The DSM IV: Major Diagnostic Criteria
Bipolar I Disorder is a disorder in which at least one
manic or mixed episode clearly is or has been present.
DSM-IV Criteria for Bipolar I Disorder
- One or more Manic or Mixed episodes.
- Commonly accompanied by a history of one or more major depressive
episodes, but not required for the diagnosis.
- Manic or Mixed episodes cannot be due to a medical condition, medication,
drugs of abuse, toxins or treatment for depression.
- Symptoms cannot be accounted for by a psychotic disorder.
Clinical Features of Bipolar I Disorder
- Greater than 90% of patients who have a single manic episode will
have a recurrence.
- Mixed episodes are more likely in younger patients.
- Episodes occur more frequently with age.
- Social and occupational consequences of Manic episodes can be severe
(e.g.; violence, child abuse, excessive debt, job loss, divorce).
- Manic episodes are more likely to receive clinical attention compared
to Depressive episodes.
- The suicide rate of bipolar patients is 10-15%.
- Common co-morbid diagnoses include substance-related disorders, eating
disorders, attention deficit hyperactivity disorder.
- Rapid cycling pattern carries a poor prognosis and may affect up to
20% of bipolar patients.
Epidemiology of Bipolar I Disorder
- The lifetime prevalence of bipolar disorder is approximately 0.5-1.5%.
- Male: female ratio-- 1:1
- The first episode in males tends to be a manic episode, while the
first episode in females tends to be a depressive episode.
- First degree relatives have higher rates of mood disorder.
- Bipolar disorder has a 70% concordance rate among monozygotic twins.
Classification of Bipolar I Disorder
- Classification of Bipolar I Disorder involves describing the current
or most recent mood episode - Manic, Hypomanic, Mixed or Depressive.
(e.g. Bipolar I Disorder - Most recent episode Mixed)
- The most recent episode can be further classified as follows:
- Without psychotic features
- With psychotic features
- With catatonic features
- With postpartum onset
Bipolar I Disorder with Rapid Cycling
- Diagnosis requires the presence of at least 4 mood episodes within
- Rapid cycling mood episodes may include Major Depressive, Manic, Hypomanic
or Mixed episodes.
- The patient must be symptom-free for at least 2 months between episodes
or the patient must switch to an opposite episode.
Differential Diagnosis of Bipolar I Disorder
- Cyclothymic Disorder:
Mood episodes never meet criteria for full manic episode or full major
- The clinical presentation of a patient at the height of a manic episode
may be indistinguishable from an acute exacerbation of paranoid schizophrenia,
making accurate diagnosis difficult unless clear history is available.
- If history is unavailable or the patient is having an initial episode,
it may be necessary to observe the patient over time to make an accurate
diagnosis. A subsequent Major Depressive Episode or Manic episode that
initially presents with mood symptoms prior to the onset of psychosis
would indicate a mood disorder rather than a psychotic disorder.
- Family history of mood disorder or psychotic disorder may be suggestive
- Substance-Induced Mood Disorder:drugs of abuse. Common
organic causes of mania include sympathomimetics, amphetamines, steroids
and blockers such as cimetidine.
- Mood Disorder Due to a General Medical condition
Treatment of Bipolar I Disorder
- Assessment of suicidality is essential, ask about suicidal ideation
as well as intent.
- Hospitalization may be necessary for either Manic or Depressive mood
- Mood stabilizers such as lithium and the anticonvulsants have
proven effective in the acute treatment as well as the prophylaxis
of mood episodes.
- ECT is very effective for bipolar disorder (Depressed or Manic
episodes) but is generally used after conventional pharmacotherapy
has failed or is contraindicated.
- Antidepressants may be used for treatment of major depressive
episodes, but should be accompanied by a mood stabilizer to prevent
precipitating a manic episode.
- Antidepressants may induce rapid cycling.
- Adjunctive use of antipsychotics (if psychosis is present) or
sedating benzodiazepines such as clonazepam and lorazepam (for severe
agitation) may be necessary.
- Therapy aimed at increasing insight and dealing with the consequences
of manic episodes may be very helpful.
- Family/Marital therapy may also help increase the family's understanding
and tolerance of the affected family member.
- Family support groups such as the Alliance for the Mentally Ill
(AMI) and patient support groups such as Manic Depressive Association
(MDA) can be very helpful.
Bipolar 1 | Bipolar II | Bipolar
III | Cyclothymic Disorder
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