The video below is the section for Bipolar Disorder from Part 1 of TSM’s lecture series on DSM-5 and the EPPP, followed by a transcript. This lecture series aims to equip those preparing for the EPPP with everything you need to know about the impact DSM-5 will be having on the EPPP. To watch all of Part 1, click here.
Transcript of DSM-5 EPPP Lecture Video: Bipolar Disorder
The term Bipolar Disorder generally refers to either Bipolar I or Bipolar II Disorder.
Bipolar I: Bipolar I Disorder is a Mood Disorder characterized by a history of at least one manic episode but may have been preceded by or followed by hypomanic or major depressive episodes.
The DSM-5 defines a Manic Episode as a “distinct period of abnormally and persistently elevated, expansive, or irritable mood” that involves symptoms such as grandiosity, decreased need for sleep, flights of ideas, feeling that one’s thoughts are racing, pressured speech, increased talkativeness, distractibility, increased goal-directed activities, and high levels of engagement in pleasurable but risky activities (e.g., gambling, sex with multiple partners).
These symptoms must last for at least one week, or be severe enough to require hospitalization, in order to qualify as a Manic Episode. Symptoms must also cause a significant impairment in functioning. Environmental stressors have been found to be more instrumental in triggering the first or second episodes of Bipolar I Disorder than they are in later episodes.
Bipolar I Disorder is characterized diagnostically by the current or most recent mood episode, which can be Manic episode, Hypomanic episode, or Major Depressive episode.
The current or most recent episode is further described according to severity of symptoms (mild, moderate, or severe) or according to course if full criteria for episode is not met (with psychotic features, in partial remission, in full remission, or unspecified).
There are several additional descriptive specifiers:
- with anxious distress: (also coded as mifld, moderate, moderate-to-severe, and severe, depending on the number of the symptoms listed that are present);
- with Mixed Features: when an individual’s mood fluctuates rapidly, so that he or she meets diagnostic criteria (save for duration) for both Manic and Major Depressive Episodes for at least one week. Individuals with Mixed Features may be agitated, have difficulty sleeping, demonstrate changes in appetite, and experience psychosis or suicidal ideation.
- with rapid cycling: presence of four or more mood episodes in the previous 12 months that meet criteria for manic, hypomanic, or major depressive episode.
- with melancholic features: when there is prominent anhedonia (loss of pleasure in all, or almost all, activities), and a distinct quality of depressed mood.
- with atypical features: presence of mood reactivity and other atypical symptoms, and when these symptoms neither meet diagnostic criteria for “with melancholia” nor for “with catatonia.”
- with mood-congruent psychotic features: when the content of delusions and/or hallucinations is consistent with typical manic themes.
- with mood-incongruent psychotic features: when the content of delusions and/or hallucinations is inconsistent with the typical themes for that polarity of mood episode (manic or depressive), or the content is a mixture of mood-congruent and mood-incongruent themes.
- with catatonia: when catatonic features are present. (Catatonia is a state of apparent unresponsiveness to external stimuli in a person who is apparently awake, and includes characteristic psychomotor symptoms) .
- with peripartum onset: described the onset of mood episode, whether manic, hypomanic, or major depressive, occurs during pregnancy or in the four weeks following delivery.
- with seasonal pattern: characterized by a regular seasonabl pattern of at least one type of episode. This specifier is applied to a lifetime pattern of mood episodes.
Bipolar II: In order to be diagnosed with Bipolar II Disorder, an individual must have a history of one or more Major Depressive Episodes, in addition to at least one Hypomanic Episode. An individual may not be diagnosed with Bipolar II Disorder if he or she has ever experienced a Manic Episode. If an individual with Bipolar II Disorder experiences a Manic Episode, his/her diagnosis will then be permanently changed to Bipolar I.
A Hypomanic Episode involves expansive, elevated, or irritated mood for at least four consecutive days and includes the same symptoms manifested during a Manic Episode.
The difference pertains to symptom severity: unlike Manic Episodes, Hypomanic Episodes do not cause significant impairment in social or occupational functioning, do not require hospitalization, and do not include psychotic features. Increased creativity and productive, goal-driven behavior is associated with Bipolar Disorder, more specifically with hypomania and cyclothymia.
Although there is only one diagnostic code for Bipolar II Disorder, specifiers (similar to those used in Bipolar I Disorder) are to be noted, describing the characteristics present in the clinical presentation.
- Specify severity of symptoms: mild, moderate, or severe
- Specify current or most recent episode: hypomanic or depressed
- Specify if: with anxious distress, with mixed features, with rapid cycling, with catatonia (associated with depression), with peripartum onset, with seasonal pattern.
- Specify course: in partial remission, in full remission
Bipolar Disorders are highly likely to be cyclic and recurrent and need to be differentiated from Cyclothymic Disorder.
Cyclothymic disorder is a Mood Disorder featured by chronic fluctuation between periods of hypomanic symptoms and periods of depressive symptoms.
A diagnosis of cyclothymic disorder is made only if there is a two-year period (one-year period for children) of cyclothymic symptoms without the presence of Major Depressive, Manic, and Hypomanic Episodes. The diagnosis cannot be made if the pattern of mood swings is better accounted for by schizoaffective Disorder, or accompanied by a Psychotic Disorder. In addition, fluctuations in mood must not be substance/medication-induced.
Cyclothymic Disorder is equally common between men and women, but women are more likely than men to seek treatment. cyclothymic Disorder usually begins early in life, during adolescence or early adult life, and is often considered to reflect a predisposition to other Mood Disorders. There is a 15-50% risk that a person diagnosed with Cyclothymic Disorder will develop Bipolar I or II disorder.
Cyclothymic Disorder must be distinguished from a Mood Disorder Due to a Another Medical Condition, a Substance-Induced Mood Disorder, Bipolar I and II, and Borderline Personality Disorder.
Bipolar I Disorder, with a lifetime prevalence rate about 0.6%, is more common than Bipolar II Disorder, which has a lifetime prevalence rate of approximately 0.3% internationally and 0.8% in the United States. Compared to Major Depressive Disorder, Bipolar I and Bipolar II Disorders typically begin more acutely and have an earlier age of onset (average: approximately age 20). Bipolar Disorder rarely develops after the age of 40.
Bipolar I Disorder is equally common in men and women, while Bipolar II Disorder may be more prevalent in women. In both disorders, sex is related to the type and frequency of episodes. Men tend to experience as many if not more Manic Episodes (in Bipolar I Disorder) or Hypomanic Episodes (in Bipolar II Disorder) than Major Depressive Episodes. Women, however, typically experience more Major Depressive Episodes than Manic or Hypomanic Episodes.
Women are more likely than men to experience rapid cycling (i.e., four or more Major Depressive, Manic, or Hypomanic Episodes during a 12-month period) in both Bipolar I and Bipolar II Disorders.
Bipolar disorder may account for one-quarter of all completed suicides. Completed suicide occurs in approximately 10 percent to 15 percent of individuals with Bipolar I and Bipolar II Disorder who are not treated; serious attempts may approach 50 percent. Suicide is most likely to occur during a Major Depressive or Mixed Episode of the disorder. Research indicates the greatest risk for suicide is when an individual’s depressive symptoms are beginning to lift, as increased energy levels may allow for the planning and carrying out of suicidal acts.
Lithium or other mood stabilizers are the preferred method of treatment for Bipolar Disorder, as they tend to stabilize or at least diminish manic or depressive symptoms as well as recurrent mood swings. Lithium has the longest track record.
In cases where lithium is ineffective or side effects cannot be tolerated, anti-seizure medications such as carbamazepine (Tegretol) or divalproex (Depakote) may be employed. The anticonvulsant lamotrigine (Lamictal) may be particularly effective for bipolar depression. Second-generation antipsychotic medications are also approved for Bipolar Disorder. Antidepressants are generally inappropriate for treating Bipolar Disorder because they can be capable of triggering a Hypomanic or Manic Episode, although there may be times antidepressant medication will be used in combination with a mood stabilizer or even an antipsychotic medication.
Medication compliance is a particular problem in Bipolar Disorder because some clients may be unwilling to give up the intensely pleasurable states associated with Manic Episodes. Successful medication treatment helps prevent suicide.
The addition of psychosocial interventions (e.g., cognitive-behavioral therapy, psychoeducation, social rhythm therapy) may increase medication compliance. Psychosocial interventions are also associated with increased mood stability, fewer hospitalizations, and increased personal functioning.
- Bipolar I Disorder is diagnosed in the presence of at least one Manic Episode (depressions often occur as well, but are not necessary for diagnosis)
- Bipolar II Disorder is diagnosed in the presence of at least one Hypomanic Episode as well as one or more Major Depressive Episodes; never meets criteria for Manic Episode
- Bipolar I and II Disorders highly likely to be recurrent/cyclic
- Average age of onset: approximately 20 years old
- Hypomanic and Manic Episodes share features of elevated or irritable mood, grandiosity, decreased need for sleep, flight of ideas, racing thoughts, pressured speech, increased talkativeness, distractibility, increased goal-directed activities, and high levels of engagement in pleasurable but risky activities (e.g., gambling, sex with multiple partners)a. Key distinction: Hypomanic Episodes are not characterized by major impairments in social or occupational functioning, do not require hospitalization, and do not incur psychosis and may result in increased creativity and productive, goal-directed behavior.
- Cyclothymic Disorder: two years of fluctuating hypomanic and depressive symptoms without meeting full criteria for hypomanic or major depressive episodes.
1. Bipolar I Disorder lifetime prevalence rate about 0.6%
2. Bipolar II disorder: lifetime prevalence rate about 0.3% internationally and 0.8% in the United States.
3. Men and women equally likely to develop Bipolar I Disorder; women, more likely to
develop Bipolar II Disorder
4. Men have more Manic and Hypomanic episodes; wome have more Major Depressive
5. Completed suicides among people with untreated Bipolar Disorders between
10-15%; serious attempts is around 50%
1. Mood stabilizing medications (including lithium, anticonvulsives and second generation antipsychotics)
3. Social rhythm therapy
A Manic Episode is best differentiated from a Hypomanic Episode by:
A. the presence of an elevated mood during Manic Episodes but not during Hypomanic Episodes.
B. an increase in goal-directed activities with Manic Episodes but not with Hypomanic Episodes.
C. the significantly impaired functioning caused by Manic Episodes but not by Hypomanic Episodes.
D. the decreased need for sleep with Manic Episodes but not with Hypomanic Episodes.
RATIONALE: C is correct, as a Manic Episode is indexed by the levels of impairment that characterize the mood episode.
Manic episodes have significant impairment, while hypomanic episodes are less severe and the person may still function rather well. A is incorrect, as an elevated mood can be present in both Manic and Hypomanic Episodes. B is incorrect, as Hypomania is characterized by increases in goal-directed activities. D is incorrect, as both Manic and Hypomanic Episodes are characterized with a decreased need for sleep.