ABCT Bipolar SIG/Listserv Topics/Diagnostic criteria for mania
This thread discusses the overlap in manic symptoms in the DSM-5 criteria. Thread was posted on 11.27.2017.
The following email thread has been edited to deidentify names.
Original question: Diagnostic criteria for mania
I have a question about the DSM-5 criteria for mania that I thought some of you could answer. It sounds simple on the surface but I wonder if it’s caused confusion. The DSM-5 “A” criteria says that a manic episode is “A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least one week and present most of the day, nearly every day.”
Then, one of the symptoms of the B criteria is “increase in goal-directed activity or psychomotor agitation (i.e., purposeless non-goal directed activity). “ This seems like double-dipping.
When I teach DSM-5 to our trainees and to community clinicians, this comes up all the time - and I, too, have referred to it as "double dipping." I have always interpreted this to be a mistake that was overlooked in the finalization of the DSM-5 criteria for mania, but perhaps there is some other rationale for this structure that I have missed? It would be interesting to do a more thorough lit search on DSM-5 revisions and field trials to see if there is a more thorough justification for the overlap between the new A criterion and the existing B criterion symptom. Per my memory, there was a lot published on the discussion to "promote" increased energy to the A criteria, but not much at all about keeping "goal directed activity or agitation" in the B criteria in light of the other change.
- I run repeatedly into the same problem. I think from discussions with Jules Angst that when he wanted activation to be additionally included, he did not intend it to be a) a ‘and’ condition with elevated or irritable mood and b) activation to reflect more general increased energy level and not necessarily goal-directed. However, that does not change the problem that there is how he risk if double counting the same behavior for two different criteria.
- There is no getting around increased energy level, which one could have before...unusual, but it works to accomplish this.
Thanks for raising this interesting question! I think there are three issues: (a) the role of activation in bipolar disorders (see Scott et al, JAMA, 2017), (b) DSM-5’s radical decision to elevate activation to a necessary symptom of mania and hypomania, and (c) wording issues in the DSM-5 mania and hypomania syndromes. My feeling is that DSM is in a state of flux (to put it kindly) on these topics, and we have reverted to DSM-IV criteria for our recently launched RCT (we will explore the more stringent DSM-5 criteria as a moderator of outcomes).
Specific wording of DSM-5: 1) In DSM-5 manic episode and hypomanic episode, symptom B6 explicitly refers to either goal-directed or non-goal-directed activity. The printed DSM-5 included the qualifier ‘goal-directed’ for activity/energy in the Criterion A symptom for manic episode. This was removed in the 2016 update. The Criterion A symptom for hypomanic episode in the printed DSM-5 never contained the qualifier ‘goal-directed’. 2) The Criterion A activation symptom is broader (‘activity or energy’) than the B6 one (‘activity’). 3) Increased activity therefore appears as both a necessary (A) and an optional (B6) symptom. I think this is best understood as an oversight: symptom B6 is logically irrelevant to the decision of presence of mania/hypomania. 4) I’m not sure that I’d characterise this as ‘double dipping’: if they’d removed B6, Criterion B would have gone from ‘three out of seven symptoms’ to ‘two out of six’. So I don’t think the reiteration of activity in the current B6 makes it any easier to meet criteria.
Whether the more stringent DSM-5 criteria for mania and hypomania will lead to a decrease in the diagnosis of BD depends on the extent to which increased activation is in fact present in mania/hypomania syndromes. Amongst a sample of 310 STEP-BD patients meeting clinical monitoring form criteria for current mania or hypomania, Machado-Vieira et al (AJP, 2017) found that all met the DSM-IV criteria, but only 52% also met the stricter DSM-5 criteria (that is, DSM-IV criteria plus the additional DSM-5 criterion of increased activity or energy levels). When it comes to lifetime diagnoses, by contrast, Gordon-Smith et al (2017, AJP letter) report that some 94% of cases with a lifetime DSM-IV diagnosis of BD-I experienced overactivity in at least one manic episode and therefore would meet lifetime DSM-5 criteria.
- I can see why including a required increase in activity under “A” would make it harder to meet mania criteria than it was in DSM-IV-TR, when activity/energy were not part of the A criteria. Given that DSM-5 added them, however, I think it is double-dipping to have activity under B as well. Think about this scenario – a patient comes in with elated mood plus increased activity, decreased need for sleep, and grandiosity. If activity was listed under A only, and not B, then the patient would need another B symptom to meet mania or hypomania criteria. If it’s counted under both A and B, then he/she meets criteria without the extra symptom.
- Yes, point taken. But I would assume that if DSM had listed activity under A and not B (i.e. simply moved B6 to A), they would then no longer require 3 additional symptoms to meet Criterion B? If they wanted to maintain some sense of face validity in the syndrome, they would have had to alter the B criterion rule ‘3 out of 7 symptoms’ to ‘2 out of 6 symptoms’. If they’d done this, then your hypothetical client below would still meet criteria, as they do under the current version.
- I thought the whole purpose of this change in DSM criteria was to make it harder to meet full criteria for mania (another attempt, along with DMDD, to reduce the number of pediatric bipolar diagnoses in the US). Your citation of Machado-Vieira would seem to bear this out. If we were to change the criteria to elated mood + activity, plus only two more B symptoms, then we’d be back where we started.
- Is increased activity that is goal-directed fundamentally different from increased activity with no goal? I have always assumed so, but in fact the DSM requires that we group goal-directed behavior with psychomotor agitation, which seems like a different phenomenon.
- Just to broaden the question a bit, at last week’s ABCT SIG meeting there was discussion of the need for a common assessment battery. If we assume that the DSM criteria are a given, how should we assess increased activity or energy? Right now it’s based on subjective report or direct observation, but I’ve certainly seen people who describe being currently manic but don’t seem unusually active in the interview. We have the YMRS for adults, the PGBI for kids, the KSADS Mania Rating Scale….
- These are points for the whole group to discuss if so inclined. Alternatively, feel free to offer the next entry for the rating system below.
- :) = positive affect
- :) :) = hypomania
- :) :) :) = mania
- :) :( :) :( = rapid cycling