Have you ever had a period of a week or so when you felt so happy and energetic that your friends told you that you were talking too fast or that you were behaving differently and strangely?
Has there been a period when you were so hyper and irritable that you got into arguments with people?
Mnemonic: DIGFAST
Recommended time: 1 minute if negative screen; 5 minutes if positive screen.
MANIC EPISODE
Bipolar disorder tends to be underdiagnosed by beginning clinicians. Most patients who present for psychiatric interviews appear demoralized, depressed, or anxious, and one isn’t intuitively moved to ask about periods of extreme happiness. It’s helpful to realize that bipolar disorder usually presents first as a major depression, and that up to 20% of patients with depression go on to develop bipolar disorder (Blacker and Tsuang 1992).
Even when you do remember to ask about mania, there is another roadblock: a high rate of false-positive responses. Many patients report periods of euphoria and high energy that represent normal variations in mood rather than mania. Thus, the most effective screening questions for mania ask about other people’s perceptions as well as the patient’s self-perception.
In general, you should keep referring to a particular period as you ask your questions, because many people experience the separate diagnostic criteria of mania at various points in their lives (e.g., spending foolishly, talking unusually fast, being unusually distractible), but unless a number of these symptoms have co-occurred during a discrete period (at least 1 week, or 4 days for hypomania), a manic episode cannot be diagnosed (Table 24.1).
Screening Questions
Have you ever had a period of a week or so in which you felt so happy and energetic that your friends told you that you were talking too fast or that you were behaving differently and strangely?
If you get a “yes” here, find out when that period was and how long it lasted, and then continually refer to that period when you ask about the diagnostic criteria for mania. If the patient cannot remember such a period lasting an entire week, you should suspect that mania is not the diagnosis. Determine the circumstances of the elevated mood. Being really happy for a couple of days after college graduation, for example, is not mania.
Has there been a time when you felt just the opposite of depressed, so that for a week or so you felt as if you were on an adrenaline high and could conquer the world?
The preceding question about mania is handy if you have just finished asking about symptoms of depression.
TABLE 24.1.DSM-IV-TRcriteria for manic episode
1.
A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week, or such a mood of any duration if hospitalization is necessary.
2.
Persistence of three or more of the following symptoms (four if the mood is only irritable) during the period of mood disturbance:
Mnemonic: DIGFAST
Distractibility
Indiscretion (excessive involvement in pleasurable activities that have a high potential for painful consequences)
Grandiosity or inflated self-esteem
Flight of ideas or racing thoughts
Activity increase (increase in goal-directed activity or psychomotor agitation)
Sleep deficit
Talkativeness (pressured speech)
Adapted from American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text revision. Washington, DC: American Psychiatric Association.
Do you experience wild mood swings in which you feel incredibly good for a week or more and then crash down into a depression?
Interpret responses to this question cautiously, because some patients who respond with an emphatic “yes” are referring to recurrent episodes of depression without mania or hypomania.
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