Chapter 6 Bipolar and related disorders The diagnoses

Chapter 6: Bipolar and related disorders

• The diagnoses included in this chapter are bipolar I disorder, bipolar II disorder, cyclothymic disorder, substance/medicationinduced bipolar and related disorder, bipolar and related disorder due to another medical condition, other specified bipolar and related disorder, and unspecified bipolar and related disorder.

Bipolar I Disorder Diagnostic Criteria For a diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes.

Manic Episode A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary). B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior: 1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep (e. g. , feels rested after only 3 hours of sleep). 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing.

5. Distractibility (i. e. , attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i. e. , puφoseless nongoal-directed activity).

7. Excessive involvement in activities that have a high potential for painful consequences (e. g. , engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. D. The episode is not attributable to the physiological effects of a substance (e. g. , a drug of abuse, a medication, other treatment) or to another medical condition. Note: A full manic episode that emerges during antidepressant treatment (e. g. , medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis. Note: Criteria A-D constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder.

Hypomanic Episode A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree: 1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep (e. g. , feels rested after only 3 hours of sleep). 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing.

5. Distractibility (i. e. , attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation. 7. Excessive involvement in activities that have a high potential for painful consequences (e. g. , engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others. E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. F. The episode is not attributable to the physiological effects of a substance (e. g. , a drug of abuse, a medication, other treatment). Note: Criteria A-'F constitute a hypomanie episode. Hypomanie episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.

Major Depressive Episode A. Five (or more) of the following symptoms have been present during the same 2 -week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly attributable to another medical condition. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e. g. , feels sad, empty, or hopeless) or observation made by others (e. g. , appears tearful). (Note: In children and adolescents, can be irritable mood. ) 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). .

3. Significant weight loss when not dieting or weight gain (e. g. , a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain. ) 4. Insomnia or hypersomnia nearly every day

5. Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or another medical condition. Note: Criteria A-C constitute a major depressive episode. Major depressive episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.

Bipolar I Disorder A. Criteria have been met for at least one manic episode (Criteria A-D under “Manic Episode” above). B. The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. -Bipolar I disorder is the diagnosis given to an individual who is experiencing or has a history of one or more manic episodes. The client may also have experienced episodes of depression. This diagnosis is further specified by the current or most recent behavioral episode experienced. For example, the specifier might be single manic episode (to describe individuals having a first episode of mania) or current (or most recent) episode manic, hypomanic, mixed, or depressed (to describe individuals who have had recurrent mood episodes). Psychotic or catatonic features and level of severity of symptoms may also be specified. •

Development and Course Mean age at onset of the first manic, hypomanie, or major depressive episode is approximately 18 years for bipolar I disorder. Prevalence Twelve-month prevalence of bipolar I disorder across 11 countries ranged from 0. 0% to 0. 6%. The lifetime male-to-female prevalence ratio is approximately 1. 1: 1.

• Risk and Prognostic Factors • Environmental. Bipolar disorder is more common in high-income than in low-income countries (1. 4 vs. 0. 7%). Separated, divorced, or widowed individuals have higher rates of bipolar I disorder than do individuals who are married or have never been married, but the direction of the association is unclear.

• Genetic and physiological. A family history of bipolar disorder is one of the strongest and most consistent risk factors for bipolar disorders. There is an average 10 -fold increased risk among adult relatives of individuals with bipolar I and bipolar II disorders. Magnitude of risk increases with degree of kinship. Schizophrenia and bipolar disorder likely share a genetic origin, reflected in familial co -aggregation of schizophrenia and bipolar disorder. • Course modifiers. After an individual has a manic episode with psychotic features, subsequent manic episodes are more likely to include psychotic features. Incomplete inter episode recovery is more common when the current episode is accompanied by mood incongruent psychotic features.

• Suicide Risk • The lifetime risk of suicide in individuals with bipolar disorder is estimated to be at least 15 times that of the general population. In fact, bipolar disorder may account for one-quarter of all completed suicides. A past history of suicide attempt and percent days spent depressed in the past year are associated with greater risk of suicide attempts or completions. •

Bipolar II Disorder • For a diagnosis of bipolar II disorder, it is necessary to meet the following criteria for a current or past hypomanic episode and the following criteria for a current or past major depressive episode.

Diagnostic Criteria: A. Criteria have been met for at least one hypomanie episode (Criteria A-F under “Hypomanic Episode” above) and at least one major depressive episode (Criteria A-C under “Major Depressive Episode” above). B. There has never been a manic episode. C. The occurrence of the hypomanie episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. D. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. •

Prevalence The 12 -month prevalence of bipolar II disorder, internationally, is 0. 3%. In the United States, 12 -month prevalence is 0. 8%. Suicide Risk Suicide risk is high in bipolar II disorder. Approximately one-third of individuals with bipolar II disorder report a lifetime history of suicide attempt. The prevalence rates of lifetime attempted suicide in bipolar II and bipolar I disorder appear to be similar (32. 4% and 36. 3%, respectively).

Cyclothymic Disorder Diagnostic Criteria A. For at least 2 years (at least 1 year in children and adolescents) there have been numerous periods with hypomanie symptoms that do not meet criteria for a hypomania episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode. B. During the above 2 -year period (1 year in children and adolescents), the hypomania and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time. C. Criteria for a major depressive, manic, or hypomanie episode have never been met.

D. The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. E. The symptoms are not attributable to the physiological effects of a substance (e. g. , a drug of abuse, a medication) or another medical condition (e. g. , hyperthyroidism). F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. • •

• Prevalence • The lifetime prevalence of cyclothymic disorder is approximately 0. 4%-l%. Prevalence in mood disorders clinics may range from 3% to 5%. In the general population, cyclothymic disorder is apparently equally common in males and females. In clinical settings, females with cyclothymic disorder may be more likely to present for treatment than males.

• Substance/Medication-Induced Bipolar and Related Disorder • The disturbance of mood associated with this disorder is considered to be the direct result of physiological effects of a substance (e. g. , ingestion of or withdrawal from a drug of abuse or a medication). The mood disturbance may involve elevated, expansive, or irritable mood, with inflated self-esteem, decreased need for sleep, and distractibility. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. •

• Bipolar Disorder Due to Another Medical Condition • This disorder is characterized by an abnormally and persistently elevated, expansive, or irritable mood and excessive activity or energy that is judged to be the result of direct physiological consequence of another medical condition (APA, 2013). The mood disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Other Specified Bipolar and Related Disorder This category applies to presentations in which symptoms characteristic of a bipolar and related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the bipolar and related disorders diagnostic class.

• 1 -Short-duration hypomanie episodes (2 -3 days) and major depressive episodes: A lifetime history of one or more major depressive episodes in individuals whose presentation has never met full criteria for a manic or hypomanie episode but who have experienced two or more episodes of short-duration hypomania that meet the full symptomatic criteria for a hypomanie episode but that only last for 2 -3 days. •

2. Hypomanie episodes with insufficient symptoms and major depressive episodes: A lifetime history of one or more major depressive episodes in individuals whose presentation has never met full criteria for a manic or hypomanie episode but who have experienced one or more episodes of hypomania that do not meet full symptomatic criteria.

3. Hypomanie episode without prior major depressive episode: One or more hypomanic episodes in an individual whose presentation has never met full criteria for a major depressive episode or a manic episode. If this occurs in an individual with an established diagnosis of persistent depressive disorder (dysthymia), both diagnoses can be concurrently applied during the periods when the full criteria for a hypomanie episode are met. •

• 4 -Short-duration cyclothymia (less than 24 months): Multiple episodes of hypomania symptoms that do not meet criteria for a hypomanie episode and multiple episodes of depressive symptoms that do not meet criteria for a major depressive episode that persist over a period of less than 24 months (less than 12 months for children or adolescents) in an individual whose presentation has never met full criteria for a major depressive, manic, or hypomanie episode and does not meet criteria for any psychotic disorder. •

• Unspecified Bipolar and Related Disorder • This category applies to presentations in which symptoms characteristic of a bipolar and related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the bipolar and related disorders diagnostic class. The unspecified bipolar and related disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific bipolar and related disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis (e. g. , in emergency room settings).

Specifiers for Bipolar and Related Disorders Specify if: With anxious distress: The presence of at least two of the following symptoms during the majority of days of the current or most recent episode of mania, hypomania, or depression: 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. Specify current severity: Mild: Two symptoms. Moderate: Three symptoms. Moderate-severe: Four or five symptoms. Severe: Four or five symptoms with motor agitation. •

• With mixed features: The mixed features specifier can apply to the current manic, hypomanic, or depressive episode in bipolar I or bipolar II disorder. (Manic or hypomanic episode, with mixed features, Depressive episode, with mixed features). • • With rapid cycling: (can be applied to bipolar I or bipolar II disorder): Presence of at least four mood episodes in the previous 12 months that meet the criteria for manic, hypomanic, or major depressive episode. •

With melancholic features: A. One of the following is present during the most severe period of the current episode; 1. Loss of pleasure in all, or almost all, activities. 2. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens). B. Three (or more) of the following: 1. A distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness or by so-called empty mood. 2. Depression that is regularly worse in the morning. 3. Early-morning awakening (i. e. , at least 2 hours before usual awakening). 4. Marked psychomotor agitation or retardation. 5. Significant anorexia or weight loss. 6. Excessive or inappropriate guilt.

With atypical features: This specifier can be applied when these features predominate during the majority of days of the current or most recent major depressive episode. A. Mood reactivity (i. e. , mood brightens in response to actual or potential positive events). B. Two (or more) of the following features: 1. Significant weight gain or increase in appetite. 2. Hypersomnia. 3. Leaden paralysis (i. e. , heavy, leaden feelings in arms or legs). 4. A long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment. C. Criteria are not met for “with melancholic features” or “with catatonia” during the same episode.

With psychotic features: Delusions or hallucinations are present at any time in the episode. If psychotic features are present, specify if mood-congruent or mood-incongruent. With catatonia: This specifier can apply to an episode of mania or depression if catatonic features are present during most of the episode. With peripartum onset: This specifier can be applied to the current or, if the full criteria are not currently met for a mood episode, most recent episode of mania, hypomania, or major depression in bipolar I or bipolar I! disorder if onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery. •

• With seasonal pattern: This specifier applies to the lifetime pattern of mood episodes. The essential feature is a regular seasonal pattern of at least one type of episode (i. e. , mania, hypomania, or depression). The other types of episodes may not follow this pattern. For example, an individual may have seasonal manias, but his or her depressions do not regularly occur at a specific time of year.

SYMPTOMATOLOGY (SUBJECTIVE AND OBJECTIVE DATA). 1. The affect of an individual experiencing a manic episode is one of elation and euphoria—a continuous “high. ” However, the affect is very labile and may change quickly to hostility (particularly in response to attempts at limit setting) or to sadness, ruminating about past failures. 2. Alterations in thought processes and communication patterns are manifested by the following: a. Flight of Ideas. There is a continuous, rapid shift from one topic to another. b. Loquaciousness. The pressure of the speech is so forceful and strong that it is difficult to interrupt maladaptive thought processes. c. Delusions of Grandeur. The individual believes he or she is all important, all powerful, with feelings of greatness and magnificence.

d. Delusions of Persecution. The individual believes someone or something desires to harm or violate him or her in some way. 3. Motor activity is constant. The individual is literally moving at all times. 4. Dress is often inappropriate: bright colors that do not match; clothing inappropriate for age or stature; excessive makeup and jewelry. 5. The individual has a meager appetite, despite excessive activity level. He or she is unable or unwilling to stop moving in order to eat. 6. Sleep patterns are disturbed. Client becomes oblivious to feelings of fatigue, and rest and sleep are abandoned for days or weeks. 7. Spending sprees are common. The individual spends large amounts of money, which is not available, on numerous items, which are not needed.

• 8. Usual inhibitions are discarded in favor of sexual and behavioral indiscretions. • 9. Manipulative behavior and limit testing are common in the attempt to fulfill personal desires. Verbal or physical hostility may follow failure in these attempts. • 10. Projection is a major defense mechanism. The individual refuses to accept responsibility for the negative consequences of personal behavior.

• 11. There is an inability to concentrate because of a limited attention span. The individual is easily distracted by even the slightest stimulus in the environment. • 12. Alterations in sensory perception may occur, and the individual may experience hallucinations. • 13. As agitation increases, symptoms intensify. Unless the client is placed in a protective environment, death can occur from exhaustion or injury.

Management of bipolar disorder: 1 -Hospitalization: hospitalizations can be necessary for situations such as: • severe mood episodes • suicidal attempts • untreated bipolar symptoms • bipolar medication adjustments • -More severe cases of bipolar disorder are more likely to require more frequent intermittent hospitalizations.

2 -Medications A number of medications are used to treat bipolar disorder. The types and doses of medications prescribed are based on your particular symptoms. Medications may include: Mood stabilizers. to control manic or hypomanic episodes. Examples of mood stabilizers include lithium (Lithobid), valproic acid (Depakene), divalproex sodium (Depakote), carbamazepine (Tegretol, Equetro, others) and lamotrigine (Lamictal).

• - Lithium: consider using lithium as first line treatment of bipolar disorder only if clinical and laboratory monitoring are available, and prescribe only under specialist supervision. If laboratory examinations are not available or feasible, lithium should be avoided and valproate or carbamazepine should be considered. • Antipsychotics. If symptoms of depression or mania persist in spite of treatment with other medications, adding an antipsychotic drug such as olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), may help. • -For women who are pregnant or breastfeeding, avoid valproate, lithium and carbamazepine. Use of low-dose haloperidol is recommended with caution and under the care of a specialist, if available. .

• Antidepressants. To help manage depression. Because an antidepressant can sometimes trigger a manic episode, it's usually prescribed along with a mood stabilizer or antipsychotic. If patient is on antidepressants: DISCONTINUE ANTIDEPRESSANTS to prevent further risk of mania. • Anti-anxiety medications. Benzodiazepines may help with anxiety and improve sleep, but are usually used on a short-term basis.

• 3 -Psychotherapy • Psychotherapy, support groups and psychoeducation about the illness are essential to treating bipolar disorder: • Interpersonal and social rhythm therapy (IPSRT). IPSRT focuses on the stabilization of daily rhythms, such as sleeping, waking and mealtimes. A consistent routine allows for better mood management. People with bipolar disorder may benefit from establishing a daily routine for sleep, diet and exercise. • Cognitive behavioral therapy (CBT) helps change the negative thinking and behavior associated with depression. The goal of this therapy is to recognize negative thoughts and to teach coping strategies. • Family-focused therapy helps people with bipolar disorder learn about the illness and carry out a treatment plan.

• Psychoeducation. Learning about bipolar disorder (psychoeducation) can help you and your loved ones understand the condition. Knowing what's going on can help you get the best support, identify issues, make a plan to prevent relapse and stick with treatment. • Family-focused therapy. Family support and communication can help you stick with your treatment plan and help you and your loved ones recognize and manage warning signs of mood swings.

4 - ECT: may be an option for bipolar treatment if don't get better with medications, can't take antidepressants for health reasons such as pregnancy or are at high risk of suicide.