Bipolar Disorder with Mixed Features (see link).

Bipolar Disorder or Depression with Anxious Distress.

This specifier is applied when a person has noticeable symptoms of nervousness/anxiety during a 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 keyed up” or tense.
  2. Feeling unusually restless.
  3. Difficulty concentrating because of worry.
  4. Fear that something awful may happen.
  5. Feeling that the individual might lose control of himself or herself.

*A mood episode can be either mania, hypomania, or depression

Bipolar Disorder or Depression with Melancholic Features.

The specifier “with melancholic features” is generally applied when, during the most severe stage of the depressive episode, there is a near-complete absence of the capacity for pleasure. A general lack of reactivity to positive stimuli is also common. A guideline for evaluating the lack of reactivity of mood is that even highly desired events are not associated with notable positive change to mood. Either mood does not brighten at all, or it brightens only partially (e.g., up to 20%–40% of normal and for only minutes at a time).

The melancholic features must be qualitatively different from those that occur during a nonmelancholic depressive state. In other words, a sustained depressed mood that is described as merely more severe, longer lasting, or present without a reason is not considered to be of melancholic quality. Changes in the rate and energy level with which the person moves or talks are nearly always present and are observable by others.

Melancholic features exhibit only a modest tendency to repeat across episodes in the same individual. They are more frequent in inpatients, as opposed to outpatients; are less likely to occur in milder than in more severe major depressive episodes; and are more likely to occur in those with psychotic features.

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 known to be present in a significant minority of others with the same episode. For example, though chronic low mood is a typical symptom of 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 (e.g., an adult receives a visit from children; a person receives compliments or an award).

Additionally, to match the criteria for atypical features, a person must have at least 2 symptoms involving changes in sleeping, eating, motor movements, or interpersonal communication. These include:

  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

Mood episodes can have their onset either during pregnancy or postpartum. Although the estimates differ according to the period of follow-up after delivery, between 3% and 6% of women will experience the onset of a major depressive episode during pregnancy or in the weeks or months following delivery.

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. Studies examining these women over time from pre-to-post-pregnancy have demonstrated that mood and anxiety symptoms during pregnancy, as well as the “baby blues,” increase the risk for a postpartum major depressive episode.

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 prior postpartum mood episodes but is also elevated for those with a prior history of a depressive or bipolar disorder (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, and more commonly, psychotic symptoms can occur in severe postpartum mood episodes without such specific delusions or hallucinations. Postpartum mood (major depressive or manic) episodes with psychotic features appear to occur in from 1 in 500 to 1 in 1,000 deliveries.

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).