Mood Disorders- Bipolar

Sub/Med-Induced bipolar and related disorder development and course

differs with each substance (e.g., phencyclidine-induced mania, the initial presentation may be one of a delirium with affective features, which then becomes an atypically appearing manic or mixed manic state OR In stimulant-induced manic or hypomanie states, the response is in minutes to 1 hour after one or several ingestions or injections. The episode is very brief and typically resolves over 1-2 days)

Other specified bipolar and related disorder

don't meet the criteria for bipolar I, II, or cycothymic disorder

Substance/Medication-Induced Bipolar and Related Disorder associated features supporting diagnosis

etiology is key: where symptoms present before substance use, intoxication, withdrawal? do symptoms persist?

bipolar 1 gender differences

females more likely to experience rapid cycling and mixed states, depressive episodes, alcohol use and disorder

bipolar 2 comorbidity

common; most common are anxiety disorders: -aprx 60% of individuals have three or more co-occurring mental disorders; 75% have an anxiety disorder; and 37% have a substance use disorder; 14% have at least one lifetime eating disorder. -more associated with mood state than course of illness --anxiety and eating disorders tend to associate most with depressive symptoms --substance use disorders are moderately associated with manic symptoms.

bipolar 1 comorbidity

common; the most frequent disorders being: -any anxiety disorder occurring in approximately three-fourths of individuals -ADHD, any disruptive, impulse- control, or conduct disorder any substance use disorder occur in over half of individuals -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 2 disorder criteria

**necessary to meet criteria for a current or past hypomanic episode and a current or past major depressive episode: A. Criteria have been met for at least one hypomanic episode and at least one 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. **specify if current or past episode was hypomanic or depressed; if with anxious distress, mixed features, With rapid cycling,With mood-(in)congruent psychotic features With mood-incongruent psychotic features, With péripartum onset, With seasonal pattern (pp. 153-154): Applies only to the pattern of major depressive episodes. Specify course if full criteria for a mood episode are not currently met: in partial or full remission Specify severity if full criteria for a mood episode are currently met: Mild, Moderate, or severe

Bipolar 1 Disorder Criteria

**necessary to meet the criteria for a manic episode 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. **Specifers: anxious distress, With mixed features, With rapid cycling, With melanchoiic features, With atypical features With mood-congruent psychotic features With mood-incongruent psychotic features With catatonia With péripartum onset With seasonal pattern **most common feature is decreased need for sleep

bipolar 1 risk and prognostic factors

-Environmental: more common in high-income countries (1.4 vs. 0.7%). Separated, divorced, or widowed individuals have higher rates but relation is unclear. -Genetic and physiological. A family history is one of the strongest and most consistent risk factors; average 10-fold increased risk among adult relatives of individuals with bipolar I and bipolar II 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. -Course modifiers. After an individual has a manic episode with psychotic features, subsequent manic episodes are more likely to include psychotic features. Incomplete interepisode recovery is more common when the current episode is accompanied by mood-incongruent psychotic features.

bipolar 2 risk and prognostic factors

-Genetic and physiological. The risk tends to be highest among relatives of individuals with bipolar II disorder, as opposed to individuals with bipolar I disorder or mdd. There may be genetic factors influencing the age at onset for bipolar disorders. -Course modifiers. A rapid-cycling pattern is associated with a poorer prognosis. --Return to previous level of social function is more likely for individuals of younger age and with less severe depression. --More education, fewer years of illness, and being married are independently associated with functional recovery

cyclothymic risk and prognostic features

-Genetic and physiological. first degree relatives diagnosed with major depressive disorder, bipolar I disorder, and bipolar II disorder --increased familial risk of substance-related disorders. --Cyclotiiymic disorder may be more common in the first-degree biological relatives of individuals with bipolar I disorder than in the general population

Other specified Bipolar and Related Disorder diagnostic criteria

-applies to presentations in which symptoms characteristic of a bipolar and related disorder that cause clinically significant distress or impairment important areas of functioning predominate but do not meet the full criteria for any of the disorders in the bipolar and related disorders diagnostic class -is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific bipolar and related disorder. --This is done by recording "other specified bipolar and related disorder" followed by the specific reason

bipolar 2 development and course

-can begin in late adolescence and throughout adulthood, average age at onset is the mid-20s -most often begins with depressive episode and isn't diagnosed as b2d until hypomanic episode -# of lifetime mood episodes tends to be higher than b1d and mdd -The interval between mood episodes tends to decrease as the individual ages. -While the hypomanic episode is the defined feature,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. -aprx 5-15% have rapid cycling specifer (4+ mood episodes in past 12 months) -aprx 5-15% will experience a manic episode and be re-diagnosed with b1d

bipolar 2 gender-related factors

-equal gender ratio and little/no gender differences --some argue is more common in females -patterns of illness and comorbidity differ: --females more likely to report hypomania with mixed depressive features and a rapid-cycling course. --- Childbirth may be a specific trigger for a hypomanic episode, which can occur in 10%-20% of females in nonclinical populations and most typically in the early postpartum period.

bipolar 2 suicide risk

-high: approximately one-third of individuals 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%) --the lethality of attempts (as defined by a lower ratio of attempts to completed suicides) may be higher in individuals with bipolar II disorder --6.5-fold higher risk of suicide among first-degree relatives of bipolar II probands compared with those with bipolar I disorder

bipolar 2 associated features supporting diagnosis

-impulsivity; which can contribute to suicide attempts and substance use disorders. may also stem from another disorder. -There may be heightened levels of creativity in some individuals --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

cyclothymic disorder prevalence

-lifetime prevalence is approximately 0.4%-l%. -Prevalence in mood disorders clinics may range from 3-5%. -equally common in males and females. -- In clinical settings, females may be more likely to present for treatment than males.

bipolar 2 functional consequences

-many individuals return to a fully functional level between mood episodes --at least 15% continue to have some inter-episode dysfunction, and 20% transition directly into another mood episode without inter-episode recovery -Functional recovery lags substantially behind recovery from symptoms --especially in regard to occupational recovery, resulting in lower socioeconomic status despite equivalent levels of education with the general population. -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.

bipolar 1 functional consequences

-many individuals 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

bipolar 1 development and course

-mean age onset ~18 years -Onset occurs throughout the life cycle, including first onsets in the 60s or 70s. [onset of manic symptoms in late mid-life or late life should prompt consideration of medical condition and of substance ingestion or withdrawal] -90% of individuals who have a single manic episode go on to have recurrent mood episodes. -60% of manic episodes occur immediately before a major depressive episode. -multiple (four or more) mood episodes (major depressive, manic, or hypomanie) within 1 year receive the specifier "with rapid cycling."

cyclothymic development and course

-usually begins in adolescence or early adult life and is sometimes considered to reflect a temperamental predisposition to other disorders -insidious onset and persistent course -15%-50% risk that an individual with cyclothymic disorder will subsequently develop bipolar I or bipolar II disorder

bipolar due to another med condition development and course

-usually has its onset acutely or subacutely within the first weeks or month of the onset of the associated medical condition. -the condition may remit before or just after the medical condition remits, particularly when treatment of the manic/hypomanic symptoms is effective

Substance/Medication-Induced Bipolar and Related Disorder diagnostic criteria

A. A prominent and persistent disturbance in mood that predominates in the clinical picture and is characterized by elevated, expansive, or irritable mood, with or without depressed mood, or markedly diminished interest or pleasure in all, or almost all, activities. B. There is evidence from the history, physical examination, or laboratory findings of both (1)and (2): 1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication. 2. The involved substance/medication is capable of producing the symptoms in Criterion A. C. The disturbance is not better explained by a bipolar or related disorder that is not substance/ medication-induced. D. The disturbance does not occur exclusively during the course of a delirium. E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Bipolar and Related Disorder Due to Another Medical Condition diagnostic criteria

A. A prominent and persistent period of abnormally elevated, expansive, or irritable mood and abnormally increased activity or energy that predominates in the clinical picture. B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition. C. The disturbance is not better explained by another mental disorder. D. The disturbance does not occur exclusively during the course of a delirium. E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning, or necessitates hospitalization to prevent harm to self or others, or there are psychotic features. **specify if: With manic features: Full criteria are not met for a manic or hypomanic episode, With manic- or hypomanic- episode: Full criteria are met except Criterion D for a manic episode or except Criterion F for a hypomanic episode, With mixed features: Symptoms of depression are also present but do not predominate in the clinical picture.

Major Depressive Episode criteria

A. FIVE+ 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. Note: Do not include symptoms that are clearly attributable to another medical condition. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation 2. Markedly diminished interest or pleasure in all, or almost all, activities (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 (observable by others; not merely subjective feelings of restlessness or being slowed down). 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. 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 anothermedical condition. **Major depressive episodes arecommon in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.**

Cyclothymic Disorder diagnostic criteria

A. For at least 2 years (at least 1 year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a MDE B. During the above 2-year period (1 year in children and adolescents), the hypomanic and depressive periods have been present for at least HALF the time and the individual has not been without the symptoms for more than 2 months C. Criteria for a major depressive, manic, or hypomanic episode have never been met. D. The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. E. The symptoms are not attributable to the physiological effects of a substance or another medical condition (e.g., hyperthyroidism). F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. **specify if with anxious distress

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 following 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 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).

Manic Episode criteria

A: distinct period of abnormally and persistently elevated, expansive, or irritable mood and increased goal directed activity or energy lasting at least 1 WEEK, most of the day and nearly every day. B: during mood disturbance period and increased energy/activity, THREE+ symptoms (4 if mood is only irritable) are present and a change from usual behavior: 1. inflated self-esteem/grandiosity 2. decreased need for sleep 3. more talkative than usual 4. flight of ideas or racing thoughts 5. distractibility is reported or observed 6. increased in goal-directed activity or psychomotor agitation 7. excessive involvement in activities with high potential for painful consequences C: mood disturbance is sufficiently severe to cause marked impairment in social/occupational functioning or hospitalization to prevent harm, or presence of psychotic features. D: episode not due to physiological effects of substance or other medical condition **at least 1 lifetime manic episode is required for B1D**

bipolar due to another med condition common conditions

Among the best known of the medical conditions that can cause a bipolar manic or hypomanic condition are Cushing's disease and multiple sclerosis, as well as stroke and traumatic brain injuries.

bipolar due to another med condition diagnostic features

Bipolar and related disorder due to another medical condition would not be diagnosed when the manic or hypomanic episodes definitely preceded the medical condition and should not be diagnosed during the course of a delirium

bipolar 2 disorder is not a "milder form" of bipolar 1

Compared with individuals with bipolar I disorder, individuals with bipolar II disorder have greater chronicity of illness and spend, on average, more time in the depressive phase of their illness, which can be severe and/ or disabling

Sub/Med-Induced Bipolar and Related Disorder prevalence

Each etiological substance may have its own individual risk of inducing a bipolar (manic/hypomanie) disorder.

mixed features in bipolar 2 disorder

Individuals experiencing hypomania with mixed features may not label their symptoms as hypomania, but instead experience them as depression with increased energy or irritability.

bipolar 2 prevalence

International 12-month prevalence of bipolar II disorder is 0.3% & U.S. prevalence is 0.8%.

bipolar 2 differential diagnoses

MDD (irritability), cyclothymia disorder (b2d has one or more MDE. If a MDE occurs after the first 2 years of cyclothymic disorder, the additional diagnosis of bipolar II disorder is given), schizphrenia spectrum, psychotic disorder, panic and anxiety disorder, SUD, ADHD, PDs

other specified bipolar and related disorder example presentations

Short-duration hypomanic episodes (2-3 days) and major depressive episodes, Hypomanic episodes with insufficient symptoms and major depressive episodes, Hypomanic episode without prior major depressive episode, Short-duration cyclothymia (less than 24 months)

Bipolar 1 associated features

Some perceive a sharper sense of smell, hearing, or vision. Gambling and antisocial behaviors may accompany the manic episode. May become physically assaultive or suicidal; rapid mood shifts to anger and hostility

cyclothymic comorbidity

Substance-related disorders and sleep disorders (i.e., difficulties in initiating and maintaining sleep)

bipolar 1 prevalence

The 12-month prevalence estimate in the continental United States was 0.6% for bipolar I disorder as defined in DSM-IV. Twelve-month prevalence across 11 countries ranged from 0.0% to 0.6%. The lifetime male-to-female prevalence ratio is approximately 1.1 to 1.

Bipolar 1 diagnostic features

The expansive mood, excessive optimism, grandiosity, and poor judgment often lead to reckless involvement in activities such as spending sprees, giving away possessions, reckless driving, foolish business investments, and sexual promiscuity that is unusual for the individual, even though these activities are likely to have catastrophic consequences. It is necessary to meet criteria for a manic episode to make a diagnosis of bipolar I disorder, but it is not required to have hypomanie or major depressive episodes. However, they may precede or follow a manic episode.

Cyclothymic disorder

adults who experience at least 2 years (for children, a full year) of both hypomanic and depressive periods without ever fulfilling the criteria for an episode of mania, hypomania, or major depression.

bipolar 1 suicide risk

at least 15 times that of the general population - bipolar disorder may account for one-quarter of all completed suicides. *indicators* 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

Bipolar 1 Disorder recording order

bipolar I disorder, type of current or most recent episode, severity/psychotic/remission specifiers, followed by as many specifiers without codes as apply to the current or most recent episode.

cyclothymic differential diagnosis

borderline personality disorder, other bipolar disorders

bipolar 1 differential diagnoses

major depressive disorder, other bipolar disorders (is differentiated from bipolar II disorder by any past manic episodes),Generalized anxiety disorder, panic disorder, posttraumatic stress disorder, or other anxiety disorders, ADHD, PDs, Disorders with prominent irritability.

Functional Consequences of Bipolar and Related Disorder Due to Another Medical Condition

may exacerbate impairments or worsen outcome of medical condition

Unspecified Bipolar and Related Disorder

presentations in which symptoms characteristic of a bipolar and related disorder that cause clinically significant distress or impairment important areas of functioning predominate but do not meet the full criteria for any of the disorders in the bipolar and related disorders diagnostic class; is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific bipolar and related disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings).

Lability

rapid shifts in mood over brief periods of time (are common in bipolar 1 disorder)

Bipolar I Disorder def

represent the modern understanding of the classic manic-depressive disorder or affective psychosis except neither psychosis nor the lifetime experience of a major depressive episode is a requirement. Most individuals whose symptoms meet the criteria for a fully syndromal manic episode also experience major depressive episodes during the course of their lives.

Bipolar II Disorder def

requires the lifetime experience of at least one episode of major depression and at least one hypomanie 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.

Bereavement

the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered.