Digfast A Mnemonic for Mania

DIGFAST is a mnemonic aid for the following concepts:

Distractibility—An inability to maintain one's concentration, as opposed to the decreased concentration of depression, where one is unable to initiate concentration. In mania, this leads to the initiation of multiple tasks, none of which are finished.

Insomnia—A decreased need for sleep, as opposed to the decreased sleep of depressive insomnia. The patient sleeps less, but has intact or increased energy the next day. Alternatively, there is no change in amount of sleep, but the patient's energy level is increased.

Grandiosity—Inflated self-esteem; it need not involve delusions.

Flight of ideas—A subjective experience of racing thoughts.

Activities—An increase in goal-directed activities (social, sexual, school, work, and home).

Speech—Pressured; an objective sign. A subjective alternative is increased talkativeness, determined by asking whether the patient has been more talkative than when euthymic.

Thoughtlessness—Commonly called risk-taking behavior—an increase in pleasurable activities with the potential for painful consequences. Four such behaviors that should be routinely assessed are sexual indiscretions, spending sprees, impulsive traveling, and reckless driving.

Mania is diagnosed when euphoric mood is present for one week with three of the DIGFAST symptoms, or irritable mood with four symptoms, and there is significant social or occupational dysfunction. If functioning is unimpaired, and manic symptoms last at least 4 days, hypomania is diagnosed. If symptoms last less than 4 days, bipolar disorder not otherwise specified is diagnosed.

Strict reliance on euphoria grossly underestimates the behaviors in bipolar illness, since irritability alone is sufficient as the primary mood change in mania, and since mixed episodes (where mood is depressed) are almost as common as pure manic episodes (Goodwin and Jamison 1990). Irritability, expressed as anger attacks, is more common in bipolar than in unipolar depression (Perlis et al. 2004), and its occurrence should trigger careful assessment of DIGFAST criteria. Other DIGFAST triggers are the depressive features of bipolar illness noted below.

According to DSM-IV-TR criteria, hypomania is distinguished from mania on the basis of social or occupational dysfunction, not specific manic symptoms. Since patients often underestimate interpersonal dysfunction, family reports become essential. Therefore, it is difficult, if not impossible, to rule out bipolar disorder without family or another third-person report.

Beyond DSM-IV-TR

If past manic or hypomanic episodes are not present or if the history of these episodes is confusing and they cannot be definitively ruled in or out, then we would recommend that clinicians move on to assessing the likelihood of bipolar illness using the four validators of psychiatric diagnosis, beginning with an assessment of depressive phenomenology, followed by course of illness, genetics, and, lastly, treatment nonre-sponse. None of the following concepts are to be found in DSM-IV-TR,

TABLE 1-1. Differences in phenomenology between bipolar and unipolar depression

More common in bipolar than in unipolar depression: Atypical symptoms Psychosis

Depressive mixed state Anxious/agitated depression Anergic depression* Irritability/ anger attacks* *Suspected, but uncertain.

which again, we emphasize, should be seen as a step in the nosological history of bipolar disorder, not the end of that history. Thus, the other validators of diagnosis should be seen as just as relevant as the single validator employed in DSM-IV-TR (i.e., presence or absence of past manic or hypomanic episodes).

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