Bipolar And Related Disorders

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Bipolar and Related Disorders

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- Bipolar I disorder
- Bipolar II disorder
- Cyclothymic disorder
- substance/medication-induced; due to another medical condition; other specified and unspecified bipolar and related disorder.

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Manic Episode

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A. 1 week+, abnormally/persistently elevated, expansive, or irritable mood and increased goal-directed activity or energy, most of the day, nearly every day (any duration if hospitalized)

B. 3+ sx (4+ if mood is irritable only) representing a change from usual behavior (see later)

C. Impairment in social or occupational functioning OR hospitalization to prevent harm to self/oth­ers, OR psychotic features.

D. Not attributable to the a substance or another medical condition.

Note: A full manic episode that emerges during antidepressant treatment but persists beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.

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Hypomanic Episode

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A. 4 day+, abnormally/persistently elevated, expansive, or irritable mood and increased activity or energy, most of the day, nearly every day.

B. 3+ sx (4+ if mood is irritable only) representing a change from usual behavior (see later)

C. Unequivocal change in functioning uncharacteristic of the individual

D. The disturbance in mood and the change in functioning are observable by others.

E. 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

Note: A full hypomanie episode that emerges during antidepressant treatment but persists beyond the physiological effect of that treatment is sufficient evidence for a hypomanie episode diagnosis.

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Manic/hypomanic Episode Criteria B

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3 + sx (4+ if mood is only irritable)

▫ Inflated self-esteem, grandiosity

▫ Decreased need for sleep

▫ More talkative than usual, pressured speech

▫ Flight of ideas, thoughts racing (subjective)

▫ Distractibility

▫ Increase in goal-directed activities or psychomotor agitation

▫ Excessive involvement in activities that have high potential for painful consequences

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Major depressive episode

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A. 5+ symptoms with a duration of 2 weeks+, represent a change from previous functioning, with at least depressed mood or anhedonia (see later)
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: Responses to a significant loss may include feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode.

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Major depressive episode criteria A

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5+ symptoms with a duration of 2 weeks+, represent a change from previous functioning, with at least depressed mood or anhedonia, present most of the day, every day:
- depressed mood (children/teens may be irritable)
- anhedonia
- weight loss or gain or decrease/increase in appetite
- insomnia/hypersomnia
- psychomotor agitation or retardation
- fatigue, loss of energy
- worthlessness, inappropriate guilt
- diminished ability to think or concentrate, or indecisiveness
- recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

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Bipolar I Disorder

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A. 1+Manic episode

B. The occurrence of the manic and major depressive episode(s) is not better explained

by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional dis­ order, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

Specify: mild to severe

Specify if

- with psychotic features

- in partial/full remission

- unspecified

Specify with: anxious distress, mixed features, rapid cycling, melancholic features, atypical features, mood congruent/incongruent psychotic features, catatonia, peripartum onset, seasonal pattern

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Emotional lability

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Rapid shifts of mood over brief periods of time: among euphoria, dysphoria, and irritability

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DDX and comorbidities of Bipolar I

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DDX
- MDD
- Other bipolar disorders
- Generalized anxiety disorder, panic disorder, PTSD, other anxiety disorders
- Substance, medication induced bipolar disorder
- ADHD
- Personality disorder: borderline
- Disorders with prominent irritability
Comorbidities: anxiety disorders, ADHD, conduct disorder, substance use disorder

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Bipolar II Disorder

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A. 1 Hypomanic + 1 Major depressive episode
B. There has never been a manic episode.
C. The occurrence of the hypomanie and major depressive episodes is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or schizophrenia spectrum and other psychotic disorder.
D. Distress or impairment in social, occupational, or other important areas of functioning.

Specify current or recent episode: depressive/hypomanic, if mild to severe and if in partial or full remission

Specify with: anxious distress, mixed features, rapid cycling, mood congruent/incongruent psychotic features, catatonia, peripartum onset, seasonal pattern

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DDx and comorbidities of Bipolar II disorder

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DDX
- MDD
- Cyclothymic disorder
- Shizophrenia spectrum and psychotic disorders
- Panic and anxiety disorders
- Substance use disorders
- ADHD
- Personality disorder:
- Other bipolar disorders
Comorbidities: anxiety, substance use, eating disorders

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Cyclothymic

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A. 2+ years (1+ in children): periods of hypomanic sx that do not meet criteria for hypomania and MDE.
B. Not been without sx for 2+ months at a time.
C. Criteria for a major depressive, manic, or hypomanie episode have never been met.
D.Not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or schizophrenia spectrum and psychotic disorder.
E. Distress or impairment in social, occupational, or other important areas of functioning.
Specify if: with anxious distress

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DDx and comorbidities of cyclothymic disorder

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DDX
- Bipolar and depressive due to another medical condition

- Substance/medication-induced bipolar and depressive disorder

- Bipolar I and II disorder, with rapid cycling.

- Borderline personality disorder.

Comorbidities: substance-related disorders, sleep disorders

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With anxious distress

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2+ sx during the majority of days of the current or most recent episode:

Keyed up or tense.

Restless.

Difficulty concentrating because of worry.

Fear that something awful may happen.

Feeling that the individual might lose control of himself or herself

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Manic/hypomanic with mixed features

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A. Full criteria for a manic/hypomanie episode and 3+ sx:

Dysphoria or depressed mood

Anhedonia

Psychomotor retardation nearly every day

Fatigue or loss of energy.

Feelings of worthlessness or excessive or inappropriate guilt

Suicide/death

B. Mixed sx observable, represent change in behavior
C.If both mania/depression- dx of mania with mixed features
D. Not attributable to substance

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Depressive episode with mixed features

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A. Criteria for MDE post-manic/hypomanic sx, 3+:

Elevated, expansive mood.

Inflated self-esteem or grandiosity.

More talkative, pressured speech.

Flight of ideas, thoughts are racing.

Increase in energy or goal-directed activity

Increased or excessive involvement in activities that have a high potential

for painful consequences

Decreased need for sleep

B. Observable by others; change from usual behavior.

C. Both mania/depression simultaneously,Dx= manic episode, with mixed features.

D. Not attributable to the physiological effects of a substance

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With rapid cycling

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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, hypomanie, or major depressive episode.

Note: Episodes are demarcated by either partial or full remissions of at least 2 months or a switch to an episode of the opposite polarity.

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With melancholic features

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1+:

Anhedonia

Lack of reactivity to usually pleasurable stimuli

3+

A distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness or by so-called empty mood.

Depression that is regularly worse in the morning.

Early-morning awakening

Marked psychomotor agitation or retardation.

Significant anorexia or weight loss.

Excessive or inappropriate guilt.

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With atypical features

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A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events).

B. 2+ of the following features:

Significant weight gain or increase in appetite.

Hypersomnia.

Leaden paralysis

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.

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With mood congruent psychotic features

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During manic episodes, the content of all delusions and hallucinations is consistent with the typical manic themes of grandiosity, invulnerability, etc., but may also include themes of suspiciousness or paranoia, especially with respect to others’ doubts about the individual’s capacities, accomplishments, and so forth.

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With mood-incongruent psychotic features:

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The content of delusions and hallucinations is inconsistent with the episode polarity themes as described above, or the content is a mixture of mood-incongruent and mood-congruent themes.

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With postpartum onset

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Within 4 weeks after childbirth

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With seasonal pattern

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A. Regular temporal relationship between the onset of manic,hypomanic, or MDE and a particular time of the year (in bipolar I or II disorder.

B. Full remissions (or change from MDE to mania/hypomania) occur at a characteristic time

C. No non-seasonal episodes of that polarity have occurred during that 2-year period.

D. Seasonal manias, hypomanias, or depressions substantially outnumber any nonseasonal ones that may have occurred over the individual’s lifetime.==
Specify remission=
- In partial remission: Sx are present, but full criteria are not met, or there is a period lasting less than 2 months without any significant symptoms following the end of such an episode.
- In full remission: During the past 2 months, no significant signs or symptoms of the disturbance were present.