287 Bipolar I Disorder (296.xx)

DSM-IV-TR criteria

The required criterion for the disorder dictates that the afflicted individual must have at least one manic episode in their life time. Mania is often followed by periods of depression. There is a cyclic nature about the illness. Individuals will fluctuate between episodes of depression and mania; hence the original label “manic depressive.” Although, it should be noted there are periods of normalcy between each episodes, where individuals are able to function. Onset of the disorder often develops in late teens to early twenties. Nearly all individuals with the disorder develop it before age 50.

Manic episodes can manifest themselves as either irritability or euphoria.

Diagnostic criteria for 296.0x Bipolar I Disorder, Single Manic Episode

• A. Presence of only one Manic Episode…and no past major Depressive Episodes.
  • Note: Recurrence is defined as either a change in polarity from depression or an interval of at least 2 months without manic symptoms.
• B. The Manic Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
• Specify if:
  • Mixed: if symptoms meet criteria for a Mixed Episode…
• Specify (for current or most recent episode).
  • Mild, moderate, severe without psychotic features or severe with psychotic features.
  • With Catatonic Features.
  • With Postpartum Onset.
• Specify the current clinical status of the bipolar I disorder or features of the most recent episode if the full criteria are not currently met for a manic, mixed, or major depressive episode.
  • In partial or full remission
  • With catatonic features
  • With postpartum onset

Diagnostic criteria for 296.40 Bipolar I Disorder, Most Recent Episode Hypomanic

• A. Currently (or most recently) in a Hypomanic Episode
• B. There has previously been at least one Manic Episode or Mixed Episode
• C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• D. The mood episodes in Criteria a and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
• Specify:
  • Longitudinal Course Specifiers (With and Without Interepisode Recovery)…
  • With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)…
  • With Rapid Cycling.

Diagnostic criteria for 296.4x Bipolar I Disorder, Most Recent Episode Manic

• A. Currently (or most recently) in a Manic Episode…
• B. There has previously been at least one Major Depressive Episode…,Manic Episode…,or Mixed Episode…
• C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
• Specify
  • Longitudinal Course Specifiers (With and Without Interepisode Recovery)…
  • With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)…
  • With Rapid Cycling…

Diagnostic criteria for 196.6x Bipolar I Disorder, Most Recent Episode Mixed

• A. Currently (or most recently) in a Mixed Episode…
• B. There has previously been at least one Major Depressive episode…, Manic Episode…,or Mixed Episode…
• C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
• Specify (for current or most recent episode):
  • Severity/Psychotic/Remission Specifiers…
  • With Catatonic Features…
  • With Postpartum Onset…
• Specify:
  • Longitudinal Course Specifiers (With and Without Interepisode Recovery)…
  • With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)…
  • With Rapid Cycling…

Diagnostic criteria for 296.5x Bipolar I Disorder, most Recent Episode Depressed

• A. Currently (or most recently) in a Major Depressive Episode…
• B. There has previously been at least one Manic Episode or Mixed Episode
• C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
• Specify (for current or most recent episode)
  • Severity/Psychotic/Remission Specifiers…
  • Chronic…
  • With Catatonic Features…
  • With Melancholic Features…
  • With Atypical Features…
  • With Postpartum Onset…
• Specify:
  • Longitudinal Course Specifiers (With and Without Interepisode Recovery)…
  • With Seasonal Pattern (applies only to the pattern of major Depressive Episodes)…
  • With Rapid Cycling…

Associated features

• Suicide is very prevalent in individuals with bipolar I disorder. It is thought that somewhere between 10 and 15% of bipolar patients will actually complete suicide; many more may attempt it. Those with bipolar I are more at risk to have an alcohol or other substance use/abuse problem, and this can lead to a worse course for their bipolar disorder. They may also show violent behaviors during the course of their disorder.
• Many problems are associated with bipolar I disorder. Violent behaviors could include child abuse, spouse abuse, or other worse violent actions. Problems with school such as truancy or failure are common, and later in life occupational success is also very difficult to attain or maintain. Episodic antisocial behaviors may also present themselves in bipolar I individuals. Maintaining stable relationships is also a problem for individuals with bipolar I disorder, and divorce is common.
• A person with Bipolar Disorder will resist treatment.
• Include mood lability and depressive symptoms that may last moments or minutes or days.

Child vs. adult presentation

• 10% to 15% of adolescents with recurrent Major depressive episodes will develop Bipolar I disorder. Mixed episodes occur most often in adolescents and young adults.
• Bipolar disorder in children:

http://www.youtube.com/watch?v=2OfNPiZz3Lw

Gender and cultural differences in presentation

• There has not been a reported difference in race or ethnicity and the presence of bipolar I. Some clinicians believe that bipolar I disorder is over-diagnosed in some ethnic groups and in younger individuals.
• Gender affects the order of which the disorder appears. Males are more likely to have manic episodes first. Women are most likely to have major depressive disorder first.
• It is equally common in men and women, even though they initially display symptoms differently.
• Manic episodes in men usually occur much more than major depressive episodes; in women, the major depressive episodes occur more frequently.
• The different episodes may be intensified in women during the premenstrual period.
• Rapid cycling is more common in women.
• The course of BD illness may be worse among African American patients,who are more likely to have attempted suicide and been hospitalized then white patients.
• African American adolescents with bipolar disorder are treated for longer periods with atypical antipsychotics than Caucasian adolescents, even after adjusting for the severity of psychotic symptoms.

Epidemiology

• Bipolar Disorder 1 is common in the United States with a lifetime prevalence between 0.4 and 1.6%. Initial onset of Bipolar 1 is between age 15 and 24. When properly diagnosed and treated, Bipolar Disorder 1 often has a remission period of 5 years. After 5 years a recurrence is common.

Etiology

• First degree biological relatives have a higher chance of getting this disorder from their relatives that have it. They have a 4% to 24% chance of getting it.
• Tests were done and twin and adoption studies show strong evidence of a genetic influence.
• Estimates of the heritability of BD range from 59% to 87%. A review of studies indicated that the concordance rates for monozygotic twins average 57%, whereas the concordance rate for dizygotic twins averages 14%.
• The risk of BD among children of bipolar parents is four times greater than the risk among children of healthy parents.

Empirically supported treatments

• The usual treatment for Bipolar I Disorder is lifelong therapy with a mood-stabilizer (either lithium, carbamazepine, or divalproex / valproic acid) often in combination with an antipsychotic medication.
• In mania, an antipsychotic medication and/or a benzodiazepine medication is often added to the mood-stabilizer.
• In depression, quetiapine, olanzapine, or lamotrigine is often added to the mood-stabilizer.
• Combination of supportive psychotherapy, psychoeducation, and the use of a mood-stabilizer.

Single Manic Episode- for the DSM-V

Draft Criteria for Bipolar I Disorder

• Retain structure, with changes limited to the definitions of mood episodes that define each.

Diagnostic criteria for Bipolar I Disorder, Single Manic Episode

• A. Presence of only one Manic Episode (see Criteria for Manic Episode) and no past Major Depressive Episodes.Note: Recurrence is defined as either a change in polarity from depression or an interval of at least 2 months without manic symptoms.
• B. The Manic Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Specifiers and/or current features have not yet been reviewed by the Workgroup for bipolar disorder. It is anticipated that specifiers and/or features that apply across the mood disorders will be consistent across major depression and bipolar disorder. The bipolar specific rapid cycling specifier is under review to consider whether to keep as is, eliminate, or modify.

Links

• Washington Post journalist, Pete Early talks about trying to get his son properly diagnosed and treated for Bipolar Disorder. His difficult experience trying to understand the nation’s mental health system led him to write: Crazy: A Father’s Search Through America’s Mental Health Madness.
• Bipolar Treatment

Both bipolar and unipolar disorders are said to be heritable. Pathological disturbances of mood may follow a ‘bipolar’ course, where normal moods may fluctuate between mania and depression or in a ‘unipolar’ course will be only depressive moods. These disorders could be heritable based on the factors of neurochemical, neuroendocrine, and automatic abnormalities. The basis for these abnormalities has not been established. Bipolar disorder can skip a generation in most cases.

Additional Information

The number of children and adolescents of being diagnosed with bipolar disorder is increasing. Along with the over diagnosis, the children and teens are being over treated with medications as well. Atypical antipsychotics have been diagnosed, and some are proven as an effective treatment for bipolar disorder (Singh, Ketter, & Chang, 2010). “The efficacy of an atypical antipsychotic is defined in terms of treatment response rates or remission of illness. Response rates are commonly reported as a change in a symptom score as determined by clinical assessments of mania from baseline to endpoint. The Young Mania Rating Scale (YMRS) is a commonly used validated instrument to determine the degree of manic symptomatology (Singh, et al., 2010).” Olanzapine is used for the treatment of manic or mixed episodes in Bipolar I disorder, usually in adolescents 13 to 17 years old. The findings indicated that weight gain might be a possibility and outweigh the benefits of the drug (Singh, et al., 2010). “In 2007, risperidone became the first atypical antipsychotic to receive FDA approval as monotherapy for short-term treatment of acute manic or mixed BD episodes in youths aged between 10 and 17 years (Singh, et al., 2010).” This drug does indicate weight gain therefore physicians need to monitor the patients every six months.

Lithium was studied to determine the relevancy of the drug in cases of severe manic episodes and other disorders related to the manic episodes such as bipolar. Lithium is a relevant drug in the treatment of moderate to severe manic episode, with an efficacy similar to those of most other compounds (Storosum, Wohlfarth, Schene, Elferink, Van Zwieten, & Brink, 2007). The justification of lithium as a first-line treatment of the algorithm in the treatment of manic episode, however, does not only depend on the magnitude of effect in placebo-controlled studies but also on other short- and long-term efficacy and safety considerations (Storosum, et al., 2007). Nevertheless, the results from our meta-analysis may contribute to the discussion about the place of lithium in the treatment of manic episode (Storosum, et al., 2007).

Bipolar disorder (BP) is a debilitating mental illness that affects a significant number of individuals. In this study, there are differences found between mixed versus manic bipolar disorder (Shah, Averill, & Shack, 2004). The primary diagnostic feature, according to DSM-IV criteria (1), is a distinct period of abnormally and persistently elevated, expansive or irritable mood lasting for at least one week. In addition, at least three of the following symptoms are present: grandiosity, decreased need for sleep, pressured speech, and flight of ideas, distractibility, hyperactivity, or risk taking behavior (Shah, et al., 2004). Subsets of BP patients are diagnosed with mixed episodes (BPX). These individuals meet the criteria for both a manic and a major depressive episode; however, the depressive symptoms need only to be present for one week. Individuals who develop BPX have a more inconsistent pattern in age of onset than those with BPM (manic bipolar). Among individuals with BPM, no gender differences have been reported in number of manic episodes; however, women were more likely to be hospitalized (Shah, et al., 2004). Among males with BP, their first episode is more likely to be manic, whereas women are more likely to experience a depressive episode. Men tend to be more hyperactive, grandiose, and to engage in risky behavior, and women tend to report more racing thoughts and distractibility. Studies report mixed findings regarding co morbid substance abuse, with either women or men being found to have more substance-related co morbidity (Shah, et al., 2004). Those diagnosed with BPX are more likely to be women and they tend to have a greater number of depressive symptoms during manic episodes. The most common co-morbidity is substance abuse, followed by anxiety disorders and eating disorders. Co-morbid substance abuse is more common among adolescents and among individuals diagnosed with BPX (Shah, et al., 2004). Although there are differences shown, these disorders also have similarities.

Several people wonder if there are differences between child and adult onset of bipolar disorder. The pediatric bipolar disorder is different from the adult by classifying nine symptom classes. Firstly there is elated mood, defined by silliness, giddiness and feeling invincible. Children in this state are easily overwhelmed, and their affect may oscillate quickly from excitation to a state of anxious distress (Bradfield, 2010). Secondly, irritable mood (one of the cardinal features of pediatric bipolar disorder) manifests in aggressive, hostile behaviors with intense, inconsolable responses to stressors (Bradfield, 2010). Inflated self-esteem or grandiosity is the next category of reported symptoms. The child may make unsupportable statements such as “I am the cleverest boy in the whole world”, or “The teachers could learn a few lessons from me”. A decreased need for sleep is evident in children with bipolar mood disorder (Bradfield, 2010). They awaken from little sleep, feeling refreshed and energized. Pressure of speech is noted, with children constantly talking, dominating the interpersonal space, and seeking attention by being excessively entertaining. Constant goal-directed activity is observed as a central feature. Children may be overwhelmed by a frenzy of activity, with aims to achieve unrealistic goals. The constant search for pleasurable activities is also observed, a feature that often manifests in children showing little awareness of the social surroundings (Bradfield, 2010) . The emergence of depression in children living with bipolar disorder is age-specific in its manifestation. Depressed children may report feeling “crabby”; their parents may describe “excessive whining” in the child; they may cry for no apparent reason, withdraw and isolate themselves, exhibit fluctuations in mood from irritability to tearfulness, and may engage in minor self-injurious behaviors such as skin-pinching (Bradfield, 2010). These children may develop a painful sensitivity to rejection, due to the incongruity of their behaviors compared with their peers. The final category of symptoms in bipolar children relates to the psychotic spectrum. Children presenting what could be called an atypical mania could exhibit auditory and visual hallucinations, usually in relation to mood-congruent delusions of grandiosity (Bradfield, 2010). In terms of thought form, the significance of flight of ideas, spontaneously, and excessive speed and production of thoughts has been noted (Bradfield, 2010).

The following can be considered as red flags pointing to heightened risk: Firstly, people with Bipolar Mood Disorder who have a family history of suicidal behaviour are more likely to attempt suicide than those who do not (Bradfield, 2010). Secondly, a history of physical or sexual abuse is positively correlated with suicide attempts. These two factors must be seen in combination with the specific clinical presentation of the bipolar child (Bradfield, 2010). The majority of people with Bipolar Mood Disorder who attempt suicide frequently present with mixed manic states, multiple depressive episodes, co-morbid anxiety or panic disorders and/or substance abuse or dependence (Bradfield, 2010). Furthermore, children presenting with a history of mixed episodes as well as concurrent psychotic symptoms are more likely to evince suicidal ideation (Bradfield, 2010). The treatment of children with psychiatric medication is a sensitive process that requires nuanced judgements and considers each child in relation to his/her development (Bradfield, 2010).