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Bipolar Disorder Specifiers
DSM-5 Course Specifiers for Bipolar Disorder: Painting a Clearer Picture of a Given Patient’s Unique Presentation

Released: November 07, 2025

Joseph F. Goldberg
Joseph F. Goldberg, MD
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Key Takeaways
  • DSM-5 course specifiers provide more detailed clinical information beyond diagnoses alone to characterize the presentation of a given mood disorder episode.
  • Course specifiers can help clarify distinctions between comorbid disorders (such as anxiety) from salient features that are fundamentally intrinsic to a current mood episode.
  • Course specifiers can provide nuanced information about target symptoms and thereby inform more tailored treatment strategies.

One of the shortcomings of categoric diagnostic systems such as the DSM-5 is the limited extent to which sheer diagnoses convey adequate detail about a patient’s clinical characteristics. Establishing a diagnosis such as bipolar disorder or major depression, offers a starting point from which to convey basic information about a cross-sectional symptom profile, and perhaps some implications about episode duration, risk for recurrence, severity, or potential chronicity. Beyond diagnosis alone, myriad additional features bear on prognosis, anticipated course, and treatment implications. 

Enter the Concept of Course Specifiers
Course specifiers are additional descriptive elements that can flesh out clinical details that diagnoses alone fail to capture, providing a more detailed and comprehensive portrait of a given patient’s presentation. These include:

  • Course of illness: Is this a first lifetime episode or multiepisode presentation? Is the episode acute, in partial remission, or in full remission? Or, have there been continuous symptoms since the initial illness onset?
  • Severity: mild, moderate, or severe
  • With anxious distress: the presence of intense worry, feeling restless, keyed up and tense, and a sense of doom
  • With mixed features: simultaneous (hypo)manic and depressive symptoms
  • With rapid cycling: that is, 4 or more distinct, separable episodes over the preceding year
  • With catatonia
  • With psychosis and, mood-congruent or mood-incongruent
  • With peripartum onset: onset during pregnancy or within 4 weeks of delivery
  • With seasonal pattern: episodes that characteristically recur at a particular time of the year

Some constructs described within course specifiers can be easily confused because they may seem to overlap. For example, waxing and waning symptom flares could be misconstrued as multiple episodes in someone whose index mood episode never fully remitted (ie, the episode is in partial remission), or when someone has had continuous symptoms with only brief periods of subthreshold symptoms. The concept of “anxious distress” during a depressive episode could involve signs of autonomic hyperarousal (feeling keyed up or tense, extreme worry or dread) that could be confused with the psychomotor activation symptoms of (hypo)mania which, in turn, might vaguely resemble the “mixed features” specifier. Differences between these latter 2 specifiers depend on the presence of goal-directed energy: (hypo)mania fundamentally involves an excessive, purposeful, goal-directed high energy state manifested in speech, thinking, and movement, while high anxiety states are driven more by fear and apprehension than uncontainable energy. One would also not want to confuse “anxious distress” with other phenomena that involve psychomotor restlessness such as akathisia or withdrawal from psychoactive substances.

Clinical Case
Let’s consider a clinical example that accounts for some of the above descriptive elements.

Brenda is a 32-year-old woman with a history of bipolar II disorder maintained on lamotrigine 200 mg/day and sertraline 150 mg/day. Her husband initiated a follow-up visit with her psychiatrist because she “seemed off.”  Although adherent to her medications and not misusing alcohol or other substances, he said she was awake much of the night on her laptop “maxing out our credit cards”, appearing uncharacteristically short-tempered and irritable, talking fast, easily distracted, frequently tearful, and saying she felt hopeless and “might as well be dead.”  Her husband thought she “might be rapid cycling” because “one minute she’s down, the next minute she’s up.”  She self-identified “panic attacks” that involve feeling intense dread coupled with excessive worry about feeling overwhelmed with “everything” in her life, which she associated with “the winter doldrums.” Brenda had their second child 11 months earlier, with an uneventful immediate aftermath. Her last episode was after the summertime birth of their first son 4 years earlier, after which she was “bedbound, disengaged, lost 15 pounds and “didn’t snap out of it” until 3 months after the current medication regimen was started.

From this limited snapshot of information, we could make several strong inferences about Brenda’s case.

  1. Her prior diagnosis of bipolar II disorder may be worth revisiting as possible bipolar I disorder if her functioning is now significantly impaired by symptoms of psychomotor acceleration.
  2. Brenda likely meets DSM-5 criteria for a current manic episode based on sleeplessness without apparent fatigue, irritability, accelerated speech, and impulsive spending (we might call this hypomania if her outward functioning remains intact and there is no psychosis).
  3. The “mixed features” specifier might apply based on the simultaneous presence of hopelessness and suicidal thinking. Irritability and distractible thinking could align with either mania or depression and therefore would not necessarily count toward the requisite symptom constellation of an opposite pole, but a careful interview could tease those things apart along with other possible depressive symptoms not spontaneously reported, such as anhedonia, appetite loss, and poor concentration.
  4. The “rapid cycling” specifier does not seem to apply because she appears to be in the midst of just 1 episode with undulating symptoms of high and low mood/energy (ie, mixed features), and no prior distinct episodes over the last year.
  5. Brenda may very well also have anxious distress. This would require teasing apart the presence of full, comorbid panic disorder or generalized anxiety disorder as comorbid conditions preceding her current episode vs subthreshold elements of those diagnoses confined to this episode.
  6. She does not have the “peripartum course specifier,” since she is now 11 months postpartum, though separate from the course specifiers construct is “postpartum mania (or depression)” which can occur up to 1 year after delivery.
  7. No seasonal pattern is evident based on the timing of her 2 known mood episodes.

How do these course specifiers inform Brenda’s treatment? In several ways. First, antidepressants such as sertraline serve no role in either mania or a mixed features presentation and should therefore be deprescribed. Simply stopping antidepressants can be an effective antimanic treatment. Second, lamotrigine has no established efficacy to treat either mania or mixed features episodes; it poses no detriment, but an antimanic mood stabilizer such as lithium or a second-generation antipsychotic should be introduced. Anxiolytic properties are associated with some second-generation antipsychotics (eg, quetiapine, cariprazine, aripiprazole) that treat mania, with or without mixed features, which might favor their use. Finally, although phototherapy can help both seasonal and nonseasonal bipolar depression, it would not be indicated for a nonseasonal, nondepressed phase manic episode with mixed features.

REFERENCES
Bowers MB Jr, McKay BG, Mazure CM. Discontinuation of antidepressants in newly admitted psychotic patients. J Neuropsychiatry Clin Neurosci. 2003;15: 227-230.

Cheniaux E, Filgueiras A, Silva Rde A, et al. Increased energy/activity, not mood changes, is the core feature of mania. J Affect Disord. 2014;152-154.

Goldberg JF. Where does lamotrigine fit in the pharmacotherapy of mood disorders? An evidence-based appraisal. J Clin Psychiatry. 2024;85:23ac15219

Sit K, Adjunctive bright light therapy for bipolar depression: a randomized double-blind placebo-controlled trial. Am J Psychiatry. 2018;175:131-139.

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