Section 1: Recognition and Diagnosis of Bipolar Disorder and Its Spectrum

Section 1:

Recognition and Diagnosis of Bipolar Disorder and Its Spectrum

Spectrum of Bipolar Disorders

• Bipolar I and II

• Hypomania

• Bipolar NOS

• Cyclothymia

• Rapidly changing mood swings

• Major depression with a strong family history of bipolar disorder

• Antidepressant-induced mania and hypomania

• Secondary mania, due to other illness or drugs

Adapted from American Psychiatric Association. Practice Guideline for the Treatment of Patients with Bipolar Disorder. 2nd ed. Washington, DC; 2002.

Bipolar TerminologyA distinct period of abnormally and persistently elevated,

expansive, or irritable mood

• Mania

– Lasting at least 1 week with a significant decline in function

• Hypomania

– Lasting at least 4 days, (clearly different from the usual non-

depressed mood), but without a significant decline in

function and no psychosis

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.

Bipolar Terminology (cont)

• Mixed Episode

– The criteria are met both for a manic episode and for a

major depressive episode (bipolar I disorder)

• Cyclothymia

– Alternating mood states that do not meet full criteria for

depressive, manic, or mixed episode for at least 2 years

• Bipolar NOS

– A mood episode that does not meet specific criteria for

any specific bipolar disorderAmerican Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.

296.80 Bipolar Disorder NOS

1. Very rapid alternation (over days) between manic symptoms and depressive symptoms that meet symptom threshold criteria but not minimal duration criteria for manic, hypomania, or major depressive episodes

2. Recurrent hypomanic episodes without intercurrent depressive symptoms

3. A manic or mixed episode superimposed on delusional disorder, residual schizophrenia, or psychotic disorder not otherwise specified

4. Hypomanic episodes, along with chronic depressive symptoms that are too infrequent to qualify for a diagnosis of cyclothymic disorder

5. Situations in which the clinician has concluded that bipolar disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced

The Bipolar Disorder Not Otherwise Specified category includes disorders with bipolar features that do not meet criteria for any specific bipolar disorder. Examples include:

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.

Diagnostic Criteria for Major Affective Disorders (DSM-IV)

Disorder Depressive EpisodeManic or Mixed

EpisodeHypomanic Episodes

Bipolar I DisorderCommon but not required

≥ 1 required Common but not required

Bipolar II Disorder ≥ 1 required None allowed ≥ 1 required

Bipolar Disorder NOS*

Common but not required

None allowedRequired, but do not meet criteria for a specific bipolar disorder

Cyclothymic Disorder

Dysthymia, but not major depression

None allowedNumerous periods over

2 years required

Major Depressive Disorder

≥ 1 required None allowed None allowed

Dysthymic Disorder≥ 2 years required but not major depression

None allowed None allowed

*NOS = Not otherwise specified

Adapted from the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000:345-428.

Diagnosing Bipolar Disorder: Challenges

• Variability of age of onset and presentation

• Commonly presenting in the depressed phase and being misdiagnosed as unipolar depression

• Prepubertal onset depression or dysthymia carries a 20–40% risk of bipolar illness

• Symptom overlap with other psychiatric conditions

• Previous misdiagnosis common

• Many clinically prominent psychiatric and medical comorbidities

Thomas P. J Affect Disord. 2004;79(suppl 1):S3-S8.Berk M, et al. Med J Aust. 2006;184:459-462.

The Bipolar Spectrum: StrongerBipolar I

4 DaysBipolar II

Bipolar NOS

“Bipolar III” Antidepressant-related hypomania

Adapted from Akiskal HS, Pinto O. Psychiatr Clin North Am. 1999;22:517-534.

< 4 Days

1 week

The Bipolar Spectrum: Weaker

Hyperthymic “Bipolar IV”

Depressive Mixed State “IV ½”

Recurrent “Unipolar” Depression “Bipolar V”

Adapted from Akiskal HS, Pinto O. Psychiatr Clin North Am. 1999;22:517-534.Akiskal HS, et al. J Affect Disord. 2006;96:197-205.

Bipolar “Missed States!” (Mixed States)

• Bipolar mixed states: depression and mania co-occurring

• Dysphoric mania common especially in women • Depressive mixed states

– Core of depression, but with racing thoughts

• Mixed hypomania

Berk M, et al. Aust N Z Psych. 2005;39:215-221.Suppes T, et al. Arch Gen Psychiatry. 2005;62:1089-1096.

Self-Rated Screening Tool:The Mood Disorder Questionnaire (MDQ)

• Hyper or more energetic than usual• Predominately or thematically

irritable• Distinctly self-confident, positive

or self-assured • Less sleep than usual• More talkative or speaking faster

than usual• Racing thoughts• Easily distracted• Problems at work and socially• More interest in sex• Taking unusual risks• Excessive spendingHirschfeld RM, et al. J Clin Psychiatry. 2003;64:53-59.

Neither bipolar disorder nor depression diagnosis

Bipolar Disorder Diagnosis Is Often Missed

• > 85,000 US adults surveyed

• Positive screen rate for bipolar illness: 3.7% (> 6 million people in US)

• For those with positive screen

Only 20% of those with a positive screen had

been told by their doctors that they had bipolar disorder Hirschfeld RM, et al. J Clin Psychiatry. 2003;64:53-59.

Diagnosed withbipolar disorder

Diagnosed with depression

but not bipolar disorder

20%

31%

49%

Bipolar disorder misdiagnosed as unipolar depression in 37% of patients (N = 85)

Ghaemi SN, et al. J Clin Psychiatry. 2000;61:804-808.

Unipolar Misdiagnosis May Lead to Inappropriate Treatment

Pat

ien

ts (

%)

0

20

40

60

80

100

Mania/Hypomania

RapidCycling

n = 38

55%

23%

n = 35

Development of mania/hypomania or rapid cycling while taking antidepressants.

The Hazards of Misdiagnosis and Delayed Diagnosis in Bipolar Disorder

Increased risk of:

• Rapid cycling or mixed features

• Suicide attempts or completion

• Violent behavior; impulsive behavior

• Sexual and other indiscretions

• Worsening substance abuse

• Loss of job or significant other

• Treatment resistant

Self-Report Diagnostic Tools For Screening Bipolar Disorder

Scale Description Limitations

Mood Disorder Questionnaire (MDQ)

13 item questionnaire ( 7 is a positive screen)

More sensitive for bipolar I than II, should not replace a full diagnostic interview

Bipolar Spectrum Diagnostic Scale (BSDS)

Screens for subtle versions of bipolar and can rate the probability of bipolar as high, moderate, low, or unlikely

Should not replace a full diagnostic interview

Quick Inventory for Depression Symptomatology

(QIDS)

16 item inventory, each item rated 0-3Takes an average of 15 minutes to implement

Scale Description Limitations

Young Mania Rating Scale (YMRS)

11 item scale, each with a varied rating scale based on severity (mania = 12, depression = 3, euthymia = 2)

Usefulness of scale is limited in populations with diagnoses other than mania

Bipolarity Index

Evaluation of bipolar presentation based on 5 “dimensions”—each worth up to 20 points for a total of 100

Time consuming, not peer reviewed

Hamilton Rating Scale for Depression (HAM-D)

17-21 item scale initially intended for identifying depressed patients

Relies heavily on clinical interviewing skills and experience of the rater

Montgomery-Asberg Depression Rating Scale

(MADRS)

10 selected items are rated on a scale of 0-6 with anchors at 2-point intervals

Cost prohibitive and time consuming

Clinician-Administered Diagnostic Tools For Screening Bipolar Disorder

Subthreshold Bipolar Disorder(The “Soft” Bipolar Spectrum)

• Boundaries of bipolarity have expanded over the past decade

• Suggest that the diagnostic criteria for hypomania need revision

• Further study is needed to evaluate the ‘hard’ and ‘soft’ definitions of bipolar II, minor bipolar disorder, and hypomania

• A more expansive definition of bipolar II yields a cumulative prevalence rate of 10.9%, compared to 11.4% for broadly defined major depression

Akiskal HS. Curr Psychiatry Rep. 2002;4:1-3.Angst J, et al. J Affect Disord. 2003;73:133-146.

The Rule of 3 Hinting at Soft Bipolarity (NOS) in a Clinically Depressed Person

• Three or more:– Major depressive episodes

– Failed marriages

– Failed antidepressants trials

– Distinct professions

– First degree relatives (or generations) with affective illness

– Fields of eminence in the family

– Substances of abuse

– Impulsive behaviors (gambling, car racing, sexual, etc.)

– Individuals dated simultaneously

– Simultaneous jobs

– Languages (for US-born citizens)

– Triad of past histrionic, psychopathic, or borderline diagnoses

– Triad of red car, necktie, or belt

Akiskal HS. J Affect Disord. 2005;84:279-290.

Importance of Interviewing the Patient and Their Family

• Patients admitted with major depression– NIMH study– Step 1: Patient screened for bipolar disorder– Step 2: Family member interviewed (by another

investigator interested in genetics)– Result: Twice as many bipolar I diagnoses

from interviewing both the patient and a family member

Blehar MC, et al. Psychopharmacol Bull. 1998;34:239-243.

Physicians Must Use Patient Perspectives to Improve Diagnosis and Care

Factors Necessary for Recovery:

1. Communication between patient and physician: best chance for recovery when patient feels he’s being heard; physician must try to understand how the world looks through patient’s eyes

2. Treatment plans that include patient input and preferences; physician must discuss all options so patient has complete understanding of illness

3. Recovery-oriented treatment based on mutually agreed goals so patient feels like a partner in care

Lewis L, et al. Adm Policy Ment Health. 2005;32:497-503.

• Bipolar disorder can masquerade in different or mixed mood states

• Bipolar disorder is often misdiagnosed as depression due to the prevalence of depressive episodes often as the presenting phase

• Misdiagnosis can have serious detrimental effects on treatment effectiveness and outcomes

Take Home Messages