Depression which is it, Unipolar or the unstable Bipolar type, Q and A
Q and A: Mood Disorders telling them apart: Differential Diagnosis a Brief Introduction< xml="true" ns="urn:schemas-microsoft-com:office:office" prefix="o" namespace="">
Are you sure you have a stable Unipolar type of mood or depressive disorder? If not read on!
Why do call this a brief introduction?
More comprehensive information about diagnosis and of medication treatment of Bipolar and other Mood Disorders are discussed elsewhere. Bipolar and Unstable Mood Disorders This is just a brief overview to help you be sure you are primarily dealing with a Unipolar depression so the correct medication choices can be make. If one is not sure of Bipolar type, or unstable type, it may be best to avoid usual antidepressants and use alternative medication, or at least have a high index of suspicion using caution watchfulness of new or worsening symptoms.
Is there a specific test to tell the mood disorders apart, and if not how do you make the diagnosis?
There is no specific test for diagnosis, some paper and pencil, or computer driven questionnaire may give you clues or a direction for further evaluation, but the diagnosis is make clinically by doing three things over and over. 1. Take history and more history of the course of the problems and to see if it fits a family history, 2. The symptom presentation should fit the agreed upon criteria for the disorder, and 3. There is a predicable treatment response to biological treatments like medications, and non biological treatments like counseling, psychotherapies, and other treatments like the use of applied mindfulness. All three of these reinforce each other and should fit like pieces of a puzzle. How to make a Diagnosis
What if you do all that and the person is still not getting better?
If they don’t the diagnosis or the treatment may be wrong and you need to start over, with more history, symptom picture clarification, and therapeutic trials. The brain is very complex and each person has very unique brain chemistry which can express itself in many ways and has its own unique treatment response. Both the expression of a disorder and its treatment response is as unique as the individual. Even identical twins that are biological clones carrying the same genetics have different expressions of the same disorder and unique treatment responses. If there is such variation in twins imagine how it is in siblings, family members, and the general public.
How do you deal with this complexity?
Don’t generalize, don’t be too quick to be so sure of your diagnosis, and individualize both the diagnostic process and the treatment to fit the individuals needs and responses to treatment, not to some preconceived idea you may have in your head. Also get more and more history from the patient, from their family, and others who may know them well.
How do you tell the mood disorders apart based on symptom pictures?
Mood disorders can be divided into three categories, Bipolar or Unstable Mood, Unipolar or Stable Mood, and a group not fitting into either that can be called and Atypical Mood Disorder or Mood Disorder NOS, which usually in unstable but doesn’t meet the full picture for Bipolar. Bipolar means you have two poles one is high energy pole[DIGFAST] and a low energy pole[SIGECAPS], that alternate, though they can cycle very rapidly, sometimes in hours, thought it could be days, weeks, months or even years. Unipolar Stable Depressive Disorder predominately only has the low energy symptoms.
Why is it important to tell these apart?
There are many reasons one, but I will only mention one now, a critically important one. The usual treatment for Unipolar the antidepressants can make the unstable Atypical and Bipolar ones worse causing more frequent and intense cycling, which may not be seen for years, and even lead to psychosis, homicidal, and suicidal problems, all very serious outcome. I have written about this under side effects of SSRI medication.
AntiDepressantWorsenSymptoms, Warning AntiDepressants
How do you tell these apart?
One needs to take a careful history not only about the presenting symptoms, but of the course of the symptoms in the individual and in the family over their lifetimes, from infancy to the present , including available medication treatment history. Unstable Mood Scales Historical Markers, Treatment Scale, Symptom Picutre All of this may take multiple visits with the patient and their family and takes time, but there is no short cut to the process. If one does this one will not miss the DIGFAST symptoms which differentiates the excitable unstable high energy pole which has its own specific medication management and can be vastly worsened by antidepressants and some usual tranquilizing medications.
Where does one begin?
First realize the Mood disturbance can be low energy, high energy , can have both called mixed states, often rapid cycling in hours, days or weeks, but the cycles may be longer like seasonal, or take years and can only be deduced from personal longitudinal history, family history and treatment response. Use these memory aids to start.
DIG FAST for the excitable, angry, nasty, overly active type of depression or mood disorder or high energy states with unstable mood swings, Dr J/Mr. H, of the Bipolar or Unstable Mood states.
SIG E CAPS for the low energy type or Unipolar depressive or Stable mood states
How long should one have symptoms and how to they present?
By definition a Mood disturbance is a distinct period, lasting 1-2 weeks, or less if rapid cycling, of sad, bad, mad, moods that may be elevated, excitable, irritable, depressed, or a loss of interest , a I don’t care attitude, and/or feeling persistently and pervasively alone and empty. As you see from this brief description sadness, feeling down, being blue is only one of many presentations, often only the triad of IRA, irritability, anger and rage may be present at first, are so intense that the other symptoms are not all that obvious or not extensively looked for.
Are there other ways mood disorders can present?
These are called Depressive equivalents may include impulse control problems e.g. aggression, sexual, D&A, gambling, and psychosomatic manifestations, e.g. migraines, IBS,GERD, eczema, asthma. Some of these represent the low energy part of the Bipolar process, being especially seen in younger people. With further evaluation by history, looking at symptom pictures now in the past, and in the family, and looking at treatment history, one can often find the symptoms usually associated with a Unipolar or more usually an Atypical or Bipolar type mood disorder.
What are the cardinal or main features of the high energy pole of Unstable Mood Disorders?
First let us discuss the general mood. Though there may be periods of sadness the predominant mood over the course of the disorders sometimes even starting in infancy and early childhood, is that of ups and downs, mostly high energy, with low energy showing itself in the younger person with physical symptoms like headache, irritable bowel or upset stomach, and many other physical manifestations. These predominately high energy states have irritability, anger and rage being persistently present, though these may occur in episodes also. The being bad, mad, sad triad especially seen in younger people is present and predominates, and may rapidly alternate. The child or older person acting mood disturbance by doing “bad” things, out of a combination of an elevated sense of self caused by grandiosity, mood driven impulsivity, predominately anger, with some mild paranoia showing itself with ideas of reference,[the mad component], sadness especially early in an unstable mood may be brief, but becomes more dominant as the person gets older, and if proper history is not taken can be confused for Unipolar depression.
Do the unstable mood or Bipolar type of disorder always start the way you describe with high energy and anger?
No, sometimes the first episode of what will become classic Bipolar will present very similar if not identical to a Unipolar stable depression. The only way you may be able to tell them apart is by getting more family and developmental and treatment history, of the individual and their family. Here treatment response is critical and may be the only clue, with a too rapid and robust response to antidepressants, only to lose their effectiveness after a short period of time.
What about the other symptoms?
Unstable Bipolar states are marked by extreme variability, both episodically with hours, days, weeks, months, or years between episodes, and developmentally in that the presentation can present looking like many other problems like the triad of sad, mad, bad, or physical symptoms, depending on the age of the person. This variability is usually not present in Unipolar depressive states. DIGFAST features are as follows:
D- Distractibility, can’t vs. won’t pay attention to boring things that normally don’t hold interest with ease, highly dependent on Milieu, Mood, Meaningfulness, Motivation and Relationships, which in part help differentiate from classic ADHD, though they both may be present.
I -Insomnia, trouble falling/staying asleep, too much/little sleep, nightmares, wetting, sleep walking.
G-Grandiosity, big unrealistic plans, ideas, fantasies, being the best, greatest, the boss, I am right, to much I, I, I, too self centered, deviously selfish, tell you what you want to hear.
F-Flight of ideas, subjective sense of distracting fast thoughts, too many and emotionally charged.
A -Activities ,too many emotionally charged goal directed , at times risky, esp. pleasurable &sexual.
S - Speech, more talkative than usual, pressured, hard to follow, off on tangents, illogical
T- Thoughtlessness or impulsivity, not aware of consequences of behavior, speech or thinking.
Is there some other features to tell ADHD from the same symptoms of HID, hyperactivity, impulsivity and distractibility from a mood problem?
In uncomplicated ADHD-Impulsivity and Hyperactivity is less driven by moods and feelings. There may be Excitability of mood with anger, irritability , but is much less intense, frequent, of shorter duration, and not relatively pervasive and persistent, and if full blow rage is present [IAR] , always consider a mood disorder, Attention is much less affected by racing thoughts and labile, unstable emotions. Discipline the bad, mad, sad triad, and not learning at school, or work or from life experiences is more related to core symptoms of ADHD, then mood, emotions and relationships. Uncomplicated ADHD is very responsive to stimulant treatment, but in mood disorder they may only help concentration and then only temporarily and usually in the long run makes all other worse or at the minimum doesn’t help them. ODD,ADHD or Mood
What about the Unipolar or Stable depressive mood disorder and the SIG E CAPS memory aid?
SIG E CAPS is short for SIG, that is prescribe, Energy CAPsules, for difficulties with Sleep, Interest or irritable or depressed mood, Guilt or negativity, low Energy level, poor Concentration, and Appetite and other physical symptoms, Psychomotor usually slowing down of the body and mind, and Suicide or ideas of negativity, that can progress to suicide intent and plans, with the progression of the usually depressed mood. Excessive and persistent irritability, anger and rage[IAR] may indicate a unstable mood disorder and mood stabilizing medication may be indicated or be the medications of first choice. IrritabilityAngerRage
What are the actual symptoms and how to they compare with their presentation in the unstable mood?
In comparing Unipolar vs. Bipolar states , Unipolar depressions are less excitable, episodic, more predictable, with less relationship reactivity. The SIGCAPS symptoms are as follows: Sleep difficulties being classically with waking up in the middle of the night, if you have trouble falling asleep it should be due to worry or anxiety, not racing thoughts with a mind you just can’t shut off. There is decreased Interest and pleasure in life and activities, with no periods of heightened interest with high energy, that require very little sleep, and yet not being tired. Guilt and negativity of thinking, feeling with hopelessness, helplessness, and haplessness [3H’s], negativity of self is predominant and doesn’t change all that much with mild but normal mood swings . One is also negative of others, things and activities, with a generalized not feeling well or right. The physical Energy depression becomes more and more to being slowed down over the long run, though there may be some speeded up times but with usually decreased rather than increased productivity, with less fluctuation, with many chronic physical complaints often vague though significant. Concentration and other thinking difficulties are associated with a too slow mind, or if the mind is agitated it is due to excessive anxiety, not due to racing thoughts or flight of ideas and excessive rapid speech. Changes in Appetites, sensual and sexual drives, weight gain/loss, that fit the usual progressive downhill low energy course. Psychomotor agitation or retardation with disassociation, of feelings and thoughts, with a fast mind slow body or the opposite. Suicide ideas, intent, plan, being better off dead, poor hygiene, less interest in getting health care are more correlated with the persistent low mood and negativity , and not with the ups and downs of the bipolar unstable mood disorder.