bipolar Flashcards
bipolar I criteria
or a diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes.
140
Manic 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 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to
a significant degree and represent a noticeable change from usual behavior:
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 (i.e., purposeless non-goal-directed activity).
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 mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition.
Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.
Note: Criteria A–D constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder.
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).
141
C. The episode is associated with an unequivocal change in functioning that is 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) or another medical condition.
Note: A full hypomanic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis.
Note: Criteria A–F constitute a hypomanic episode. Hypomanic episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.
Major Depressive Episode
A. Five (or more) of the following 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 (e.g., feels sad, empty, or hopeless) 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).
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 gain.)
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.
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 another medical condition.
Note: Criteria A–C constitute a major depressive episode. Major depressive episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.
142
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires
the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.1
Bipolar I Disorder
A. Criteria have been met for at least one manic episode (Criteria A–D under “Manic Episode” above).
B. At least one manic episode is not better explained by schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
Coding and Recording Procedures
The diagnostic code for bipolar I disorder is based on type of current or most recent episode and its status with respect to current severity, presence of psychotic features, and remission status. Current severity and psychotic features are only indicated if full criteria are currently met for a manic or major depressive episode. Remission specifiers are only indicated if the full criteria are not currently met for a manic, hypomanic, or major depressive episode. Codes are as follows:
Bipolar I disorder
Mild (p. 175) Moderate (p. 175) Severe (p. 175)
143
With psychotic features* (p. 173) In partial remission (p. 175)
In full remission (p. 175) Unspecified
hypomanic* depressed unspecified
Current or most recent episode manic
Current or most recent episode
Current or most recent episode
Current or most recent episode
NA F31.31 NA NA F31.32 NA
F31.11
F31.12
F31.13 NA F31.4 NA
F31.2 NA F31.5 NA
F31.73 F31.74 F31.9
F31.71 F31.75 NA F31.72 F31.76 NA F31.9 F31.9 NA
Severity and psychotic specifiers do not apply; code F31.0 for cases not in remission.
**Severity, psychotic, and remission specifiers do not apply. Code F31.9.
**If psychotic features are present, code the “with psychotic features” specifier irrespective of episode severity.
In recording the name of a diagnosis, terms should be listed in the following order: bipolar I disorder, type of current episode (or most recent episode if bipolar I disorder is in partial or full remission), severity/psychotic/remission specifiers, followed by as many of the following specifiers without codes as apply to the current episode (or the most recent episode if bipolar I disorder is in partial or full remission). Note: The specifiers “with rapid cycling” and “with seasonal pattern” describe the pattern of mood episodes.
Specify if:
With anxious distress (pp. 169–170)
With mixed features (pp. 170–171)
With rapid cycling (p. 171)
With melancholic features (pp. 171–172)
With atypical features (pp. 172–173)
With mood-congruent psychotic features (p. 173; applies to manic episode and/or major depressive episode)
With mood-incongruent psychotic features (p. 173; applies to manic episode and/or major depressive episode)
With catatonia (p. 173). Coding note: Use additional code F06.1. With peripartum onset (pp. 173–174)
With seasonal pattern (pp. 174–175)
bipolar II criteria
For a diagnosis of bipolar II disorder, it is necessary to meet the following criteria for a current or past hypomanic episode and the following criteria for a current or past major depressive episode:
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 have persisted (four if the mood is only irritable), 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.
151
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 is associated with an unequivocal change in functioning that is 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) or another medical condition.
Note: A full hypomanic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis.
Major Depressive Episode
A. Five (or more) of the following 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 a medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) 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).
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
B. C.
gain.)
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.
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The episode is not attributable to the physiological effects of a substance or another medical condition.
Note: Criteria A–C constitute a major depressive episode. 152
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.1
Bipolar II Disorder
A. Criteria have been met for at least one hypomanic episode (Criteria A–F under “Hypomanic Episode” above) and at least one major depressive episode (Criteria A–C under “Major Depressive Episode” above).
B. There has never been a manic episode.
C. At least one hypomanic episode and at least one major depressive episode are not better explained by schizoaffective disorder and are not superimposed on 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.
Coding and Recording Procedures
Bipolar II disorder has one diagnostic code: F31.81. Its status with respect to current severity, presence of psychotic features, course, and other specifiers cannot be coded but should be indicated in writing (e.g., F31.81 bipolar II disorder, current episode depressed, moderate severity, with mixed features; F31.81 bipolar II disorder, most recent episode depressed, in partial remission).
Specify current or most recent episode: Hypomanic
Depressed
If current episode is hypomanic (or most recent episode if bipolar II disorder is in
partial or full remission):
153
In recording the diagnosis, terms should be listed in the following order: bipolar II disorder, current or most recent episode hypomanic, in partial remission/in full remission (p. 175) (if full criteria for a hypomanic episode are not currently met), plus any of the following hypomanic episode specifiers that are applicable. Note: The specifiers “with rapid cycling” and “with seasonal pattern” describe the pattern of mood episodes.
Specify if:
With anxious distress (p. 169–170) With mixed features (pp. 170–171) With rapid cycling (p. 171)
With peripartum onset (pp. 173–174) With seasonal pattern (pp. 174–175)
If current episode is depressed (or most recent episode if bipolar II disorder is in partial or full remission):
In recording the diagnosis, terms should be listed in the following order: bipolar II disorder, current or most recent episode depressed, mild/moderate/severe (if full criteria for a major depressive episode are currently met), in partial remission/in full remission (if full criteria for a major depressive episode are not currently met) (p. 175), plus any of the following major depressive episode specifiers that are applicable. Note: The specifiers “with rapid cycling” and “with seasonal pattern” describe the pattern of mood episodes.
Specify if:
With anxious distress (pp. 169–170) With mixed features (pp. 170–171)
With rapid cycling (p. 171)
With melancholic features (pp. 171–172)
With atypical features (pp. 172–173)
With mood-congruent psychotic features (p. 173)
With mood-incongruent psychotic features (p. 173)
With catatonia (p. 173). Coding note: Use additional code F06.1. With peripartum onset (pp. 172–174)
With seasonal pattern (pp. 174–175)
Specify course if full criteria for a mood episode are not currently met: In partial remission (p. 175)
In full remission (p. 175)
Specify severity if full criteria for a major depressive episode are currently met: Mild (p. 175)
Moderate (p. 175) Severe (p. 175)
cyclothymic disorder
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 major depressive episode.
B. During the above 2-year period (1 year in children and adolescents), Criterion A symptoms have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time.
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 (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).
160
F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
With anxious distress (see pp. 169–170)
substance/medication-induced bipolar and related disorder criteria
A. A prominent and persistent disturbance in mood that predominates in the clinical picture and is characterized by abnormally elevated, expansive, or irritable mood and abnormally increased activity or energy.
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 or withdrawal from 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. Such evidence of an independent bipolar or related disorder could include the following:
The symptoms precede the onset of the substance/medication use; the symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication; or there is other evidence suggesting the existence of an independent non- substance/medication-induced bipolar and related disorder (e.g., a history of recurrent non-substance/medication-related episodes).
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.
Note: This diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the symptoms in Criterion A predominate in the clinical picture and when they are sufficiently severe to warrant
clinical attention.
Coding note: The ICD-10-CM codes for the [specific substance/medication]-induced bipolar and related disorders are indicated in the table below. Note that the ICD-10- CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. In any case, an additional separate diagnosis of a substance use disorder is not given. If a mild substance use disorder is comorbid with the substance-induced bipolar and related disorder, the 4th position character is “1,” and the clinician should record “mild [substance] use disorder” before the substance-induced bipolar and related disorder (e.g., “mild cocaine use disorder with cocaine-induced bipolar and related disorder”). If a moderate or severe substance use disorder is comorbid with the substance-induced bipolar and related disorder, the 4th position character is “2,” and the clinician should record “moderate [substance] use disorder” or “severe [substance] use disorder,” depending on the severity of the comorbid substance use disorder. If there is no comorbid substance use disorder (e.g., after a one-time heavy use of the substance), then the 4th position character is “9,” and the clinician should record only the substance-induced bipolar and related disorder.
Alcohol
Phencyclidine
Other hallucinogen
Sedative, hypnotic, or anxiolytic
Amphetamine-type substance (or other stimulant)
Cocaine
Other (or unknown) substance
163
With mild use disorder
F10.14 F16.14 F16.14 F13.14 F15.14
F14.14 F19.14
ICD-10-CM
With moderate or severe use disorder
F10.24 F16.24 F16.24 F13.24 F15.24
F14.24 F19.24
Without use disorder
F10.94 F16.94 F16.94 F13.94 F15.94
F14.94 F19.94
Specify (see Table 1 in the chapter “Substance-Related and Addictive Disorders,” which indicates whether “with onset during intoxication” and/or “with onset during withdrawal” applies to a given substance class; or specify “with onset after medication use”):
With onset during intoxication: If criteria are met for intoxication with the substance and the symptoms develop during intoxication.
With onset during withdrawal: If criteria are met for withdrawal from the substance and the symptoms develop during, or shortly after, withdrawal.
With onset after medication use: If symptoms developed at initiation of medication, with a change in use of medication, or during withdrawal of medication.
bipolar and related disorder due to another medical condition
A. A prominent and persistent disturbance in mood that predominates in the clinical picture and is characterized by abnormally elevated, expansive, or irritable mood and abnormally increased activity or energy.
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.
Coding note: The ICD-10-CM code depends on the specifier (see below). Specify if:
F06.33 With manic features: Full criteria are not met for a manic or hypomanic episode.
F06.33 With manic- or hypomanic-like episode: Full criteria are met except Criterion D for a manic episode or except Criterion F for a hypomanic episode.
F06.34 With mixed features: Symptoms of depression are also present but do not predominate in the clinical picture.
Coding note: Include the name of the other medical condition in the name of the mental disorder (e.g., F06.33 bipolar disorder due to hyperthyroidism, with manic features). The other medical condition should also be coded and listed separately immediately before the bipolar and related disorder due to the medical condition (e.g., E05.90 hyperthyroidism; F06.33 bipolar disorder due to hyperthyroidism, with manic features).
other specified bipolar and related disorder
This category applies to presentations in which symptoms characteristic of a bipolar and related disorder that cause clinically significant distress or impairment in social,
occupational, or other 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. The other specified bipolar and related disorder category 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 (e.g., “short-duration cyclothymia”).
Examples of presentations that can be specified using the “other specified” designation include the following:
1. Short-duration hypomanic episodes (2–3 days) and major depressive episodes: A lifetime history of one or more major depressive episodes in individuals whose presentation has never met full criteria for a manic or hypomanic episode but who have experienced two or more episodes of short- duration hypomania that meet the full symptomatic criteria for a hypomanic episode but that only last for 2–3 days. The episodes of hypomanic symptoms do not overlap in time with the major depressive episodes, so the disturbance does not meet criteria for major depressive episode, with mixed features.
2. Hypomanic episodes with insufficient symptoms and major depressive episodes: A lifetime history of one or more major depressive episodes in individuals whose presentation has never met full criteria for a manic or hypomanic episode but who have experienced one or more episodes of hypomania that do not meet full symptomatic criteria (i.e., at least 4 consecutive days of elevated mood and one or two of the other symptoms of a hypomanic episode, or irritable mood and two or three of the other symptoms of a hypomanic episode). The episodes of hypomanic symptoms do not overlap in time with the major depressive episodes, so the disturbance does not meet criteria for major depressive episode, with mixed features.
3. Hypomanic episode without prior major depressive episode: One or more hypomanic episodes in an individual whose presentation has never met full criteria for a major depressive episode or a manic episode.
169
4. Short-duration cyclothymia (less than 24 months): Multiple episodes of hypomanic symptoms that do not meet criteria for a hypomanic episode and multiple episodes of depressive symptoms that do not meet criteria for a major depressive episode that persist over a period of less than 24 months (less than 12 months for children or adolescents) in an individual whose presentation has never met full criteria for a major depressive, manic, or hypomanic episode and does not meet criteria for any psychotic disorder. During the course of the disorder, the hypomanic or depressive symptoms are present for more days than not, the individual has not been without symptoms for more than 2 months at a time, and the symptoms cause clinically significant distress or impairment.
5. Manic episode superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum
and other psychotic disorder. Note: Manic episodes that are part of schizoaffective disorder do not merit an additional diagnosis of other specified bipolar and related disorder.
unspecified bipolar and related disorder
This category applies to presentations in which symptoms characteristic of a bipolar and related disorder that cause clinically significant distress or impairment in social, occupational, or other 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. The unspecified bipolar and related disorder category 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).
unspecified mood disorder
This category applies to presentations in which symptoms characteristic of a mood dis-order that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not at the time of the evaluation meet the full criteria for any of the disorders in either the bipolar or the depressive disorders diagnostic classes and in which it is difficult to choose between unspecified bipolar and related disorder and unspecified depressive disorder (e.g., acute agitation).
specifiers for bipolar and related disorder
pecify if:
With anxious distress: The presence of at least two of the following symptoms during the majority of days of the current manic, hypomanic, or major depressive episode in bipolar I disorder (or the most recent episode if bipolar I disorder is in partial or full remission); or of the current hypomanic or major depressive episode in bipolar II disorder (or the most recent episode if bipolar II disorder is in partial or full remission); or during the majority of symptomatic days in cyclothymic disorder:
1. Feeling keyed up or tense.
2. Feeling unusually restless.
3. Difficulty concentrating because of worry.
4. Fear that something awful may happen.
5. Feeling that the individual might lose control of himself or herself.
Specify current severity:
Mild: Two symptoms.
Moderate: Three symptoms.
Moderate-severe: Four or five symptoms.
Severe: Four or five symptoms with motor agitation.
Note: Anxious distress has been noted as a prominent feature of both bipolar and major depressive disorders in both primary care and specialty mental health settings. High levels of anxiety have been associated with higher suicide risk, longer duration of illness, and greater likelihood of treatment nonresponse. As a result, it is clinically useful to specify accurately the presence and severity levels of anxious distress for treatment planning and monitoring of response to treatment.
With mixed features: The mixed features specifier can apply to the current manic, hypomanic, or major depressive episode in bipolar I disorder (or the most recent episode if bipolar I disorder is in partial or full remission) or to the current hypomanic or major depressive episode in bipolar II disorder (or the most recent episode if bipolar II disorder is in partial or full remission):
Manic or hypomanic episode, with mixed features:
A.
Full criteria are met for a manic episode or hypomanic episode, and at least three of the following symptoms are present during the majority of days of the current or most recent episode of mania or hypomania:
1. Prominent dysphoria or depressed mood as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
2. Diminished interest or pleasure in all, or almost all, activities (as indicated by either subjective account or observation made by others).
3. Psychomotor retardation nearly every day (observable by others; not merely subjective feelings of being slowed down).
4. Fatigue or loss of energy.
5. Feelings of worthlessness or excessive or inappropriate guilt (not merely self-reproach or guilt about being sick).
6. 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
170
committing suicide.
B. Mixed symptoms are observable by others and represent a change from the person’s usual behavior.
C. For individuals whose symptoms meet full episode criteria for both mania and depression simultaneously, the diagnosis should be manic episode, with mixed features, due to the marked impairment and clinical severity of full mania.
D. The mixed symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment).
Depressive episode, with mixed features:
A. Full criteria are met for a major depressive episode, and at least three of the following manic/hypomanic symptoms are present during the majority of days of the current or most recent episode of depression:
1. Elevated, expansive mood.
2. Inflated self-esteem or grandiosity.
171
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Increase in energy or goal-directed activity (either socially, at work or school, or sexually).
6. Increased or 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).
7. Decreased need for sleep (feeling rested despite sleeping less than usual; to be contrasted with insomnia).
B. Mixed symptoms are observable by others and represent a change from the person’s usual behavior.
C. For individuals whose symptoms meet full episode criteria for both mania and depression simultaneously, the diagnosis should be manic episode, with mixed features.
D. The mixed symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment).
Note: Mixed features associated with a major depressive episode have been found to be a significant risk factor for the development of bipolar I or bipolar II disorder. As a result, it is clinically useful to note the presence of this specifier for treatment planning and monitoring of response to treatment.
With rapid cycling: Presence of at least four mood episodes in the previous 12 months that meet the criteria for manic, hypomanic, or major depressive episode in bipolar I disorder or that meet the criteria for hypomanic or major depressive
episode in bipolar II disorder.
Note: Episodes are demarcated by either partial or full remissions of at least 2 months or a switch to an episode of the opposite polarity (e.g., major depressive episode to manic episode).
Note: The essential feature of a rapid-cycling bipolar disorder is the occurrence of at least four mood episodes during the previous 12 months. These episodes can occur in any combination and order. The episodes must meet both the duration and the symptom number criteria for a major depressive, manic, or hypomanic episode and must be demarcated by either a period of full remission or a switch to an episode of the opposite polarity. Manic and hypomanic episodes are counted as being on the same pole. Except for the fact that they occur more frequently, the episodes that occur in a rapid-cycling pattern are no different from those that occur in a non-rapid- cycling pattern. Mood episodes that count toward defining a rapid-cycling pattern exclude those episodes directly caused by a substance (e.g., cocaine, corticosteroids) or another medical condition.
With melancholic features:
A. One of the following is present during the most severe period of the current major depressive episode (or the most recent major depressive episode if bipolar I or bipolar II disorder is currently in partial or full remission):
B.
1. Loss of pleasure in all, or almost all, activities.
2. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens).
Three (or more) of the following:
1. A distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness or by so-called empty mood.
2. Depression that is regularly worse in the morning.
172
3. Early-morning awakening (i.e., at least 2 hours before usual awakening).
4. Marked psychomotor agitation or retardation.
5. Significant anorexia or weight loss.
6. Excessive or inappropriate guilt.
Note: The specifier “with melancholic features” is applied if these features are present at the most severe stage of the episode. There is a near- complete absence of the capacity for pleasure, not merely a diminution. A guideline for evaluating the lack of reactivity of mood is that even highly desired events are not associated with marked brightening of mood. Either mood does not brighten at all, or it brightens only partially (e.g., up to 20%– 40% of normal for only minutes at a time). The “distinct quality” of mood
that is characteristic of the “with melancholic features” specifier is experienced as qualitatively different from that during a nonmelancholic depressive episode. A depressed mood that is described as merely more severe, longer lasting, or present without a reason is not considered distinct in quality. Psychomotor changes are nearly always present and are observable by others.
Melancholic features exhibit only a modest tendency to repeat across episodes in the same individual. They are more frequent in inpatients, as opposed to outpatients; are less likely to occur in milder than in more severe major depressive episodes; and are more likely to occur in individuals with psychotic features.
With atypical features: This specifier is applied when these features predominate during the majority of days of the current major depressive episode (or the most recent major depressive episode if bipolar I or bipolar II disorder is currently in partial or full remission).
A. B.
Mood reactivity (i.e., mood brightens in response to actual or potential positive events).
Two (or more) of the following:
1. Significant weight gain or increase in appetite.
2. Hypersomnia.
3. Leaden paralysis (i.e., heavy, leaden feelings in arms or legs).
4. A long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment.
C. Criteria are not met for “with melancholic features” or “with catatonia” during the same episode.
Note: “Atypical depression” has historical significance (i.e., atypical in contradistinction to the more classical agitated, “endogenous” presentations of depression that were the norm when depression was rarely diagnosed in outpatients and almost never in adolescents or younger adults) and today does not connote an uncommon or unusual clinical presentation as the term might imply.
Mood reactivity is the capacity to be cheered up when presented with positive events (e.g., a visit from children, compliments from others). Mood may become euthymic (not sad) even for extended periods of time if the external circumstances remain favorable. Increased appetite may be manifested by an obvious increase in food intake or by weight gain. Hypersomnia may include either an extended period of nighttime sleep or daytime napping that totals at least 10 hours of sleep per day (or at least 2 hours more than when not depressed). Leaden paralysis is defined as feeling heavy, leaden, or weighted down, usually in the arms or legs. This sensation is generally present for at least an hour a day but often lasts for many
173
hours at a time. Unlike the other atypical features, pathological sensitivity to perceived interpersonal rejection is a trait that has an early onset and persists throughout most of adult life. Rejection sensitivity occurs both when the person is and is not depressed, though it may be exacerbated during depressive periods.
With psychotic features: Delusions or hallucinations are present at any time in the current manic or major depressive episode in bipolar I disorder (or the most recent manic or major depressive episode if bipolar I disorder is currently in partial or full remission) or in the current major depressive episode in bipolar II disorder (or the most recent major depressive episode if bipolar II disorder is currently in partial or full remission). If psychotic features are present, specify if mood-congruent or mood-incongruent:
When applied to current or most recent manic episode (in bipolar I disorder):
With mood-congruent psychotic features: The content of all delusions and hallucinations is consistent with the typical manic themes of grandiosity, invulnerability, etc., but may also include themes of suspiciousness or paranoia, especially with respect to others’ doubts about the individual’s capacities, accomplishments, and so forth.
With mood-incongruent psychotic features: The content of the delusions and hallucinations does not involve typical manic themes as described above, or the content is a mixture of mood-incongruent and mood-congruent themes.
When applied to current or most recent major depressive episode (in bipolar I disorder or bipolar II disorder):
With mood-congruent psychotic features: The content of all delusions and hallucinations is consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment.
With mood-incongruent psychotic features: The content of the delusions and hallucinations does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment, or the content is a mixture of mood-incongruent and mood-congruent themes.
With catatonia: This specifier is applied to the current manic or major depressive episode in bipolar I disorder (or the most recent manic or major depressive episode if bipolar I disorder is currently in partial or full remission) or to the current major depressive episode in bipolar II disorder (or the most recent major depressive episode if bipolar II disorder is currently in partial or full remission) if catatonic features are present during most of the episode. See criteria for catatonia associated with a mental disorder in the chapter “Schizophrenia Spectrum and Other Psychotic Disorders.”
With peripartum onset: This specifier is applied to the current manic, hypomanic, or major depressive episode in bipolar I disorder (or the most recent manic, hypomanic, or major depressive episode if bipolar I disorder is currently in partial or full remission) or to the current hypomanic or major depressive episode in bipolar II disorder (or the most recent hypomanic or major depressive episode if bipolar II disorder is currently in partial or full remission) if onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery.
Note: Mood episodes can have their onset either during pregnancy or postpartum. About 50% of postpartum major depressive episodes begin prior to delivery. Thus, these episodes are referred to collectively as peripartum episodes.
Between conception and birth, about 9% of women will experience a major depressive episode. The best estimate for prevalence of a major depressive episode between birth and 12 months postpartum is just below 7%.
Peripartum-onset mood episodes can present either with or without psychotic features. Infanticide (a rare occurrence) is most often associated with postpartum
174
psychotic episodes that are characterized by command hallucinations to kill the infant or delusions that the infant is possessed, but psychotic symptoms can also occur in severe postpartum mood episodes without such specific delusions or hallucinations.
Postpartum mood (major depressive or manic) episodes with psychotic features appear to occur in from 1 in 500 to 1 in 1,000 deliveries and may be more common in primiparous women. The risk of postpartum episodes with psychotic features is particularly increased for women with prior postpartum psychotic mood episodes but is also elevated for those with a prior history of a depressive or bipolar disorder (especially bipolar I disorder) and those with a family history of bipolar disorders.
Once a woman has had a postpartum episode with psychotic features, the risk of recurrence with each subsequent delivery is between 30% and 50%. Postpartum episodes must be differentiated from delirium occurring in the postpartum period, which is distinguished by a fluctuating level of awareness or attention.
Peripartum-onset depressive disorders must be distinguished from the much more common “maternity blues,” or what is known in lay terms as “baby blues.” Maternity blues is not considered to be a mental disorder and is characterized by sudden changes in mood (e.g., the sudden onset of tearfulness in the absence of depression) that do not cause functional impairment and that are likely caused by physiological changes occurring after delivery. It is temporary and self-limited, typically improving quickly
(within a week) without the need for treatment. Other symptoms of maternity blues include sleep disturbance and even confusion that can occur shortly after delivery.
Perinatal women may be at higher risk for depressive disorders due to thyroid abnormalities as well as other medical conditions that can cause depressive symptoms. If the depressive symptoms are judged to be due to another medical condition related to the perinatal period, depressive disorder due to another medical condition should be diagnosed instead of a major depressive episode, with peripartum onset.
With seasonal pattern: This specifier applies to the lifetime pattern of mood episodes. The essential feature is a regular seasonal pattern of at least one type of episode (i.e., mania, hypomania, or depression). The other types of episodes may not follow this pattern. For example, an individual may have seasonal manias but have depressions that do not regularly occur at a specific time of year.
A. There has been a regular temporal relationship between the onset of manic, hypomanic, or major depressive episodes and a particular time of the year (e.g., in the fall or winter) in bipolar I or bipolar II disorder.
Note: Do not include cases in which there is an obvious effect of seasonally related psychosocial stressors (e.g., regularly being unemployed every winter).
B. Full remissions (or a change from major depression to mania or hypomania or vice versa) also occur at a characteristic time of the year (e.g., depression disappears in the spring).
C. In the last 2 years, the individual’s manic, hypomanic, or major depressive episodes have demonstrated a temporal seasonal relationship, as defined above, and no nonseasonal episodes of that polarity have occurred during that 2-year period.
D. Seasonal manias, hypomanias, or depressions (as described above) substantially outnumber any nonseasonal manias, hypomanias, or depressions that may have occurred over the individual’s lifetime.
Note: The specifier “with seasonal pattern” can apply to the pattern of major depressive episodes in bipolar I and bipolar II disorder, to the pattern of manic episodes
175
and hypomanic episodes in bipolar I disorder, and to the pattern of hypomanic episodes in bipolar II disorder. The essential feature is the onset and remission of major depressive, manic, or hypomanic episodes at characteristic times of the year. In most cases, the seasonal major depressive episodes begin in fall or winter and remit in spring. Less commonly, there may be recurrent summer depressive episodes. This
pattern of onset and remission of episodes must have occurred during at least a 2-year period, without any nonseasonal episodes occurring during this period. In addition, the seasonal depressive, manic, or hypomanic episodes must substantially outnumber any nonseasonal depressive, manic, or hypomanic episodes over the individual’s lifetime.
This specifier does not apply to those situations in which the pattern is better explained by seasonally linked psychosocial stressors (e.g., seasonal unemployment or school schedule). It is unclear whether a seasonal pattern of major depressive episodes is more likely in recurrent major depressive disorder or in bipolar disorders. However, within the bipolar disorders group, a seasonal pattern of major depressive episodes appears to be more likely in bipolar II disorder than in bipolar I disorder. In some individuals, the onset of manic or hypomanic episodes may also be linked to a particular season, with peak seasonality of mania or hypomania from spring through summer. The prevalence of winter-type seasonal pattern appears to vary with latitude, age, and sex. Prevalence increases with higher latitudes. Age is also a strong predictor of seasonality, with younger persons at higher risk for winter depressive episodes.
Specify if:
In partial remission: Symptoms of the immediately previous manic, hypomanic, or major depressive episode are present but full criteria are not met, or there is a period lasting less than 2 months without any significant symptoms of a manic, hypomanic, or major depressive episode following the end of such an episode.
In full remission: During the past 2 months, no significant signs or symptoms of the disturbance were present.
Specify current severity of manic episode:
Severity is based on the number of criterion symptoms, the severity of those
symptoms, and the degree of functional disability.
Mild: Minimum symptom criteria are met for a manic episode.
Moderate: Very significant increase in activity or impairment in judgment.
Severe: Almost continual supervision is required in order to prevent physical harm to self or others.
Specify current severity of major depressive episode:
Severity is based on the number of criterion symptoms, the severity of those
symptoms, and the degree of functional disability.
Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, the intensity of the symptoms is distressing but manageable, and the symptoms result in minor impairment in social or occupational functioning.
Moderate: The number of symptoms, intensity of symptoms, and/or functional impairment are between those specified for “mild” and “severe.”
Severe: The number of symptoms is substantially in excess of that required to make the diagnosis, the intensity of the symptoms is seriously distressing and
unmanageable, and the symptoms markedly interfere with social and occupational functioning.
176
neural correlates of bp
Emotional control circuit
amygdala hyperactivated in manic states- reduced ventrolateral pfc activity shown across manic depressed and euthmic states and may be traitlike characteristic bp disorder
