as a human being. The label provides a convenient way to refer to your condition among insurance and healthcare providers. It helps all the people involved in your treatment to quickly recognize the illness that afflicts you and to provide the appropriate medications and therapy. You aren’t bipolar disorder. Bipolar disorder is an illness you have, and you can manage it with the right treatments.
Digging Deeper with Bipolar Specifiers
The DSM provides specifiers to help doctors more fully describe a person’s condition. Think of specifiers as adjectives used to describe nouns, the noun being the primary diagnosis.
Specifiers indicate the nature of the person’s current or most recent episode, the severity of symptoms, the presence or absence of psychosis, the course of the illness, and other features of the illness, such as anxiety or a seasonal pattern. Specifiers serve two useful purposes:
✔ They allow for the subgrouping of individuals with bipolar disorder who share certain features, such as people who have bipolar disorder with anxious distress.
✔ They convey information that’s helpful and relevant to the treatment and management of a person’s condition. For example, someone who has bipolar with anxious distress likely needs treatment for both bipolar and anxiety.
In the following sections, we describe the bipolar specifiers in greater detail.
This specifier identifies the most active or recent phase of illness, with a primary goal of identifying the most appropriate treatment. These specifiers are coded in the patient’s medical record, where they’re also important for insurance reimbursement purposes:
✔ Manic: The current or most recent episode is primarily mania.
✔ Hypomanic: The most recent or current episode is primarily hypomania.
✔ Depressed: The most recent or current episode is primarily depression.
These specifiers have been part of the diagnostic system for a long time, and they continue to be part of the DSM-5. They assist in treatment planning and in following the course of illness; for example, a patient moving from severe to mild symptoms suggests that the acute episode is resolving. Historically the doctor making the diagnosis would use his clinical judgment and experience to estimate severity. DSM-5 strongly encourages the use of more objective data, particularly by using scales that patients or doctors fill out, to provide more consistent ratings across patients and across treatment providers.
Severity typically relates to the intensity and frequency of symptoms as well as the degree to which symptoms impair function:
✔ Mild: Symptoms are less frequent, milder in intensity (causing some distress), and sometimes affect function seriously.
✔ Moderate: Symptoms are more persistent and intense (causing more distress) and often affect function seriously.
✔ Severe: Symptoms are very persistent to continuous, very intense (causing high levels of distress), and often affect function seriously.
Perhaps the most frightening accompaniment to depression or mania is psychosis, which may include delusional thinking, paranoia, and hallucinations (typically auditory as opposed to visual). Although psychosis isn’t a necessary part of the bipolar diagnosis, it can accompany a mood episode. The extremes of depression and mania are sometimes associated with profound changes in the reality-testing system of the brain, which lead to severe distortions in perception and thinking. During a psychotic episode, you may experience any of the following symptoms:
✔ Feel as though you have special powers
✔ Hear voices that other people can’t hear and that make you believe they’re talking about you or instructing you to perform certain acts
✔ Believe that people can read your mind or put thoughts into your head
✔ Think that the television or radio is sending you special messages
✔ Think that people are following or trying to harm you when they’re not
✔ Believe that you can accomplish goals that are well beyond your abilities and means
This specifier overlaps with the presence or absence of psychosis when a diagnosis is coded. If the illness is active, the specifier notes whether or not psychosis is present.
If the illness is moving out of active phase, then one of the following specifiers is used:
✔ In partial remission: If symptoms have started to decline in severity and/or frequency, function has improved to some degree, and these improvements have been sustained over at least several weeks, this label is appropriate.
✔ In full remission: If function has returned to levels that existed before the illness, symptoms are much less active, and this state has sustained for several weeks to months, this label would be appropriate.
Bipolar is often accompanied by other conditions, such as anxiety, and may have some features that vary among those who have the diagnosis. The following specifiers are used to label these extras:
✔ With anxious distress: Anxiety commonly co-occurs with bipolar disorder even in the absence of a full-blown anxiety disorder and the presence of this anxiety may influence treatment decisions.
✔ With mixed features: Mood episodes in bipolar disorder often aren’t completely clear-cut. People with mostly manic symptoms may still express symptoms of depression, such as guilt and hopelessness or suicidal thoughts. Or someone who is primarily depressed may have a lot of physical agitation and racing thoughts characteristic of mania. This specifier accounts for these types of presentations, which may affect treatment planning.
✔ With rapid cycling: Rapid cycling is a specifier that identifies bipolar disorder that presents with four or more mood episodes in a 12-month period. This subtype is thought to be more severe and often doesn’t respond as well to medications.
✔ With melancholic features: This subtype of depression is quite severe. It includes features such as very low mood that shows little or no response to improved external circumstance, very low energy, almost no interest in or response to pleasurable stimuli, agitation or slowing of movements, diurnal variation (mood and energy worse in the morning), sleep interruptions including early morning awakening, impaired thinking and concentration, and loss of appetite. It’s really the most extreme presentation of most or all of the symptoms of a major depressive episode.
✔ With atypical features: This specifier describes a pattern of depression symptoms that used to be considered less typical of depression, but are now recognized as a frequent feature of depression. The name has stuck though. Symptoms include responsiveness to changes in external stimuli – feeling better if things improve or worse if something bad is going on, increased appetite or weight gain, excessive sleep and severe fatigue, feelings of leaden paralysis (heaviness in the limbs), and longstanding patterns of sensitivity to interpersonal rejection.
✔ With mood-congruent psychotic features: This label is used when psychosis is present and the hallucinations and delusions are similar to the mood episode – delusions of grandiosity and power in mania or delusions of guilt and hurting other people in depressed periods.
✔ With mood-incongruent psychotic features: This label