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Bipolar and Related Disorders 24

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Bipolar and Related Disorders 24

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Bipolar and Related Disorders:

Mood Disorders
 DSM-III: Mood Disorders
 Characterized by gross deviation in mood.
 Fundamental experiences of depression and mania contribute either singly or together.
 Major Depressive Episode: It is an extremely depressed mood state that lasts at least 2 weeks
ands includes cognitive symptoms (Feeling of worthlessness, indecisiveness) and disturbed
physical functions (altered sleeping patterns, significant changes in appetite and weight, or
notable memory loss).
 Mania: It is abnormally exaggerated elation, joy or euphoria. Individuals find extreme pleasure in
every activity;
 Some clients compare their daily experiences of mania with a continuous sexual orgasm.
 They become extraordinary active (hyperactive) require little sleep and may develop grandiose
plans, believing they can accomplish anything they desire.
 DSM-5 added “persistently increased goal-directed activity or energy”.
 Speech is typically rapid and may become incoherent, because he/she want express so many
ideas at once (flight of ideas).
 Hypomanic episode: Less severe version of manic episode that does not mark
significant impairment in functioning and need last only four days rather than
a full week.
 It is itself problematic, but its presence does contribute to the definition of
several other disorders.
 Bipolar and related: disorders are separated from the depressive disorders in DSM-5 and placed
between the schizophrenia spectrum and other psychotic disorders and depressive disorders in
recognition of their place as a bridge between the two diagnostic classes in terms of
symptomatology, family history, and genetics.
 The diagnoses included in this are
 bipolar I disorder,
 bipolar II disorder,
 cyclothymic disorder,
 substance/medication-induced 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.
 The bipolar I disorder criteria represent the modern understanding of the classic
manic-depressive disorder or affective psychosis described in the nineteenth
century, differing from that classic description only to the extent that neither
psychosis nor the lifetime experience of a major depressive episode is a
requirement.
 Bipolar II disorder, requiring the lifetime experience of at least one episode of major depression
and
 at least one hypomanic episode, is no longer thought to be a "milder" condition than bipolar I
disorder,
 largely because of the amount of time individuals with this condition spend in depression and
because the instability of mood experienced by individuals with bipolar II disorder is typically
accompanied by serious impairment in work and social functioning.
 CASE
 This is an interesting case, as we take a look at this 23-year-old female who first
comes in to see her psychiatrist with moderate depressive symptoms.
 At the time of the interview, her chief complaint included feeling like she’s
lacking energy, she’s feeling depressed.
 She’s also reporting difficulty in paying attention, organizing her day, and
accomplishing her tasks at work. Notably these symptoms started abruptly.
 Three weeks early, prior to that, she had been functioning better than usual,
requiring very little sleep and getting more accomplished.
 Of significance, she reported two brief episodes of depression over the past 2
years. Each lasting about 2 months.
 And although the patient reported these depressive episodes as coming out of
the blue, she learned after consulting with her therapist that they were related to
significant psychosocial stress, stemming from the loss of her job and the deaths
of 2 uncles, both of which were related to the COVID-19 pandemic. The patient
reported that she still finds enjoyment talking to friends and socializing and she
has hope of finding a new job and she’s constantly looking.
 It’s noteworthy to bear in mind that in her first depressive episode she was
treated with methylphenidate 25mg titrated up to 50 m and she stated feeling
improved on this does with psychotherapy. Her second depressive episode, her
does was bumped up to 100 mg which we saw improvement in depression, but
she noted she felt a little activated and had trouble sleeping. With her third
depressive episode, the therapist and PCP referred the patient over to a
psychiatrist.
 Of great note should be her past psychological history: she was diagnosed with
ADHD in middle school, during which time she responded well to
methylphenidate.
 She continued to do well until her college years at which time she began
experiencing difficulty falling asleep as well as irritability. At that time, she
discontinued methylphenidate and was psychiatric drug free.
 She found that practicing mindfulness and yoga on a daily basis helped her
residual ADHD symptoms. Of note, she had no history of suicidal thoughts or
behavior, self-injurious behaviors, psychiatric hospitalization, or problems with
substance abuse.
 Of note, regarding medical comorbidities, she was diagnosed a year earlier with
type 2 diabetes, which was managed with metformin 1000 mg twice daily and
her hemoglobin A1C was not poorly controlled. She was also diagnosed with
high blood pressure 2 years earlier, that is managed by lisinopril 20 mg once
daily. We noted that her BMI is 31, which is indicative of obesity.
 All other lab values were within normal limit. Significantly, her TSH was in the
normal range and her urine toxicology screening was negative.
 Upon further querying of her family history, her maternal grandmother was
diagnosed with a nervous breakdown and spent 2 months in a psychiatric hospital
in her 30s.
 Her mother required little sleep, had a history of impulsive spending, and had a
history of starting projects that she didn’t finish.
 The patient’s paternal uncles had a history of depression as well as alcohol abuse.
 Upon doing assessments, her PHQ9 is indicative of 18 points and her mood
questionnaire she scored an 8.
 Bipolar I Disorder:
 Diagnostic Criteria

 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 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., purposeless non-goal-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 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 a clear 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: A full hypomanic 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
hypomanic episode diagnosis.
Major Depressive Episode
 A. Five (or more) of the 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.
 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.
 4. Insomnia or hypersomnia nearly every day.
 5. Psychomotor agitation or retardation nearly every day
 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.

 This decision inevitably requires the exercise of clinical judgment based on the
individual’s history and the cultural norms for the expression of distress in the
context of loss.
 Bipolar I Disorder
 A. Criteria have been met for at least one manic episode (Criteria A-D under
“Manic Episode”)

 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.
 The depressed mood of a MDE is more persistent and not tied to specific
thoughts or preoccupations.
 The pain of grief may be accompanied by positive emotions and humor that are
uncharacteristic of the pervasive unhappiness and misery characteristic of a
major depressive episode.
 The thought content associated with grief generally features a preoccupation
with thoughts and memories of the deceased, rather than the self-critical or
pessimistic ruminations seen in a MDE.
 Diagnostic Features
 The essential feature of a manic episode is a distinct period during which
there is an abnormally, persistently elevated, expansive, or irritable mood
and persistently increased activity or energy
 that is present for most of the day, nearly every day, for a period of at least
1 week (or any duration if hospitalization is necessary), accompanied by at
least three additional symptoms from Criterion B.
 If the mood is irritable rather than elevated or expansive, at least four
Criterion B symptoms must be present.
 Rapid shifts in mood over brief periods of time may occur and are referred to as lability (i.e., the
alternation among euphoria, dysphoria, and irritability).

 In children, happiness, silliness and "goofiness" are normal in the context of special occasions;
however, if these symptoms are recurrent, inappropriate to the context, and beyond what is
expected for the developmental level of the child, they may meet Criterion A.
 Inflated self-esteem is typically present, ranging from uncritical self-confidence
to marked grandiosity, and may reach delusional proportions (Criterion Bl).

 Despite lack of any particular experience or talent, the individual may embark
on complex tasks such as writing a novel or seeing publicity for some impractical
invention.

 Grandiose delusions (e.g., of having a special relationship to a famous person)


are common.
 One of the most common features is a decreased need for sleep (Criterion B2) and is distinct from
insomnia in which the individual wants to sleep or feels the need to sleep but is unable.

 The individual may sleep little, if at all, or may awaken several hours earlier than usual, feeling
rested and full of energy.

 Speech can be rapid, pressured, loud, and difficult to interrupt (Criterion B3). Individuals may talk
continuously and without regard for others' wishes to communicate, often in an intrusive manner or
without concern for the relevance of what is said.
 Loudness and forcefulness of speech often become more important than what is
conveyed.
 If the individual's mood is more irritable than expansive, speech may be marked
by complaints, hostile comments, or angry tirades, particularly if attempts are
made to interrupt the individual. Both Criterion
 Associated Features Supporting Diagnosis
 During a manic episode, individuals often do not perceive that they are ill or in
need of treatment and vehemently resist efforts to be treated.

 Individuals may change their dress, makeup, or personal appearance to a more


sexually suggestive or showy style.

 Catastrophic consequences of a manic episode (e.g., involuntary hospitalization,
difficulties with the law, serious financial difficulties) often result from poor
judgment, loss of insight, and hyperactivity.
 Mood may shift very rapidly to anger or depression. Depressive symptoms may
occur during a manic episode and, if present, may last moments, hours, or, more
rarely, days (see "with mixed features" specifier, pp. 149-150).
 Prevalence
 The 12-month prevalence estimate in the continental United States was 0.6% for
bipolar I disorder.
 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.
 Development and Course
 Mean age at onset of the first manic, hypomanic, or major depressive episode is
approximately 18 years for bipolar I disorder. Special considerations are
necessary to detect the diagnosis in children.
 Since children of the same chronological age may be at different developmental
stages, it is difficult to define with accuracy what is ''normal" or "expected“ at
any given point.
 More than 90% of individuals who have a single manic episode go on to have
recurrent mood episodes. Approximately 60% of manic episodes occur
immediately before a major depressive episode.
 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. 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.
 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.
 Functional Consequences of Bipolar I Disorder
 Although many individuals with bipolar disorder return to a fully functional level
between episodes, approximately 30% show severe impairment in work role
function.
 Functional recovery lags substantially behind recovery from symptoms,
especially with respect to occupational recovery, resulting in lower
socioeconomic status despite equivalent levels of education when compared with
the general population.
 Individuals with bipolar I disorder perform more poorly than healthy individuals
on cognitive tests.
 Cognitive impairments may contribute to vocational and interpersonal difficulties
and persist through the lifespan, even^ during euthymic periods.
 Differential Diagnosis
 1. Major depressive disorder.
 2. Other Bipolar disorder
 3. Generalized anxiety disorder, panic disorder, posttraumatic stress disorder, or
other anxiety disorders
 4. Substance/medication-induced bipolar disorder
 5. Attention-deficit/hyperactivity disorder
 6. Personality disorders
 7. Disorders with prominent irritability
 Comorbidity
 Co-occurring mental disorders are common, with the most frequent disorders
being any anxiety disorder (e.g., panic attacks, social anxiety disorder [social
phobia], specific phobia), occurring in approximately three-fourths of
individuals;
 ADHD, any disruptive, impulse- control, or conduct disorder (e.g., intermittent
explosive disorder, oppositional defiant disorder, conduct disorder), and any
substance use disorder (e.g., alcohol use disorder) occur in over half of
individuals with bipolar I disorder.
 Adults with bipolar I disorder have high rates of serious and/or untreated co-occurring medical
conditions.
 Metabolic syndrome and migraine are more common among individuals with bipolar disorder
than in the general population.
 More than half of individuals whose symptoms meet criteria for bipolar disorder have an alcohol
use disorder, and those with both disorders are at greater risk for suicide attempt.
 Bipolar II Disorder
 Diagnostic Criteria 296.89 (F31.81)
 For a diagnosis of bipolar II disorder, it is necessary to meet the criteria for a
current or past hypomanic episode and the criteria for a current or past major
depressive episode:
 Hypomanic episode: Same as in Bipolar-I
 Major Depressive Episodes: Same as in Bipolar-I
 Bipolar II Disorder
 A. Criteria have been met for at least one hypomanic episode (Criteria A-F under
“Hypomanic Episode”) and at least one major depressive episode (Criteria A-C
under “Major Depressive Episode” ).
 B. There has never been a manic episode.
 C. The occurrence of the hypomanic 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.
 Diagnostic Features
 Bipolar II disorder is characterized by a clinical course of recurring mood
episodes consisting of one or more major depressive episodes (Criteria A-C
under "Major Depressive Episode") and at least one hypomanic episode (Criteria
A-F under "Hypomanic Episode").
 The major depressive episode must last at least 2 weeks, and the hypomanic
episode must last at least 4 days, to meet the diagnostic criteria.
 Associated Features Supporting Diagnosis
 A common feature of bipolar II disorder is impulsivity, which can contribute to suicide attempts
and substance use disorders.
 Impulsivity may also stem from a concurrent personality disorder, substance use disorder,
anxiety disorder, another mental disorder, or a medical condition. There may be heightened levels
of creativity in some individuals with a bipolar disorder.
 However, that relationship may be nonlinear; that is, greater lifetime creative accomplishments
have been associated with milder forms of bipolar disorder, and higher creativity has been found
in unaffected family members.
 The individual's attachment to heightened creativity during hypomanic episodes may contribute
to ambivalence about seeking treatment or undermine adherence to treatment.
 Prevalence
 The 12-month prevalence of bipolar II disorder, internationally, is 0.3%. In the
United States, 12-month prevalence is 0.8%. The prevalence rate of pediatric
bipolar II disorder is difficult to establish.
 bipolar I, bipolar II, and bipolar disorder not otherwise specified yield a
combined prevalence rate of 1.8% in U.S. and non-U.S. community samples,
with higher rates (2.7% inclusive) in youths age 12 years or older.
 Development and Course
 Although bipolar II disorder can begin in late adolescence and throughout adulthood, average age
at onset is the mid-20s, which is slightly later than for bipolar I disorder but earlier than for major
depressive disorder.
 The illness most often begins with a depressive episode and is not recognized as bipolar II
disorder until a hypomanic episode occurs; this happens in about 12% of individuals with the
initial diagnosis of major depressive disorder.
 Anxiety, substance use, or eating disorders may also precede the diagnosis, complicating its
detection. Many individuals experience several episodes of major depression prior to the first
recognized hypomanic episode.
 The number of lifetime episodes (both hypomanic and major depressive
episodes) tends to be higher for bipolar II disorder than for major depressive
disorder or bipolar I disorder.
 However, individuals with bipolar I disorder are actually more likely to
experience hypomanic symptoms than are individuals with bipolar II disorder.
The interval between mood episodes in the course of bipolar II disorder tends to
decrease as the individual ages.
 While the hypomanic episode is the feature that defines bipolar II disorder,
depressive episodes are more enduring and disabling over time.
 Despite the predominance of depression, once a hypomanic episode has occurred,
the diagnosis becomes bipolar II disorder and never reverts to major depressive
disorder.
 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).
 However, the lethality of attempts, as defined by a lower ratio of attempts to
completed suicides, may be higher in individuals with bipolar II disorder
compared with individuals with bipolar I disorder.
 Functional Consequences of Bipolar II Disorder
 Individuals with bipolar II disorder perform more poorly than healthy individuals on cognitive
tests and, with the exception of memory and semantic fluency, have similar cognitive impairment
as do individuals with bipolar I disorder.
 Cognitive impairments associated with bipolar II disorder may contribute to vocational
difficulties.
 Prolonged unemployment in individuals with bipolar disorder is associated with more episodes of
depression, older age, increased rates of current panic disorder, and lifetime history of alcohol use
disorder.
 Approximately 60% of individuals with bipolar II disorder have three or more
co-occurring mental disorders; 75% have an anxiety disorder; and 37% have a
substance use disorder.
 Children and adolescents with bipolar II disorder have a higher rate of co-
occurring anxiety disorders compared with those with bipolar I disorder, and the
anxiety disorder most often predates the bipolar disorder.
 Anxiety and substance use disorders occur in individuals with bipolar II disorder
at a higher rate than in the general population. Approximately 14% of individuals
with bipolar II disorder have at least one lifetime eating disorder, with binge-
eating disorder being more common than bulimia nervosa and anorexia nervosa.

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