Mood Disorders: Bipolar I

Bipolar Disorders - General

• First characterized by Kraepelin

• The presence of manic or hypomanic episodes

  • Abnormally and persistently elevated, expansive,
    or irritable mood, and abnormally and persistently increased activity
    or energy

• Usually (~70%) mania immediately precede / follow depressive periods

• Manic episodes tend to be ~3X shorter than depressive bouts (2-3
  moths)

• When a bipolar individual is between episodes but not experiencing
  symptoms of either depression or mania, that is referred to as euthymic

How are depressive episodes different in bipolar disorders compared to depressive disorders?

• Depressive episodes in BD= mood lability, psychotic
  features, psychomotor retardation, substance abuse (NOT IN DMS)
  

• Depressive episodes in MDD= anxiety, agitation,
  insomnia, weight loss

Manic and Hypomanic Episodes: Diagnostic Criteria

1. Inflated self-esteem or grandiosity (unrealistic sense of superiority).

2. Decreased need for sleep.
   - This is different than insomnia (this is a source of unreliability when diagnosing –
   important)

3. More talkative.

4. Flight of ideas or subjective experience that thoughts are racing.

5. Distractibility

6. Increase in goal-directed activity or 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). “value judgements”

Manic vs. Hypomanic

Both Include: Abnormally and Persistently elevated, Expansive, or Irritable mood and abnormally

• Manic Episode: lasting at least 1 week and present most of the day, nearly every day

  • abnormally and persistently increased goal-directed activity or energy

  • Causes marked impairment

• Hypomanic Episode: lasting at least 4 consecutive days and present most of the day, nearly every day.

  • Includes abnormally and persistently increased activity or energy

  • Does NOT cause marked impairment

Bipolar I

• Manic episode and also possible hypomania.

• Experiences episodes of mania and can have periods of depression.
  Even if the periods of depression do not reach the threshold for a major
  depressive episode, the diagnosis of bipolar I disorder is still given.

  • i.e. If you have a manic episode, the diagnosis is bipolar I

Bipolar II

• Person experiences hypomanic episodes, but his or her symptoms are below
  the threshold for full-blown mania.

• Person experiences periods of depressed mood that meet the criteria for
  major depression.

  • i.e. Must have hypomania AND major depressive episode

• Usually have more lifetime episodes than BPI

Cyclothymic Disorder

• ≥ 2 years (≥ 1 year in kids/teens) of:

  • Mild hypomanic symptoms (not full episode)

  • Mild depressive symptoms (not full episode)

• Symptoms present at least half the time

• No symptom-free period longer than 2 months

• Causes distress or problems in daily functioning

• Think of it as: long-term, milder mood swings (highs + lows)

Bipolar Spectrum

• Bipolar I:

  • Full mania (may also have depression)

• Bipolar II:

  • Hypomania + major depression

• Cyclothymia:

  • Mild highs + mild lows (not full episodes)

• Key idea:

  • Severity increases: Cyclothymia → Bipolar II → Bipolar I

• Note:

  • Cyclothymia = no full hypomanic or depressive episodes

Bipolar Disorder Specifiers

Specifiers are extra labels added to a diagnosis to describe how the disorder looks in that person. They help show that mood disorders do not look the same in everyone.

Specifiers are extra labels added to a diagnosis to describe how the disorder looks in that person. They help show that mood disorders do not look the same in everyone.

1. With melancholic features

2. With atypical features

3. With catatonic features

4. With seasonal pattern

5. With peripartum onset

6. With anxious distress

7. With psychotic features

8. With mixed features

1. With melancholic features

Depression with:

• loss of pleasure in almost everything

• worse mood in the morning

• not feeling better even when good things happen

• excessive guilt

• waking up very early

2. With atypical features

Mood can improve when good things happen, plus 2 or more of these:

• weight gain or increased appetite

• sleeping too much

• “leaden paralysis” = arms and legs feel very heavy

• very sensitive to rejection

3. With catatonic features

Strong psychomotor symptoms, such as:

• very little movement / immobility

• extreme movement or agitation

• mutism (not speaking)

• rigidity (stiffness)

4. With seasonal pattern

Mood episodes:

• happen at the same time of year for at least 2 years

• usually happen in fall or winter

• full remission usually happens in spring

• there are no nonseasonal episodes during that same 2-year period

5. With peripartum onset

Mood symptoms begin:

• during pregnancy, or

• within 4 weeks after delivery

6. With anxious distress

Person feels:

• keyed up

• distressed

• anxious

• afraid of losing control or that something bad will happen

Note: this is generally the only specifier used for cyclothymia.

7. With psychotic features

There are:

• delusions or

• hallucinations

These are usually mood-congruent, meaning they match the person’s mood.
For example, in depression they often involve themes like:

• guilt

• worthlessness

• death

This can be further described as:

• mood-congruent = psychotic symptoms match the mood

• mood-incongruent = psychotic symptoms do not match the mood

8. With mixed features

This means symptoms of the opposite mood state are also present.

• In depression: there may also be increased energy, elevated/expansive mood, and being very talkative

  • looks somewhat like mania, but not enough to meet full bipolar criteria

• In mania or hypomania: there may also be depressed mood, loss of interest, etc.

  • looks somewhat like depression, but not enough to meet full depressive disorder criteria

Remission specifiers Partial remission

• Some symptoms of the last episode are still present, but full criteria are not met
  or

• there has been a symptom-free period of less than 2 months

Full remission

• For 2 months or more, there have been no significant signs or symptoms

Severity specifiers Mild

• only a few extra symptoms beyond what is needed for diagnosis

• symptoms are upsetting but manageable

• only minor problems in social or work functioning

Moderate

• symptoms and impairment are between mild and severe

Severe

• many more symptoms than the minimum needed for diagnosis

• symptoms are very distressing and hard to manage

• major interference with social or work functioning

Bipolar Disorder: With Rapid Cycling

Rapid cycling means a person has had at least 4 mood episodes in the past 12 months.

These episodes can be:

• manic

• hypomanic

• major depressive

They can happen in any order or combination.

When does one episode count as separate from another?

To count as separate, episodes must be divided by either:

• full remission = at least 2 months with no symptoms
  or

• a switch to the opposite mood state

  • for example, depression switching to mania/hypomania, or the reverse

Important facts

• Females are more likely to have rapid cycling

• It is more common in bipolar II than bipolar I

• It is linked to:

  • earlier onset

  • worse long-term outcome

  • more suicide attempts

How to name a bipolar diagnosis (3 parts)

1) Name the bipolar disorder

• Bipolar I

• Bipolar II

• Cyclothymia

2) Name the current or most recent mood episode

• Manic

• Hypomanic

• Depressed

• Euthymic = currently stable / normal mood

3) Add specifiers

Include:

• severity (mild, moderate, severe)

• psychotic features if present

• remission status if relevant

• any other important specifiers that apply to that episode

Example

Bipolar II disorder, current episode depressed, moderate severity, with mixed features

Can episodes happen more than 4 times per year? Yes.

The DSM says rapid cycling = 4 or more episodes per year, but it does not officially create extra DSM labels beyond that.

Terms some people use (not special official DSM categories):

Ultra-rapid cycling

• mood switches over days to weeks

Ultra-ultra rapid cycling (ultradian)

• mood switches over hours to days

Bipolar Disorder: Rapid Cycling

Rapid cycling means 4 or more separate mood episodes in 1 year.

These episodes can be:

• major depressive episodes (MDE)

• manic episodes

• hypomanic episodes

An episode counts as separate if there is either:

• full remission for 2 months = 2 months with no symptoms
  or

• a switch to the opposite polarity

  • example: depression → mania

  • or mania → depression