Lecture 8: Natural history and differential diagnosis of bipolar disorder (Workshop)

Question 1

What is the difference between mood disorders and affective disorders?

Answer 1

• Mood disorders: Group of diagnoses in theDSM classification system

• main feature: disturbance in mood
• include: depressive and bipolar disorders

• Affective disorders: set of psychiatric diseases
- include: depression, bipolar, anxiety

Question 2

How did the DSM-5 change the categorisation of BD in comparison to DSM-IV?

Answer 2

• Has a new chapter (no longer a mood disorder), placed between depression and schizophrenia
• “Types” dropped from criteria for BD-I
• New specifiers:
  • “with mixed features” added for manic, hypomanic, and major depressive episode MDD. (Replaces “mixed episodes”)
  • “with anxious distress” added for manic, hypomanic, and major depressive episode MDD.
• Increased activity/energy added as a core mood elevation symptom (criterion A)
• Episode that starts due to antidepressants and persists beyond physiological treatment is diagnosed as mania or hypomania.
• New category: “other specified bipolar and related disorders”
  • Deleted: bipolar disorder not otherwise specified

Question 3

Can bipolar II have psychotic features?

Answer 3

No. If it has, it is by definition manic

Question 4

Time criterion for cyclothymia:

Answer 4

• At least two years, present at least half of the time, and not without symptoms for longer than 2 months
• At least one year (children and adolescents)

Question 5

When is unspecified bipolar and related disorder most used?

Answer 5

• Emergency room settings

- Paediatric bipolar disorder

Question 6

Does the rapid-cycling specifier refer to mood changes within an episode?

Answer 6

No, it refers to four or more mood episodes in the lapse of 12 months

Question 7

How can we distinguish Bipolar I from Schizoaffective disorder?

Answer 7

Schizoaffective disorder: psychotic symptoms occur in absence of mood symptoms

Question 8

How can we distinguish BD-I from Schizophrenia or delusional disorder?

Answer 8

In schizophrenia, psychotic symptoms are dominant and occur without prominent mood episodes

Question 9

How can we distinguish BD-II from cyclothymia?

Answer 9

Cyclothymia does not have hx of major depressive episode

Question 10

How can we distinguish Bipolar II from ADHD?

Answer 10

• ADHD does not have features of elevated mood

Question 11

How can we distinguish cyclothymia from BD-I?

Answer 11

Cyclothymia does not reach mania

Question 12

Roughly, what is the proportion of change from depression to mania / hypomania per year?

Answer 12

1%

Question 13

What role does gender play in BD?

Answer 13

• Females could have more depressive episodes
• Males could have more cyclic episodes

(Angst, 1978)

Question 14

According to Angst, what is the mean BD episode length?

Answer 14

Around 4 months

Other authors:
• Kraepelin: 6 – 8 months

• Panse: 7 for manic and depressive episodes
• Wertham: 4-6 months for mania (first admission)
• Mixed or cycling:
• slower to recover than depressed or manic (pure)
• Perugi: mixed states (13 months) longer than manic (9 months)
• Cyclic: could be shorter, but last episode longer due to chronicity

• Angst: mean 4.3 months

• Pure manic, pure depressive, mixed: 3 months
• Cyclic episodes: 50% longer than pure/mixed states

Question 15

How does the DSM5 intend to help separate BD from other illnesses with similar symptoms, and avoid misdiagnosis?

Answer 15

By adding the increased activity/energy as a core mood elevation symptom (criterion A)

Question 16

Which are the two core MDE features?

Answer 16

• Low mood

- Anhedonia

Question 17

When is the onset of manic episodes?

Answer 17

Early 20s

Question 18

What differentiates hypomania from mania?

Answer 18

• Length of time: 4 days

- Impairment not as severe and does not necessitate hospitalization.

Question 19

Which specifier is the only one not shared by BD and MDE?

Answer 19

rapid cycling

Question 20

Which dx require the low mood criterion?

Answer 20

• MDE
• OS BD: short duration hypomanic episodes and MDE
• OD BD: hypomanic episodes w/insuff symptoms and MDE
• MDD
• Dysthymia
• Substance/medication-induced depressive disorder
• Depressive disorder due to a medical condition
• OS DD (all)
• Schizoaffective (if w/depressive episode)

Question 21

Why do we say that BD is a highly recurrent disorder?

Answer 21

In studies:
- High recurrence for pure mania and higher for mixed cycling

• BDII and BDI could have similar relapse/recurrence
• Timeframe:
  • Fleiss: 80% of BD-I have recurrence in 70 weeks
  • Recovery could be associated with lower recurrence over 4 years but not over 10 years
  • Patients could have relapse/recurrence over 4.3 years even with maintenance pharmacotherapy