

The second “building block” of the mood disorders, manic episode, has been recognized for at least 150 years. The classic triad of manic symptoms consists of heightened self-esteem, increased motor activity, and pressured speech. These symptoms are obvious and often outrageous, so manic episode is not often overdiagnosed. However, the psychotic symptoms that sometimes attend manic episode can be so florid that clinicians instead diagnose schizophrenia. This tendency to misdiagnosis may have decreased since 1980, when the DSM-III criteria increased clinicians’ awareness of bipolar illness. The introduction of lithium treatment for bipolar disorders in 1970 also helped promote the diagnosis.

Manic episode is much less common than major depressive episode, perhaps affecting 1% of all adults. Men and women are about equally likely to have mania.

The features that must be present in order to diagnose manic episode are identical to those for major depressive episode: (1) A mood quality that (2) has existed for a required period of time, (3) is attended by a required number of symptoms, (4) has resulted in a considerable degree of disability, and (5) violates none of the listed exclusions.

Quality of Mood

Some patients with relatively mild symptoms just feel jolly; this bumptious good humor can be quite infectious and may make others feel like laughing with them. But as mania worsens, this humor becomes less cheerful as it takes on a “driven,” unfunny quality that creates discomfort in patients and listeners alike. A few patients will have mood that is only irritable; euphoria and irritability sometimes occur together.

Duration

The patient must have had symptoms for a minimum of 1 week. This time requirement helps to differentiate manic episode from hypomanic episode.

Symptoms

In addition to the change in mood (euphoria or irritability), the patient must also have an increase in energy or activity level during a 1-week period. With these changes, at least three of the italicized symptoms listed below must also be present to an important degree during the same time period. (Note that if the patient’s abnormal mood is only irritable—that is, without any component of euphoria—four symptoms are required in addition to the increased activity level.)

Heightened self-esteem, found in most patients, can become grandiose to the point that it is delusional. Then patients believe that they can advise presidents and solve the problem of world hunger, in addition to more mundane tasks such as conducting psychotherapy and running the very medical facilities that currently house them. Because such delusions are in keeping with the euphoric mood, they are called mood-congruent.

Manic patients typically report feeling rested on little sleep. Time spent sleeping seems wasted; they prefer to pursue their many projects. In its milder forms, this heightened activity may be goal-directed and useful; patients who are only moderately ill can accomplish quite a lot in a 20-hour day. But as they become more and more active, agitation ensues, and they may begin many projects they never complete. At this point they have lost judgment for what is reasonable and attainable. They may become involved in risky business ventures, indiscreet sexual liaisons, and questionable religious or political activities.

Manic patients are eager to tell anyone who will listen about their ideas, plans, and work, and they do so in speech that is loud and difficult to interrupt. Manic speech is often rapid and pressured, as if there were too many dammed-up words trying to escape through a tiny nozzle. The resulting speech may exhibit what is called flight of ideas, in which one thought triggers another to which it bears only a marginally logical association. As a result, a patient may wander far afield from where the conversation (or monologue) started. Manic patients may also be easily distracted by irrelevant sounds or movements that other people would ignore.

Some manic patients retain insight and seek treatment, but many will deny that anything is wrong. They rationalize that no one who feels this well or is so productive could possibly be ill. Manic behavior therefore continues until it ends spontaneously or the patient is hospitalized or jailed. I consider manic episodes to be acute emergencies, and I don’t expect many clinicians will argue.

Some symptoms not specifically mentioned in the DSM-5 criteria are also worth noting here.

1. Even during an acute manic episode, many patients have brief periods of depression. These “microdepressions” are relatively common; depending on the symptoms associated with them, they may suggest that the specifier with mixed features is appropriate.

2. Patients may use substances (especially alcohol) in an attempt to relieve the uncomfortable, driven feeling that accompanies a severe manic episode. Less often, the substance use temporarily obscures the symptoms of the mood episode. When clinicians become confused about whether the substance use or the mania came first, the question can usually be sorted out with the help of informants.

3. Catatonic symptoms occasionally occur during a manic episode, sometimes causing the episode to resemble schizophrenia. But a history (obtained from informants) of acute onset and previous episodes with recovery can help clarify the diagnosis. Then the specifier with catatonic features may be indicated.

What about episodes that don’t start until the patient undergoes treatment for a depression? Should they count as fully as evidence of spontaneous mania or hypomania? To count as evidence for either manic or hypomanic episode, DSM-5 requires that the full criteria (not just a couple of symptoms, such as agitation or irritability) be present, and that the symptoms last longer than the expected physiological effects of the treatment. This declaration nicely rounds out the list of possibilities: DSM-IV stated flatly that manic episodes caused by treatment could not count toward a diagnosis of bipolar I disorder, whereas DSM-III-R implied that they could. And DSM-III kept silent on the whole matter.

The authors of the successive DSMs may have been thinking of Emerson’s famous epigram: A foolish consistency is the hobgoblin of little minds.

Impairment

Manic episodes typically wreak havoc on the lives of patients and their associates. Although increasing energy and effort may at first actually improve productivity at work (or school), as mania worsens a patient becomes less and less able to focus attention. Friendships are strained by arguments. Sexual entanglements can result in disease, divorce, and unwanted pregnancy. Even when the episode has resolved, guilt and recriminations remain behind.

Exclusions

The exclusions for manic episode are the same as for major depressive episode. General medical conditions such as hyperthyroidism can produce hyperactive behavior; patients who misuse certain psychoactive substances (especially amphetamines) will appear speeded up and may report feeling strong, powerful, and euphoric.

Essential Features of Manic Episode

Patients in the throes of mania are almost unmistakable. These people feel euphoric (though sometimes they’re only irritable), and there’s no way you can ignore their energy and frenetic activity. They are full of plans, few of which they carry through (they are so distractible). They talk and laugh, and talk some more, often very fast, often with flight of ideas. They sleep less than usual (“a waste of time, when there’s so much to do”), but feel great anyway. Grandiosity is sometimes so exaggerated that they become psychotic, believing that they are exalted personages (monarchs, rock stars) or that they have superhuman powers. With deteriorating judgment (they spend money unwisely, engage in ill-conceived sexual adventures), functioning becomes impaired, often to the point they must be hospitalized to force treatment or for their own protection or that of other people.

The Fine Print

The D’s: • Duration (most of nearly every day, 1+ weeks) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, schizoaffective disorder, neurocognitive disorders, hypomanic episodes, cyclothymia)

Coding Notes

Manic episode is not a diagnosable illness; it is a building block of bipolar I disorder.

Elisabeth Jacks had a manic episode; you can read her history beginning on page 131. Another example is that of Winona Fisk. Look for other cases in the patient histories given in Chapter 20.

Hypomanic Episode

Hypomanic episode is the final mood disorder “building block.” Comprising most of the same symptoms as manic episode, it is “manic episode writ small.” Left without treatment, some patients with hypomanic episode may become manic later on. But many, especially those who have bipolar II disorder, have repeated hypomanic episodes. Hypomanic episode isn’t codable as a diagnosis; it forms the basis for bipolar II disorder, and it can be encountered in bipolar I disorder, after the patient has already experienced an episode of actual mania. Hypomanic episode requires (1) a mood quality that (2) has existed for a required period of time, (3) is attended by a required number of symptoms, (4) has resulted in a considerable degree of disability, and (5) violates none of the listed exclusions. Table 3.1 compares the features of manic and hypomanic episodes.

TABLE 3.1 . Comparing Manic and Hypomanic Episodes

Manic episode

Hypomanic episode

Duration

1 week or more

4 days or more

Mood

Abnormally and persistently high, irritable, or expansive

Activity/energy

Persistently increased

Symptoms that are changes from usual behavior

Three or more a of grandiosity, ↓ need for sleep, ↑ talkativeness, flight of ideas or racing thoughts, distractibility (self-report or that of others), agitation or ↑ goal-directed activity, poor judgment

Severity

Results in psychotic features, hospitalization, or impairment of work, social, or personal functioning

Clear change from usual functioning and Others notice this change and No psychosis, hospitalization, or impairment

Other

Rule out substance/medication-induced symptoms With mixed features if appropriate b

a Four or more if the only abnormality of mood is irritability. b Both manic and hypomanic episodes can have the specifier with mixed features.

Quality of Mood

The quality of mood in hypomanic episode tends to be euphoric without the driven quality present in manic episode, though mood can instead be irritable. However described, it is clearly different from the patient’s usual nondepressed mood.

Duration

The patient must have had symptoms for a minimum of 4 days—a marginally shorter time requirement than that for manic episode.

Symptoms

As with manic episode, in addition to the change in mood (euphoria or irritability), the patient must also have an increase in energy or activity level—but again, only for 4 days. Then at least three symptoms from the same list must be present to an important degree (and represent a noticeable change) during this 4 days. If the patient’s abnormal mood is irritable and not elevated, four symptoms are required. Note that hypomanic episode precipitated by treatment can be adduced as evidence for, say, bipolar II disorder—if it persists longer than the expected physiological effects of the treatment.

The sleep of hypomanic patients may be brief, and activity level may be increased, sometimes to the point of agitation. Although the degree of agitation is less than in a manic episode, hypomanic patients can also feel driven and uncomfortable. Judgment deteriorates, and may lead to untoward consequences for finances or for work or social life. Speech may become rapid and pressured; racing thoughts or flight of ideas may be noticeable. Easily becoming distracted can be a feature of hypomanic episode. Heightened self-esteem is never so grandiose that it becomes delusional, and hypomanic patients are never psychotic.

In addition to the DSM-5 criteria, note that in hypomanic episode, as in manic episode, substance use is common.

Impairment

How severe can the impairment be without qualifying as a manic episode? This is to some extent a judgment call for the practitioner. Lapses of judgment, such as spending sprees and sexual indiscretions, can occur in both manic and hypomanic episodes—but, by definition, only the patient who is truly manic will be seriously impaired. If behavior becomes so extreme that hospitalization is needed or psychosis is evident, the patient can no longer be considered hypomanic, and the label must be changed.

Exclusions

The exclusions are the same as those for manic episode. General medical conditions such as hyperthyroidism can produce hyperactive behavior; patients who misuse certain substances (especially amphetamines) will appear speeded up and may also report feeling strong, powerful, and euphoric.

Essential Features of Hypomanic Episode

Hypomania is “mania lite”—many of the same symptoms, but never to the same outrageous degree. These people feel euphoric or irritable and they experience high energy or activity. They are full of plans, which, despite some distractibility, they sometimes actually implement. They talk a lot, reflecting their racing thoughts, and may have flight of ideas. Judgment (sex and spending) may be impaired, but not to the point of requiring hospitalization for their own protection or that of others. Though the patients are sometimes grandiose and self-important, these features never reach the point of delusion. You would notice the change in such a person, but it doesn’t impair functioning; indeed, sometimes these folks get quite a lot done!

The Fine Print

The D’s: • Duration (most of nearly every day, 4+ days) • Disability (work/educational, social, and personal functioning are not especially impaired) • Differential diagnosis (substance use and physical disorders, other bipolar disorders)

Coding Notes

Specify if: With mixed features.

There is no severity code.

Hypomanic episode is not a diagnosable illness; it is a building block of bipolar II disorder and bipolar I disorder.

MOOD DISORDERS BASED ON THE MOOD EPISODES

From this point, the format of my presentation differs somewhat from both that of the DSM-5 and that of the Quick Guide at the beginning of the chapter. First, I’ll discuss the mood disorders that use the mood episode “building blocks”—major depressive disorder and bipolar I and II disorders. Afterwards, I’ll cover the disorders that do not crucially involve these episodes.

Major Depressive Disorder

A patient who has one or more major depressive episodes, and no manic or hypomanic symptoms, is said to have major depressive disorder (MDD). It is a common condition, affecting about 7% of the general population, with a female preponderance of roughly 2:1. MDD usually begins in the middle to late 20s, but it can occur at any time of life, from childhood to old age. The onset may be sudden or gradual. Although episodes last on average from 6 to 9 months, the range is enormous, from a few weeks to many years. Recovery usually begins within a few months of onset, though that too can vary enormously. A full recovery is less likely for a person who has a personality disorder or symptoms that are more severe (especially psychotic features). MDD is strongly hereditary; first-degree relatives have a risk several times that of the general population.

Some patients have only a single episode during an entire lifetime; then they are diagnosed with (no surprise) MDD, single episode. However, roughly half the patients who have one major depressive episode will have another. At the point they develop a second episode (to count, it must be separated from the first by at least 2 months), we must change the diagnosis to MDD, recurrent type.

For any given patient, symptoms of depression remain pretty much the same from one episode to the next. These patients will have an episode roughly every 4 years; there is some evidence that the frequency of episodes increases with age. Multiple episodes of depression greatly increase the likelihood of suicide attempts and completed suicide. Unsurprisingly, patients with recurrent episodes are also much more likely than those with a single episode to be impaired by their symptoms. One of the most severe consequences is suicide, which is the fate of about 4% of patients with MDD.

Perhaps 25% of patients with MDD will eventually experience a manic or hypomanic episode, thereby requiring yet another change in diagnosis—this time to bipolar (I or II) disorder. We’ll talk more about them later.

Essential Features of Major Depressive Disorder, {Single Episode}{Recurrent}

The patient has {one}{or more} major depressive episodes and no spontaneous episodes of mania or hypomania.

The Fine Print

Two months or more without symptoms must intervene for episodes to be counted as separate.

Decide on the D’s: • Differential diagnosis (substance use and physical disorders, other mood disorders, ordinary grief and sadness, schizoaffective disorder)

Coding Notes

From type of episode and severity, find code numbers in Table 3.2. If applicable, choose specifiers from Table 3.3.

TABLE 3.2 . Coding for Bipolar I and Major Depressive Disorders

Severity

Bipolar I, current or most recent episode a

Major depressive, current or most recent episode

Manic

Hypomanic

Depressed

Single

Recurrent

Mild b

F31.11 [296.41]

F31.0 [296.40] (no severity, no psychosis for hypomanic episodes)

F31.31 [296.51]

F32.0 [296.21]

F33.0 [296.31]

Moderate c

F31.12 [296.42]

F31.32 [296.52]

F32.1 [296.22]

F33.1 [296.32]

Severe d

F31.13 [296.43]

F31.4 [296.53]

F32.2 [296.23]

F33.2 [296.33]

With psychotic features e

F31.2 [296.44]

—

F31.5 [296.54]

F32.3 [296.24]

F33.3 [296.34]

In partial remission f

F31.73 [296.45]

F31.71 [296.45]

F31.75 [296.55]

F32.4 [296.25]

F33.41 [296.35]

In full remission g

F31.74 [296.46]

F31.72 [296.46]

F31.76 [296.56]

F32.5 [296.26]

F33.42 [296.36]

Unspecified

F31.9 [296.40]

F31.9 [296.50]

F32.9 [296.20]

F33.9 [296.30]

Note. Here are two examples of how you put it together: Bipolar I disorder, manic, severe with mood-congruent psychotic features, with peripartum onset, with mixed features. Major depressive disorder, recurrent, in partial remission, with seasonal pattern. Note the order: name → episode type → severity/psychotic/remission → other specifiers. Purchasers of this ebook can download a copy of this table from www.guilford.com/morrison2-forms. a If the bipolar I type isn’t specified, code as F31.9 [296.7]. b Mild. Meets the minimum of symptoms, which are distressing but interfere minimally with functionality. c Moderate. Intermediate between mild and severe. d Severe. Many serious symptoms that profoundly impede patient’s functioning. e If psychotic features are present, use these code numbers regardless of severity (it will almost always be severe, anyway). Record these features as mood-congruent or mood-incongruent. f Partial remission. Symptoms are no longer sufficient to meet criteria. g Full remission. For 2 months or more, the patient has been essentially free of symptoms.

TABLE 3.3 . Descriptors and Specifiers That Can Apply to Mood Disorders

Note. This table can help you to choose the sometimes lengthy string of names, codes, and modifiers for the mood disorders. Start reading from left to right in the table, putting in any modifiers that apply in the order you come to them. Dysthymia can also have early or late onset, plus a variety of additional specifiers. aThe catatonia specifier requires its own line of code and description. (See p. 100.) Purchasers of this ebook can download a copy of this table from www.guilford.com/morrison2-forms.

Brian Murphy

Brian Murphy had inherited a small business from his father and built it into a large one. When he sold out a few years later, he invested most of his money; with the rest, he bought a small almond farm in northern California. With his tractor, he handled most of the farm chores himself. Most years the farm earned a few hundred dollars, but as Brian was fond of pointing out, it really didn’t make much difference. If he never made a dime, he felt he got “full value from keeping busy and fit.”

When Brian was 55, his mood, which had always been normal, slid into depression. Farm chores seemed increasingly to be a burden; his tractor sat idle in its shed.

As his mood blackened, Brian’s body functioning seemed to deteriorate. Although he was constantly fatigued, often falling into bed by 9 P.M., he would invariably awaken at 2 or 3 A.M. Then obsessive worrying kept him awake until sunrise. Mornings were worst for him. The prospect of “another damn day to get through” seemed overwhelming. In the evenings he usually felt somewhat better, though he’d sit around working out sums on a magazine cover to see how much money they’d have if he “couldn’t work the farm” and they had to live on their savings. His appetite deserted him. Although he never weighed himself, he had to buckle his belt two notches smaller than he had several months before.

“Brian just seemed to lose interest,” his wife, Rachel, reported the day he was admitted to the hospital. “He doesn’t enjoy anything any more. He spends all his time sitting around and worrying about being in debt. We owe a few hundred dollars on our credit card, but we pay it off every month!”

During the previous week or two, Brian had begun to ruminate about his health. “At first it was his blood pressure,” Rachel said. “He’d ask me to take it several times a day. I still work part-time as a nurse. Several times he thought he was having a stroke. Then yesterday he became convinced that his heart was going to stop. He’d get up, feel his pulse, pace around the room, lie down, put his feet above his head, do everything he could to ‘keep it going.’ That’s when I decided to bring him here.”

“We’ll have to sell the farm.” That was the first thing Brian said to the mental health clinician when they met. Brian was casually dressed and rather rumpled. He had prominent worry lines on his forehead, and he kept feeling for his pulse. Several times during the interview, he seemed unable to sit still; he would get up from the bed where he was sitting and pace over to the window. His speech was slow but coherent. He talked mostly about his feelings of being poverty-stricken and his fears that the farm would have to go on the block. He denied having hallucinations, but admitted to feeling tired and “all washed up—not good for anything any more.” He was fully oriented, had a full fund of information, and scored a perfect 30 on the MMSE. He admitted that he was depressed, but he denied having thoughts about death. Somewhat reluctantly, he agreed that he might need treatment.

Rachel pointed out that with his generous disability policy, his investments, and his pension from his former company, they had more money coming in than when he was healthy.

“But still we have to sell the farm,” Brian replied.

Evaluation of Brian Murphy

Unfortunately, clinicians (including some mental health specialists) commonly make two sorts of mistakes when evaluating patients with depression.

First, we sometimes focus too intently on a patient’s anxiety, alcohol use, or psychotic symptoms and ignore underlying symptoms of depression or dysthymia. Here’s my lifelong rule, formulated from bitter experience (not all mine) as far back as when I was a resident: Always look for a mood disorder in any new patient, even if the chief complaint is something else.

Second, the presenting depressive or manic symptoms can be quite noticeable, even dramatic—to the point that clinicians may fail to notice, lurking underneath, the presence of alcohol use disorder or another disorder (good examples are neurocognitive and somatic symptom disorders). And that suggests another, equally important rule, almost the mirror image of the first rule: Never assume that a mood disorder is your patient’s only problem.

First, let’s try to identify the current (and any previous) mood episodes. Brian Murphy had been ill much longer than 2 weeks (criterion A). Of the major depressive episode symptoms listed (five are required by DSM-5), he had at least six: low mood (A1), loss of interest (A2), fatigue (A6), sleeplessness (A4), low self-esteem (A7), loss of appetite (A3), and agitation (A5). (Note that either low mood or loss of interest is required for diagnosis; Brian had both.) He was so seriously impaired (B) that he required hospitalization. Although we do not have the results of his physical exam and laboratory testing, the vignette provides no history that would suggest another medical condition (for example, pancreatic carcinoma) or substance use (C). However, his clinician would definitely need to ask both Brian and his wife about this—depressed people often increase their drinking. He was clearly severely depressed and different from his usual self. He easily fulfilled the criteria for major depressive episode.

Next, what type of mood disorder did Brian have? There had been no manic or hypomanic episodes (E), ruling out bipolar I or II disorder.His delusions of poverty could suggest a psychotic disorder (such as schizoaffective disorder), but he had too few psychotic symptoms, and the timing of mood symptoms versus delusions was wrong (D). He was deluded but had no additional A criteria for schizophrenia. His mood symptoms ruled out brief psychotic disorder and delusional disorder. He therefore fulfilled the requirements for MDD.

There are just two subtypes of MDD: single episode and recurrent. Although Brian Murphy might subsequently have other episodes of depression, this was the only one so far.

For the further description and coding of Brian Murphy’s depression, let’s turn to Table 3.2. His single episode dictates the column to highlight under MDD. And he was delusional, so we’d code him as with psychotic features.

But wait: Suppose he hadn’t been psychotic? What severity would we assign him then? Despite the fact that he wasn’t suicidal (he didn’t want death; rather, he feared it), he did have most of the required symptoms, and he was seriously impaired by his depressive illness. That’s why I’d rate him as severely depressed (but remember, the code number has already been determined).

Now we’ll turn to the panoply of other specifiers, which I’ll discuss toward the end of this chapter. Brian had no manic symptoms; that rules out with mixed features. His delusion that he was poor and would have to sell the farm was mood-congruent—that is, in keeping with the usual cognitive themes of depression. (However, the thought that his heart would stop and the pulse checking were probably not delusional. I’d regard them as signifying the overwhelming anxiety he felt about the state of his health.) The words we’d attach to his diagnosis (so far) would be MDD, single episode, severe with mood-congruent psychotic features.

But wait; there’s more. There were no abnormalities of movement suggestive of catatonic features, nor did his depression have any atypical features (for example, he didn’t have increased appetite or sleep too much). Of course, he would not qualify for peripartum onset. But his wife complained that he didn’t “enjoy anything any more,” suggesting that he might qualify for melancholic features. He was agitated when interviewed (marked psychomotor slowing would have also qualified for this criterion), and he had lost considerable weight. He reported awakening early on many mornings (terminal insomnia). The interviewer did not ask him whether this episode of depression differed qualitatively from how he felt when his parents died, but I’d bet that it did. So, we’ll add with melancholic features to the mix.

I wrote this vignette before a new specifier, with anxious distress, was a gleam in anyone’s eye, but I think Brian Murphy qualifies for it as well. He appeared edgy and tense, and he was markedly restless. Furthermore, he seemed to be expressing the fear that something horrible—possibly a catastrophic health event—would occur. Even though nothing was said about poor concentration, he had at least three of the symptoms required for the with anxious distress specifier, at a moderate severity rating. The evidence is that this specifier has real prognostic importance, suggesting, in the absence of treatment, the possibility of a poor outcome—even suicide.

Some patients with severe depression also report many of the symptoms typical of panic disorder, generalized anxiety disorder, or some other anxiety disorder. In such a case, two diagnoses could be made. Usually the mood disorder is listed first as the primary diagnosis. Anxiety symptoms that do not fulfill criteria for one of the disorders described in Chapter 4 may be further evaluated as evidence for the anxious distress specifier.

Of course, Brian wouldn’t qualify for rapid cycling or seasonal pattern; with only one episode, there could be no pattern. I’d give him a GAF score of 51, and his final diagnosis would be as given below.

Let me just say that the prospect of using so many different criteria sets to code one patient may seem daunting, but taking it one step at a time reveals a process that is really quite logical and (once you get the hang of it) fairly quick. The same basic methods should be applied to all examples of depression. (Of course, you could argue—I certainly would—that using the prototypical descriptions of depression and mania and their respective disorders simplifies things still further. But again, remember always to consider the possibility of substance use and physical causes of any given symptom set.)

F32.3 [296.24]

Major depressive disorder, single episode, severe with mood-congruent psychotic features, with melancholic features, with moderate anxious distress

There’s a situation in which I like to be extra careful about diagnosing MDD. That’s when a patient also has somatic symptom disorder. The problem is that many people who seem to have too many physical symptoms can also have mood symptoms that closely resemble major depressive episodes (and sometimes manic episodes). Over the years, I’ve found that these people tend to get treatment with medication, electroconvulsive therapy (ECT), and other physical therapies that don’t seem to help them much—certainly not for long. I’m not saying that drugs never work; I maintain only that if you encounter a patient with somatic symptom disorder who is depressed, other treatments (such as cognitive-behavioral therapy or other forms of behavior modification) may be more effective and less fraught with complications.

Aileen Parmeter

“I just know it was a terrible mistake to come here.” For the third time, Aileen Parmeter got out of her chair and walked to the window. A wiry 5 feet 2 inches, this former Marine master sergeant (she had supervised a steno pool) weighed a scant 100 pounds. Through the slats of the Venetian blinds, she peered longingly at freedom in the parking lot below. “I just don’t know whatever made me come.”

“You came because I asked you to,” her clinician explained. “Your nephew called and said you were getting depressed again. It’s just like last time.”

“No, I don’t think so. I was just upset,” she explained patiently. “I had a little cold for a few days and couldn’t play my tennis. I’ll be fine if I just get back to my little apartment.”

“Have you been hearing voices or seeing things this time?”

“Well, of course not.” She seemed rather offended. “You might as well ask if I’ve been drinking.”

After her last hospitalization, Aileen had been well for about 10 months. Although she had taken her medicine for only a few weeks, she had remained active until 3 weeks ago. Then she stopped seeing her friends and wouldn’t play tennis because she “just didn’t enjoy it.” She worried constantly about her health and had been unable to sleep. Although she didn’t complain of decreased appetite, she had lost about 10 pounds.

“Well, who wouldn’t have trouble? I’ve just been too tired to get my regular exercise.” She tried to smile, but it came off crooked and forced.

“Miss Parmeter, what about the suicidal thoughts?”

“I don’t know what you mean.”

“I mean, each time you’ve been here—last year, and 2 years before that—you were admitted because you tried to kill yourself.”

“I’m going to be fine now. Just let me go home.”

But her therapist, whose memory was long, had ordered Aileen held for her own protection in a private room where she could be observed one-on-one.

Sleepless still at 3 A.M., Aileen got up, smiled wanly at the attendant, and went in to use the bathroom. Looping a strip she had torn from her sweatsuit over the top of the door, she tried to hang herself. As the silence lengthened, the attendant called out softly, then tapped on the door, then opened it and sounded the alarm. The code team responded with no time to spare.

The following morning, the therapist was back at her bedside. “Why did you try to do that, Miss Parmeter?”

“I didn’t try to do anything. I must have been confused.” She gingerly touched the purple bruises that ringed her neck. “This sure hurts. I know I’d feel better if you’d just let me go home.”

Aileen remained hospitalized for 10 days. Once her sore neck would allow, she began to take her antidepressant medication again. Soon she was sleeping and eating normally, and she made a perfect score on the MMSE. She was released to go home to her apartment and her tennis, still uncertain why everyone had made such a fuss about her.

Evaluation of Aileen Parmeter

Aileen never acknowledged feeling depressed, but she had lost interest in her usual activities. This change had lasted longer than 2 weeks, and—as in previous episodes—her other symptoms included fatigue, insomnia, loss of weight, and suicidal behavior (criterion A). (Although she reproached herself for entering the hospital, these feelings referred exclusively to her being ill and would not be scored as guilt.) She was sick enough to require hospitalization, fulfilling the impairment criterion (B).

Aileen could have a mood disorder due to another medical condition, and this would have to be pursued by her clinician, but the history of recurrence makes this seem unlikely (C). Symptoms of apathy and poor memory raise the question of mild neurocognitive disorder, but her MMSE showed no evidence of memory impairment. She denied alcohol consumption, so a substance-induced mood disorder would also appear unlikely (her clinician had known her for so long that further pursuit of the possibility would be wasted effort).

There was no evidence that Aileen had ever had mania or hypomania, ruling out bipolar I or II disorder (E), and absence of any psychotic symptoms rules out psychotic disorders (D). She therefore fulfills the criteria for MDD. She’d had more than one episode separated by substantially longer than 2 months, which would satisfy the requirement for the term recurrent. Turning to Table 3.2, we can reject the rows there describing psychotic features (she emphatically denied having delusions or hallucinations) and remission.

Now we must consider the severity of her depression. It is always a problem how best to score someone with so little insight. Even with the suicide attempt, Aileen appeared barely to meet the five symptoms needed for major depressive episode. According to the rules, she should receive a severity coding of no greater than moderate. However, for a patient who has just nearly killed herself, this would be inaccurate and possibly dangerous; one of her symptoms, suicidal behavior, was very serious indeed. As I’ve said before, the coding instructions are meant to be guides, not shackles: I’d call Aileen’s depression severe.

She wouldn’t qualify for any of the specifiers for the most recent episode—perhaps because her lack of insight prevented her from providing full information. (I suppose that longer observation might reveal criteria adequate for with melancholic features.)

Other diagnoses are sometimes found in patients with MDD. These include several of the anxiety disorders, obsessive–compulsive disorder, and the substance-related disorders (especially alcohol use disorder). There is no evidence for any of these. I’d give her a GAF score of only 15 on admission. Her GAF had improved to 60 by the time she was released. Her complete diagnosis would be as follows:

F33.2 [296.33]

Major depressive disorder, recurrent, severe

Bipolar I Disorder

Bipolar I disorder is shorthand for any cyclic mood disorder that includes at least one manic episode. Although this nomenclature has only been adopted within the past several decades, bipolar I disorder has been recognized for over a century. Formerly, it was called manic–depressive illness; older clinicians may still refer to it this way. Men and women are about equally affected, for a total of approximately 1% of the general adult population. Bipolar I disorder is strongly hereditary.

There are two technical points to consider in evaluating episodes of bipolar I disorder. First, for an episode to count as a new one, it must either represent a change of polarity (for example, from major depressive to manic or hypomanic episode), or it must be separated from the previous episode by a normal mood that lasts at least 2 months.

Second, a manic or hypomanic episode will occasionally seem to be precipitated by the treatment of a depression. Antidepressant drugs, ECT, or bright light (used to treat seasonal depression) may cause a patient to move rapidly from depression into a full-blown manic episode. Bipolar I disorder is defined by the occurrence of spontaneous depressions, manias, and hypomanias; therefore, any treatment-induced manic or hypomanic episode can only be used to make the diagnosis of a bipolar I (or, for that matter, bipolar II) condition if the symptoms persist beyond the physiological effect of that treatment. Even then, DSM-5 urges caution: Demand the full number of manic or hypomanic symptoms, not just edginess or agitation that some patients experience following treatment of depression.

In addition, note the warning that the mood episodes must not be superimposed on a psychotic disorder—specifically schizophrenia, schizophreniform disorder, delusional disorder, or unspecified psychotic disorder. Because the longitudinal course of bipolar I disorder differs strikingly from those of the psychotic disorders, this should only rarely cause diagnostic problems.

Usually a manic episode will be current, and the patient will have been admitted to a hospital. Occasionally, you might use the category current or most recent episode manic for a newly diagnosed patient who is on a mood-stabilizing regimen. Most will have had at least one previous manic, major depressive, or hypomanic episode. However, a single manic episode is hardly rare, especially early in the course of bipolar I disorder. Of course, the vast majority of such patients will later have subsequent major depressive episodes, as well as additional manic ones. Males are more likely than females to have a first episode that is manic.

Current episode depressed (I’m intentionally shorthanding the long and unwieldy official phrase) will be one of the most frequently used of the bipolar I subtypes; nearly all patients with this disorder will receive this diagnosis at some point during their lifetimes. The depressive symptoms will be very much like those in the major depressive disorders of Brian Murphy and Aileen Parmeter. Elisabeth Jacks, whose current episode was manic, had been depressed a few weeks before her current evaluation.

In a given patient, symptoms of mood disorder tend to remain the same from one episode to the next. However, it is possible that after an earlier manic episode, a subsequent mood upswing may be less severe, and therefore only hypomanic. (The first episode of a bipolar I disorder couldn’t be hypomanic; otherwise, you’d have to diagnose bipolar II.) Although I have provided no vignette for bipolar I, most recent episode hypomanic, I have described a hypomanic episode in the case of Iris McMaster, a patient with bipolar II disorder.

Researchers who have followed bipolar patients for many years report that some have only manias. The concept of unipolar mania has been debated off and on for a long time. There are probably some patients who will never have a depression, but most will, given enough time. I have known of patients who had as many as seven episodes of mania over a 20-year period before finally having a first episode of depression. What’s important here is that all patients with bipolar I (and II) disorder—and their families—should be warned to watch out for depressive symptoms. Bipolar I patients have a high likelihood of completing suicide; some reports suggest that these people account for up to a quarter of all suicides.