Utilizing the WHIPLASHED Mnemonic to Distinguish Unipolar from Bipolar Despair

Ladies with bipolar dysfunction (BD) are at extraordinarily excessive danger for postpartum psychiatric sickness, together with postpartum psychosis.  Whereas the American Faculty of Obstetrics and Gynecology now recommends that each one ladies be screened for despair throughout being pregnant and the postpartum interval, we have now little data relating to the screening instruments which are finest suited to the identification of ladies with bipolar dysfunction.  Many websites now use the Edinburgh Postnatal Despair Scale for postpartum screening.  This instrument is pretty good for figuring out ladies with despair however just isn’t helpful for distinguishing between unipolar and bipolar despair.   

If there’s a clear historical past of hypomania or mania, one would make a prognosis of bipolar dysfunction in a affected person who presents with depressive signs.  However in ladies, who’re extra possible than males to current with combined signs, there could also be no clear historical past of hypomania or mania.  Whereas the DSM outlines indicators and signs of a significant depressive episode, which will be both bipolar or unipolar in nature, there do look like scientific options which will distinguish bipolar from unipolar despair.  

WHIPLASHED is a mnemonic gadget developed by Dr. Ronald Pies to assist distinguish bipolar from unipolar despair, specializing in these distinctive scientific options:

W Worse or “wired” when taking antidepressants. The affected person typically complains of feeling “antsy,” unable to sleep, or extra agitated on standard antidepressants. Quite a few failed antidepressant trials; obvious “tolerance” to antidepressants not overcome with elevated dosage (pseudotolerance); and antidepressant-induced “switching” into mania or cycle acceleration could also be reported.
H Hypomania, hyperthymic temperament, or temper swings by historical past. Individuals with hyperthymic character exhibit intense optimism, elevated vitality, decreased want for sleep, extroversion, and overconfidence.  Intervals of elevated temper or vitality typically don’t match formal DSM standards for hypomania; some might final solely a day or two. 
I Irritable, hostile, or exhibiting combined options in the course of the presenting episode of despair. Some sufferers might present a number of hypomanic options (eg, racing ideas) even whereas depressed.
P Psychomotor retardation seems to be extra widespread in bipolar I despair than in unipolar main despair; nevertheless, a number of research observe that psychomotor agitation is extra widespread in bipolar II than in unipolar main despair.
L Loaded household historical past, both for temper swings, bipolar dysfunction, or affective sickness on the whole. A household historical past of comorbid temper dysfunction and alcoholism may additionally level towards bipolarity.
A Abrupt onset and/or termination of depressive bouts, or comparatively temporary depressive episodes (lower than 2 to three months). Some sufferers may even report a short burst of elevated vitality or subthreshold hypomanic signs instantly earlier than the onset of despair.
S Seasonal or postpartum sample of despair. “Winter-type” seasonal affective dysfunction (depressed in fall/winter, hypomanic in spring) and postpartum psychosis each have scientific and epidemiological hyperlinks with bipolar dysfunction.
H Hyperphagia and hypersomnia, what are typically termed atypical options, look like extra widespread in bipolar than in unipolar despair. Paradoxically, hypersomnia might coexist with psychomotor agitation in bipolar II sufferers (“sleepy speeders”).
E Early age at despair onset (youthful than 25 years). Main despair first showing throughout adolescence, particularly with psychotic options, might herald subsequent bipolarity.
D Delusions, hallucinations, or different psychotic options look like extra widespread in bipolar than in unipolar despair.

WHIPLASHED, though first developed in 2007, has not been extensively used or validated.  A latest examine regarded on the skill of the WHIPLASHED questionnaire to tell apart between unipolar and bipolar despair in a gaggle of ladies.

Feminine sufferers with despair (n=82) have been recruited from an outpatient ladies’s psychological well being clinic.  Information have been collected utilizing a self-report questionnaire designed to parallel the WHIPLASHED interview questions. A optimistic display was outlined as a rating of 5 or better on the WHIPLASHED questionnaire.  Diagnostic assessments have been made utilizing the Mini Worldwide Neuropsychiatric Interview.

Primarily based on the MINI, 54 of the ladies have been recognized with unipolar despair and 28 with bipolar despair.  Nearly all of topics have been white (67%), employed (68%) and married (57%) with a imply age of 36.eight years. 

A cutoff rating of ? 5 generated 96% sensitivity and 52% specificity, whereas elevating the edge to six generated 89% sensitivity and 76% specificity for a bipolar dysfunction prognosis. Translation: If we administer the WHIPLASHED questionnaire to ladies with despair utilizing a cutoff rating of 5, we might miss or misclassify solely 4% of ladies with bipolar despair (excessive sensitivity), though half of these ladies recognized would even have unipolar despair (low specificity).   If we up the cutoff to six, we might miss 11% of ladies with bipolar despair, however the check can be extra particular.  

Even for expert psychiatrists with years of scientific expertise, it may be extraordinarily troublesome to tell apart unipolar from bipolar despair, and this turns into much more troublesome in the course of the postpartum interval.  Hypomania and mania are unusual in the course of the postpartum interval; mostly we see ladies with depressive or combined signs.  On this setting, ladies typically current with profound sleep disruption; this might be a symptom of bipolar despair, however sleep issues may be attributed to extreme anxiousness or the calls for of caring for a new child who’s waking each two hours.  

As well as, postpartum ladies typically current with anxiousness signs and typically irritability.  How does one distinguish when these signs are a traditional response to the calls for of caring for a new child or signs of a psychiatric episode, comparable to unipolar or bipolar despair, and even the earliest levels of postpartum psychosis.    

So far as I do know, WHIPLASHED has not but been examined in pregnant and postpartum populations, so we  wouldn’t suggest this questionnaire as a standalone instrument for making scientific choices. Nonetheless, there’s a clear want for instruments that may assist clinicians make well-informed choices relating to the referral and care of pregnant and postpartum ladies with psychiatric sickness. We at the moment are asking OB-GYNs, who usually shouldn’t have intensive psychiatric coaching, to make very troublesome scientific assessments and choices.  If we would like this method to achieve success, we have now to offer them with the suitable instruments.  

Ruta Nonacs, MD PhD

Mahmoud DR, Yang A, Ciolino JD, Fisher SD, Sit D, Pinheiro E, Pendergrast T, O’Shea Okay, Wisner KL, Clark CT. Validity of the WHIPLASHED as a device to determine bipolar dysfunction in ladies.  J Have an effect on Disord. 2018 Dec 17;246:69-73. 

WHIPLASHED: A Mnemonic for Recognizing Bipolar Despair (Ronald Pies, Psychiatric Instances)

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