Bipolar Disorder in DSM-IV


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  • This table summarizes the key mood criteria that differentiate BPD I, BPD II, and cyclothymia. BPD I is characterized by a clinical course in which at least 1 manic or mixed episode occurs. Patients with BPD I may also experience hypomania, which is characterized by excitement symptoms that are not sufficient to meet criteria for mania. However, patients who are hypomanic and have never had a manic episode should be diagnosed with BPD II if they have experienced at least one major depressive episode (MDE). Some patients with BPD I will never have experienced an MDE; however, these patients are the exception. Mixed states, defined as intervals lasting at least 1 week during which patients experience rapidly alternating periods of mania and depression, may also be experienced by patients with BPD I. Diagnosis of BPD II is assigned to patients who have had at least 1 hypomanic episode but never a full manic episode. To meet criteria for BPD II, a patient must also have had at least 1 MDE. Cyclothymia refers to a more chronic unstable mood state. This diagnosis requires at least 2 years (1 for adolescents and children) during which the patient has numerous periods of hypomanic symptoms alternating with numerous periods of depressive symptoms that do not meet full criteria for MDE. 7
  • Recognition of the 4 key types of episodes of bipolar disorder is the first step in ensuring an accurate diagnosis. Each mood episode has its own distinct criteria, and the episodes exist in various combinations in each of the bipolar disorders. The first of the additional criteria, inflated self-esteem or grandiosity, frequently reaches delusional proportions. Decreased need for sleep, when the patient sleeps or rests for just a few hours and then feels fully refreshed, is an almost invariable symptom of mania. It is not unusual for patients experiencing severe manic episodes to go for days without sleeping. Pressured speech of mania tends to be loud, rapid, dramatic, and difficult to interrupt. It is frequently characterized by clanging; sound rather than sense determines word choice. Racing, disjointed thoughts are a very common symptom; in severe mania, the patient may be completely incoherent. No stimulus is too inconsequential to escape notice by the patient with severe mania. He or she may be completely unable to distinguish between what is meaningful and what is irrelevant. Patients experiencing mania often involve themselves in innumerable simultaneous goal-directed activities. However, these activities are often entirely unrealistic in the context of the patient’s life. A hallmark of mania is excessive involvement in pleasurable activities that have a high potential for dangerous or negative consequences. Examples of such activities include participation in promiscuous sexual activity and extremely high-risk sports. 9
  • The key differential diagnoses for manic episode, according to DSM-IV, are mood disorder due to a general medical condition, substance-induced mood disorder, hypomanic episode, mixed episode, and attention-deficit/hyperactivity disorder. Mood disorder due to a general medical condition should be diagnosed if the patient has a mood disturbance that is judged, based on history (H/O), laboratory findings, or physical examination, to be the direct physiologic result of a general medical condition. Examples of medical conditions that may cause manic symptoms include multiple sclerosis, Cushing’s syndrome, and brain tumor. Onset of a first manic episode after age 50 years is an indication to consider a diagnosis of either mood disorder due to a general medical condition or substance-induced mood disorder. A substance-induced mood disorder is distinguished from a manic episode based on the finding that a substance—whether a medication, a recreational drug, or a toxin, is etiologically related to the mood disturbance. Note that manic symptoms precipitated by antidepressant therapy—medication, light therapy, or electroconvulsive therapy—should be diagnosed as substance-induced mood disorder, not mania. Hypomanic episode should be diagnosed if excitement symptoms are present but are not sufficient to meet the criteria for manic episode. Mixed episode should be diagnosed if the criteria for both manic episode and major depressive episode (MDE) are met nearly every day for at least 1 week. 10
  • Attention-deficit/hyperactivity disorder (ADHD) and mania have several symptoms in common, including excessive psychomotor activity, impulsivity, impaired judgment, and denial of pathology. ADHD is discerned from manic episode by a chronic rather than episodic course, a lack of clear onsets and offsets of mood disturbance, the absence of abnormally elevated mood or psychotic features, and a history of (H/O) early-childhood onset (prior to the age of 7 years). Although it is important to be able to differentiate the two, it is important to note that ADHD can coexist with bipolar disorder. Eating disorders, panic attacks, borderline personality disorder, ADHD, and compulsive behavior may be signs of bipolar disorder among other psychologic syndromes. 11
  • A mixed episode consists of at least 1 week during which criteria for both a manic episode and a major depressive episode (MDE) are met nearly every day. Mood tends to alternate rapidly between euphoria, sadness, and irritability. Symptoms must be sufficient to impair social or occupational functioning or to require hospitalization. Alternatively, hospitalization must be required. Common symptoms include agitation, appetite disturbance, insomnia, psychosis, and suicidal ideation. Relative to manic episodes, mixed episodes are more commonly characterized by dysphoria and disorganization; therefore, patients experiencing mixed episodes may be more likely to seek help than those experiencing purely manic episodes. Mixed episodes may be more common in younger and older persons with bipolar disorder and may be more likely to occur in male than in female individuals. 16
  • Although estimates vary, data from community samples estimate the lifetime prevalence of bipolar I disorder (BPD I) at up to 1.6%. The lifetime prevalence of bipolar II disorder (BPD II) alone is approximately 0.5%. There is no apparent differential incidence of bipolar disorder based on race or ethnicity. However, there is some evidence of a greater tendency to overdiagnose schizophrenia instead of bipolar disorder in some ethnic groups. BPD I is believed to be equally common in men and women. BPD II, on the other hand, may be more common in women. In men with bipolar disorder, the first episode is likely to be manic; in women, the first episode is likely to be depressive. 1
  • Bipolar I disorder (BPD I) is recurrent in more than 90% of cases. Approximately 60% to 70% of manic episodes occur immediately before or after a major depressive episode (MDE). Each individual tends to develop a pattern in which manic and depressive episodes precede and follow each other. In the absence of treatment, individuals with BPD I will suffer an average of 4 episodes in a 10-year period. In the case of bipolar II disorder (BPD II), approximately 60% to 70% of hypomanic episodes occur immediately before or after an MDE. Both BPD I and BPD II show tendencies to run in families, although this tendency is more evident in BPD I. First-degree biological relatives of individuals with BPD I have increased rates of BPD II and major depressive disorder (MDD), and twin and adoption studies provide convincing evidence of genetic predisposition. Some studies also suggest that first-degree relatives of individuals with BPD II have increased rates of BPD II, BPD I, and MDD. 2
  • The peak age of onset for bipolar disorders is adolescence through early 20s. Approximately one fourth of first episodes occur before the age of 20 years. Onset of a first manic episode after the age of 40 years should signal substance use or a general medical condition as the possible cause of the symptoms. Seasonal variation of episodes have been noted in some patients. Depression appears to be more common in the spring, specifically, March through May, and in the autumn, specifically, in September through November. Manic episodes appear to be more common in the summer months. 3
  • In the clinical setting, bipolar depression can be difficult to distinguish from unipolar depression. In a recent study, 48 consecutively admitted patients diagnosed with bipolar I disorder (BPD I) (n=44) or schizoaffective disorder, bipolar type (n=4), were systematically interviewed using strict DSM-IV criteria, and their charts were reviewed to confirm preadmission diagnoses. In this sample, 43% of the patients (19 of 44 available patients), were found to have previously undiagnosed bipolar disorder; all had previously been believed to have unipolar major depression. It took an average of 7.5 years to establish an accurate diagnosis for these patients. Although some have criticized these criteria for being too narrow, this study shows that strict application of DSM-IV criteria can help clinicians distinguish unipolar depression from bipolar disorders. This slide summarizes some factors that may help differentiate these diagnoses. Evaluating patients’ interepisode personalities can be particularly helpful. Hyperthymic temperament is characterized by a hypomanic state at baseline; these patients have been described as cheerful, extroverted, and habitually short sleepers. Patients with cyclothymic personalities also have hypomanic baseline personalities, but their hypomania alternates with mildly depressive episodes that do not meet criteria for major depressive episode (MDE). The bottom line is that bipolar disorder should always be considered in the differential diagnosis of patients with depression. H/O = history of. 17
  • Bipolar Disorder in DSM-IV

    1. 1. Bipolar Disorder in DSM-IV <ul><li>Bipolar I disorder: manic episode(s) or mixed episode(s) plus MDE(s) </li></ul><ul><li>Bipolar II disorder: major depressive episode(s) plus hypomanic episode(s) </li></ul><ul><li>Cyclothymia: hypomanic symptoms plus depressive symptoms </li></ul>
    2. 2. Bipolar Disorders: DSM-IV Nosology Criteria Mania Hypomania Major depression Mixed state BPD I Required Possible Possible Possible BPD II No Required Required No Cyclothymia No No No No
    3. 3. Manic Episode: Diagnostic Criteria <ul><li>Elevated, expansive, or irritable mood for 1 week or longer, plus 3 or more of the following </li></ul><ul><ul><li>Inflated self-esteem or grandiosity </li></ul></ul><ul><ul><li>Decreased need for sleep </li></ul></ul><ul><ul><li>Pressured speech </li></ul></ul><ul><ul><li>Racing thoughts/flight of ideas </li></ul></ul><ul><ul><li>Distractibility </li></ul></ul><ul><ul><li>Psychomotor agitation/increased goal-directed activity </li></ul></ul><ul><ul><li>Excessive involvement in high-risk activities </li></ul></ul>
    4. 4. Manic Episode: Differential Diagnoses <ul><li>Differential diagnosis </li></ul><ul><li>Consider if . . . </li></ul>Mood disorder due to a general medical condition Substance-induced mood disorder Hypomanic episode Mixed episode Major medical condition present First episode at >50 years of age Symptoms in context of intoxication or withdrawal History of treatment for depression Mood disturbance not severe enough to require hospitalization or impair functioning Manic episode and MDE in 1 week
    5. 5. Manic Episode: Differential Diagnoses (cont.) <ul><li>Differential diagnosis </li></ul><ul><li>Consider if . . . </li></ul>AD/HD Early childhood mood disturbance onset Chronic rather than episodic course No clear onsets and offsets No abnormally elevated mood No psychotic features American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) . 4th ed. 1994.
    6. 6. <ul><li>Depressed mood and/or loss of interest or pleasure  2 weeks duration </li></ul><ul><li>Associated symptoms </li></ul><ul><ul><li>Physical: insomnia/hypersomnia, appetite/weight change, decreased energy, psychomotor change </li></ul></ul><ul><ul><li>Psychological: feelings of guilt or worthlessness, poor concentration/indecisiveness, thoughts of death/suicidal intentions (SI) </li></ul></ul>Major Depressive Episode: DSM-IV Criteria
    7. 7. <ul><li>Physical </li></ul><ul><ul><li>Sleep disorder </li></ul></ul><ul><ul><li>Appetite change </li></ul></ul><ul><ul><li>Fatigue </li></ul></ul><ul><ul><li>Psychomotor retardation </li></ul></ul><ul><li>Psychological </li></ul><ul><ul><li>Low self esteem/guilt </li></ul></ul><ul><ul><li>Poor concentration/ indecisiveness </li></ul></ul><ul><ul><li>Thoughts of death/SI </li></ul></ul>… and  4 of the following symptoms
    8. 8. Mixed Episode: Diagnostic Criteria <ul><li>Criteria met for both manic episode + MDE for  1 week </li></ul><ul><li>Symptoms </li></ul><ul><ul><li>Are sufficient to impair functioning </li></ul></ul><ul><ul><li>or </li></ul></ul><ul><ul><li>Necessitate hospitalization </li></ul></ul><ul><ul><li>or </li></ul></ul><ul><ul><li>Are accompanied by psychotic features </li></ul></ul>
    9. 9. Bipolar Disorders: Epidemiology Characteristics BPD I BPD II Prevalence  1.6% 0.5% Ethnic/racial differential None None Gender differential M = F F›M (?)
    10. 10. Bipolar Disorders: Epidemiology <ul><li>Hypomanic episodes in BPD II immediately precede or follow MDEs in 60% to 70% of cases </li></ul><ul><li>First-degree relatives may have increased rates of BPD I, BPD II, and MDD </li></ul><ul><li>Recurrent in >90% of cases </li></ul><ul><li>First-degree relatives have increased rates of BPD I, BPD II, and MDD </li></ul>Characteristics BPD I BPD II Course Familial pattern
    11. 11. Epidemiology <ul><li>Peak age of onset: adolescence through early 20s </li></ul><ul><ul><li>Onset of first manic episode after age 40 years is “red flag” to consider substance use or general medical condition </li></ul></ul><ul><li>Seasonal variation </li></ul><ul><ul><li>Depression more common in spring and autumn </li></ul></ul><ul><ul><li>Mania more common in summer </li></ul></ul>
    12. 12. Diagnostic Dilemmas: Unipolar Versus Bipolar <ul><li>No evidence of hypomania, cyclothymia, hyperthymic personality, or family history of BPD </li></ul><ul><li> 1 manic episode </li></ul><ul><li>Recurrent major depression with hypomania and/or cyclothymic temperament </li></ul><ul><li>Recurrent major depression without spontaneous hypomania but often with hyperthymic temperament and/or family history of BPD </li></ul>Unipolar BPD I BPD II BPD NOS
    13. 13. Etiology
    14. 14. Heritability <ul><li>Evidence for heritability is much stronger for bipolar than for unipolar disorders </li></ul><ul><li>Specific genetic association has not been consistently replicated </li></ul>
    15. 15. EVIDENCE FOR HERITABILITY OF BIPOLAR DISORDER <ul><li>Family Studies- First degree relatives are 8 to 18 times more likely to have Bipolar I </li></ul><ul><li>2 to 10 times to have MDD. </li></ul><ul><li>Risk is 25% if one parent has illness, and 50% to 75% with both parents affected </li></ul>
    16. 16. FAMILY STUDIES <ul><li>The majority of individuals with bipolar disorder have a positive family history of some type of mood disorder </li></ul><ul><li>About 50% of all bipolar I patients have at least one parent with a mood disorder </li></ul>
    17. 17. ADOPTION STUDIES <ul><li>Prevalence of bipolar disorder in adopted away offspring corresponds to rates in biological, but not adoptive relatives </li></ul><ul><li>Twin Studies- Concordance rate in MZ twins is 33 to 90%, in DZ is 5 to 25% </li></ul>
    18. 18. Cognitive Deficits <ul><li>Working memory </li></ul><ul><li>Sustained attention </li></ul><ul><li>Abstract reasoning </li></ul><ul><li>Visuomotor skills </li></ul><ul><li>Verbal memory </li></ul><ul><li>Verbal fluency </li></ul><ul><li>Cognitive flexibility </li></ul><ul><li>General cognitive functioning </li></ul>
    19. 19. Potential Explanations for Cognitive Deficits <ul><li>Iatrogenic or Alcohol use </li></ul><ul><li>Temporary functional changes </li></ul><ul><li>Degenerative brain changes </li></ul><ul><li>Permanent structural lesions </li></ul><ul><li>Permanent functional alterations of neural networks underlying affect and cognition </li></ul>
    20. 20. Alcohol Use <ul><li>Alcohol use occurs in 30-50% of cases </li></ul><ul><li>Impairs memory and executive functioning </li></ul><ul><li>Gorp et al (1998) </li></ul><ul><ul><li>Compared BP only, BP + AD, Control </li></ul></ul><ul><ul><li>BP + AD > BP only for cognitive impairment </li></ul></ul><ul><ul><li>No difference between Control and BP only </li></ul></ul><ul><li>Other studies have reported cognitive deficits in non substance abusing BP patients </li></ul>
    21. 21. Iatrogenic <ul><li>Lithium </li></ul><ul><ul><li>Memory and psychomotor functioning </li></ul></ul><ul><li>Valproate and Carbemazepine </li></ul><ul><ul><li>Attentional deficitis </li></ul></ul><ul><li>Neuroleptics </li></ul><ul><ul><li>Sustained attention </li></ul></ul><ul><ul><li>Visuomotor speed deficits </li></ul></ul><ul><li>Benzodiazapines </li></ul><ul><ul><li>Memory </li></ul></ul><ul><li>Crews et al. </li></ul><ul><ul><li>Performance on WCST negatively related to years of exposure to antipsychotic drugs </li></ul></ul>
    22. 22. Questions <ul><li>Some evidence indicates that Lithium exerts a neuroprotective effect on neuronal tissue </li></ul><ul><ul><li>Are studies indicating adverse effects of lithium not accounting for complex combinations of meds? </li></ul></ul><ul><li>Could we even study this issue empirically?? </li></ul><ul><ul><li>Ethics </li></ul></ul><ul><ul><li>Generalizability </li></ul></ul>
    23. 23. Temporal Functional Deficits <ul><li>Are cognitive deficits specific to depressive or manic states? </li></ul><ul><li>Depression </li></ul><ul><ul><li>Decreased dorsal prefrontal cortex and anterior cingulate gyrus activation </li></ul></ul><ul><ul><li>Increased ventral prefrontal cortex activation </li></ul></ul><ul><ul><li>Reductions in left hemisphere activity </li></ul></ul><ul><li>Mania </li></ul><ul><ul><li>Opposite pattern </li></ul></ul><ul><ul><li>Decreased ventral and increased dorsal activity of the prefrontal cortex </li></ul></ul><ul><ul><li>Reductions in right hemisphere activity </li></ul></ul><ul><li>Remission of depressive symptoms associated with increased blood flow to dorsolateral and medial prefrontal cortex </li></ul>
    24. 24. <ul><li>Distractibility and behavioral dysregulation during mania </li></ul><ul><ul><li>Heightened left hemisphere prefontal corticol activity </li></ul></ul><ul><li>Attentional deficits accompanying depression </li></ul><ul><ul><li>Right hemisphere disturbance of dorsal prefrontal cortex, cingulate gyrus, parlimbic cortex </li></ul></ul>
    25. 25. Summary <ul><li>Authors contend (Savitz et al, 2005) that functional disturbances have a neurodevelopmental and possibly genetic etiology that may be exacerbated by mood disturbances </li></ul>