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Bipolar Disorder

Diagnosis

Bipolar disorder is characterised by cycles of mania and depression, which vary in intensity, duration and frequency. In its classic presentation, particularly in the presence of manic symptoms, bipolar disorder does not usually present a diagnostic dilemma to the physician. However, milder cases of mania or depressive episodes interspersed with hypomania may make diagnosis more difficult. Early onset bipolar disorder – especially pre-pubertally – may also be diagnostically challenging. When presented with psychotic symptoms, some clinicians automatically diagnose schizophrenia. Bipolar disorder can however, also present with psychotic symptoms in both manic and the depressive phases, this can lead to bipolar disorder being misdiagnosed as schizophrenia. The depressive phase of bipolar disorder usually precedes a manic or hypomanic episode, so as the disorder progresses over time it is difficult to predict if bipolarity will be the result of an initial depressive episode. The following symptoms should allow differentiation of bipolar disorder from other psychotic conditions:

  • a family history of bipolar disorder
  • a rapid onset of symptoms
  • a hypomanic response to antidepressant treatment
  • periods of unstable and liable mood preceding the depressive episode
  • mood congruent symptoms (if psychosis is present).

In moderate to severe cases, patients with bipolar disorder are usually quickly identified. However, in mild cases the identification and treatment can be delayed – usually as a result of misdiagnosis or absence of diagnosis. In adolescents, the expectation of chaotic behaviour and mood dysregulation as a part of normal development can prevent the recognition of a significant mood disorder. So, particular attention should be paid to the identification of mood disorders in the primary care setting.

One study noted that a number of patients with bipolar disorder experienced delays of up to 5 years before a proper diagnosis was made (Evans, 2000). This was partly due to patients not seeking treatment; 35% of patients failed to seek treatment for as long as 10 years from their initial episode. Delays in diagnosis are also due to the difficulty of diagnosing bipolar disorder; 34% of patients received a diagnosis other than bipolar disorder when they first consulted a physician (Evans, 2000).

The diagnostic criteria for depressive and manic episodes are listed below.

DSM IV diagnostic criteria for a major depressive episode (American Psychiatric Association, 1994)

  • Five or more of the following symptoms have been present during the last 2-week period and represent a change from previous functioning. At least one of the symptoms must be (1) depressed mood, or (2) loss of interest or pleasure. NB do not include symptoms that are due to a medical condition, or mood-incongruentdelusions or hallucinations.
  1. Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others. NB 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 report or observation made by others.
  3. Significant weight loss when not dieting or weight gain (e.g. a change in more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. NB 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 being 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 the fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
  • The symptoms do not meet criteria for a mixed episode.
  • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The symptoms are not due to the direct physiological affects of a substance (e.g. a drug of abuse, a medication, or other treatment) or a general medical condition (e.g. hypothyroidism).
  • 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 characterised by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Read more about the diagnosis of unipolar depression.

DSM IV Diagnostic criteria for a manic episode (American Psychiatric Association, 1994)

  • A distinct period of abnormality and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalisation is necessary).
  • During the period of mood disturbance, 3 (or more) of the following symptoms have persisted (4 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 sleep).
  3. More talkative than usual or pressure to keep talking.
  4. Flights 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).
  • The symptoms do not meet criteria for a mixed episode.
  • The mood disturbance is sufficiently severe to cause marked impairments in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalisation to prevent harm to self or others, or their psychotic features.
  • The symptoms are not due to the direct physiological affects of a substance (e.g. a drug of abuse, a medication, or other treatment) or a general medical condition (e.g. hyperthyroidism). NB manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g. medication, electroconvulsive therapy, and light therapy) should not count towards a diagnosis of bipolar I disorder.

Manic States

Manic episodes can be subdivided into three groups: mania, hypomania and mixed episode mania. Mania is the classic acute manic state, as described in the DSM-IV criteria above. Hypomania shares the same clinical features as pure mania, but is less severe, may not require hospitalisation and may cause less impairment in functioning. The symptoms are still noticeable to others and are often associated with significant social and vocational difficulties (Evans, 2000; NIMH, 2000).

In the majority of cases, patients will experience distinct episodes of mania and depression. However, depressive symptoms can often occur during a manic episode. This is called a mixed episode and is defined by sufficient depressive and manic symptoms occurring concurrently, such that both diagnostic criteria are met. Approximately 30% of patients with bipolar disorder will experience a mixed symptom episode during the course of their illness (Keck, Jr. et al, 2001).

Secondary Mania

Secondary mania is mania (or hypomania/mixed mania) occurring as a result of a concurrent medical condition. It can be differentiated from primary mania by a later age of onset in patients with no family history of mania or affective disorders. Treatment for secondary mania may differ to that of primary mania. Secondary mania associated with the central nervous system (CNS) or renal disease may be more effectively treated with anticonvulsants whereas secondary mania associated with liver disease may be more effectively treated with lithium (Evans, 2000).

Read about the treatment of bipolar disorder.

Bipolar I and II Disorder

There are 2 distinct forms of bipolar disorder and different criteria must be met for a diagnosis of either, see below.

Required for the diagnosis of bipolar I(Keck, Jr. et al, 2001; NIMH, 2000):

  • the presence of at least one severe manic episode (with or without past major depressive episodes)
  • the manic episode not being accounted for by a schizoaffective disorder
  • the manic episode not being superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified.

Required for the diagnosis of bipolar II:

  • one or more episodes of major depression
  • at least one hypomanic episode (Keck, Jr. et al, 2001; NIMH, 2000)
  • no manic episode.

Diagnostic Instruments and Rating Scales

Diagnostic instruments are available to assist the clinician in the diagnosis of bipolar disorder. There are a number of useful tools, including the Structured Clinical Interview for DSM-IV (SCID), Schedule for Affective Disorders and Schizophrenia (SADS) and the Mini-Mental State Exam (MINI). These all require extensive clinician training for optimal use and are not suitable for screening.

A new screening questionnaire for bipolar disorder – the Mood Disorders Questionnaire (MDQ) – has recently become available. While it has only been tested on 198 patients as a screening instrument for bipolar spectrum in psychiatry; it was shown to be both specific and sensitive in distinguishing bipolar disorder from other psychiatric conditions (Hirschfeld et al, 2000; Maj et al, 2002).

The severity of the depressive and manic episodes can be measured objectively, using a variety of symptom rating scales. Some of the tools most often used in the assessment of patients with bipolar disorder are the Young Mania Scale and the Brief Psychiatric Rating Scale; both of these require rater training to ensure rating reliability.

 

 

 

 
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