Diagnosing Bipolar Disorder: Index It

When’s the last time you’ve cast a critical eye toward the DSM IV criteria for Bipolar Disorder? Do the criteria for Bipolar I and Bipolar II assemble a clear, usable diagnostic path for you, or do you find yourself mired in exclusionary clauses, modifiers, specifiers, qualifiers, categorical systems, or whatever all of this extraneous stuff is called nowadays?

Let’s be clear: This disorder is diagnostically challenging to say the least. This is because it is complex, highly nuanced and does not lend itself to black-or-white judgments. For this reason assessment and diagnosis is all over the place. So simplify the process by indexing the disorder’s key components. Here’s how:

  1. Start with the manic markers first. If you don’t have these on your fingertips, here’s a mnemonic to help you: D I G F A S T– accompanied by the breakdown:D– distractibility
    – insomnia
    – grandiosity
    – flight of ideas
    – activity (increased)
    – Speech (pressured)
    – Thoughtlessness (poor judgment, risk-taking)You need to systematically wade through these seven criteria and ask about each one of them because many (or most) will not be volunteered. You don’t want to sit in your chair waiting to be struck by these symptoms, so ask about past phases in which the client may have experienced an exaggerated sense of confidence; an extraordinary feeling of happiness; an excessively loving feeling toward others; an uncommon ability to get things done; huge bursts of energy; and considerable ease with multi-tasking; to name just a few.
  2. Next, move on to assessing for non-manic markers.There are numerous considerations here, but place your emphasis on the following four of these.
    • A first-degree relative (mother/father, brother/sister, son/daughter) has a diagnosis of bipolar disorder
    • The first major depressive episode occurred before the age of 25 (the younger someone is at the first episode, the greater the possibility that bipolar disorder, not “unipolar,” was the basis for that first episode)
    • When depressed, symptoms follow this pattern: very low energy and activity levels; hypersomnia; increased appetite; and increased interpersonal sensitivity to the comments and actions of others; also, depressive episodes are brief – less than 3 months in duration
    • Three or more antidepressants have been tried, none have worked; the individual has experienced mania or hypomania while taking an antidepressant.
  1. Now score both the manic and non-manic markers. You can use any scoring system you’d like; here’s a recommendation though: Assign a maximum of 20 points to the D I G F A S T symptoms as a whole entity. Then assign 20 points to each of the four non-manic marker parameters.

This makes for a 100-point scale. Note than 80 percent of the weight in this system is devoted to the non-manic markers because these are the most difficult to nail down and assess. Do your best with the scoring system and understand that the point total is an indicator of acuity — that’s what indexing is all about.

Use this as your barometer: A point total of 60 or greater (manic and non-manic markers combined) is a likely indicator of Bipolar I. The point total then helps establish initial guidelines for treatment, and since this is a biologically based illness, pharmacological management is the mainstay — with psychotherapy as an adjunct to care.

Strongly consider collateral sources of information to confirm your assessment as these patients are notoriously poor historians and uncooperative — with poor insight and judgment.

The main point of this index is to help us routinely assess for this disorder as a UNIT of symptoms, eschewing the nebulous Bipolar I and Bipolar II classifications.

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Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.

To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.