|
| |
Bipolar I Disorder
DSM IV Criteria
Diagnostic Features
The
essential feature of Bipolar I Disorder is a clinical course that
is characterized by the occurrence of one or more Manic Episodes...or
Mixed Episodes... Often individuals have also had one or
more Major Depressive Episodes...Episodes of Substance-Induced
Mood Disorder (due to the direct effects of a medication, other
somatic treatments for depression, a drug of abuse, or toxin exposure)
or of Mood Disorder Due to a General Medical Condition do not
count toward a diagnosis of Bipolar I Disorder. In addition, the
episodes are not better accounted for by Schizoaffective Disorder
and are not superimposed on Schizophrenia, Schizophreniform Disorder,
Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
Bipolar I Disorder is subclassified in the fourth digit of the
code according to whether the individual is experiencing a first
episode (i.e., Single Manic Episode) or whether the disorder is
recurrent. Recurrence is indicated by either a shift in the polarity
of the episode or an interval between episodes of at least 2 months
without manic symptoms. A shift in polarity is defined as a clinical
course in which a Major Depressive Episode evolves into a Manic
Episode or a Mixed Episode or in which a Manic Episode or a Mixed
Episode evolves into a Major Depressive Episode. In contrast,
a Hypomanic Episode that evolves into a Manic Episode or a Mixed
Episode, or a Manic Episode that evolves into a Mixed Episode
(or vice Versa), is considered to be only a single episode. For
recurrent Bipolar I Disorders, the nature of the current (or most
recent) episode can be specified (Most Recent Episode Hypomanic,
Most Recent Episode Manic, Most Recent Episode Mixed, Most Recent
Episode Depressed, Most Recent Episode Unspecified).
Specifiers
The
following specifiers for Bipolar I Disorder can be used to describe
the current Manic, Mixed, or Major Depressive Episode (or, if
criteria are not currently met for a Manic, Mixed, or Major Depressive
Episode, the recent Manic, Mixed, or Major Depressive Episode):
Mild, Moderate, Severe Without Psychotic Features, Severe With
Psychotic Features, In Partial Remission, In Full Remission...
With Catatonic
Features...
With Postpartum
Onset...
The following specifiers apply only to the current (or most recent)
Major Depressive Episode only if it is the most recent type of
mood episode:
Chronic...
With
Melancholic Features...
With
Atypical Features...
The following specifiers can be used to indicate the pattern
of episodes:
Longitudinal Course Specifiers (With or Without Full Interepisode
Recovery)...
With Seasonal Pattern (applies only to the pattern of Major Depressive
Episodes)...
With Rapid Cycling...
Recording
Procedures
The
diagnostic codes for Bipolar I Disorder are selected as follows:
1.
The first three digits are 296.
2. The fourth digit is 0 if there is a single Manic Episode. For
recurrent episodes, the fourth digit is 4 if the current or most
recent episode is a Hypomanic Episode or a Manic Episode, 6 if
it is a Mixed Episode, 5 if it is a Major Depressive Episode,
and 7 if the current or most recent episode is Unspecified.
3. The fifth digit (except for Bipolar I Disorder, Most Recent
Episode Hypomanic, and Bipolar I Disorder, Most Recent Episode
Unspecified) indicates the following: 1 for Mild severity, 2 for
Moderate severity, 3 for Severe Without Psychotic Features, 4
for Severe With Psychotic Features, 5 for in Partial Remission,
6 for in Full Remission, and 0 if Unspecified. Other specifiers
for Bipolar I Disorder cannot be coded. For Bipolar I Disorder,
Most Recent Episode Hypomanic, the fifth digit is always 0. For
Bipolar Disorder, Most Recent Episode Unspecified, there
is no fifth digit.
In
recording the name of a diagnosis, terms should be listed in the
following order: Bipolar I Disorder, specifiers coded in the fourth
digit (e.g., Most Recent Episode Manic), specifiers coded in the
fifth digit (e.g., Mild, Severe With Psychotic Features, In Partial
Remission), as many specifiers (without codes) as apply to the
course of episodes (e.g., With Rapid Cycling); for example, 296.54
Bipolar I Disorder, Most Recent Episode Depressed, Severe With
Psychotic Features, With Melancholic Features, With Rapid Cycling.
Note
that if the single episode of Bipolar I Disorder is a Mixed Episode,
the diagnosis would be indicated as 296.0x Bipolar I Disorder,
Single Manic Episode, Mixed.
Associated
Features and Disorders
Associated
descriptive features and mental disorders.
Completed suicide occurs in 10% - 15% of individuals with Bipolar
I Disorder. Child abuse, spouse abuse, or other violent behavior
may occur during severe Manic Episodes or during those with psychotic
features. Other associated problems include school truancy, school
failure, occupational failure, divorce, or episodic antisocial
behavior. Other associated mental disorders include Anorexia Nervosa,
Bulimia, Nervosa, Attention-Deficit/Hyperactivity Disorder, Panic
Disorder, Social Phobia, Substance - Related Disorders.
Associated
laboratory findings. There appears to be no laboratory features
that distinguish Major Depressive Episodes found in Major Depressive
Disorder from those in Bipolar I Disorder.
Associated
physical examination finding and general medication conditions.
An age at onset for a first Manic Episode after age 40 year should
alert the clinician to the possibility that the symptoms may be
due to a general medical condition or substance use. There is
some evidence that untreated thyroid disease worsens the prognosis
of bipolar I Disorder.
Specific
Culture, Age, and Gender Features
There
are no reports of differential incidence of Bipolar I Disorder
based on race or ethnicity. There is some evidence that clinicians
may have a tendency to overdiagnose Schizophrenia (instead of
Bipolar Disorder) in some ethnic groups and in younger individuals.
Approximately
10% - 15% of adolescents with recurrent Major Depressive Episodes
will go on to develop Bipolar I Disorder. Mixed Episodes Appear
to be more likely in adolescents and young adults than in older
adults.
Recent
epidemiological studies in the United States indicate that Bipolar
I Disorder is approximately equally common in men and women (unlike
Major Depressive Disorder, which is more common in women). Gender
appears to be related to the order of appearance of Manic and
Major Depressive Episodes. The first episode in males is more
likely to be a Manic Episode. The first episode in females is
more likely to be a Major Depressive Episode. Women with Bipolar
I Disorder have an increased risk of developing subsequent episodes
(often psychotic) in the immediate postpartum period. Some women
have their first episode during the postpartum period. The specifier
With Postpartum Onset may be used to indicate that the onset of
the episode is within 4 weeks of delivery...The Premenstrual period
may be associated with worsening of an ongoing Major Depressive,
Manic, Mixed, or Hypomanic Episode.
Prevalence
The
lifetime prevalence of Bipolar I Disorder in community samples
has varied from 0.4% to 1.6%.
Course
Bipolar
I Disorder is a recurrent disorder - more than 90% of individuals
who have a single Manic Episode go on to have future episodes.
Roughly 60% - 70% of Manic Episodes occur immediately before or
after a Major Depressive Episode. Manic Episodes often precede
or follow the Major Depressive Episodes in a characteristic pattern
for a particular person. The number of lifetime episodes (both
Manic and Major Depressive) tends to be higher for Bipolar I Disorder
compared with Major Depressive Disorder, Recurrent, Studies of
course of Bipolar I Disorder compared with Major Depressive Disorder,
Recurrent. Studies of the course of Bipolar I Disorder prior to
lithium maintenance treatment suggest that, on average, four episodes
occur in 10 years. The interval between episodes tends to decrease
as the individual ages. There is some evidenced that changes in
sleep-wake schedule such as occur during time zone changes or
sleep deprivation may precipitate or exacerbate a Manic, Mixed,
or Hypomanic Episode. Approximately 5% - 15% of individuals with
Bipolar I Disorder have multiple (four or more) mood episodes
(Major Depressive, Manic, Mixed, or Hypomanic) that occur within
a given year. if this pattern is present, it is noted by the specifier
With Rapid Cycling...A rapid-cycling pattern is associated with
a poorer prognosis.
Although
the majority of individuals with Bipolar I Disorder return to
a fully functional level between episodes, some (20% - 30%) continue
to display mood lability and interpersonal or occupational difficulties.
Psychotic symptoms may develop after days or weeks in what was
previously a nonpsychotic Manic or Mixed Episode. When an individual
has Manic Episodes with psychotic features, subsequent Manic Episodes
are more likely to have psychotic features. Incomplete interepisode
recovery is more common when the current episode is accompanied
by mood-incongruent psychotic features.
Familial Pattern
First-degree biological relatives of individuals
with Bipolar I Disorder have elevated rates of Bipolar I Disorder
(4%-24%), Bipolar II Disorder (1%-5%), and Major Depressive
Disorder (4%-24%). Twin and adoption studies provide strong
evidence of a genetic influence for Bipolar I Disorder.
Differential Diagnosis
Major Depressive, Manic, Mixed, and Hypomanic
Episodes in Bipolar I Disorder must be distinguished from episodes
of a Mood Disorder Due to a General Medical Condition. The
diagnosis is Mood Disorder Due to a General Medical Condition for
episodes that are judged to be the direct physiological
consequence of a specific general medical condition (e.g.,
multiple sclerosis, stroke, hypothyroidism). This determination is
based on the history, laboratory findings, or physical
examination.
A Substance-Induced Mood Disorder is
distinguished from Major Depressive, Manic, or Mixed Episodes that
occur in Bipolar I Disorder by the fact that a substance (e.g., a
drug of abuse, a medication, or exposure to a toxin) is judged to
be etiologically related to the mood disturbance. Symptoms like
those seen in a Manic, Mixed, or Hypomanic Episode may be part of
an intoxication with or withdrawal from a drug of abuse and should
be diagnosed as a Substance-Induced Mood Disorder (e.g., euphoric
mood that occurs only in the context of intoxication with cocaine
would be diagnosed as Cocaine-Induced Mood Disorder, With Manic
Features, With Onset During Intoxication). Symptoms like those
seen in a Manic or Mixed Episode may also be precipitated by
antidepressant treatment such as medication, electroconvulsive
therapy, or light therapy. such episodes may be diagnosed as a
Substance-Induced Mood Disorder (e.g., Amitriptyline-Induced Mood
Disorder, With Manic Features; Electroconvulsive Therapy - Induced
Mood Disorder, With Manic Features) and would not count toward a
diagnosis of Bipolar I Disorder. however, when the substance use
or medication is judged not to fully account for the episode
(e.g., the episode continues for a considerable period
autonomously after the substance is discontinued), the episode
would count toward a diagnosis of Bipolar I Disorder.
Bipolar I Disorder is distinguished from Major
Depressive Disorder and Dysthymic Disorder by the lifetime
history of at least one Manic or Mixed Episode. Bipolar I Disorder
is distinguished from Bipolar II Disorder by the presence of one
or more Manic or Mixed Episodes. When an individual previously
diagnosed with Bipolar II Disorder develops a Manic or Mixed
Episode, the diagnosis is changed to Bipolar I Disorder.
In Cyclothymic Disorder, there are numerous
periods of hypomanic symptoms that do not meet criteria for a
Manic Episode and periods of depressive symptoms that do not meet
symptom or duration criteria for a Major Depressive Episode.
Bipolar I Disorder is distinguished from Cyclothymic
Disorder by the presence of one or more Manic or Mixed Episodes.
If a Manic or Mixed Episode occurs after the first 2 years of
Cyclothymic Disorder, then Cyclothymic Disorder and Bipolar I
Disorder may both be diagnosed.
The differential diagnosis between Psychotic
Disorders (e.g., Schizoaffective Disorder, Schizophrenia, and
Delusional Disorder) and Bipolar I Disorder may be difficult
(especially in adolescents) because these disorders may share a
number of presenting symptoms (e.g., grandiose and persecutory
delusions, irritability, agitation, and catatonic symptoms),
particularly cross-sectionally and early in their course. In
contrast to Bipolar I Disorder, Schizophrenia, Schizoaffective
Disorder, and Delusional Disorder are all characterized by periods
of psychotic symptoms that occur in the absence of prominent mood
symptoms. Other helpful considerations include the accompanying
symptoms, previous course, and family history, Manic and
depressive symptoms may be present during Schizophrenia,
Delusional Disorder, and Psychotic Disorder Not Otherwise
Specified but rarely with sufficient number, duration and
pervasiveness to meet criteria for a Manic Episode or a Major Depressive
Episode. However, when full criteria are met (or the symptoms are
of particular clinical significance), a diagnosis of Bipolar
Disorder Not Otherwise Specified may be made in addition to
the diagnosis of Schizophrenia, Delusional Disorder, or Psychotic
Disorder Not Otherwise Specified.
If there is a very rapid alternation (over days)
between manic symptoms and depressive symptoms (e.g., several days
of purely manic symptoms followed by several days of purely
depressive symptoms) that do not meet minimal duration criteria
for a Manic Episode or Major Depressive Episode, the diagnosis is Bipolar
Disorder Not Otherwise Specified.
|
