Depressive Episodes with Short-Duration Hypomania DSM-5
DSM-5 Category: Conditions for Further Study
Introduction
The fifth edition of the Diagnostic and Statistical Manual of mental disorders (American Psychiatric Association, 2013) consists of 3 Sections and an Appendix. Section I outlines the organization of the manual, summarizes directions for its use in clinical practice. Section II contains the diagnostic criteria for the “official” psychiatric disorders currently recognized. Section III covers “Emerging Measures and Models”, including assessment measures which are not yet standard, the Cultural Formulation Interviews for patients and informants that are intended to improve the cultural sensitivity of psychiatric evaluation and an alternative system for the diagnosis of personality disorders that had been proposed to replace the one used in DSM-4 (American Psychiatric Association, 2000) but which was deferred for subsequent study and discussion. Section III also includes 8 “Conditions for Further Study”, clinical entities which are widely considered to be distinct from the diagnoses included in Section II but which have also been deferred for additional study and discussion before they can be formally diagnosed, treated and coded. Candidates of this type for inclusion in the canon of psychiatric diagnoses had in earlier editions of the Manual been placed in an Appendix, which in the recent edition is used to highlight changes from DSM-4-TR to DSM-5, to provide a glossary of technical terms and concepts of distress in different cultures and to summarize the diagnostic codes applied to the various psychiatric disorders.
The cyclical alteration of mood was first noted by Karl-Ludwig Kahlbaum, who described cyclothymia in 1882. Ewald Hecker described a syndrome of more drastic alteration between elevated and depressed mood in 1898, and this influenced the differentiation shortly thereafter of “manic-depressive insanity” from the psychotic disorders of the schizophrenic spectrum by Emil Kraepelin (Baethge, Salvatore & Baldessarini, 2003). Since that time, the history of bipolar illness has been one of progressive differentiation into subtypes, resulting in the present tripartite classification of type I and II bipolar disorder plus cyclothymia, with a considerable residual population of manic-depression that cannot be specified in type, often on account of the duration or variability of periods of mood elevation (Géraud, 1997).
The syndrome of Depressive Episodes with Short-Duration Hypomania is included in Section III, and has attracted much attention because of the frequency with which depressed patients who may have Bipolar Disorder have or might have episodes of hypomania which are too brief to qualify under the present diagnostic criteria (Benazzi & Akiskal, 2006).The appropriate duration of hypomanic episodes for diagnosis of type II bipolar disorder has been the subject of controversy, with hypomania of 4 days duration required by the DSM-4 criteria (American Psychiatric Association, 2000), while the Research Diagnostic Criteria (Spitzer, Endicott & Robins, 1977) distinguished between hypomania for 7 or more days (definite) and 2 to 6 days of hypomania (probable) for the diagnosis of bipolar II. This is a question of clinical importance, as the administration of antidepressants to patients who have recurrent depressive episodes but no hypomania is appropriate if not mandatory, while giving antidepressants to a patient with type II bipolar disorder characterized by hypomania and major depression can precipitate mania and may even be contraindicated (Bond, Noronha, Kauer-Sant’Anna, Lam & Yatham, 2008). In addition, it is estimated that 10 to 15 per cent of patients with both types of bipolar disorder cycle rapidly and have cycle lengths shorter than the diagnostic criteria may call for (Coryell, Endicott & Keller, 1992). It is therefore appropriate to recognize, and possibly diagnose and treat differently, individuals with depressive episodes punctuated by short periods of mood elevation.
Symptoms of Depressive Episodes with Short-Duration Hypomania
The proposed new disorder is similar in clinical manifestations to Bipolar II disorder, with predominant depression, periods of mood lability and some hypomania but no manic episodes (Benazzi, 2007). The hypomanic periods in this condition may be less than 4 days in length, but must meet at least 2 of the symptomatic criteria for hypomania, which have also been revised because of the recognition that energy or activity level is as often affected as mood itself in these episodes (Angst, 2013).
The depressive symptoms, which can be subsyndromal are the usual cause for patients to seek treatment, include low energy levels, cessation of usual activities, a black and white style of thinking, overgeneralization, maladaptive assumptions and undue pessimism, automatic thoughts, isolation from others and thoughts of suicide. The depression is thought to be predominantly atypical, as in bipolar II, with reversed vegetative symptoms such as overeating and hypersomnia. Depression may be combined with non-euphoric hypomania, also often subsyndromal, to cause periods of depressed mood with irritability and increased mental and behavioral activity. These symptoms may be exacerbated by antidepressants, and the suicide risk is greater with such episodes (Berk & Dodd, 2005).
Hypomania is characterized by abnormally and persistently elevated, expansive or irritable mood, but there must also be abnormally and persistently increased energy or activity. There must be 3 or more of the other symptoms, which can include grandiosity, decreased need for sleep, talkativeness, racing thoughts, distractibility, and participation in risky behaviors, such as hypersexuality (Suppes, 2011).
Decreasing the required duration of hypomanic episodes for the diagnosis of bipolar II disorder was extensively discussed during the preparation of DSM-5, and it was suggested that this would double or triple the prevalence of that disorder (Bauer, Graf, Rasgon, Marsh, Muñoz, Sagduyu, Alda, Quiroz, Glenn, Baethge & Whybrow, 2006). Long-term studies of bipolar II patients have shown no difference between patients with shorter and longer periods of hypomania (Judd, Akiskal, Schettler, Coryell, Endicott, Maser, Solomon, Leon & Keller, 2003). The multicenter BRIDGE study compared the specificity of bipolar II diagnosis in a large number of patients with current major depression using 1 day, 2-3 day and 4-6 day cutoffs for hypomania duration, and found that the best correlation with external validators of the diagnosis, such as mood disorder in first-degree relatives, mood lability, seasonal occurrence and history of suicide attempts, was with a 4-day duration criterion for hypomanic episodes (Angst, Azorin, Bowden, Perugi, Vieta, Gamma & Young, 2011). It was also found, however, that 47 per cent of the patients had at least for a time been mistakenly diagnosed according to existing criteria with unipolar depression rather than bipolar disorder (Angst, Gamma, Bowden, Azorin, Perugi, Vieta & Young, 2013). A recent study (Parker, Graham, Synnott & Anderson, 2014) has shown that patients with depressive episodes and brief hypomania were indistinguishable in measures of mood symptoms and mood swings from bipolar II patients with 4-day hypomanic episodes.
Treatment for Depressive Episodes with Short-Duration Hypomania
Pharmaceutical treatment of depressive episodes with short-duration hypomania is likely to be similar to that of the recognized bipolar disorders, particularly type II. The inadvertent precipitation or exacerbation of mania by the administration of antidepressants is a significant concern, but antidepressants, particularly SSRI agents, are sometimes appropriate as an adjunct to other mood stabilizing medications (El-Mallakh, Weisler,Townsend & Ginsberg, 2006). A recent large multi-center study suggested that antidepressants do not hasten the emergence of manic symptoms in patients with bipolar depression, but the combination of antidepressants and mood stabilizers was not more effective for severe depression than mood stabilizers alone (Sachs, Nierenberg, Calabrese, Marangell, Wisniewski, Gyulai, Friedman & Bowden, 2007).
Algorithms have been published for the effective use of lithium, mood-stabilizing anticonvulsants and antipsychotic drugs, particularly the atypical or second-generation agents, in bipolar I disorder (Texas Consensus Conference Panel on Medication Treatment of Bipolar Disorder, 2005). The evidence regarding drug treatment of bipolar II disorder is less voluminous, but controlled studies support the use of lithium with a view toward prophylaxis of mania, anticonvulsants for individuals with rapidly-cycling episodes, antipsychotics and especially quetiapine (which is FDA-approved) and dopamine receptor agonists (pramipexole). Recent studies suggest that SSRI or SNRI antidepressants do have a place in bipolar II treatment (Suppes, 2010). Some recent evidence suggests that inflammation, mitochondrial dysfunction and oxidative stress may play a role in bipolar disorders as in migraine and narcolepsy (Berk, Kapczynski, Andreazza, Dean O, Giorlando, Maes, Yücel, Gama, Dodd, Dean B, Magalhães, Amminger, McGorry & Malhi, 2011), and suggests that individual treatment regimens may be appropriate, based upon whether inflammation, oxidative stress or metabolic disturbance are the predominant factors in a patient’s mood disorder (Scott, 2011).
There is also little evidence regarding non-pharmacologic treatment of depression with short hypomanic episodes, but it is likely that modalities that help bipolar disorders, particularly type II, will work for this new entity. There are numerous randomized controlled trials of psychotherapy for bipolar disorder, although many are not directly comparable because of many differences in diagnostic and therapeutic methods and outcome measures. Nevertheless, the addition of psychotherapy to ongoing treatment produces in almost all studies a significant improvement over treatment as usual or waiting for treatment (Schöttle, Huber, Bock & Meyer, 2011). Cognitive behavior therapy for individual patients or groups, psychoeducation for patients and companions, family therapy and psychoeducation for caregivers have been to be effective. Freud and his disciples had little to say about manic-depresive illness, but Jungian analysis has likened manic and hypomanic symptoms to the “puer” archetype and depressive episodes to “senex”, the figure of caution, thought and melancholy epitomized by Saturn or Kronos, and has used patients’ mental imagery to reintegrate the two (Thompson, 2012).
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