Bipolar disorder criteria

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

An initial assessment includes a comprehensive history and physical examination by a physician. Although there are no biological tests which confirm bipolar disorder, tests are carried out to exclude medical illnesses which may rarely present with psychiatric symptoms. These include blood tests measuring TSH to exclude hypo- orhyperthyroidism, basic electrolytes and serum calcium to rule out a metabolic disturbance, full blood count including ESR to rule out a systemic infection or chronic disease, and serology to exclude syphilis or HIV infection; two commonly ordered investigations are EEG to exclude epilepsy, and a CT scan of the head to exclude brain lesions. There are several psychiatric illnesses which may present with similar symptoms; these include schizophrenia, drug intoxication, brief drug-induced psychosis, schizophreniform disorder and borderline personality disorder.

The last is important as both diagnoses involve symptoms commonly known as "mood swings". In bipolar disorder, the term refers to the cyclic episodes of elevated and depressed mood which generally last weeks or months (notwithstanding Rapid Cycling variant of greater than four episodes a year). The term in borderline personality refers to the marked lability and reactivity of mood, known as emotional dysregulation, due to response to external psychosocial and intrapsychic stressors; these may arise or subside suddenly and dramatically and last for seconds, minutes, hours or days. A bipolar depression is generally more pervasive with sleep, appetite disturbance and nonreactive mood, whereas the mood in dysthymia of borderline personality remains markedly reactive and sleep disturbance not acute.

The relationship between bipolar disorder and borderline personality disorder has been debated; some hold that the latter represents a subthreshold form of affective disorder, while others maintain the distinctness, though noting they often coexist.

Investigations are not generally repeated for relapse unless there is a specific medical indication. These may include serum BSL if olanzapine has previously been prescribed, lithium or valproate level to check compliance or toxicity with those medications, renal or thyroid function if lithium has been previously prescribed and taken regularly. Assessment and treatment are usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to self or others.

The most widely used criteria for diagnosing bipolar disorder are from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, the current version being DSM-IV-TR, and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems, currently the ICD-10. The latter criteria are typically used in European countries while the DSM criteria are used in the USA or the rest of the world, as well as prevailing in research studies.

DSM-IV-TR diagnostic categories and criteria for Bipolar Disorder

The DSM-TR details four categories of bipolar disorder: Bipolar I, Bipolar II, Cyclothymia and Bipolar Disorder NOS (Not Otherwise Specified).

1. Bipolar disorder type I
2. Bipolar disorder type II
3. Cyclothymia
4. Bipolar disorder NOS (Not Otherwise Specified)

The Diagnosis Summary(s) and Definition(s)

According to the DSM-IV-TR, a diagnosis of Bipolar I disorder requires one or more manic or mixed episodes. The criteria for Bipolar I (Bipolar Type 1, BP 1, or BPD 1) are defined in the DSM-IV-TR. The current or previous course of the illness may include hypomanic and depressive episodes also, but the diagnosis of BP I requires only one manic or mixed episode. A depressive episode is not required for a diagnosis of BP I disorder, although the overwhelming majority of people with BP I suffer from them as well.

Bipolar II, the more common but by no means less severe type of the disorder, is characterized by episodes of hypomania and disabling depression. A diagnosis of bipolar II disorder requires at least one hypomanic episode. This is used mainly to differentiate it from unipolar depression. Although a patient may be depressed, it is very important to find out from the patient or patient's family or friends if hypomania has ever been present using careful questioning. This, again, avoids the antidepressant problem.

A diagnosis of cyclothymic disorder requires the presence of numerous hypomanic episodes, intermingled with depressive episodes that do not meet full criteria for major depressive episodes. The main idea here is that there is a low grade cycling of mood which appears to the observer as a personality trait, but does not interfere with functioning.

If an individual clearly seems to be suffering from some type of bipolar disorder but does not meet the criteria for one of the conditions laid out above, he or she receives a diagnosis of Bipolar Disorder NOS (Not Otherwise Specified).

The criteria for a "major depressive episode" directly below refers also to a bipolar depression. These criteria may apply to unipolar or bipolar depression.

Criteria for a major depressive episode DSM-IV-TR

1. Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) or (2).
   1. depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) 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 made by others)
   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. Note: In children, consider failure to make expected weight gains.
   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 for committing suicide
2. The symptoms do not meet criteria for a Mixed Episode.
3. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
4. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
5. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Criteria for a hypomanic episode DSM-IV-TR

1. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual non depressed mood.
2. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) 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)
   6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
   7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
3. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
4. The disturbance in mood and the change in functioning are observable by others.
5. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
6. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Criteria for a mixed episode DSM-IV-TR

1. The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.
2. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
3. The symptoms are not due to the direct physiological effects of a substance (e.g., an illicit drug, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Criteria for a manic episode DSM-IV-TR

1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalization is necessary).
2. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
   1. inflated self-esteem or grandiosity, potentially including grandiose delusions
   2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep) or persistent difficulty falling asleep
   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)
   6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
   7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
3. The symptoms do not meet criteria for a Mixed Episode.
4. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
5. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

This last point has been under scrutiny for some time. One of the leaders in mood disorders research, Hagop Akiskal, M.D., believes that medications (particularly antidepressants) that induce hypomania, mania or mixed states "unmask" bipolar disorder.

Bipolar Disorder DSM-IV Diagnosis Codes

1. DSM-IV-TR Diagnosis Code List - Bipolar Disorder Section.

Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, also known as DSM-IV-TR is a manual published by the American Psychiatric Association and includes all currently recognized mental health disorders.

Delay in diagnosis

The behavioral manifestations of bipolar disorder are often not understood by patients nor recognized by mental health professionals, so people may suffer unnecessarily for over 10 years in some cases before receiving proper treatment.

That treatment lag is apparently not decreasing, even though there is now increased public awareness of this mental health condition in popular magazines and health websites. Recent TV specials, for example the BBC's The Secret Life of the Manic Depressive, MTV's True Life: I'm Bipolar, talk shows, and public radio shows, and the greater willingness of public figures to discuss their own bipolar disorder, have focused on psychiatric conditions thereby further raising public awareness.

Despite this increased focus, individuals are still commonly misdiagnosed.

Children

Main article: Bipolar disorder in children

Children with bipolar disorder do not often meet the strict DSM-IV definition. In pediatric cases, the cycling can occur very quickly (see section above on rapid cycling). Children with bipolar disorder tend to have rapid-cycling or mixed-cycling. Rapid cycling occurs when the cycles between depression and mania occur quickly, sometimes within the same day or the same hour. When the symptoms of both mania and depression occur simultaneously, mixed cycling occurs.

Often other psychiatric conditions are diagnosed in bipolar children. These other diagnoses may be concurrent problems, or they may be misdiagnosed as bipolar disorder. Depression, ADHD, ODD, schizophrenia, and Tourette syndrome are common comorbid conditions. Furthermore some children with histories of abuse or neglect may have Bipolar I Disorder. There is a high comorbidity between Reactive attachment disorder and Bipolar I Disorder with about 50% of children in the Child Welfare System who have Reactive Attachment Disorder also have Bipolar I Disorder

Misdiagnosis can lead to incorrect medication.

On September, 2007, experts (from New York, Maryland and Madrid) found that the number of Americanchildren and adolescents treated for bipolar disorder increased 40-fold from 1994 to 2003, and it was increasing ever since. However, the increase was due to the fact that doctors more aggressively applied the diagnosis to children, and not that the incidence of the disorder had increased. The study calculated the number of visits which increased, from 20,000 in 1994 to 800,000 in 2003, or 1% of the population under age 20.