Subclinical/subthreshold hypomania and MDD

[foreverbull]

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Curious as a psychologist who sometimes has seen clients with depressive episodes occasionally but then a few VERY rapid-onset hypomanic symptoms that end in a few days (not linked to PMDD due to following outside of specified cycle or seen in clients who do not menstruate). With some folks it looks like intense agitated/irritable mood for 1-2 days with increased energy, happening more frequently and with increased duration correlating with environmental stressors, but not accompanied by insomnia/lack of need for sleep, grandiosity, or marked impulsivity, and furthermore not lasting long enough to meet criteria for hypomania (and is not part of a personality disorder).

Have any of you seen this in practice?

Here’s an article that discusses the subclinical symptoms of bipolar disorder seen with folks who have MDD (the review found that those with subclinical symptoms of bipolar disorder but diagnosed with MDD tend to have a more severe course): Subthreshold bipolarity: diagnostic issues and challenges

I’m guessing this has probably been discussed before, but what are your thoughts on symptom presentations like this and a possible “spectrum of bipolar disorder” approach mentioned in the article? How do you approach diagnosis/treatment with clients who have these kinds of symptoms?

 

[Sushirolls]

Great... now they are talking about sub-clinical bipolar.
1) not all people who are depressed have a constant depressed state. At times people may have surges of other mood states.
2) Review for Axis II again.
3) Review for PTSD, Substance use, Domestic Violence, *cannabis* use, SLEEP APNEA, etc during time periods of past "subclinical"/Hypo/mania episodes.
4) bipolar should have never been renamed. Manic Depressive Disorder was a more reflective label.

The time it takes to peel back these bipolar diagnoses that lack (hypo)mania is a pain. And when you do finally get old records, they almost never have sufficient documentation, nor formulation to support the bipolar diagnosis at that time. Irritable? *bipolar*, couldn't sleep for 2 nights with a little energy boost but no functional or social impairment during that time period? *bipolar*

 

[tr]

If only lasting 1-2 days and no change in sleep need or other cardinal symptoms, I wouldn't generally flag that as bipolar spectrum illness to the point where I would be hesitant to treat with unopposed antidepressant.

 

[whopper]

Great... now they are talking about sub-clinical bipolar.

Cyclothymia.

I've even seen top psychiatrists say "Cyclothymia? What's that?"

1. Periods of elevated mood and depressive symptoms for at least half the time during the last two years for adults and one year for children and teenagers.
2. Periods of stable moods last only two months at most.
3. Symptoms create significant problems in one or more areas of life.
4. Symptoms do not meet the criteria for bipolar disorder, major depression, or another mental disorder.
5. Symptoms are not caused by substance use or a medical condition.

 

[Sushirolls]

I know what Cyclothymia is.
I've maybe diagnosed it once. Possibly twice.
Meeting all 5 criteria is pretty difficult, that's why its not diagnosed.

 

[foreverbull]

Cyclothymia.

I've even seen top psychiatrists say "Cyclothymia? What's that?"

1. Periods of elevated mood and depressive symptoms for at least half the time during the last two years for adults and one year for children and teenagers.

Criterion 1 In the Dsm-5 for Cyclothymia is not met in the case I’m thinking of because the client fully met criteria for MDD and had Occasional but recurring depressive episodes (Criteria should not be met for MDD). The subclinical hypomanic episodes were separate, happened 2-4 times per month, and created social impairment and occasionally mild functional impairment either with or without depressive episodes happening outside of those mood swings.

Great... now they are talking about sub-clinical bipolar.
1) not all people who are depressed have a constant depressed state. At times people may have surges of other mood states.
2) Review for Axis II again.
3) Review for PTSD, Substance use, Domestic Violence, *cannabis* use, SLEEP APNEA, etc during time periods of past "subclinical"/Hypo/mania episodes.
4) bipolar should have never been renamed. Manic Depressive Disorder was a more reflective label.

The time it takes to peel back these bipolar diagnoses that lack (hypo)mania is a pain. And when you do finally get old records, they almost never have sufficient documentation, nor formulation to support the bipolar diagnosis at that time. Irritable? *bipolar*, couldn't sleep for 2 nights with a little energy boost but no functional or social impairment during that time period? *bipolar*

With the most recent case I’m thinking of, double-checked all of the above that you mentioned given how easily they can be confused. No sleep apnea or sleep issues at all—client actually slept well even in the midst of mood swings. The mood swings created moderate social impairment and mild functional impairment and were regular to the tune of 2-4x/per month (1-2 days duration). If I recall, it was frustrating enough for the client that they considered couples therapy just to deal with the arguing that happened during these mood swings because the partner was sick of being snapped at during the mood swings (and yes, I double checked BPD, given the interpersonal concern—client didn’t meet criteria).

 

[clausewitz2]

Great... now they are talking about sub-clinical bipolar.
1) not all people who are depressed have a constant depressed state. At times people may have surges of other mood states.
2) Review for Axis II again.
3) Review for PTSD, Substance use, Domestic Violence, *cannabis* use, SLEEP APNEA, etc during time periods of past "subclinical"/Hypo/mania episodes.
4) bipolar should have never been renamed. Manic Depressive Disorder was a more reflective label.

The time it takes to peel back these bipolar diagnoses that lack (hypo)mania is a pain. And when you do finally get old records, they almost never have sufficient documentation, nor formulation to support the bipolar diagnosis at that time. Irritable? *bipolar*, couldn't sleep for 2 nights with a little energy boost but no functional or social impairment during that time period? *bipolar*

The concept of manic-depressive insanity was that mania and depression of whatever kind was all different manifestations of the same illness. If you want to make a very sharp and clear distinction between bipolar and not bipolar, MDI is actually the opposite of what you're pushing for.

Criterion 1 In the Dsm-5 for Cyclothymia is not met in the case I’m thinking of because the client fully met criteria for MDD and had Occasional but recurring depressive episodes (Criteria should not be met for MDD). The subclinical hypomanic episodes were separate, happened 2-4 times per month, and created social impairment and occasionally mild functional impairment either with or without depressive episodes happening outside of those mood swings.



With the most recent case I’m thinking of, double-checked all of the above that you mentioned given how easily they can be confused. No sleep apnea or sleep issues at all—client actually slept well even in the midst of mood swings. The mood swings created moderate social impairment and mild functional impairment and were regular to the tune of 2-4x/per month (1-2 days duration). If I recall, it was frustrating enough for the client that they considered couples therapy just to deal with the arguing that happened during these mood swings because the partner was sick of being snapped at during the mood swings (and yes, I double checked BPD, given the interpersonal concern—client didn’t meet criteria).

MDD is a garbage diagnosis for so many reasons but one of them is the blurring of the distinction between people who get depressed like once or twice in their life for a couple months v. people who get depressed on an annual basis and/or have these apparently unprovoked periods of noticeable affective shift so regular you could set your watch to them. If depression had been something people cared about as much as anxiety when DSM-III was being put together those people probably don't end up in the same category.

Yes, I have definitely seen this person and persons like this a number of times. I am very curious, what if anything does collateral say? Sometimes when I encounter clients like these they describe subclinical presentations like you describe and then their partner tells me that during these times they lock themselves in their studio and paint for 12 hours straight or buy multiple expensive handguns and ride their motorcycles on a busy highway at 90 miles per hour. Or they are so consumed with some suddenly urgent household project that they forget to eat for a couple of days.

Like @tr I wouldn't not give them an antidepressant but I am probably going to follow up a little more closely and be readier to go down a more bipolar-y augmentation pathway if there are signs antidepressant treatment is going poorly.

 

[erg923]

Many high functioning people (and academics?) can meet this, technically, I would think? This sounds like a (personality) temperament to be honest....

And no...I don't really know anything about "Cyclothymic Disorder." The problem with spectrums, at least in this case, is that is may not account for more psychosocial and parsimonious explanation of said disturbance?

 

[nexus73]

If patient is naive to psycho-pharmaceutical treatment, they should go on Vraylar immediately. /s

 

[tr]

Many high functioning people (and academics?) can meet this, technically, I would think? This sounds like a (personality) temperament to be honest....

And no...I don't really know anything about "Cyclothymic Disorder." The problem with spectrums, at least in this case, is that is may not account for more psychosocial and parsimonious explanation of said disturbance?

Calling all low-level mood cycling personality related may feel virtuously parsimonious, but it isn't helpful for making good care decisions.

I have seen two very florid and impressive cases of manic switching from unopposed antidepressant in people who had clear low-level mood cycling but did not meet DSM criteria for bipolar disorder.

I've also seen at least two people who were labeled borderline by community psychiatrists and taken off their lithium, both of whom promptly devolved into nasty irritable manias with severe consequences for their interpersonal relationships.

I actually think it is much more dangerous to underdiagnose bipolar disorder than to overdiagnose it.

 

[clozareal]

This person at most probably meets criteria for Other Specified Bipolar and Related Disorder, with Short-Duration Hypomanic Episodes and Major Depressive Episodes. People at UCSD (e.g., Akiskal, Stahl) would argue for more subtyping of bipolar disorder (Bipolar 1.5 protracted hypomania without depression, 2.5 depressive episodes with cyclothymic temperament, 3 antidepressant-induced hypomania, 3.5 substance abuse, 4 depressive episodes with hyperthymic temperament, 5 depression with mixed hypomania)

The temporal cutoff of 4 days is not mirrored by a clear cutpoint in reported data. Some have suggested that this period should be shortened to 2 days so that patients categorized with unipolar depression could be diagnosed with bipolar disorder (Toward a re-definition of subthreshold bipolarity: epidemiology and proposed criteria for bipolar-II, minor bipolar disorders and hypomania). It was lengthened to 4 days as to not capture those with borderline and related disorders as well as adjustment disorders.

31% of patients with a diagnosis of major depressive disorder had subthreshold hypomanic or manic symptoms with broader criteria (Prevalence and Characteristics of Undiagnosed Bipolar Disorders in Patients With a Major Depressive Episode: The BRIDGE Study). Hard to tell without a biomarker if this is true underdiagnosis or false positives though.

Decreased need for sleep I've heard is the most specific symptom if a patient has euphoric/elevated/expansive/irritable mood. All the others are non-specific to (hypo)mania. Also, this patient doesn't seem to meet criteria for the mixed features specifier for MDD (need 3 symptoms for >50% of the major depressive episode.

 

[clausewitz2]

This person at most probably meets criteria for Other Specified Bipolar and Related Disorder, with Short-Duration Hypomanic Episodes and Major Depressive Episodes. People at UCSD (e.g., Akiskal, Stahl) would argue for more subtyping of bipolar disorder (Bipolar 1.5 protracted hypomania without depression, 2.5 depressive episodes with cyclothymic temperament, 3 antidepressant-induced hypomania, 3.5 substance abuse, 4 depressive episodes with hyperthymic temperament, 5 depression with mixed hypomania)

The temporal cutoff of 4 days is not mirrored by a clear cutpoint in reported data. Some have suggested that this period should be shortened to 2 days so that patients categorized with unipolar depression could be diagnosed with bipolar disorder (Toward a re-definition of subthreshold bipolarity: epidemiology and proposed criteria for bipolar-II, minor bipolar disorders and hypomania). It was lengthened to 4 days as to not capture those with borderline and related disorders as well as adjustment disorders.

31% of patients with a diagnosis of major depressive disorder had subthreshold hypomanic or manic symptoms with broader criteria (Prevalence and Characteristics of Undiagnosed Bipolar Disorders in Patients With a Major Depressive Episode: The BRIDGE Study). Hard to tell without a biomarker if this is true underdiagnosis or false positives though.

Decreased need for sleep I've heard is the most specific symptom if a patient has euphoric/elevated/expansive/irritable mood. All the others are non-specific to (hypo)mania. Also, this patient doesn't seem to meet criteria for the mixed features specifier for MDD (need 3 symptoms for >50% of the major depressive episode.

I agree with most of what you said, but have to chime in with the historical fact that the specific 4 day threshold was motivated per recollection of relevant DSM committee participants by the finding that on average women who reported peri-menstrual mood fluctuations reported 3days of irritability. This was the simplest way they could think of to make sure not everyone with what would become PMDD was diagnosed as bipolar II. It was not motivated by anything more empirical or principled than that.

@erg923 unfortunately attributing it to temperament or "psychosocial factors" is parsimonious only in the sense that we can describe those things with a single word or phrase, not because they pick out unitary or super well-defined entities. I would say you have to sort out how impervious this pattern seems to be to the details of the patient's contemporaneous experience. So if it is just happening in the context of one or two relationships, or only problems at work, sure. If it seems to reliably happen across a broad range of circumstances and relationships, at what point is identifying particular relational or environmental stimuli providing more predictive power than identifying something about their more general response characteristics or tendencies?

Temperament in folks with these cycling tendencies is probably not that separable from the affective disorder. The classical idea of bipolar I is that people are absolutely fine between episodes but from as early as Kraeplin it was observed that folks who get very impressively manic or psychotically depressed may get hugely better when not acute but very often have perpetual if subtle disturbances of affect regulation and interpersonal functioning.

 

[whopper]

I know what Cyclothymia is.
I've maybe diagnosed it once. Possibly twice.

No intention of snubbing you. Just that I've seen top guys in the field forget what this disorder is. They're so focused on the severe stuff they forget about the other stuff.

 

[Heist]

No intention of snubbing you. Just that I've seen top guys in the field forget what this disorder is. They're so focused on the severe stuff they forget about the other stuff.

I see some therapists dx this sometimes

 

[Stagg737]

The subclinical hypomanic episodes were separate, happened 2-4 times per month, and created social impairment and occasionally mild functional impairment either with or without depressive episodes happening outside of those mood swings.

How long has this been going on for? A few months? A few years? Could be some kind of prodrome for true mania or totally unrelated. If the latter, how good of an ADHD screen was performed? What's the pattern of caffeine intake? Do they take any "natural" substances or supplements?

If I recall, it was frustrating enough for the client that they considered couples therapy just to deal with the arguing that happened during these mood swings because the partner was sick of being snapped at during the mood swings (and yes, I double checked BPD, given the interpersonal concern—client didn’t meet criteria).

Just because they didn't meet BPD criteria doesn't mean they don't have traits/features which are severe. How many of these patients have you tried or referred for CBT/DBT or done actual couples or interpersonal therapy with? Which criteria did they meet? I've had patients like this and they almost always have a personality component to it or ADHD, even when they legitimately have a bipolar disorder as well.

 

[Merovinge]

Temperament in folks with these cycling tendencies is probably not that separable from the affective disorder. The classical idea of bipolar I is that people are absolutely fine between episodes but from as early as Kraeplin it was observed that folks who get very impressively manic or psychotically depressed may get hugely better when not acute but very often have perpetual if subtle disturbances of affect regulation and interpersonal functioning.

That's similar to research in pediatric age range bipolar who do have inter-episodic impairment and neuroimaging differences even during non acute mood episodes.

 

[hebel]

How long has this been going on for? A few months? A few years? Could be some kind of prodrome for true mania or totally unrelated. If the latter, how good of an ADHD screen was performed? What's the pattern of caffeine intake? Do they take any "natural" substances or supplements?



Just because they didn't meet BPD criteria doesn't mean they don't have traits/features which are severe. How many of these patients have you tried or referred for CBT/DBT or done actual couples or interpersonal therapy with? Which criteria did they meet? I've had patients like this and they almost always have a personality component to it or ADHD, even when they legitimately have a bipolar disorder as well.

I agree. Many of the "psychopharmacologist" psychiatrist types are quick to view bipolar as being on this VERY broad and alarmingly common spectrum, while looking at borderline personality as this black-and-white diagnosis (that word choice was sort of on purpose haha). I agree that there does seem to be this population of patients in which "unipolar" depressive agents seem to be destabilizing, but again when I hear or go to lectures by these well-known psychopharmacologists, It seems like they see bipolar everywhere. And when you look at their backgrounds and treatment armament, I can see why.

Lives can be messed up from a manic episode, but I also don't think putting someone on lithium or an SGA for 30+ years is all that great either when they could have gotten a lot further from some therapy.

Cyclothymia.

I've even seen top psychiatrists say "Cyclothymia? What's that?"

1. Periods of elevated mood and depressive symptoms for at least half the time during the last two years for adults and one year for children and teenagers.
2. Periods of stable moods last only two months at most.
3. Symptoms create significant problems in one or more areas of life.
4. Symptoms do not meet the criteria for bipolar disorder, major depression, or another mental disorder.
5. Symptoms are not caused by substance use or a medical condition.

Yes, but what are we dealing with here really? There's no FDA approved meds for this and therapy is typically the mainstay of treatment (while watching out for BP1/2).

 

[hebel]

Curious as a psychologist who sometimes has seen clients with depressive episodes occasionally but then a few VERY rapid-onset hypomanic symptoms that end in a few days (not linked to PMDD due to following outside of specified cycle or seen in clients who do not menstruate). With some folks it looks like intense agitated/irritable mood for 1-2 days with increased energy, happening more frequently and with increased duration correlating with environmental stressors, but not accompanied by insomnia/lack of need for sleep, grandiosity, or marked impulsivity, and furthermore not lasting long enough to meet criteria for hypomania (and is not part of a personality disorder).

Have any of you seen this in practice?

Here’s an article that discusses the subclinical symptoms of bipolar disorder seen with folks who have MDD (the review found that those with subclinical symptoms of bipolar disorder but diagnosed with MDD tend to have a more severe course): Subthreshold bipolarity: diagnostic issues and challenges

I’m guessing this has probably been discussed before, but what are your thoughts on symptom presentations like this and a possible “spectrum of bipolar disorder” approach mentioned in the article? How do you approach diagnosis/treatment with clients who have these kinds of symptoms?

Also to your question OP, I have one other suggestion in addition to the great ideas others have proposed. I'm going to suggest a different angle, and really really press to be SURE you can rule out environmental stressors. This means literally walking people through the preceding days leading up to the mood changes.

I can't tell you how many times this results in people who deny any recent stressors suddenly describing an interpersonal situation in which they understandably would have a strong emotional reaction. Unfortunately, with this "hypomanic" and periodically irritable bunch, they often don't recognize or feel their core emotions but instead react to their emotions in a variety of ways, with anxiety and irritability being some of the most common ways.