Bipolar and Related Disorders 24
Bipolar and Related Disorders 24
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.
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.
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.
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.