How I assess for mania in adults

Disclaimer: This blog is merely an opinion.It does not equate to a psychiatric consultation and does not imply patient-doctor relationship.

Unfortunately, it seems that my clinic is booked out till September 2010 for initial evaluations. So, I thought I may start sharing with local medical providers some of the techniques I use in my practice. Hopefully you may find some of this helpful for your own practice.

One of the most common referral question my clinic gets is this : does this person have bipolar disorder?

I think I may safely say that the term “Bipolar” has now entered the American vocabulary as common parlance (much like ‘ADD’ or ‘psychotic’). Unfortunately, it is used with the same looseness that these other terms are used. Even more unfortunate is the fact that through a series of events, it somehow finds its way into medical records. I don’t think any one individual or institution is to blame. It is what it is. Now what is to be done about it?

Here is how I approach an evaluation for Bipolar disorder. It is not the only approach or the best approach. It is merely my approach.

· As you know, in order to be diagnosed with bipolar disorder, you need to have experienced an episode of mania or hypomania. This is how I assess for an episode of mania/hypomania:

I say to the patient this: “I am going to describe a person to you, alright? Now, you and I have had an episode of the common cold. We’re doing kinda alright, and then one day we wake up with a stuffy nose, headache, sore throat, tiredness (symptoms of a common cold).These symptoms stick with us from 4- 14 days and then, they go away.

Similarly, this person I am talking about has an episode. During this episode, instead of a headache and a stuffy nose and sore throat, they start showing the following symptoms out of nowhere: they start experiencing a decreased need for sleep-I’m not talking about a situation where you wish you could fall asleep but find yourself unable to do so (the insomnia seen in depression, anxiety), I’m talking about a person who’s feeling ‘I don’t need sleep! Let’s get some stuff done!’ During this episode, people around this person start noticing that he or she has been talking more than usual, and that they get distracted more easily than usual. They may start doing random projects around the house, often moving to the next project before the first one is completed. They may start showing greater interest in sex, and may become more disinhibited, they start doing impulsive things, like spending money they don’t have or driving recklessly. (An important point to keep in mind in explaining this episode is that these behaviors are a distinct change from their baseline behaviors. So if at any point, if the patient says ”Oh I’m always like that”, that point is null and void and does not going into assessment of a manic episode.)

And then, just like a common cold, these symptoms disappear, vanish. Often, the person ‘crashes’ for a few weeks- kinda like a person coming down from a meth binge. In fact, many people may suspect that this person may have been on a meth binge, considering how they’d been acting!

Now- I want you to imagine such a person having such an episode. I want you to keep that image in your head. Got it? Good. Now- does this person remind you of yourself? Have you ever had a distinct episode like this in your life?”

When I put it this way, 90% of my patients who come in wondering if they’re bipolar end up saying” No, that doesn’t sound like me”

· So why do so many people wonder they are bipolar? The most common reason I hear is ‘mood swings’.

Let me be clear about this point: ‘mood swings’ does not equate mania. The most common manner in which people describe ‘mood swings’ in my clinic is this: “I’ll be having a good time, and doing just fine, and then something stupid or trivial happens and Bam! I get mad or sad or upset.” What the patient has just described is either Emotional Reactivity or Poor Frustration Tolerance. The most common psychiatric reasons for these symptoms is depression or anxiety. This is very distinct from the phenomenon of Mood Lability that one sometimes sees in mania- where you go from happy-to-sad- to –happy again.

· Thus,

Happy –to- sad in 1 second = emotional reactivity (depression/anxiety/certain personality organizations)

Happy-to-sad-to-happy in 2 seconds = true mood lability (? Mania)

Hope this helps. In the near future, I will write about how assess for pediatric mania.