This document discusses Bipolar Disorders I and II as defined by the DSM-5. Bipolar I Disorder requires at least one manic episode, along with potential hypomanic or depressive episodes. Diagnostic criteria for manic, hypomanic, and depressive episodes are provided. Bipolar II Disorder involves at least one hypomanic and one depressive episode, without mania. It further defines hypomanic and depressive episode criteria and discusses the development, course, and age of onset for both disorders.

1. Bipolar Disorders I & II
University of Massachusetts, Amherst
Nursing 690M
Donna Petko, MSN, RN, APN, FNP-BC
April 7, 2015

2. Objective
• prevalence
• diagnostic criteria
• development
• functional
consequences
• cultural issues
• measurements
• diagnostic features
• specifiers
• severity levels
• differential diagnoses
• ICD-10 coding
To increase understanding of Bipolar Disorders I & II
listed in the DSM-5 (APA, 2013):

3. Bipolar Disorders I & II

4. Bipolar I Disorder
Prevalence (APA, 2013):
• 12-month prevalence estimate in US is 0.6%
• Lifetime male-to-female ratio is 1.1:1

5. Bipolar I Disorder Cont.
Diagnostic Criteria (APA, 2013):
• At least one lifetime manic episode required for
diagnosis
• Manic episode may be preceded/followed by hypomanic
or major depressive episode
• Specific criteria must be met for a current/past
hypomanic episode and current/past major depressive
episode

6. Bipolar I Disorder Cont.
Manic Episode (APA, 2013):
• Distinct period of abnormally and persistently elevated,
expansive, or irritable mood
• Increased energy or activity
• Lasting at least 1 week and present most of the day,
nearly every day

7. Bipolar I Disorder Cont.
Manic Episode cont. (APA, 2013):
• 3 or more of the following (4 if mood is only irritable):
• Inflated self-esteem or grandiosity
• Decreased need for sleep
• More talkative than usual
• Flight of ideas
• Distractibility
• Increase in goal-directed activity
• Excessive involvement in risk taking activities
• Spending sprees
• Sexual indiscretions

8. Bipolar I Disorder Cont.
Manic Episode cont. (APA, 2013):
• Mood disturbance is severe to cause marked impairment
in social/occupational functioning or requires
hospitalization
• Episode not attributable to the physiological effects of a
substance or another medical condition

9. Bipolar I Disorder Cont.
Hypomanic Episode (APA, 2013):
• Distinct period of abnormally and persistently elevated,
expansive, or irritable mood
• Increased activity or energy
• Lasting at least 4 consecutive days and present most of
the day, nearly every day

10. Bipolar I Disorder Cont.
Hypomanic Episode cont. (APA, 2013):
• 3 or more of the following (4 if mood is only irritable):
• Inflated self-esteem or grandiosity
• Decreased need for sleep
• More talkative than usual
• Flight of ideas
• Distractibility
• Increase in goal-directed activity
• Excessive involvement in risk taking activities
• Spending sprees
• Sexual indiscretions

11. Bipolar I Disorder Cont.
Hypomanic Episode cont. (APA, 2013):
• Episode associated with change in functioning
• Uncharacteristic when asymptomatic
• Disturbance in mood/change in functioning observed by
others
• Not severe enough to cause impairment in
social/occupational functioning
• Not requiring hospitalization
• Not attributable to the physiological effects of a
substance
• Are common in bipolar I but not required for diagnosis

12. Bipolar I Disorder Cont.
Major Depressive Disorder (APA, 2013):
• 5 or more of the following symptoms during the same 2-
week period and represent change from prior
functioning:
• 1 symptom must be (1) depressed mood or (2) loss of
interest/pleasure
• Depressed mood most of the day, nearly every day per subjective
report or observation
• Diminished interest, pleasure in all, or most, activities
• Significant weight-loss or weight-gain
• Insomnia or hypersomnia
• Psychomotor agitation
• Fatigue

13. Bipolar I Disorder Cont.
Major Depressive Disorder cont. (APA, 2013):
• Feelings of worthlessness
• Diminished ability to think/concentrate
• Recurrent thoughts of death, suicidal ideation
• Symptoms cause clinically significant distress/impairment
in social, occupational functioning
• Not attributable to the physiological effects of a
substance or another medication
• Are common in bipolar I but not required for diagnosis

14. Bipolar I Disorder Cont.
Development and Course (APA, 2013):
• Mean age of onset: 18 years
• Onset may occur throughout the life cycle
• Manic symptoms later in life may indicate medical conditions
• > 90% of individuals who have 1 episode experience
recurrent
• Approx. 60% of manic episodes occur immediately
before a major depressive episode
• Rapid cycling occurs when individuals experience 4 or
more mood episodes in 1 year

15. Bipolar I Disorder Cont.
Functional Consequences (APA, 2013):
• Approx. 30% of individuals experience severe
impairment in work role function
• Functional recovery may be slow
• Cognitive impairments may occur
Cultural issues (APA, 2013):
• Little data exists on specific cultural differences
• Lack of transcultural validation
• One U.S. study shows 12-month prevalence significantly lower
in Afro-Caribbeans than African Americans and Whites

16. Bipolar I Disorder Cont.
Measurements (STABLE, 2007):
• The Mood Disorder Questionnaire (MDQ)
• Screening tool: present and past episodes of mania/hypomania.
• Includes 13 questions associated with the symptoms of bipolar
disorder
• Plus items assessing clustering of symptoms and functional
impairment
• May be used in primary care settings
• Efficient way to identify patients most likely to have a bipolar
disorder

17. Bipolar I Disorder Cont.
Measurements cont. (STABLE, 2007):
• The Composite International Diagnostic Interview (CIDI)
Bipolar Disorder Screening Scale
• Can accurately identify threshold/sub-threshold bipolar disorder
• Scale detected between 67-96% of true cases in clinical studies
• Compares favorably with the MDQ screening scale

18. Bipolar I Disorder Cont.
Diagnostic Features (APA, 2013):
• Manic Episode:
• Euphoric: “feeling on top
of the world”
• Increased activity
• Irritable
• Grandiose delusions
• Decreased need for sleep
• Rapid, pressured speech
• Racing thoughts
• Distractibility
• Marked impairment in
social/occupational
function
• Rapidly shifting mood to
anger or depression
• Depressive symptoms may
occur during a manic
episode

19. Brief I Disorder Cont.
Specifiers (APA, 2013):
• With anxious distress
• With mixed features
• With rapid cycling
• With melancholic
features
• With atypical features
• With mood-congruent
psychotic features
• With mood-incongruent
psychotic features
• With catatonia
• With peripartum onset
• With seasonal pattern

20. Bipolar I Disorder Cont.
ICD-10 Coding and severity (APA, 2013):
Bipolar I
disorder
Current/most recent
episode manic
Current/most recent
episode hypomanic*
Current/most recent
episode depressed
Current/most recent
episode unspecified**
Mild 296.41
(F31.11)
NA 296.51
(F31.31)
NA
Moderate 296.42
(F31.12)
NA 296.52
(F31.32)
NA
Severe 296.43
(F31.13)
NA 296.53
(F31.4)
NA
With psychotic
features***
296.44
(F31.2)
NA 296.54
(F31.5)
NA
In partial
remission
296.45
(F31.73)
296.45
(F31.73)
296.55
(F31.75)
NA
In full
remission
296.46
(F31.74)
296.46
(F31.74)
296.56
(F31.76)
NA
Unspecified 296.40
(F31.9)
296.40
(F31.9)
296.50
(F31.9)
NA
*Severity & psychotic specifiers do not apply; code 296.40 (F31.0) for cases not in remission.
**Severity, psychotic, and remission specifiers do not apply; code 296.7 (F31.9).

21. Bipolar I Disorder Cont.
Differential Diagnoses (APA, 2013):
• Major depressive disorder
• Other bipolar disorders
• Generalized anxiety disorder, panic disorder,
posttraumatic stress disorder, or other anxiety disorders
• Substance/medication-induced bipolar disorder
• Attention-deficit/hyperactivity disorder
• Personality disorders
• Disorders with prominent irritability

22. Bipolar II Disorder
Prevalence (APA, 2013):
• 12-month prevalence estimate in US is 0.8%
• Internationally 0.3%
Diagnostic Criteria (APA, 2013):
• One hypomanic and one major depressive episode
• Never experienced a manic episode
• Specific criteria must be met for a current/past
hypomanic episode and current/past major depressive
episode:

23. Bipolar II Disorder Cont.
Hypomanic Episode (APA, 2013):
• Distinct period of abnormally and persistently
elevated, expansive, or irritable mood
• Increased activity or energy
• Lasting at least 4 consecutive days and present most of
the day, nearly every day

24. Bipolar II Disorder Cont.
Hypomanic Episode cont. (APA, 2013):
• 3 or more of the following (4 if mood is only irritable):
• Inflated self-esteem or grandiosity
• Decreased need for sleep
• More talkative than usual
• Flight of ideas
• Distractibility
• Increase in goal-directed activity
• Excessive involvement in risk taking activities
• Spending sprees
• Sexual indiscretions

25. Bipolar II Disorder Cont.
Hypomanic Episode cont. (APA, 2013):
• Episode associated with change in functioning
• uncharacteristic when asymptomatic
• Disturbance in mood and change in functioning observed
by others
• Not severe enough to cause impairment in
social/occupational functioning
• Not requiring hospitalization
• Not attributable to the physiological effects of a
substance

26. Bipolar II Disorder Cont.
Major Depressive Disorder (APA, 2013):
• 5 or more of the following symptoms during the same 2-
week period and represent change from prior
functioning:
• 1 symptom must be (1) depressed mood or (2) loss of
interest/pleasure
• Depressed mood most of the day, nearly every day per subjective
report or observation
• Diminished interest, pleasure in all, or most, activities
• Significant weight-loss or weight-gain
• Insomnia or hypersomnia
• Psychomotor agitation
• Fatigue

27. Bipolar II Disorder Cont.
Major Depressive Disorder cont. (APA, 2013):
• Feelings of worthlessness
• Diminished ability to think/concentrate
• Recurrent thoughts of death, suicidal ideation
• Symptoms cause clinically significant distress/impairment
in social, occupational functioning
• Not attributable to the physiological effects of a
substance or another medication

28. Bipolar II Disorder Cont.
Development and Course (APA, 2013):
• Can begin in late adolescence
• Average age of onset in mid-20s
• Slightly later than bipolar I
• Most often begins with depressive episode and not
recognized until hypomanic episode occurs
• May be preceded by anxiety, substance use, or eating
disorders
• Lifetime episodes of hypomanic and depressive episodes
greater than in bipolar I

29. Bipolar II Disorder Cont.
Functional Consequences (APA, 2013):
• Most individuals return to fully functional state between
episodes
• 15% may continue to have some inter-episode
dysfunction
• 20% transition directly into another mood episode
without inter-episode recovery
• Functional recovery may be slow
• Cognitive impairments may occur

30. Bipolar II Disorder Cont.
Cultural Issues (APA, 2013):
• Little data exists on specific cultural differences
• Lack of transcultural validation

31. Bipolar II Disorder Cont.
Measurements (STABLE, 2007):
• The Mood Disorder Questionnaire (MDQ)
• Screening tool: present and past episodes of mania/hypomania.
• Includes 13 questions associated with the symptoms of bipolar
disorder
• Plus items assessing clustering of symptoms and functional
impairment
• May be used in primary care settings
• Efficient way to identify patients most likely to have a bipolar
disorder

32. Bipolar II Disorder Cont.
Measurements cont. (STABLE, 2007):
• The Composite International Diagnostic Interview (CIDI)
Bipolar Disorder Screening Scale
• Can accurately identify threshold/sub-threshold bipolar disorder
• Scale detected between 67-96% of true cases in clinical studies
• Compares favorably with the MDQ screening scale

33. Bipolar II Disorder Cont.
Diagnostic Features (APA, 2013):
• Recurring mood episodes:
• 1 or more major depressive episodes
• Episode lasting at least 2 weeks
• At least 1 hypomanic episode
• Episode lasting at least 4 days
• During episode(s), required number of symptoms must be
present most of the day, nearly every day
• A manic episode precludes the diagnosis of bipolar II
• Individuals typically present for treatment during major
depressive episode

34. Bipolar II Disorder Cont.
Specifiers and Severity(APA, 2013):
• Specify current or most recent episode:
• Hypomanic
• Depressed
• Specify if (APA, 2013):
• With anxious distress
• With mixed features
• With rapid cycling
• With mood-congruent psychotic features
• With mood-incongruent psychotic features
• With catatonia
• With peripartum onset
• With seasonal pattern

35. Bipolar II Disorder Cont.
• Specify course if full criteria for a mood episode not
currently met (APA, 2013):
• In partial remission
• In full remission
• Specify severity if full criteria for a mood episode are
currently met (APA, 2013):
• Mild
• Moderate
• Severe

36. Bipolar II Disorder Cont.
Differential diagnoses (APA, 2013):
• Major depressive disorder
• Cyclothymic disorder
• Schizophrenia spectrum and other related psychotic
disorders
• Panic disorder or other related anxiety disorders
• Substance use disorders
• Attention-deficit/hyperactivity disorder
• Personality disorders
• Other bipolar disorders

37. Bipolar II Disorder Cont.
ICD-10 (APA, 2013, p. 111):
• Bipolar II disorder has only one diagnostic code:
• 296.89 (F31.81)
• Severity, presence of psychotic features, course, and other
specifiers cannot be coded but should be indicated in writing

38. Differences Between Bipolar I & II
Bipolar I
• At least 1 manic or mixed
episode
Bipolar II
• Never had a manic episode
• At least 1 hypomanic episode
• At least 1 major depressive
episode

39. Bipolar Disorders I & II Cont.

40. Bipolar Disorders I & II Cont.
Treatment Options for Bipolar I & II (Epocrates, 2015):
• Pharmacologic:
• Mood stabilizers
• Atypical antipsychotic
• Typical antipsychotic
• Alternative antipsychotic
• Neuroleptic
• Other neurologic
• Benzodiazepine
• Antidepressants

41. Bipolar I & II Disorders Cont.
Treatment cont. (Epocrates, 2015):
• Education to recognize and manage early symptoms
• Psychotherapies:
• Cognitive behavioral therapy
• Family-focused therapy
• Interpersonal social rhythm therapy
• Psychoeducation
• Electroconvulsive therapy (ECT)

42. Case Study
(Novac, 1998, p. 108)

43. Case Study Cont.
(Novac, 1998, p. 108)

44. Case Study Cont.
Did you recognize the symptoms of Bipolar I Disorder?
• Mania:
• Insomnia
• Rapid speech
• Euphoria
• Intermittent irritability
• Hospitalized for a previous manic episode
• Depression 2 months prior and treated with SSRI
• Antidepressants can worsen mania and cause rapid cycling
• Rapid cycling

45. The End

46. References
American Psychiatric Association. (2013). Clinician-rated
dimensions of psychosis symptom severity. Retrieved
from http://www.psychiatry.org /File%20Library/
Practice/DSM/DSM-5/ClinicianRatedDimensionsOf
PsychosisSymptomSeverity.pdf
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.).
Washington D.C.: Author.
Epocrates. (2015). Bipolar disorder in adults. Retrieved from
https://online.epocrates.com/u/2942488/Bipolar+disord
er+in+adults/Treatment/Tx+Details

47. References Cont.
Novac, A. (1998). Atypical antipsychotics as enhancement
therapy in rapid cycling mood states: A case study.
Retrieved from http://link.springer.com/article/
10.1023/A%3A1022398104353
Stable National Coordinating Council. (2007). Stable resource
toolkit. Retrieved from http://www.integration.
samhsa.gov/images/res/STABLE_toolkit.pdf