Bipolar disorder Flashcards
What characterises bipolar disorder?
Bipolar disorder is characterised by episodes of mania or hypomania and depression
How is depression charcterised within the bipolar disorder diagnosis?
Depression in bipolar disorder has the same diagnostic criteria as in unipolar major depression.
Bipolar I Disorder (DSM5)
At least one manic episode. Manic and depressive episodes
are not better explained by another disorder (e.g. a schizophrenia spectrum
disorder).
Bipolar II Disorder (DSM5)
One or more episodes of both hypomania and depression, but no manic episodes, which together cause clinically significant distress or functional impairment. Episodes are not better explained by another disorder (e.g. a schizophrenia spectrum disorder).
Hypomanic episode (DSM5)
A.
A distinct period of abnormally and persistently elevated, expansive or
irritable mood and abnormally and persistently increased goal-directed 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 or activity, 3 (or
more) of the following symptoms (4 if the mood is only irritable) are present
to a significant degree and represent a noticeable change from usual behaviour
and have been present to a significant degree:
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep
3. More talkative than usual or pressured speech
4. Flight of ideas or racing thoughts
5. Distractibility
6. Increased goal-directed activity or psychomotor agitation
7. Excessive involvement in activities that have a high potential for painful
consequences (e.g. buying sprees or sexual indiscretion)
C. The episode is associated with an unequivocal change in functioning that is
uncharacteristic of the individual when not symptomatic.
D. The mood disturbance and change in functioning is observed by others.
E. Does not cause marked functional impairment, psychotic features or
hospitalization.
F. Not due to the physiological effects of a substance, or a medical condition
(although may be precipitated by antidepressants or ECT).
Criteria for a depressive episode are given in Table 9.1.
Manic episode (DSM5)
A.
A distinct period of abnormally and persistently elevated, expansive or
irritable mood and abnormally and persistently increased goal-directed activity
or energy lasting at least a 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, 3
(or more) of the following symptoms (4 if the mood is only irritable) are
present to a significant degree and represent a noticeable change from usual
behaviour:
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep
3. More talkative than usual or pressured speech
4. Flight of ideas or racing thoughts
5. Distractibility
6. Increased goal-directed activity or psychomotor agitation
7. Excessive involvement in activities that have a high potential for painful
consequences (e.g. buying sprees or sexual indiscretion)
C. Causes functional impairment or leads to hospitalization to prevent harm to
self or others, or there are psychotic features.
D. Not due to the physiological effects of a substance, or a medical condition
(although may be precipitated by antidepressants or ECT)
Bipolar disorder (ICD10)
Bipolar disorder is characterized by repeated (i.e. at least two) episodes in
which the patient’s mood and activity levels are significantly disturbed,
this disturbance consisting on some occasions of an elevation of mood
and increased energy and activity (mania or hypomania), and on others
of a lowering of mood and decreased energy and activity (depression).
Characteristically, recovery is usually complete between episodes, and
the incidence in the two sexes is more nearly equal than in other mood
disorders. As patients who suffer only from repeated episodes of mania
are comparatively rare, and resemble (in their family history, premorbid
personality, age of onset and long-term prognosis) those who also have
at least occasional episodes of depression, such patients are classified as bipolar. Manic episodes usually begin abruptly and last for between 2 weeks
and 4–5 months (median duration about 4 months). Depressions tend to
last longer (median length about 6 months), though rarely for more than
a year, except in the elderly. Episodes of both kinds often follow stressful
life events or other mental trauma, but the presence of such stress is not essential for the diagnosis. The first episode may occur at any age. The frequency of episodes and the pattern of remissions and relapses are both very variable, though remissions tend to get shorter as time goes on and
depressions to become commoner and longer lasting after middle age.
What kind of manic episodes does ICD10 distinguish between?
Distinctions are made between hypomania, mania and mania with psychotic
symptoms, mixed episodes and depressive episodes
Manic episode (ICD10)
Mood is elevated out of keeping with the individual’s circumstances
and may vary from carefree joviality to almost uncontrollable excitement.
Elation is accompanied by increased energy, resulting in overactivity,
pressure of speech and a decreased need for sleep. Normal social
inhibitions are lost, attention cannot be sustained and there is often
marked distractibility.
Self-esteem is inflated, and grandiose or over-optimistic ideas are freely
expressed. Perceptual disorders may occur, such as the appreciation of
colours as especially vivid (and usually beautiful), a preoccupation with fine
details of surfaces or textures and subjective hyperacusis. The individual
may embark on extravagant and impractical schemes, spend money
recklessly, or become aggressive, amorous or facetious in inappropriate circumstances. In some manic episodes the mood is irritable and suspicious rather than elated. The first attack occurs most commonly between the ages of 15 and 30 years, but may occur at any age. The episode should last for at least 1 week and should be severe enough to disrupt ordinary work and social activities more or less completely. The mood change should be accompanied by increased energy and several of the symptoms referred
to above (particularly pressure of speech, decreased need for sleep, grandiosity and excessive optimism).
Hypomania (ICD10)
Hypomania is a lesser degree of mania, in which abnormalities
of mood and behaviour are too persistent and marked to be included
under cyclothymia but are not accompanied by hallucinations or delusions.
There is a persistent mild elevation of mood (for at least several days on
end), increased energy and activity, and usually marked feelings of well-being
and both physical and mental efficiency. Increased sociability, talkativeness, overfamiliarity, increased sexual energy and a decreased need for sleep are
often present, but not to the extent that they lead to severe disruption of
work or result in social rejection. Irritability, conceit and boorish behaviour
may take the place of the more usual euphoric sociability. Concentration
and attention may be impaired, thus diminishing the ability to settle
down to work or to relaxation and leisure, but this may not prevent the appearance of interests in quite new ventures and activities, or mild overspending. Hypomania covers the range of disorders of mood and level of activities between cyclothymia and mania.
The increased activity and
restlessness (and often weight loss) must be distinguished from the same
symptoms occurring in hyperthyroidism and anorexia nervosa; early states
of ‘agitated depression’ may bear a superficial resemblance to hypomania of
the irritable variety.
Mania with psychotic symptoms (ICD10)
The clinical picture is that of a more
severe form of mania as described above. Inflated self-esteem and grandiose
ideas may develop into delusions, and irritability and suspiciousness into
delusions of persecution. In severe cases, grandiose or religious delusions
of identity or role may be prominent, and flight of ideas and pressure of
speech may result in the individual becoming incomprehensible. Severe
and sustained physical activity and excitement may result in aggression or
violence, and neglect of eating, drinking and personal hygiene may result in dangerous states of dehydration and self-neglect. One of the commonest
problems is differentiation of this disorder from schizophrenia, particularly
if the stages of development through hypomania have been missed and the
patient is seen only at the height of the illness when widespread delusions,
incomprehensible speech and violent excitement may obscure the basic
disturbance of affect. Patients with mania that is responding to neuroleptic
medication may present a similar diagnostic problem at the stage when
they have returned to normal levels of physical and mental activity but still
have delusions or hallucinations.
Mixed episode (ICD10)
Although the most typical form of bipolar disorder consists of alternating manic and depressive episodes separated by periods of normal mood, it is not uncommon for depressive mood to be accompanied
for days or weeks on end by overactivity and pressure of speech, or for a
manic mood and grandiosity to be accompanied by agitation and loss of
energy and libido. Depressive symptoms and symptoms of hypomania or
mania may also alternate rapidly, from day to day or even from hour to
hour.
What is the prevalence rate of bipolar disorder?
Prevalence studies in the UK, continental Europe and the US indicate a prevalence rate of 1–1.9% of clients meeting formal diagnostic criteria for bipolar disorder
Are there any disagreements about the prevalence rate? What do they imply?
Angst and colleagues have argued that in fact current diagnostic criteria for bipolar disorder incorrectly exclude people with illnesses that fit within a bipolar spectrum; when these clients are included, prevalence rates increase to around 11%. Among these are clients who don’t meet the time-limit criteria.
Historically bipolar disorder was seen as being characterised by periods of mania and depression interspersed with periods of ‘normality’. Is bipolar disorder still viewed this way?
Contrary to this view, Judd and others
have conducted a series of long-term follow-up studies in which individuals with bipolar I and II disorders spend 32–50% of time between episodes experiencing significant mood symptoms, primarily depression-relatedistorically bipolar disorder was seen as being characterised by periods of mania and depression interspersed with periods of ‘normality’. Contrary to this view, Judd and others
have conducted a series of long-term follow-up studies in which individuals with bipolar I and II disorders spend 32–50% of time between episodes experiencing significant mood symptoms, primarily depression-related.
(Bonus: we call this subsyndromal symptomes; symptomes that indicate a disorder, but doesn’t meet the criteria of said diagnosis)
