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 Table of Contents  
PERSPECTIVE
Year : 2019  |  Volume : 35  |  Issue : 2  |  Page : 137-141

Hypomania: A clinician's perspective


Avon and Wiltshire Mental Health Partnership NHS Trust, England

Date of Submission13-Jun-2018
Date of Decision24-Sep-2018
Date of Acceptance29-Oct-2018
Date of Web Publication26-Jun-2019

Correspondence Address:
Dr. Avneet Sharma
Avon and Wiltshire Mental Health Partnership NHS Trust, Civic Center, High Street, Kingswood Bristol, BS15 9TR
England
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_46_18

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  Abstract 


Hypomania as a syndrome retains a central place in diagnosis of milder forms of bipolar illnesses, especially bipolar II. This article highlights some of the challenges that the clinicians are faced with and lists strategies that they could use while diagnosing hypomania and bipolar illnesses.

Keywords: Bipolar II, diagnosis, hypomania


How to cite this article:
Sharma A. Hypomania: A clinician's perspective. Indian J Soc Psychiatry 2019;35:137-41

How to cite this URL:
Sharma A. Hypomania: A clinician's perspective. Indian J Soc Psychiatry [serial online] 2019 [cited 2019 Sep 22];35:137-41. Available from: http://www.indjsp.org/text.asp?2019/35/2/137/261482




  Hypomania: the Clinical Importance Top


The demand and hence pressure on the clinicians for diagnosing hypomania and bipolar illness in their routine practice have been on the rise. There could be several factors behind this.

The current diagnostic systems have included the concept of bipolar being a spectrum illness – the categories of bipolar I and bipolar II are well described in the Diagnostic and Statistical Manual of Mental Disorder (DSM) 5,[1] the International Statistical Classification of Diseases (ICD)-10[2] does not draw this distinction though ICD-11 is likely to. DSM 5 has also included the category of recurrent depression with antidepressant-induced mania/hypomania. Although the clinical utility of bipolar spectrum is yet to be established and there is currently no indication whether treatment is necessary or effective, it is generally acknowledged that these patients present as suffering from depression and get diagnosed and treated as recurrent unipolar depression as opposed to bipolar depression.[3] There is a strong argument for treating bipolar depression not with antidepressants but in a rather specific way, for example, with mood stabilizers such as lithium, as it has better chances of preventing suicides and improving course of the bipolar illness. Experts indeed argue for a more frequent diagnosis of bipolar II on the basis that a milder condition is usually more frequent than a severe one[4] and that bipolar patients spend much more time in milder conditions.[5] There is some acceptance of the evidence that unipolar depression is reportedly the most frequent misdiagnosis in patients with bipolar disorder (BD), especially in BD Type II, because patients with this illness, by definition, never experience an episode of mania[6] and between 25% and 50% of people with recurrent depression may in fact be part of bipolar group of illnesses.[7] A recent study from the UK suggested that up to 21% of primary care patients with depression have in fact unrecognized BD.[8]

Mood instability is a common reason for referral to adult community mental health teams with up to 80% of patients reporting this symptom at assessment.[9] Many of us working in the field of general adult psychiatry in the NHS UK may have come across referrals for persons seeking an assessment for confirming the diagnosis of bipolar illness.[10] This trend could be looked as a form of help seeking and qualitative research has shown these patients to be looking for an explanation of their symptoms (rather than an outright diagnosis) and for consistent support.[11] There is however a worry that the spectrum definitions especially around what constitutes hypomania might subsume cases with non-BDs and “diagnosis creep” may lead practitioners to overdiagnose BD in marginal cases and the more diagnoses of BD will increase aggressive pharmacotherapy.[12]

Indeed, there is an ongoing debate about the inaccurate diagnosis of bipolar illness in clinical practice, and recent studies indicate that overdiagnosis of bipolar illness might already have become a bigger problem with the rate of over diagnosis likely to be threefold higher to that of underdiagnosis.[13] This may largely be a reflection of how the clinical practices have changed over a period of time especially while diagnosing hypomania both in clinical population and epidemiological studies. Evidence from two studies[3],[14] suggests that if a clinician diagnosed a patient with BD, the chance that the patient effectively met criteria for that diagnosis according to the structured clinical interview for DSM disorders (SCID)[15] was modest. In terms of the requirement to “do no harm,” the consequences of being falsely diagnosed with BDs tend to be more severe than those of being falsely diagnosed with major depressive disorder,[16] including the negative effects of unnecessary labeling, the risk of harm related to unnecessary treatments, and the misuse of health care resources, with important human and financial implications.[13]

There is a case for looking more closely for bipolar spectrum cases, especially of bipolar II type in clinical population which in simpler terms will largely boil down to accurately diagnosing hypomania.


  Why Diagnosing Hypomania Accurately Is not as Straightforward? Top


The challenge before the clinicians nowadays is to elicit the diagnostic symptoms of hypomania that too in retrospect in somebody who is presenting as depressed and try and differentiate it from other conditions such as borderline personality disorder (PD).

Establishing diagnosis in retrospect is challenging as depression is the most frequent clinical presentation of BD more so with bipolar II.[17] Furthermore, unipolar depression is more prevalent than BD: The lifetime prevalence of unipolar major depressive disorder is 16.2%, whereas the lifetime prevalence of bipolar spectrum disorders is 4.5%.[18] The clinical presentation of a patient with BD when depressed may not differ from that of a nonbipolar-depressed patient. Hypomanic symptoms also largely go undetected as these are often desirable and individuals are often unaware of these as problematic. Recalling information about the past is prone to bias more so especially when patients are depressed.[19] One will end up relying heavily on information provided by close relatives though that may not be available in all the cases.

There is some consistent evidence to indicate that psychomotor activation forms the core of hypomania and mania – it means rapidity of thoughts, feelings, and activities and this should be enough to differentiate hypomania from other disorders.[20] In actual practice, it is harder in retrospect, for example, to evaluate euphoria than overactivity[21] while the place of irritable mood as a primary symptom for hypomania has been questioned.[22] DSM 5 now requires the change in mood in hypomania to be accompanied also by persistently increased activity and energy as well as three other symptoms of hypomania (four if irritability only) over the same period. The inclusion of increased activity and energy as a defining symptom will also be included in ICD-11; this change is expected to prevent overdiagnosis of hypomania and bipolar II disorder.[23] Nevertheless, it might still be difficult for clinicians to make a decision about whether the elevated mood and increased activity levels might be within normal limits or warrant a diagnosis of hypomania.[24]

In both DSM 5 and ICD-10, the diagnosis of hypomanic episode requires symptoms of hypomania to last for at least 4 days, which was reduced from the 7 days required by earlier versions. Although the initial decision to agree to this cutoff was labeled as arbitrary, a multicenter study found 4-day duration criterion for hypomania to be best correlated with external validators.[21] Those who have hypomanic symptoms lasting between 1 and 3 days have been shifted from DSM 4 category of “BD not otherwise specified” in DSM 5 to major depressive episode with specifier of brief hypomanic episodes. It is expected that short-lived periods of hypomania though an indicator of bipolar illness may go undetected as these will be much harder to clinically distinguish from the rapid mood alterations seen, for example, in borderline PD or normal variants in temperament.

Differential diagnosis poses a major challenge as hypomanic symptoms are shared by many other disorders such as attention-deficit hyperactivity disorder (ADHD) or substance abuse; the issue, however, is not only of differential diagnosis but also that of comorbidity.[25]

ADHD can often be mistaken as BD due to features of irritability, rapid or impulsive speech, physical restlessness, impaired attention, and sometimes defiant or oppositional behavior. Symptoms such as grandiosity, decreased need for sleep, elated mood, flight of ideas, and hypersexuality have been suggested to be the hypomanic features that would differentiate BD II from ADHD.[26]

Substance misuse (with stimulants/cocaine) can induce hypomanic symptoms, and in clinical practice, this can be very hard to distinguish due to problems in judging what the “direct physiological consequence of a drug, medication, or somatic treatment” means.[27]

A common clinical dilemma nowadays is distinguishing between borderline PD and BD, especially bipolar II – the misdiagnosis has serious implications as both the disorders will have very different treatment approaches.

The challenge here is whether the clinician can identify the mood changes in these two conditions especially when the focus is on emotional instability or rapid and brief mood swings. Whereas anger or irritability may occur in hypomania, elevated bipolar states are more generally characterized by euphoria, grandiosity, and feeling creative with an individual coming across as consistently free from anxiety and worry while by contrast those with borderline PD manifest painful extremes of normally regulated emotions (principally anger, hostility, and sadness and anxiety).[28] At times, the only way to reduce the dilemma seems to be by considering the longitudinal and as well as broader cross-sectional features.[29] Imprecision in differentiating these two would reflect either diagnostic difficulty or true comorbidity.[30]

One strategy suggested to improve the detection of bipolar illnesses especially in patients presenting as depressed is to use screening questionnaires in addition to clinical interview as a two-stage assessment. Two of the self-report instruments that have been developed are the mood disorder questionnaire[31] and the HCL-32 checklist[32] to screen clinical and nonclinical samples for hypomania and bipolar illness. The instruments or the scales have not achieved widespread clinical usage, especially among professionals in the UK – there is some evidence to show that these tend to be better at ruling out diagnosis of BD while rather poor in ruling the diagnosis of BD in.[33] Similarly, the explosion of apps over recent years for monitoring and self-management of BDs appears to be an opportunity though a recent review[34] pointed out that most of the apps are being developed independently of research data and without reference to clinical guidelines.


  Strategies for Tackling the Issue of Accurate Diagnosis of Hypomania Top


Young and Macpherson[35] have asserted that the improved detection of bipolar illness rests on better ascertainment of history of hypomania.

[Table 1] lists strategies which have been used to accurately diagnose hypomania and Bipolar illness in patients presenting with depression. Some of these especially those based on risk factors do enjoy a certain level of recognition among clinicians, relying solely on these will be seen as working on clinical beliefs and expectations rather than on directly accessible signs and symptoms in arriving at a diagnosis. Also listed are the strategies which can be used to minimize the risk of overdiagnosis, for example, use of semi-structured interviews such as SCID for accurate diagnosis or using experienced clinicians, though none of these will be considered practical or possible given the constraints in busy clinical settings. Using screening questionnaire or using mood diaries in clinical practice has been found to be not useful especially in process of assessment.[33],[41]
Table 1: Improving diagnosis of hypomania in clinical settings

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Sticking with criteria and focus on phenomenology though crucial might be hard as in routine practice while looking for bipolar illness clinicians appear to use an instinctive approach instead of strictly adhering to diagnostic criteria and tend to follow an additive model while making the diagnosis while relying not upon a specific criterion but on the total number of criteria.[24]


  Conclusion Top


Mood instability has a relatively high prevalence in the general population (estimated at 13.9%[42] and making a reliable diagnosis is important to inform current treatment decisions – it has been suspected that a broadening of the BD diagnostic category, leading to greater heterogeneity, might have led to the perceived reduction in effectiveness of lithium.[43] An accurate diagnosis of bipolar illnesses will also to contribute in developing future treatment options – for example, having patients with falsely diagnosed BDs in genome-wide association studies may cloud statistically significant associations with important implications about development of personalized treatment options.[44]

Clinicians may want to reflect whether and how their clinical practice in relation to diagnosis of hypomania and bipolar illness may have undergone change particularly in view of the popular concept of bipolar spectrum disorders and start asking the questions whether they have patients in their practice who are possibly bipolar but not diagnosed as such, or more importantly in my view whether they have patients who are being treated as bipolar but may not have bipolar at all.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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