Bipolar and Related Disorders -Diagnostic criteria -Differential Diagnosis -Assessment -Etiology -Intervention

1. BIPOLAR AND
RELATED DISORDERS

2. CHANGES FROM DSM IV TR TO DSM 5
 Bipolar Disorders
Criterion A for manic and hypomanic
episodes now includes an emphasis on
changes in activity and energy as well as
mood to enhance accuracy of diagnosis
Bipolar I disorder, mixed episode= Removed
A new specifier, “with mixed features,” has
been added
It can be applied to episodes of mania or
hypomania when depressive features are
present.

3. CHANGES CONT.
 Other Specified Bipolar and Related Disorder
Particular conditions: categorization for
individuals with a past history of a major
depressive disorder who meet all criteria
for hypomania except the duration criterion
(i.e., at least 4 consecutive days)
second condition: too few symptoms of
hypomania are present to meet criteria for
the full bipolar II syndrome
Although Duration sufficient at 4 or more
days.

4. CHANGES CONT.
Anxious Distress Specifier
This specifier is intended to identify patients
with anxiety symptoms that are not part of
the bipolar diagnostic criteria.

5. Bipolar I Disorder
Diagnostic Criteria
For a diagnosis of bipolar I disorder, it
is necessary to meet the following
criteria for a manic episode. The manic
episode may have been preceded by
and may be followed by hypomanic or
major depressive episodes.

6. MANIC EPISODE
A. A distinct period of abnormally and
persistently elevated, expansive, or irritable
mood and abnormally and persistently
increased goal-directed activity or energy,
lasting at least 1 week and present most of
the day, nearly every day (or any duration if
hospitalization is necessary).

7. MANIC EPISODE
 B. During the period of mood disturbance and
increased energy or activity, three (or more) of the
following symptoms (four if the mood is only irritable)
are present to a significant degree and represent a
noticeable change from usual behavior:
 1. Inflated self-esteem or grandiosity.
 2. Decreased need for sleep (e.g., feels rested after
only 3 hours of sleep).
 3. More talkative than usual or pressure to keep talking.
 4. Flight of ideas
 5. Distractibility as reported or observed.
 6. Increase in goal-directed activity or psychomotor
agitation
 7. Excessive involvement in activities that have a high
potential for painful consequences

8. MANIC EPISODE
C. The mood disturbance is sufficiently
severe to cause marked impairment in
social or occupational functioning or to
necessitate hospitalization to prevent harm
to self or others, or there are psychotic
features.
D. The episode is not attributable to the
physiological effects of a substance (e.g., a
drug of abuse, a medication, other
treatment) or to another medical condition.

9. Note: A full manic episode that emerges
during antidepressant treatment (e.g.,
medication, electroconvulsive therapy)
but persists at a fully syndromal level
beyond the physiological effect of that
treatment is sufficient evidence for a
manic episode and, therefore, a bipolar I
diagnosis.
Note: Criteria A-D constitute a manic
episode. At least one lifetime manic
episode is required for the diagnosis of
bipolar I disorder.

10. HYPOMANIC EPISODE
A. A distinct period of abnormally and
persistently elevated, expansive, or irritable
mood and abnormally and persistently
increased activity or energy, lasting at least
4 consecutive days and present most of the
day, nearly every day.

11. HYPOMANIC EPISODE
 B. During the period of mood disturbance and
increased energy and activity, three (or more) of the
following symptoms (four if the mood is only irritable)
have persisted, represent a noticeable change from
usual behavior, and have been present to a significant
degree:
 1. Inflated self-esteem or grandiosity.
 2. Decreased need for sleep
 3. More talkative than usual or pressure to keep talking.
 4. Flight of ideas or subjective experience that thoughts
are racing.
 5. Distractibility
 6. Increase in goal-directed activity or psychomotor
agitation.
 7. Excessive involvement in activities that have a high
potential for painful consequences

12. HYPOMANIC EPISODE
 C. The episode is associated with an unequivocal
change in functioning that is uncharacteristic of the
individual when not symptomatic.
 D. The disturbance in mood and the change in
functioning are observable by others.
 E. The episode is not severe enough to cause
marked impairment in social or occupational
functioning or to necessitate hospitalization. If there
are psychotic features, the episode is, by definition,
manic.
 F. The episode is not attributable to the physiological
effects of a substance (e.g., a drug of abuse, a
medication, other treatment).

13.  Note: A full hypomanic episode that emerges
during antidepressant treatment (e.g., medication,
electroconvulsive therapy) but persists at a fully
syndromal level beyond the physiological effect of
that treatment is sufficient evidence for a
hypomanic episode diagnosis. However, caution is
indicated so that one or two symptoms
(particularly increased irritability, edginess, or
agitation following antidepressant use) are not
taken as sufficient for diagnosis of a hypomanic
episode, nor necessarily indicative of a bipolar
diathesis.
 Note: Criteria A-'F constitute a hypomanic
episode. Hypomanic episodes are common in
bipolar I disorder but are not required for the
diagnosis of bipolar I disorder.

14. MAJOR DEPRESSIVE EPISODE
A. Five (or more) of the following
symptoms have been present during the
same 2-week period and represent a
change from previous functioning; at least
one of the symptoms is either (1)
depressed mood or (2) loss of interest or
pleasure.
Note: Do not include symptoms that are
clearly attributable to another medical
condition.

15. MAJOR DEPRESSIVE EPISODE
1. Depressed mood most of the day, nearly every
day (e.g., feels sad, empty, or hopeless appears
tearful). (Note: In children and adolescents, can
be irritable mood.)
2. Markedly diminished interest or pleasure in all,
or almost all, activities most of the day, nearly
every day
3. Significant weight loss when not dieting or
weight gain, or decrease or increase in appetite
nearly every day. (Note: In children, consider
failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.

16. 5. Psychomotor agitation or retardation
nearly every day
6. Fatigue or loss of energy nearly
every day.
7. Feelings of worthlessness or
excessive or inappropriate guilt (which
may be delusional) nearly every day
8. Diminished ability to
think/concentrate, or indecisiveness,
nearly every day.
9. Recurrent thoughts of death,
recurrent suicidal ideation without a
specific plan, or a suicide attempt or a
specific plan for committing suicide.

17. B. The symptoms cause clinically
significant distress or impairment in
social, occupational, or other important
areas of functioning.
C. The episode is not attributable to
the physiological effects of a
substance or another medical
condition.

18. Note: Criteria A-C constitute a major
depressive episode. Major depressive
episodes are common in bipolar I disorder
but are not required for the diagnosis of
bipolar I disorder.
Note: Responses to a significant loss (e.g.,
bereavement, financial ruin, losses from a
natural disaster, a serious medical illness or
disability) may include the feelings of
intense sadness, rumination about the loss,
insomnia, poor appetite, and weight loss
noted in Criterion A, which may resemble a
depressive episode. Normal responses.
Clinical judgment is required

19. Bipolar I Disorder
A. Criteria have been met for at least one
manic episode (Criteria A-D under “Manic
Episode” above).
B. The occurrence of the manic and major
depressive episode(s) is not better
explained by schizoaffective disorder,
schizophrenia, schizophreniform disorder,
delusional disorder, or other specified or
unspecified schizophrenia spectrum and
other psychotic disorder.

20.  Specify.
 With anxious distress
 With mixed features
 With rapid cycling
 With melancholic features
 With atypical features
 With mood-congruent psychotic features
 With mood-incongruent psychotic features
 With catatonia.
 With peripartum onset
 With seasonal pattern

21. Prevalence
The 12-month prevalence estimate in the
continental United States was 0.6% for
bipolar I disorder as defined in DSM-IV.
Twelve-month prevalence of bipolar I
disorder across 11 countries ranged from
0.0% to 0.6%. The lifetime male-to-female
prevalence ratio is approximately 1.1:1.

22. DEVELOPMENT AND COURSE
Mean age of onset is 18 years
Children should be judged according
to their baseline
Onset occurs throughout the life cycle

23. RISK AND PROGNOSTIC FACTORS
 Environmental.
 More in high income countries
 More in Separated, divorced, or widowed
individuals but the direction of the
association is unclear.
 Genetics.
 Family history is a strong predictor
 Course modifiers. After an individual has a
manic episode with psychotic features,
subsequent manic episodes are more likely
to include psychotic features.

24. COMORBIDITY
Anxiety Disorders
ADHD
Impulse control disorders
Substance use disorders
Metabolic syndrome and migraine

25. DIFFERENTIAL DIAGNOSIS
Major depressive disorder
Similarity: MDD has associated
symptoms of mania and hypomania
and symptoms of irritability
Difference: The associated symptoms
are few or of shorter duration than
required for mania/ hypomania

26. DIFFERENTIAL DIAGNOSIS
Other bipolar disorders
Bipolar I and Bipolar II: Past episodes
of mania in Bipolar I
Unspecified and Other specified
Bipolar disorders: fail to meet the
criteria fully
Another Medical Condition: Causal
factor is medical

27. DIFFERENTIAL DIAGNOSIS
GAD
Anxious
rumination
Efforts to reduce
feelings of
anxiety
Bipolar I
Racing thoughts
Impulsive
behavior

28. DIFFERENTIAL DIAGNOSIS
Substance
induced bipolar
disorder
Response to mood
stabilizers during a
substance/medicat
ion induced mania
may not
necessarily be
diagnostic for
bipolar disorder
Bipolar I
May overuse
substance during an
episode
Symptoms remain
when substance isn’t
used

29. DIFFERENTIAL DIAGNOSIS
ADHD
Symptom overlap
E.g., rapid
speech, racing
thoughts, less
need for sleep,
distractibility
Bipolar I
Manic episode is to
be clarified by the
clinician

30. DIFFERENTIAL DIAGNOSIS
Boderline
Personality
Disorder
Similarity: Mood
lability and
impulsivity
Diff: Absent here
Bipolar I
Distinct episode
Noticeable increase
over baseline

31. DIFFERENTIAL DIAGNOSIS
Disorders with
prominent
irritability
(Child/Adolescent)
Disruptive mood
dysregulation
disorder
If persistent
Bipolar I
Episodic irritability
Clear change from
typical behavior

32. Bipolar II Disorder
Diagnostic Criteria
For a diagnosis of bipolar II disorder, it
is necessary to meet the following
criteria for a current or past
hypomanic episode and the following
criteria for a current or past major
depressive episode

33.  A. Criteria have been met for at least one
hypomanic episode and at least one major
depressive episode
 B. There has never been a manic episode.
 C. The occurrence of the hypomanic episode(s)
and major depressive episode(s) is not better
explained by schizoaffective disorder,
schizophrenia, and other psychotic disorder.
 D. The symptoms of depression or the
unpredictability caused by frequent alternation
between periods of depression and hypomania
causes clinically significant distress or impairment
in social, occupational, or other important areas of
functioning.
BIPOLAR II DISORDER

34. SPECIFY CURRENT OR MOST RECENT EPISODE:
HYPOMANIC
DEPRESSED
SPECIFY COURSE IF FULL CRITERIA FOR A MOOD EPISODE
ARE NOT CURRENTLY MET:
IN PARTIAL REMISSION
IN FULL REMISSION
SPECIFY SEVERITY IF FULL CRITERIA FOR A MOOD
EPISODE ARE CURRENTLY MET:
MILD
MODERATE
SEVERE

35. Specify.
With anxious distress
With mixed features
With rapid cycling
With melancholic features
With atypical features
With mood-congruent psychotic features
With mood-incongruent psychotic features
With catatonia.
With peripartum onset
With seasonal pattern (For Depressive
episode)

36. • 0.3% international
• 12 month prevalence
Prevalence
• High in relatives
• Educated; married and few
years of illness= Recovery
Risk and
Prognostic
Factors
• Anxiety, Substance use,
• Eating disorder
Comorbidity

37. DIFFERENTIAL DIAGNOSIS
Major depressive disorder
Similarity: MDD has associated
symptoms of hypomania and
symptoms of irritability
Difference: The associated symptoms
are few or of shorter duration than
required for hypomania

38. DIFFERENTIAL DIAGNOSIS
Cyclothymia
Numerous
hypomanic and
depressive
episodes but do
not meet criteria
Bipolar II
Presence of one or
more Major
depressive episodes
Additional
diagnosis if
depressive episode
occurs after 2 yrs of
cyclothymia

39. DIFFERENTIAL DIAGNOSIS
Schizophrenia
and other
psychotic
disorders
Psychotic
symptoms occur
in absence of
prominent mood
symptoms
Bipolar II
Presence of mood
symptoms

40. DIFFERENTIAL DIAGNOSIS
ADHD
Symptom overlap
E.g., rapid
speech, racing
thoughts, less
need for sleep,
distractibility
Bipolar II
Episodic symptoms
is to be clarified by
the clinician

41. DIFFERENTIAL DIAGNOSIS
Boderline
Personality
Disorder
Similarity: Mood
lability and
impulsivity
Diff: Absent here
Bipolar II
Distinct episode
Noticeable increase
over baseline

42. CYCLOTHYMIC DISORDER
 Diagnostic Criteria
 A. For at least 2 years (at least 1 year in children
and adolescents) there have been numerous
 periods with hypomanic symptoms that do not meet
criteria for a hypomanic episode and numerous
periods with depressive symptoms that do not meet
criteria for a major depressive episode.
 B. During the above 2-year period (1 year in
children and adolescents), the hypomanic and
depressive periods have been present for at least
half the time and the individual has not been without
the symptoms for more than 2 months at a time.

43.  C. Criteria for a major depressive, manic, or
hypomanic episode have never been met.
 D. The symptoms in Criterion A are not better
explained by schizoaffective disorder,
schizophrenia, schizophreniform disorder,
delusional disorder, or other specified or
unspecified schizophrenia spectrum and other
psychotic disorder.
 E. The symptoms are not attributable to the
physiological effects of a substance (e.g., a drug of
abuse, a medication) or another medical condition
(e.g., hyperthyroidism).
 F. The symptoms cause clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.

44. SPECIFY IF: WITH ANXIOUS DISTRESS

45. PREVALENCE
The lifetime prevalence is
approximately 0.4%-l%.
In the general population, equally
common in males and females.
 In clinical settings, females with
cyclothymic disorder may be more
likely to present for treatment than
males.

46. RISK FACTORS
More common in first degree biological
relatives
Comorbidity
Substance-related disorders, sleep
disorders, ADHD

47. DIFFERENTIAL DIAGNOSIS
 Bipolar and related
disorder due to another
medical condition and
depressive disorder due
to another medical
condition
Mood disturbance is
attributable to
physiological effect
of chronic medical
condition
 Cyclothymia
 Mood disturbance is
not only
attributable to
physiological effect
of chronic medical
condition

48. DIFFERENTIAL DIAGNOSIS
 Substance/medication-
induced bipolar and
related disorder and
substance/medication-
induced depressive
disorder
Cause= Substance
Symptoms end with
cessation of
substance/
medication
 Cyclothymia
Symptoms do not
end with
cessation of
substance/
medication

49. DIFFERENTIAL DIAGNOSIS
 Bipolar I and bipolar II
disorder, with rapid
cycling.
Similarity= Marked
Frequent shifts in
mood
Diff= Criteria met for
depressive, manic
and hypomanic
episodes
 Cyclothymia
Criteria never
met for
depressive,
manic and
hypomanic
episodes

50. SUBSTANCE/MEDICATION-INDUCED BIPOLAR
AND RELATED DISORDER
Diagnostic Criteria
A. A prominent and persistent
disturbance in mood that
predominates in the clinical picture
and is characterized by elevated,
expansive, or irritable mood, with or
without depressed mood, or markedly
diminished interest or pleasure in all,
or almost all, activities.

51. B. There is evidence from the history, physical
examination, or laboratory findings of both
(1) and (2):
1. The symptoms in Criterion A developed
during or soon after substance intoxication or
withdrawal or after exposure to a medication.
2. The involved substance/medication is capable
of producing the symptoms in Criterion A.
C. The disturbance is not better explained by
a bipolar or related disorder that is not
substance/ medication-induced.

52.  D. The disturbance does not occur exclusively
during the course of a delirium.
 E. The disturbance causes clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.
 Specify if
 With onset during intoxication: If the criteria are
met for intoxication with the substance and the
symptoms develop during intoxication.
 With onset during withdrawal: If criteria are met
for withdrawal from the substance and the
symptoms develop during, or shortly after,
withdrawal.

53. BIPOLAR AND RELATED DISORDER DUE TO
ANOTHER MEDICAL CONDITION
 Diagnostic Criteria
A. A prominent and persistent period of
abnormally elevated, expansive, or irritable
mood and abnormally increased activity or
energy that predominates in the clinical
picture.
B. There is evidence from the history,
physical examination, or laboratory findings
that the disturbance is the direct
pathophysiological consequence of another
medical condition.

54. C. The disturbance is not better explained
by another mental disorder.
D. The disturbance does not occur
exclusively during the course of a delirium.
E. The disturbance causes clinically
significant distress or impairment in social,
occupational,
or other important areas of functioning, or
necessitates hospitalization to prevent harm
to self or others, or there are psychotic
features.

55. Specify if:
With manic features: Full criteria are
not met for a manic or hypomanic
episode.
With manic- or hypomanic-like
episode: Full criteria are met except
Criterion D for a manic episode or
except Criterion F for a hypomanic
episode.
With mixed features: Symptoms of
depression are also present but do not
predominate in the clinical picture.

56. OTHER SPECIFIED BIPOLAR AND RELATED
DISORDER
When presentation does not meet the full
criteria of any disorder and clinician chooses
to report the reason.
Short-duration hypomanic episodes (2-3 days)
and major depressive episodes
Hypomanic episodes with insufficient
symptoms and major depressive episodes
Hypomanic episode without prior major
depressive episode
Short-duration cyclothymia (less than 24
months)

57. UNSPECIFIED BIPOLAR AND RELATED DISORDER
When presentation does not meet the
full criteria of any disorder and clinician
chooses not to report the reason.
Insufficient information e.g., in
Emergency room settings

58. SPECIFIERS FOR BIPOLAR AND RELATED DISORDERS
 With anxious distress: The presence of at least two
of the following symptoms during the majority of days
of the current or most recent episode of mania,
hypomania, or depression:
 1. Feeling keyed up or tense.
 2. Feeling unusually restless.
 3. Difficulty concentrating because of worry.
 4. Fear that something awful may happen.
 5. Feeling that the individual might lose control of
himself or herself.
 Specify current severity:
 Mild: Two symptoms. Moderate: Three
symptoms.
 Moderate-severe: Four or five symptoms.
 Severe: Four or five symptoms with motor agitation.

59. With rapid cycling (can be applied
to bipolar I or bipolar II disorder):
Presence of at least four mood
episodes in the previous 12 months
that meet the criteria for manic,
hypomanic, or major depressive
episode.

60.  With melancholic features:
 A. One of the following is present during the most
severe period of the current episode;
 1. Loss of pleasure in all, or almost all, activities.
 2. Lack of reactivity to usually pleasurable stimuli
 B. Three (or more) of the following:
 1. A distinct quality of depressed mood
characterized by profound despair, by so-called
empty mood.
 2. Early-morning awakening (i.e., at least 2 hours
before usual awakening).
 3. Marked psychomotor agitation or retardation.
 4. Significant anorexia or weight loss.
 5. Excessive or inappropriate guilt.

61. With psychotic features: Delusions or
hallucinations are present at any time in the
episode. If psychotic features are present,
specify if mood-congruent or mood-
incongruent
With catatonia: This specifier can apply to
an episode of mania or depression if
catatonic features are present during most
of the episode.

62. With peripartum onset: This specifier
can be applied to the current or, if the
full criteria are not currently met for a
mood episode, most recent episode of
mania, hypomania, or major
depression in bipolar I or bipolar II
disorder if onset of mood symptoms
occurs during pregnancy or in the 4
weeks following delivery.

63. With seasonal pattern: This specifier
applies to the lifetime pattern of mood
episodes.
The essential feature is a regular
seasonal pattern of at least one type of
episode (i.e., mania, hypomania, or
depression). The other types of
episodes may not follow this pattern.
For example, an individual may have
seasonal manias, but his or her
depressions do not regularly occur at a
specific time of year.

64.  With atypical features: This specifier can be applied when
these features predominate during the majority of days of the
current or most recent major depressive episode.
 A. Mood reactivity (i.e., mood brightens in response to actual
or potential positive events).
 B. Two (or more) of the following features:
 1. Significant weight gain or increase in appetite.
 2. Hypersomnia.
 3. Leaden paralysis (i.e., heavy, leaden feelings in arms or
legs).
 4. A long-standing pattern of interpersonal rejection
sensitivity that results in significant social or occupational
impairment.
 C. Criteria are not met for “with melancholic features” or
“with catatonia” during the same episode.

65. ETIOLOGY
Genetics
 Family Studies: There is a 4.5%
prevalence of bipolar disorder among
relatives of bipolar patients, and a
1.5% prevalence among relatives of
depressed patients.
Adoption Studies: Compared with a
control group, the biological parents of
bipolar adoptees had an increase
prevalence of bipolar disorder, but the
adoptive parents of bipolar adoptees did
not.

66.  Neuroanatomical differences
 Small abnormal areas in the white matter of
the brain (especially in the frontal lobe).
 Smaller amygdala: Involvement of the
amygdala in BD is consistent with its central
role in emotional and social behavior
(assigning emotional valence to stimuli and
memories, facilitating encoding). The
amygdala plays a key role in emotions and
forming emotional memories.

67.  Decreased hippocampal volume: The
hippocampus is a horseshoe-shaped brain
structure involved in memory, learning, and
emotion. It forms new memories and organizes
them with related memories and emotions.
 Social rhythm stability hypothesis: Life events
can act as zeitstorers, which disrupt established
social and circadian rhythms For example,
previously unemployed patient who gets a job
with constantly shifting work hours is forced to
adopt a new pattern of daily routines, which may
include changes in sleep-wake habits. Major
events can also result in loss of social zeitgebers,
people or events that help maintain the stability of
the rhythms.

68. ASSESSMENT
 Clinical Interview
 Mental Status Examination (MSE): It
occupies the information related to
appearance, hygiene, eye contact,
perception, thinking, mood, speech, volume,
orientation, memory etc of the client.
 Daily Mood Chart
 Behavioral Checklist
 Subjective Ratings of the problems

69. Other Assessment Tools
Goldberg Bipolar Spectrum Screening
Questionnaire
Minnesota Multiphasic Personality
Inventory (D-scale for depression and
Ma-scale for hypomania)
The Mood Disorder Questionnaire
MDS
The Child Bipolar Questionnaire

70. MANAGEMENT
 Psycho education
 Drug Therapy
 Cognitive Therapy
 Cognitive Behavior Therapy (CBT)
 Family Focused Therapy (FFT)
 Interpersonal Social Rhythm Therapy
(IPSRT)
 Dialectical Behavior Therapy
 Improving Self-Esteem
 Activity Monitoring
 Managing Sleep Disturbance

71.  Lithium: For classic, euphoric mania; for mixed
manic episode
 Selective serotonin reuptake inhibitors : For
Bipolar Depression
 An antipsychotic agent: For mania with psychosis
or psychotic depression.
 Valproic acid (Depakene): For classic, euphoric
mania; for mixed manic episode; for mania with rapid
cycling
 Benzodiazepine: Sleep and sedation in mania or
hypomania; insomnia in depression
DRUG THERAPY

72. COGNITIVE BEHAVIOR THERAPY
Identifying Thoughts, Emotions &
Behaviors
Understanding the Links between
Thoughts, Feelings & Behaviors
Making Changes – Behaviors
Making Changes - Thoughts
Challenging Thoughts
Distancing or Defusing from Thoughts
Imagery

73. DIALECTICAL BEHAVIOR THERAPY
Skills Modules include:
Distress Tolerance
Emotion Regulation
Interpersonal Effectiveness

74. INTERPERSONAL SOCIAL RHYTHM THERAPY (IPSRT)
The reciprocal relationships between life
stress and the onset of mood disorder
symptoms.
The importance of maintaining regular
daily rhythms and sleep–wake cycles.
The identification and management of
potential precipitants of rhythm
dysregulation, with special attention to
interpersonal triggers.

75. THANK YOU

76.  References
 American Psychiatric Association (2000). Diagnostic
and statistical manual of mental disorders-text
revised (4th ed.). Washington, DC: American
Psychiatric Association.
 American Psychiatric Association (2013). Diagnostic
and statistical manual of mental disorders (5th ed.).
Arlington, VA: American Psychiatric Publishing.
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