Gordon Parker suggests changes to the DSM-5 criteria for bipolar disorder, and unveils a new screening instrument that aims to separate hypomania from normal happiness.
Published On: 12/20/2021
Duration: 16 minutes, 07 seconds
Referenced Article: “How to Diagnose Bipolar Disorder,” The Carlat Psychiatry Report, November/December 2021
Chris Aiken, MD, Kellie Newsome, PMHNP, Gordon Parker, MD, PhD, DSc, and have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.
There’s a fine line between hypomania and normal happiness. Today, Gordon Parker shows us how to find it.
Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the report’s editor and co-author of the new textbook Prescribing Psychotropics. And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.
CHRIS AIKEN: I have a problem with diagnostic screening instruments. Most of them, like the Mood Disorder Questionnaire for bipolar disorder or the Physicians Health Questionnaire (PHQ-9) for depression simply restate the DSM criteria in patient-friendly language. No wonder then that they correlate pretty well with a DSM-based diagnostic interview, but does this really add much to what we are already doing? If you’re not doing a structured interview than no, but – admittedly – if you’re not than these are a great tool to have.
KELLIE NEWSOME: So what would you have instead?
CHRIS AIKEN: Well, if you’ve ever tried to use a structured DSM based interview – like the SCID or the MINI – you’ll quickly find you run into problems. Take the mania section. You’re asking someone whose just told you how depressed they are if they’ve ever had times when they felt more upbeat, high, or confident than usual – they’re likely to say “Yes, when I’m not depressed.” Ever been much more active than usual, taking on new projects, socializing more than usual? “Yes – of course doc – that’s how I was before I got depressed.”
KELLIE NEWSOME: It’s hard to know what to do with that. I mean, it could be that they are often hypomanic when they’re not depressed, or it could be that they still recall their normal states and want so much to have more energy, motivation, and confidence that every time you ask those questions they answer yes.
CHRIS AIKEN: Gordon Parker has come up with a solution. Recently he developed a more pragmatic screening instrument for bipolar disorder. His idea was quite simple. He got together a panel of international experts and had them submit the top symptoms they saw in mania and hypomania. Then he tested those on in patients who had been followed by mood experts for a long time so their diagnoses were well known – one group with unipolar recurrent depression, and another group with bipolar disorder. Next, he looked at which of the dozens of symptoms helped separate the two.
KELLIE NEWSOME: So he filtered out all the hypomanic items that depressed people tended to endorse when they were thinking of their better days.
CHRIS AIKEN: Exactly. You could say he tried to separate hypomania from normal happiness.
KELLIE NEWSOME: Dr. Parker is the founder of the Black Dog Institute at the University of New South Wales in Australia. We met with him by Zoom, and he was kind enough to allow us to publish the screening instrument in this month’s Carlat Report. But before we start the interview, here’s a preview of the CME question for this podcast. To get CME credit, use the link in the podcast notes.
According to DSM-5, a patient must have full hypomanic symptoms for at least how many days to meet the diagnosis of hypomania?
A. There is no duration limit; rather, the cut-off is based on severity
B. 3 days
C. 4 days
D. 7 days
CHRIS AIKEN: Thank you for joining us Dr. Parker. I want to talk to you about this new rating scale you helped develop, but first I understand that it’s part of a larger project called AREDOC where you’ve gathered together an international group of bipolar experts to suggest changes to the DSM criteria for bipolar. What would you change there?
Dr. PARKER: So criterion A, which gives a general definition, really only brings in happy states of hypomania or mania, and we know that while 80% of people during a high are happy, 20% are snappy. So we want to change criterion A or would recommend changing criterion A to argue that the person might feel elevated, expansive, but also they may have an irritable mood, so we build that into criterion A.
What we really did is tweaked it slightly so our definition that we recommend is a distinct period of a persistently elevated, expansive or irritable mood with the individual feeling highly energized, which is perceived as an “overshoot” and “not simply a state of happiness,” and generally oscillating with periods of depression. So it’s a minor tweak.
CHRIS AIKEN: You added in a bit about cycling with depression. Is that to reduce the false positives?
Dr. PARKER: Yes, I think the occurrence of people just having hypomanic episodes and not having depression is very rare. In my experience, I’ve seen maybe three or four people over my lifetime. So one of the things that I find as a clinician when I want to establish a diagnosis of bipolar, I not only run through the features of highs, but I also check out the nature of the depression.
CHRIS AIKEN: Anything else you’d change in the DSM criteria?
Dr. PARKER: One is that the DSM says hospitalization puts you into bipolar-I. Now I don’t know of any medical condition where hospitalization is a criterion. So I think up front it’s not a particularly wise one. Secondly, we’ve looked at data within Australia – statewide data – and shown that in fact hospitalization is more common in bipolar-II than in bipolar-I. So I’d throw out hospitalization or do what we’ve done: we’ve incorporated hospitalization into a modified impairment criteria.
And that’s the other caveat I’d put up in regard to DSM. DSM says for bipolar-I there must be marked impairment, and for bipolar-II impairment is less distinctive. What we’re getting when you talk to patients, and they tell you all the time, a significant percentage say that they’re functioning is distinctly improved, and we know that from all the creative people around. So what we’ve recommended is changing the impairment criterion for both bipolar-I and bipolar-II and say that the mood change is associated with a clear change in functioning. It may be distinctly impairment: an individual not able to work, interact with friends and so on, and it may be so severe that protective strategies, including medical referral or hospitalization may be required to lower reputational, interpersonal and financial risks. In some individuals, however, manic and hypomanic states may be associated with improved functioning: being more productive or more creative. So the criterion that we would put up is met by the presence of a distinct change in functioning rather than impairment being required of necessity
CHRIS AIKEN: Another controversial area is the duration. DSM requires 4 days of hypomania or 7 days of mania (unless the patient was hospitalized for mania then the duration is thrown out). But some argue the duration should be shorter, especially for hypomania. What's your take?
Dr. PARKER: DSM historically never empirically established the imposed minimum of four days for hypomania and seven days for mania. And I don’t blame them for that; they wanted to be conservative, but if you apply those criteria you’ll fail to diagnose a lot of people with true bipolar disorder. So we find that 60% of bipolar-II patients who have hypomanic episodes lasting less than four days and 40% of bipolar-I patients who have manic episodes lasting less than seven days. So the duration criterion to my mind needs to be dismissed from DSM.
CHRIS AIKEN: Do you mean 60% have less than four days as their longest episode?
Dr. PARKER: Their average episode. But when you actually ask your longest episode ever, then in fact you still get a distinct percentage of people with bipolar-II where it’s never lasted more than you know four or five days. So with bipolar-II they’re often oscillating like this the whole time.
CHRIS AIKEN: Are there important symptoms of mania or hypomania you see in practice that aren't in the DSM?
Dr. PARKER: The other thing that I’ve found very interesting and I published a couple of papers in The American Journal of Psychiatry is the capacity for people with bipolar disorder to have extrasensory perception. So they’ll frequently say any smell is all powerful. And I remember one patient saying they were getting a cup of coffee one day and they stepped on some dog poo – they wiped it off but they could smell it for the whole day. I have patients sitting in my room and they’ll say, “I can hear a car in the street three blocks away” and I can’t hear anything. So that’s the other important issue that both bipolar-I’s and bipolar-II’s will have these extrasensory perceptions, and they’re not delusional. And they’re often the source of creativity that goes with bipolar.
CHRIS AIKEN: Okay, then we would classify them maybe as like illusions or not psychotic. Like a lot of people will hear their name being called a lot. Just hear their name in a crowd, kind of an illusion.
Dr. PARKER: Yes that would be more an illusion. But what I’m talking about with these extrasensory perceptions is something that’s really there: it’s a smell; it’s a sound; it’s a noise, but they hear it in an amplified way. Again, one of the patients described it quite beautifully. When she’s listening to an orchestra she has the capacity to bring out and separate every individual musician’s instrument and then rejoin them together. And so I think it’s important to recognize that if you hear a patient reporting those features, and they rarely report them; you have to ask about them, they are not psychotic in my view.
CHRIS AIKEN: Tell us about the new rating scale you've developed for bipolar disorder.
Dr. PARKER: We haven’t given it a name as yet. I mean I previously developed two hypomania rating scales. This one we haven’t given a name, but the latest version is published in The Journal of Affective Disorders and basically this is picking up hypomania and mania. And the importance of it is we used, as you would know, a machine learning approach. And we found these 20 symptoms which differentiated people with bipolar from unipolar depression at a level of 90%-plus.
CHRIS AIKEN: Which of those 20 symptoms had the strongest association with bipolar disorder?
Dr. PARKER: The most distinguishing item was an energy item. So it was item 53 saying: “I have very high levels of energy.” Now in previous DSM versions energy wasn’t in the definition; it was brought in with DSM 5 and I think it’s very wise. But when I’m screening for bipolar my screening question is: “Apart from the times when you’re depressed when your mood is normal, do you have periods of times when you’re energized and wired?” And that’s my first screening question. So I think the empirical research supports the utility of high energy in those with a mood disorder when you’re screening for bipolar.
CHRIS AIKEN: Interesting. I've arrived at the same screening question in my own practice - "Do you ever have periods when you feel energized or wired?"
Dr. PARKER: The limitation to that, however, is when we got out to the RDoC, which was an international collaboration, a number of psychiatrists from other countries said look people in my country wouldn’t understand what the word wired means. And we have to respect that. So I think in Australia and England and the United States wired works, but it may not work in other countries.
CHRIS AIKEN: What's next for this scale?
Dr. PARKER: The limitation to this study was that these people had already been diagnosed with a bipolar disorder. So I’m about to do a new study where we’re getting people sent to me for the first time for a diagnosis, and at that state that won’t have received a diagnosis of bipolar even if they’ve got it, to work out it’s sensitivity and specificity on picking up on new cases.
KELLIE NEWSOME: Dr. Parker did come up with a name for the scale after the interview, and you can find it in our November-December issue – the 10 item Sydney Mood Screener. Ahhh. Every time I read it I think of the harbor and the opera house. Gordon Parker is a Scientia professor of psychiatry at the University of New South Wales. In 2002 he founded the Black Dog Institute, a clinical research center for mood disorders. He has written hundreds of research articles and is the editor of the first textbook on Bipolar II disorders which was recently updated in its third edition.
And now for the word of the day….Nocebo
KELLIE NEWSOME: Nocebo. The simple answer is – it’s the opposite of a placebo. Here’s the full definition:
A Nocebo is a harmless substance or treatment that when taken by a patient is associated with harmful side effects or worsening of symptoms due to negative expectations or the psychological condition of the patient. Simply learning about frightening side effects can induce a nocebo response, but so can anything that gives the patient the impression that the medication is too weak – such as over the counter treatments or switching from brand to generic – or too strong – such as meds that come in high doses like quetiapine, gabapentin, and Depakote. One place to watch out for the nocebo effect is when tapering off a medication that the patient has some psychological attachment to.
CHRIS AIKEN: Sugar pills can have unexpected effects, and of course so can medications. Next week, we’ll delve into some paradoxical effects of psych meds as we look back on what we learned in 2021.
Would you rather read a book or listen to the audio? If you’re an auditory learner – and we have a feeling you are – check out Dr. Aiken’s book on bipolar II disorder, Bipolar, Not So Much. It’s written for patients and professionals and covers the diagnosis, medication, and lifestyle approaches to bipolar. Here’s what Dr. David Dunner – the psychiatrist who developed bipolar II back in the 1970’s wrote about it: “This informative book is easy to read and provides practical information for patients and families. . . . I would also recommend it to mental health trainees.” Or as an Amazon Reviewer put it, “A must-read for all psychiatrists and therapists… Honestly, I’m addicted to this book.” An audio version of Bipolar, Not So Much was just released on Amazon and Audible.com read by Charles Constant for WW Norton.
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