DSM-5-TR Updates to Bipolar I Disorder Severity Specifiers — Patient Case: Mild Mania Video

This patient case video illustrates the mild manic episode severity specifier, as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR).

Transcript:

Hello. I’m Dr Jamie Winderbaum Fernandez. I’m a psychiatrist in private practice in Tampa, Florida, and an associate professor at the University of South Florida in the Department of Psychiatry and Behavioral Neurosciences.

I welcome you to this patient case video that will illustrate the mild manic episode severity specifier, as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), released in March of 2022. Understanding how to apply this severity specifier can lead to a more precise diagnosis and help you make informed and appropriate treatment decisions for your patients with bipolar I disorder.

Let’s get started.

This case depicts a patient experiencing a mild manic episode. The patient’s chief complaints are irritability and insomnia impacting functioning at work for 1 week.

The patient is a 44-year-old male with previously diagnosed generalized anxiety disorder (GAD) and insomnia who self-referred for consultation. Over the past week, in addition to experiencing irritability and insomnia, he reports increased energy and motivation to achieve his goals at work, racing thoughts that distract from his daily functioning, a lack of focus that results in him moving from task to task, sometimes erratically, and increased talkativeness.

When asked about prior mood symptoms, the patient reports that in his early 20s, he experienced periods of high productivity and irritable mood, along with symptoms of edginess, insomnia, and distractibility. Early onset in a patient less than 25 years of age is important to note here because it is a key probabilistic factor of bipolar disorder.

Additionally, the patient reports that multiple antidepressants were prescribed to him during that time, but they all worsened his symptoms. They also caused him to feel agitated and have racing thoughts. This is an important finding because patients with bipolar disorder may experience treatment-emergent affective switch, or TEAS, in response to antidepressant therapy.¹ TEAS is another key probabilistic factor of bipolar disorder.

Upon further questioning, the patient endorses a family history of bipolar disorder diagnosed in his mother and sister. Family history of bipolar disorder is also a key probabilistic factor of bipolar disorder.

As is the case for many patients, this patient was unable to find a psychiatrist who took insurance and was accepting new patients.²

As a result, he receives mental health care for GAD and insomnia from his primary care provider, as many patients with mental health needs do.³

The realities of our current healthcare landscape drive home the importance of primary care providers in accurately diagnosing and effectively treating patients with bipolar I disorder.

As previously mentioned, this patient has several probabilistic factors that point to a diagnosis of bipolar disorder. He began experiencing symptoms of undiagnosed bipolar disorder before the age of 25. His symptoms have included irritability and psychomotor agitation, among other manic symptoms. He has tried multiple antidepressants and experienced antidepressant-induced mania, also known as TEAS, following antidepressant treatment. Additionally, he has a diagnosis of GAD and reports a family history of bipolar disorder.

In summary, the impression for this patient is as follows:

This patient is a 44-year-old male with bipolar I disorder, mild manic episode, manifesting largely as irritability, insomnia, increased goal-directed activity, racing thoughts, distractibility, psychomotor agitation, and increased talkativeness over the past week. His current symptoms are having a noticeable impact on his functioning at work.

It is these 2 final factors, symptoms lasting for at least 7 days and impaired functioning, that distinguish this as a mild manic episode rather than a hypomanic episode.

As for the treatment plan, the patient is judged to be competent to consent to treatment for bipolar I disorder, mild manic episode.

As this case illustrates, bipolar I disorder is commonly misdiagnosed, with some patients waiting 10 years or even longer after symptom onset to receive a diagnosis.^4,5 Longer delays in diagnosis have been observed for an earlier age of symptom onset.⁴ This patient reports symptoms since his early 20s but was not diagnosed with bipolar disorder until 2 decades later.

Bipolar I disorder can be difficult to diagnose because its associated symptoms both overlap with and mimic those of other psychiatric disorders, including GAD.⁶ For these reasons, mild manic episodes are especially underrecognized by healthcare providers.

Screening tools can be particularly useful in identifying bipolar I disorder. Several semi-structured interviews have been developed to screen for bipolar disorder in adults. Two commonly used ones include the Structured Clinical Interview for DSM-5, or SCID, and the Schedule for Affective Disorders and Schizophrenia, or SADS. The SCID is divided into modules to cover different diagnoses and is based on DSM-5 diagnostic criteria for bipolar disorder. The SADS was designed to assess a broad range of diagnoses and to capture bipolar diagnoses across many groups.⁷

The most reliable way to reach a diagnosis of bipolar disorder is through a structured, psychiatric interview. However, given the time commitment that requires, several self-report measures have been developed to help clinicians identify patients most likely to meet criteria for bipolar disorder. Remember that these are screening tools. They are not diagnostic tools. Such self-report measures include the Rapid Mood Screener (RMS) and the Mood Disorder Questionnaire (MDQ).⁷

The 6-item RMS can be useful in helping to differentiate between bipolar I disorder and MDD among patients with depressive symptoms.⁸ The RMS takes about 2 minutes to complete. A positive response on 4 or more items of the RMS indicates potential bipolar I disorder and should be followed by a targeted clinical interview towards making the diagnosis of bipolar I disorder if it is present.

For example, our patient with mild mania would score a 4 out of 6 on the RMS, with positive answers for questions 3 through 6:

Have you ever had to stop or change your antidepressant because it made you highly irritable or hyper?
Have you ever had a period of at least 1 week during which you were more talkative than normal with thoughts racing in your head?
Have you ever had a period of at least 1 week during which you felt any of the following: unusually happy; unusually outgoing; or unusually energetic?
Have you ever had a period of at least 1 week during which you needed much less sleep than usual?

This patient’s score would indicate to us as clinicians that we should proceed with a more in-depth clinical interview.

In closing, it is important that healthcare providers understand what constitutes a mild manic episode so that patients presenting with mild mania can be diagnosed and treated early for bipolar I disorder. Inaccurate diagnosis and inappropriate treatment can result in treatment complications and are associated with an increased risk of recurrent mood episodes, worse long-term outcomes, worse quality of life, increased risk of emergency room visits and hospitalizations, and deterioration in cognitive function.^9,10

I hope this case has been informative for you and helps you better understand how a mild manic episode presents. Following the DSM-5-TR severity specifier criteria for manic episodes can lead to a more precise diagnosis and help you make informed and appropriate treatment decisions for your patients with bipolar I disorder.

Thank you for joining me today, and I look forward to seeing you next time.

Relationships with coworkers, friends, and acquaintances may also be affected by depressive symptoms. People with major depressive disorder can miss work due to their illness and, when at work, may perform responsibilities poorly or ineffectively due to their condition.²⁶ In a survey from 2001–2003, people with major depressive disorder lost an average of 27.2 workdays—8.7 days were due to absenteeism and 18.2 days from presenteeism.²⁹Problems with memory, attention, and executive function are also associated with lower wages and unemployment.^26,28 Patients with major depressive disorder may have difficulty extricating themselves from their own thoughts and, as a result, may appear self-focused and disinterested in social activities and forging bonds with others.³⁰ Along with a diminished ability to read nonverbal cues from other people, they may come across as insensitive and have few friends.³⁰
Caregivers such as family and friends of people with major depressive disorder can also be negatively impacted. This unpaid informal work can be time consuming and emotionally challenging,³¹ possibly leading to lost income and health insurance due to reduced work hours.³² In addition, they may experience fatigue, distress, and poor sleep, and may develop depressive symptoms themselves.³
Relationships with coworkers, friends, and acquaintances may also be affected by depressive symptoms. People with major depressive disorder can miss work due to their illness and, when at work, may perform responsibilities poorly or ineffectively due to their condition.²⁶ In a survey from 2001–2003, people with major depressive disorder lost an average of 27.2 workdays—8.7 days were due to absenteeism and 18.2 days from presenteeism.²⁹Problems with memory, attention, and executive function are also associated with lower wages and unemployment.^26,28 Patients with major depressive disorder may have difficulty extricating themselves from their own thoughts and, as a result, may appear self-focused and disinterested in social activities and forging bonds with others.³⁰ Along with a diminished ability to read nonverbal cues from other people, they may come across as insensitive and have few friends.³⁰
Caregivers such as family and friends of people with major depressive disorder can also be negatively impacted. This unpaid informal work can be time consuming and emotionally challenging,³¹ possibly leading to lost income and health insurance due to reduced work hours.³² In addition, they may experience fatigue, distress, and poor sleep, and may develop depressive symptoms themselves.³²

References

Patel R, Reiss P, Shetty H, et al. Do antidepressants increase the risk of mania and bipolar disorder in people with depression? A retrospective electronic case register cohort study. BMJ Open. 2015;5(12):e008341. doi:10.1136/bmjopen-2015-008341
Bishop TF, Press MJ, Keyhani S, Pincus HA. Acceptance of insurance by psychiatrists and the implications for access to mental health care. JAMA Psychiatry. 2014;71(2):176–181.
Beck AJ, Page C, Buche J, Rittman D, Gaiser M. Estimating the distribution of the U.S. psychiatric subspecialist workforce. 2018. Accessed November 21, 2022. https://behavioralhealthworkforce.org/wp-content/uploads/2019/02/Y3-FA2-P2-Psych-Sub_Full-Report-FINAL2.19.2019.pdf
Berk M, Dodd S, Callaly P, et al. History of illness prior to a diagnosis of bipolar disorder or schizoaffective disorder. J Affect Disord. 2007;103(1-3):181-186. doi:10.1016/j.jad.2007.01.027
Hirschfeld RM. The Mood Disorder Questionnaire: a simple, patient-rated screening instrument for bipolar disorder. Prim Care Companion J Clin Psychiatry. 2002;4(1):9-11. doi:10.4088/pcc.v04n0104
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.
Miller CJ, Johnson SL, Eisner L. Assessment tools for adult bipolar disorder. Clin Psychol (New York). 2009;16(2):188-201. doi:10.1111/j.1468-2850.2009.01158.x
McIntyre RS, Patel MD, Masand PS, et al. The Rapid Mood Screener (RMS): a novel and pragmatic screener for bipolar I disorder. Curr Med Res Opin. 2021;37(1):135-144. doi:10.1080/03007995.2020.1860358
Singh T, Rajput M. Misdiagnosis of bipolar disorder. Psychiatry (Edgmont). 2006;3(10):57-63.
McIntyre RS, Laliberté F, Germain G, MacKnight SD, Gillard P, Harrington A. The real-world health resource use and costs of misdiagnosing bipolar I disorder. J Affect Disord. 2022;316:26-33.

This resource is intended for educational purposes only and is intended for US healthcare professionals. Healthcare professionals should use independent medical judgment. All decisions regarding patient care must be handled by a healthcare professional and be made based on the unique needs of each patient.  

NP Psych Navigator is sponsored by AbbVie Medical Affairs. The contributor is a paid consultant for AbbVie Medical Affairs and was compensated for their time.

The Rapid Mood Screener is not a diagnostic tool.

The Rapid Mood Screener was developed with funding and input provided by AbbVie and external experts, who received financial support from AbbVie for research, honoraria and/or consulting services depending on the author.