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Psychiatric Times.
No. 3
WHIPLASHED: A Mnemonic for Recognizing Bipolar Depression
By Ronald Pies, MD |
March 1, 2007
Dr Pies is clinical professor of psychiatry at Tufts University in Massachusetts. His most recent books include Creeping Thyme, a collection of poetry (Brandylane Publishers); Zimmerman's Tefillin, a short story collection (PublishAmerica); and Handbook of Essential Psychopharmacology, 2nd edition (American Psychiatric Publishing).
Seasonal or postpartum pattern of depression. "Winter-type" seasonal affective
disorder (depressed in fall/winter, hypomanic in spring) and postpartum psychosis
both have clinical and epidemiological links with bipolar disorder.
Hyperphagia and hypersomnia—sometimes termed atypical features—appear to
be more common in bipolar than in unipolar depression. Paradoxically, hypersomnia may coexist with psychomotor agitation in bipolar II patients ("sleepy speeders").
Early age at depression onset (younger than 25 years). Major depression first
appearing during adolescence, especially with psychotic features, may herald
subsequent bipolarity.
Delusions, hallucinations, or other psychotic features appear to be more common
in bipolar than in unipolar depression. |
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*People with hyperthymic temperament show persistent traits such as intense optimism, increased energy, reduced
need for sleep, extroversion, and overconfidence. |
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Arguably, the least secure of the WHIPLASHED components is its association of bipolar depression with psychomotor retardation.As Dr Nassir Ghaemi has pointed out to me, the literature is somewhat contradictory on the issue of psychomotor change. On the one hand, consistent with many older textbooks, there are convincing data that patients who are depressed with bipo- lar Idemonstrate more psychomotor retardation than do patients with unipolar major depression. This holds true even when one controls for melancholic features.10 On the other hand, several studies comparing depressed patients with bipolar IIwith patients who have unipolar depression have found higher rates of psychomotor activation in the bipolar II group—this, despite the presence of hypersomnia. This seeming paradox may point to the high prevalence of mixed features in depressed patients with bipolar II.11 Perhaps the term "sleepy speeder" might apply to such bipolar II presentations.
Notwithstanding these uncertainties, my working hypothesis is that those patients who meet 5 or more of the WHIPLASHED criteria will, on structured diagnostic interviewing, prove to have some form of bipolar disorder. Clinicians are free to use this screening instrument in their practice, and I welcome feedback on its utility. However, use of this mnemonic is only a first step in what must be a comprehensive and ongoing diagnostic process.
Perhaps some day we will be able to send our patients for a bipolar blood test. Indeed, there is already preliminary evidence that variation in the serotonin transporter gene may predict the likelihood of manic switching on antidepressants.13 In the meantime, I believe that use of the WHIPLASHED mnemonic, in concert with screening instruments such as Falk's DIGFAST mnemonic,14 the Bipolar Spectrum Diagnostic Scale,15 and the Mood Disorder Questionnaire16 will aid the clinician in spotting subtle forms of bipolar disorder. Primary care physicians may find these instruments especially useful, but I believe they are suitable for general psychiatric practice as well.
But what about the patient?
Oh, yes—what about our patient, Ms T? Given her presentation, family history, and previous response to antidepressants, I would probably diagnose Bipolar Disorder Not Otherwise Specified, possibly with psychotic and/or mixed features. I would most likely recommend treatment with lithium(Drug information on lithium), divalproex, or lamotrigine(Drug information on lamotrigine) (Lamictal), perhaps in combination with one of the atypical antipsychotics. Each of these agents has its pros and cons, depending on the preponderance of symptoms, medical concerns, and patient preference.
