bipolar%20disorder
BIPOLAR DISORDER
Bipolar I disorder is primarily defined by manic or mixed episodes that last for at least 7 days, or very severe manic symptoms needing immediate hospital care. The patient also has depressive episodes which may last for at least 2 weeks.
Bipolar II disorder is usually misdiagnosed. It is characterized by occurence of ≥1 major depressive episodes with at least 1 hypomanic episode.
Cyclothymic disorder or cyclothymia is a mild form of bipolar disorder. Patients have  episodes of hypomania alternating with mild depression that lasts for 2 years.
Rapid-cycling bipolar disorder patients have ≥4 episodes of major depression, mania, hypomania or mixed symptoms within a year.

Diagnosis

  • Clinical diagnosis is the gold standard in determining patients with bipolar disorder
  • Type of most recent mood may be specified in the diagnosis (ie hypomanic, manic, depressed, mixed)
  • Severity of the episode should be specified (ie mild, moderate, severe with or without psychotic features, in partial or full remission, with catatonia)
  • An episode is a distinctive period of mood disturbance fulfilling list of criteria for each type of bipolar disorder
    • An interval of at least 2 months free of symptoms is required to distinguish between episodes
Diagnostic Criteria for Bipolar I Disorder
  • Based on DSM-5 diagnostic criteria, bipolar I disorder is diagnosed when the following have been met:
    • There is at least one manic episode
    • The manic and major depressive episode occurrence is not due to schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder or other specified or unspecified schizophrenia spectrum and other psychotic disorder
  • Bipolar I disorder can be further described with:
    • Anxious distress
    • Mixed features
    • Rapid cycling
    • Melancholic features
    • Atypical features
    • Mood-congruent psychotic features
    • Mood-incongruent psychotic features
    • Catatonia
    • Peripartum onset
    • Seasonal pattern

Manic Episode

  • As defined by DSM-5, it is having for at least a week of profound mood disturbance characterized by elation,irritability or expansiveness with at least 3 of the following symptoms that causes significant impairment in occupational or social functioning or may lead to hospitalization:
    • Feeling of grandiosity
    • Feeling rested despite less sleep
    • Feeling compelled to talk continuously
    • Racing thoughts or flight of ideas
    • Easily distracted
    • Increased psychomotor agitation, or engaged more in goal-directed activity at home, work or sexually
    • Indulge or participate excessively in pleasurable activities that often leads to painful consequences
  • Above symptoms should not be caused by any physiological effects of any substance or medical condition

Hypomanic Episode

  • Defined by DSM-5, it is having for at least 4 consecutive days of elevated, expansive or irritable mood with 3 or more of the following symptoms:
    • Feeling of grandiosity
    • Feeling rested despite less sleep
    • Feeling compelled to talk continuously
    • Racing thoughts or flight of ideas
    • Easily distracted
    • Increased psychomotor agitation, or engaged more in goal-directed activity at home, work or sexually
    • Indulge or participate excessively in pleasurable activities that often leads to painful consequences
  • The episode causes an obvious change in the patient’s functionalities that is uncharacteristic of the patient when asymptomatic
  • The mood disturbance and the change in functioning are observable by others
  • The mood disturbance is not severe enough to cause social/occupational impairment or hospitalization
  • Above symptoms should not be caused by any physiological effects of any substance or medical condition

Major Depressive Episode

  • Based on DSM-5 diagnostic criteria, major depressive disorder is diagnosed when 5 or more of the following symptoms that causes change or distress in previous functioning have been present during the same 2 week (and at least one of the symptoms is either depressed mood or lack of interest or pleasure):
    •  Depressed mood in adults or irritable mood in children that either self-reported or observable most of the day, nearly daily
    • Lack or diminished interest or pleasure in almost all activities most of the time, nearly daily
    • Significant weight loss, weight gain or appetite disturbance in adults. While in children, this can be failure to attain expected weight gain
    • Sleep disturbance that can be insomnia or hypersomnia nearly daily
    • Psychomotor agitation or retardation
    • Feeling of fatigue or lack of energy nearly daily
    • Feelings of being insignificant
    • Inability to concentrate and there is indecisiveness
    • Frequent thoughts of death, could be of suicidal attempts, with or without specific plan
  • The symptoms should not be caused by any substance as well as any general medical condition
  • The disorder occurrence is not due to schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorders
  • Manic and hypomanic episodes have not occurred
  • Distinguishing between normal sadness and grief from major depressive disorder is important
    • Bereavement induces great suffering but does not typically induces major depressive disorder
    • When bereavement and major depressive disorder concurrently exist, the latter has more severe symptoms and functional impairment and worse prognosis compared to bereavement alone
    • Diagnosis of major depressive disorder in a patient who had significant loss would need clinical judgment based on the patient’s history and cultural context for expression of grief

Diagnostic Criteria for Bipolar II Disorder

  • Based on DSM-5 diagnostic criteria, bipolar II disorder is diagnosed when the following have been met:
    • There is at least one hypomanic episode and at least one major depressive episode that have met the criteria of the said episodes
    • No manic episode have occurred
    • The hypomanic and major depressive episode occurrence is not associated with schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder or other specified or unspecified schizophrenia spectrum and other psychotic disorder
    • Depression symptoms or symptoms caused by frequent alternation between periods of depression and hypomania causes significant social or occupational impairment or other areas of functioning
  • Bipolar II disorder can be further described with:
    • Anxious features
    • Mixed features
    • Rapid cycling
    • Mood-congruent psychotic features
    • Mood-incongruent psychotic features
    • Catatonia
    • Peripartum onset
    • Seasonal pattern

Hypomanic Episode

  • Defined by DSM-5, it is having for at least 4 consecutive days of elevated, expansive or irritable mood with 3 or more of the following symptoms:
    • Feeling of grandiosity
    • Feeling rested despite less sleep
    • Feeling compelled to talk continuously
    • Racing thoughts or flight of ideas
    • Easily distracted  
    • Increased psychomotor agitation, or engaged more in goal-directed activity at home, work or sexually
    • Indulge or participate excessively in pleasurable activities that often leads to painful consequences 
  • The episode causes an unequivocal change in functioning of the patient that is uncharacteristic of the patient when not symptomatic
  • The mood disturbance and the change in functioning are observable by others
  • The mood disturbance is not severe enough to cause social/occupational impairment or hospitalization
  • Above symptoms should not be caused by any physiological effects of any substance or medical condition

Major Depressive Episode

  • Based on DSM-5 diagnostic criteria, major depressive disorder is diagnosed when 5 or more of thefollowing symptoms that causes change or distress in previous functioning have been present during thesame 2 week (and at least one of the symptoms is either depressed mood or lack of interest or pleasure):
    • Depressed mood in adults or irritable mood in children that either self-reported or observable most of the day, nearly daily
    • Lack or diminished interest or pleasure in almost all activities most of the time, nearly daily
    • Significant weight loss, weight gain or appetite disturbance in adults. While in children, this can be failure to attain expected weight gain
    • Sleep disturbance that can be insomnia or hypersomnia nearly daily
    • Psychomotor agitation or retardation
    • Feeling of fatigue or lack of energy nearly daily
    • Feelings of being insignificant
    • Inability to concentrate and there is indecisiveness
    • Frequent thoughts of death, could be of suicidal attempts, with or without specific plan

Diagnostic Criteria for Cyclothymic Disorder

  • Based on DSM-5 criteria, cyclothymic disorder be diagnosed if the following criteria have been met:
    • Numerous periods of hypomanic and depressive symptoms (that do not meet the criteria of hypomanic episode and major depressive episode) have occurred for at least 2 years in adults or 1 year in children and adolescents
    • Hypomanic and depressive periods in the span of 2 years have occurred for at least half the time and the patient has not been without the symptoms for >2 months at a time
    • Manic, major depressive and hypomanic episode criteria have not been met
    • Hypomanic and depressive periods accompanying symptoms have not been better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder or other specified or unspecified schizophrenia spectrum and other psychotic disorder
    • Hypomanic and depressive periods accompanying symptoms should not be caused by any physiological effects of any substance or medical condition 
    • Hypomanic and depressive periods accompanying symptoms causes significant impairment in social and occupational functioning
  • Cyclothymic disorder can be further described with anxious distress

Diagnostic Criteria for Other Specified Bipolar and Related Disorder

  • This is the category that would represent having symptoms that characterize a bipolar and related disorder but does not meet all the criteria to be categorized as any of the bipolar and related disorder. The symptoms can cause significant social and occupational impairment

Diagnostic Criteria for Unspecified Bipolar Related Disorder

  • This is the category that would represent having symptoms that characterize a bipolar and related disorder but does not meet all the criteria to be categorized as any of the bipolar and related disorder. The symptoms can cause significant social and occupational impairment. This category is used when the clinician chooses not to disclose the reason why the criteria for bipolar and related disorder were not met but includes presentations that have insufficient information to make a more specific diagnosis

 

Evaluation

Psychiatric Evaluation

  • Patient should undergo both complete medical (assess cardiovascular risk factors eg obesity, smoking) and psychiatric (aggressiveness, poor judgement, psychotic features, risk of suicide and homicide) history and evaluation
  • Patient evaluation should include physical exam especially of the neurologic and endocrine systems,  and observe for signs of alcohol or substance abuse
  • To assess comorbid conditions, the following tests should be done: Complete blood count (CBC), general chemistry screening, urinalysis, urine screening for substance abuse, pregnancy test (if relevant) and electrocardiogram (ECG) for patients >40 years old
  • If patient is on Lithium, Valproate or Carbamazepine, serum levels should be taken

Treatment Setting

  • Outpatient vs inpatient treatment will depend on assessment of patient’s safety, safety of others and the patient’s level of functioning
    • It also depends on the severity of clinical symptoms
      • Tools that can be used to assess severity of clinical symptoms are: Young Mania Rating Scale (YMRS), Hamilton Rating Scale for Depression (HAM-D), Montgomery Asberg Depression Rating Scale (MADRS)
    • Always consider hospital admission when mania is diagnosed
    • When patient is in mixed or depressed state, the patient should be asked about suicidal ideation, extent of plans and preparation for suicide
    • Should assess for suicide risk factors (ie history of suicide attempt, family history of suicidal behavior, severity/number of depressive episodes, alcohol/substance abuse, level of pessimism, level of aggression/impulsivity, young age at onset)
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