Bipolar Disorder with Mixed Features (see link).

Bipolar Disorder or Depression with Anxious Distress.

This specific manifestation of bipolar disorder (BD) is applied when a person has noticeable symptoms of nervousness/anxiety during a BD-related mood episode. A person must have at least 2 of the following symptoms the majority of days during the current or most recent mood episode*:

  1. Feeling irritable, short-fused, or “keyed up”
  2. Feeling unusually restless.
  3. Difficulty concentrating because of worry.
  4. Feeling of dread that something awful may happen.
  5. Feeling that the individual might lose control of himself or herself.

*mood episodes include mania, hypomania, or depression

Bipolar Disorder or Depression with Melancholic Features.

The specifier “with melancholic features” is applied when an individual is at the depths of a depressive episode. In this state, there is almost no access of capacity for feelings of pleasure. A helpful guideline for determining whether you are in a melancholic state is the inability to react emotionally in a way that is expected given the event. Either mood does not brighten at all, or it brightens only slightly. For example, one may only feel only fleeting positive reactions for 20%–40% of the time to a positive event.

During melancholic depression, individuals exhibit a slower rate and energy level for responding to events (compared to their norm).

Melancholic features are more frequent in inpatients, as opposed to outpatients. These features are also less prevalent in mood episodes of persons who are not diagnosed with a severe mood or psychotic disorder.

Bipolar Disorder or Depression with Atypical Features.

This specifier refers to the case when the clinical presentation of a mood episode does not fit the significant majority of those with the same episode. However, these atypical symptoms are prevalent enough in those with mood disorders to be noteworthy. For instance, though chronic low mood is typical major depression, in atypical cases, a person can be “cheered up” to the degree that they no longer feel depressed for a period of time in response to a positive event (for example, an adult receives a visit from children; a person receives compliments or an award).

To be diagnosed with this subtype of depression, 2 symptoms involving changes in sleeping, eating, motor movements, or interpersonal communication must be evident, including:

  1. Significant weight gain or increased appetite.
  2. Hypersomnia (sleeping more/for longer periods than usual).
  3. Feeling heavy or leaden in arms/legs as if one is “weighed down.”
  4. Having constant fear of rejection (this can be consistent with when a person is not depressed, but is exacerbated during a period of depression); this interpersonal sensitivity must interfere at the workplace or in personal life.

Bipolar Disorder or Depression with Psychotic Features.

This specifier applies if delusions or hallucinations (auditory or visual) are present at any point during a mood episode. See psychotic disorder for a description of such symptoms.

Bipolar Disorder or Depression with Peripartum Onset

Although the estimates differ depending on time of assessment, between 3% and 6% of women will experience major depressive symptoms during pregnancy or in the weeks or months following delivery. Women who have a pre-existing history of symptoms of bipolar disorder or depression have a higher likelihood of experiencing mood disturbance during and/or after pregnancy.

Fifty percent of “postpartum” major depressive episodes actually begin prior to delivery. Thus, these episodes are referred to collectively as peripartum episodes. Women with peripartum major depressive episodes often have severe anxiety and even panic attacks during the peripartum period. Moreover, studies examining women pre-to-post-pregnancy demonstrate that those with anxiety or the “baby blues” during pregnancy are at increased risk for postpartum depression.

Peripartum-onset mood episodes can present either with or without psychotic features. The risk of postpartum episodes with psychotic features is particularly increased for women with a pre-existing mood disturbance (especially bipolar I disorder) and those with a family history of bipolar disorders.

Once a woman has had a postpartum episode with psychotic features, the risk of recurrence with each subsequent delivery is between 30% and 50%. Infanticide (killing one’s infants), which has been publicized in the news in several cases, is most often associated with postpartum psychotic episodes that are characterized by command hallucinations to kill the infant or delusions that the infant is possessed. However, psychotic symptoms can occur absent of such specific delusions or hallucinations.

Bipolar Disorder or Depression with Seasonal Pattern

This specifier can be applied to the pattern of major depressive episodes in bipolar I disorder, bipolar II disorder, or major depressive disorder, recurrent. The essential feature is that periods of depression tend to occur and remit during certain times of the year. In most cases, the episodes begin in fall or winter and remit in spring. Less commonly, there may be recurrent summer depressive episodes.

This pattern of onset and remission of episodes must have occurred during at least a 2-year period, without any nonseasonal episodes occurring during this period. In addition, the seasonal depressed periods must substantially outnumber any nonseasonal depressive episodes over the individual’s lifetime. Younger persons are more at-risk for seasonal depression. This specifier does not apply to those situations in which the pattern is better explained by seasonally linked psychosocial stressors (e.g., seasonal unemployment or school schedule).