Bipolar disorder in primary care: the bipolar spectrum is larger than was once believed, and misdiagnosis can lead to an unfavorable treatment response

Journal of Family Practice, March, 2003 by J. Sloan Manning

Screening for bipolar disorder. No all-purpose screening instruments for bipolar illness are available at this time. Hirschfeld et al have validated a patient-rated instrument--the Mood Disorder Questionnaire (MDQ)--in an outpatient psychiatric setting with mostly bipolar I patients. (9) Preliminary data have also been presented on the Bipolar Spectrum Diagnostic Scale (BSDS), a patient self-rating test of bipolar symptoms developed by Pies. (10) The BSDS's emphasis on mood lability may improve its sensitivity for bipolar II disorder, and the MDQ may have better sensitivity for bipolar I illness.

As yet, information on either instrument's reliability in primary care practice is lacking. However, you may find both very useful to introduce and support a discussion of symptoms and syndromes commonly experienced by bipolar patients. The potential value of these instruments in aiding clinician-patient communication should not be underestimated.

Four steps to diagnosis

Bipolar disorder is diagnosed with interviews that examine phenomenology (symptoms), family history (pedigree), longitudinal course of illness, and treatment response.

Phenomenology. DSM-IV considers two clinical syndromes specific to bipolar illness--mania and hypomania. Both are defined as periods of abnormally expansive or irritable mood that represent distinct changes from usual functioning. Hypomania differs from mania in its lesser intensity and duration. The symptoms of hypomania are similar to mania, however, and include decreased need for sleep, grandiose or elated mood, talkativeness or pressured speech, distractibility, flight of ideas, an increase in goal-oriented activity, and risk-taking, often with negative consequences.

By definition, hypomania is never psychotic. Far the typical bipolar II patient, hypomania is an abrupt switch (often upon awakening or in late evening) from a depressed state to one of elated mood or vice versa. Patients characteristically describe hypomanic periods as "my normal self," and they typically last 1 to 3 days (Figure 2). During these periods, patients will be active (mentally and/or physically), often in adaptive ways, and accomplish tasks considered overwhelming during their depressed baseline mood.

[FIGURE 2 OMITTED]

At times the mood may be more irritable or become more irritable as the hypomania continues. (11) That these periods of activity and sense of well being are abnormal is evidenced by their abrupt appearance and disappearance--normal happiness is not recurrent. (2) Patients often have difficulty remembering hypomanic episodes while they are depressed, so information from significant others is often helpful in making the diagnosis.

Prospective studies suggest that the formal presence of hypomania may not be the best predictor of bipolar II outcome. Temperamental traits such as mood lability (86% specific for bipolar II) and mental and physical activity during depressed states are better predictors of bipolar II than DSM-IV hypomania. Intense fantasy lives and social anxiety are also more common in bipolar II than in unipolar depression.