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Bipolar I disorder

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Bipolar I Disorder

Diagnostic Features

The essential feature of Bipolar I Disorder is a clinical course that is characterized by the occurrence of one or more Manic Episodes (see p. 357) or Mixed Episodes (see p. 362 ). Often individuals have also had one or more Major Depressive Episodes (see p. 349). Episodes of Substance-Induced Mood Disorder (due to the direct effects of a medication, other somatic treatments for depression, a drug of abuse, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Bipolar I Disorder. In addition, the episodes are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. Bipolar I Disorder is subclassified in the fourth digit of the code according to whether the individual is experiencing a first episode (i.e., Single Manic Episode) or whether the disorder is recurrent. Recurrence is indicated by either a shift in the polarity of the episode or an interval between episodes of at least 2 months without manic symptoms. A shift in polarity is defined as a clinical course in which a Major Depressive Episode evolves into a Manic Episode or a Mixed Episode or in which a Manic Episode or a Mixed Episode evolves into a Major Depressive Episode. In contrast, a Hypomanic Episode that evolves into a Manic Episode or a Mixed Episode, or a Manic Episode that evolves into a Mixed Episode (or vice versa), is considered to be only a single episode. For recurrent Bipolar I Disorders, the nature of the current (or most recent) episode can be specified (Most Recent Episode Hypomanic, Most Recent Episode Manic, Most Recent Episode Mixed, Most Recent Episode Depressed, Most Recent Episode Unspecified).

Specifiers

If the full criteria are currently met for a Manic, Mixed, or Major Depressive Episode, the following specifiers may be used to describe the current clinical status of the episode and to describe features of the current episode:

If the full criteria are not currently met for a Manic, Mixed or Major Depressive Episode, the following specifiers may be used to describe the current clinical status of the Bipolar I Disorder and to describe features of the most recent episode:

If criteria are currently met for a Major Depressive Episode, the following may be used to describe features of the current episode (or, if criteria are not currently met but the most recent episode of Bipolar I Disorder was a Major Depressive Episode, these specifiers apply to that episode):

The following specifiers can be used to indicate the pattern of episodes:

Recording Procedures

The diagnostic codes for Bipolar I Disorder are selected as follows:

  1. The first three digits are 296.
  2. The fourth digit is 0 if there is a single Manic Episode. For recurrent episodes, the fourth digit indicates the nature of the current episode (or, if the Bipolar I Disorder is currently in partial or full remission, the nature of the most recent episode) as follows: 4 if the current or most recent episode is a Hypomanic Episode or a Manic Episode, 5 if it is a Major Depressive Episode, 6 if it is a Mixed Episode, and 7 if the current or most recent episode is Unspecified.
  3. The fifth digit (except for Bipolar I Disorder, Most Recent Episode Hypomanic, and Bipolar I Disorder, Most Recent Episode Unspecified) indicates the severity of the current episode if full criteria are met for a Manic, Mixed, or Major Depressive Episode as follows: 1 for Mild severity, 2 for Moderate severity, 3 for Severe Without Psychotic Features, 4 for Severe With Psychotic Features. If full criteria are not met for a Manic, Mixed, or Major Depressive Episode, the fifth digit indicates the current clinical status of the Bipolar I Disorder as follows: 5 for In Partial Remission, 6 for In Full Remission. If current severity or clinical status is unspecified, the fifth digit is 0. Other specifiers for Bipolar I Disorder cannot be coded. For Bipolar I Disorder, Most Recent Episode Hypomanic, the fifth digit is always 0. For Bipolar Disorder, Most Recent Episode Unspecified, there is no fifth digit.

In recording the name of a diagnosis, terms should be listed in the following order: Bipolar I Disorder, specifiers coded in the fourth digit (e.g., Most Recent Episode Manic), specifiers coded in the fifth digit (e.g., Mild, Severe With Psychotic Features, In Partial Remission), as many specifiers (without codes) as apply to the current or most recent episode (e.g., With Melancholic Features, With Postpartum Onset), and as many specifiers (without codes) as apply to the course of episodes (e.g., With Rapid Cycling); for example, 296.54 Bipolar I Disorder, Most Recent Episode Depressed, Severe With Psychotic Features, With Melancholic Features, With Rapid Cycling.

Note that if the single episode of Bipolar I Disorder is a Mixed Episode, the diagnosis would be indicated as 296.0x Bipolar I Disorder, Single Manic Episode, Mixed.

Associated Features and Disorders

Associated descriptive features and mental disorders.

Completed suicide occurs in 10%-15% of individuals with Bipolar I Disorder. Suicidal ideation and attempts are more likely to occur when the individual is in a depressive or mixed state. Child abuse, spouse abuse, or other violent behavior may occur during severe Manic Episodes or during those with psychotic features. Other associated problems include school truancy, school failure, occupational failure, divorce, or episodic antisocial behavior. Bipolar Disorder is associated with Alcohol and other Substance Use Disorders in many individuals. Individuals with earlier onset of Bipolar I Disorder are more likely to have a history of current alcohol or other substance use problems. Concomitant alcohol and other substance use is associated with an increased number of hospitalizations and a worse course of illness. Other associated mental disorders include Anorexia Nervosa, Bulimia Nervosa, Attention-Deficit/Hyperactivity Disorder, Panic Disorder, and Social Phobia.

Associated laboratory findings.

There appear to be no laboratory features that are diagnostic of Bipolar I Disorder or that distinguish Major Depressive Episodes found in Bipolar I Disorder from those in Major Depressive Disorder or Bipolar II Disorder. Imaging studies comparing groups of individuals with Bipolar I Disorder with groups with Major Depressive Disorder or groups without any Mood Disorder tend to show increased rates of right-hemispheric lesions, or bilateral subcortical or periventricular lesions in those with Bipolar I Disorder.

Associated physical examination findings and general medical conditions.

An age at onset for a first Manic Episode after age 40 years should alert the clinician to the possibility that the symptoms may be due to a general medical condition or substance use. Current or past hypothyroidism or laboratory evidence of mild thyroid hypofunction may be associated with Rapid Cycling (see p. 427). In addition, hyperthyroidism may precipitate or worsen manic symptoms in individuals with a preexisting Mood Disorder. However, hyperthyroidism in individuals without preexisting Mood Disorder does not typically cause manic symptoms.

Specific Culture, Age, and Gender Features

There are no reports of differential incidence of Bipolar I Disorder based on race or ethnicity. There is some evidence that clinicians may have a tendency to overdiagnose Schizophrenia (instead of Bipolar Disorder) in some ethnic groups and in younger individuals.

Approximately 10%-15% of adolescents with recurrent Major Depressive Episodes will go on to develop Bipolar I Disorder. Mixed Episodes appear to be more likely in adolescents and young adults than in older adults.

Recent epidemiological studies in the United States indicate that Bipolar I Disorder is approximately equally common in men and women (unlike Major Depressive Disorder, which is more common in women). Gender appears to be related to the number and type of Manic and Major Depressive Episodes. The first episode in males is more likely to be a Manic Episode. The first episode in females is more likely to be a Major Depressive Episode. In men the number of Manic Episodes equals or exceeds the number of Major Depressive Episodes, whereas in women Major Depressive Episodes predominate. In addition, Rapid Cycling (see p. 427) is more common in women than in men. Some evidence suggests that mixed or depressive symptoms during Manic Episodes may be more common in women as well, although not all studies are in agreement. Thus, women may be at particular risk for depressive or intermixed mood symptoms. Women with Bipolar I Disorder have an increased risk of developing subsequent episodes in the immediate postpartum period. Some women have their first episode during the postpartum period. The specifier With Postpartum Onset may be used to indicate that the onset of the episode is within 4 weeks of delivery (see p. 422). The premenstrual period may be associated with worsening of an ongoing Major Depressive Episode, Manic, Mixed, or Hypomanic Episode.

Prevalence

The lifetime prevalence of Bipolar I Disorder in community samples has varied from 0.4% to 1.6%.

Course

Average age at onset is 20 for both men and women. Bipolar I Disorder is a recurrent disorder-more than 90% of individuals who have a single Manic Episode go on to have future episodes. Roughly 60%-70% of Manic Episodes occur immediately before or after a Major Depressive Episode. Manic Episodes often precede or follow the Major Depressive Episodes in a characteristic pattern for a particular person. The number of lifetime episodes (both Manic and Major Depressive) tends to be higher for Bipolar I Disorder compared with Major Depressive Disorder, Recurrent. Studies of the course of Bipolar I Disorder prior to lithium maintenance treatment suggest that, on average, four episodes occur in 10 years. The interval between episodes tends to decrease as the individual ages. There is some evidence that changes in sleep-wake schedule such as occur during time zone changes or sleep deprivation may precipitate or exacerbate a Manic, Mixed, or Hypomanic Episode. Approximately 5%-15% of individuals with Bipolar I Disorder have multiple (four or more) mood episodes (Major Depressive, Manic, Mixed, or Hypomanic) that occur within a given year. If this pattern is present, it is noted by the specifier With Rapid Cycling (see p. 427). A rapid-cycling pattern is associated with a poorer prognosis.

Although the majority of individuals with Bipolar I Disorder experience significant symptom reduction between episodes, some (20%-30%) continue to display mood lability and other residual mood symptoms. As many as 60% experience chronic interpersonal or occupational difficulties between acute episodes. Psychotic symptoms may develop after days or weeks in what was previously a nonpsychotic Manic or Mixed Episode. When an individual has Manic Episodes with psychotic features, subsequent Manic Episodes are more likely to have psychotic features. Incomplete interepisode recovery is more common when the current episode is accompanied by mood-incongruent psychotic features.

Familial Pattern

First-degree biological relatives of individuals with Bipolar I Disorder have elevated rates of Bipolar I Disorder (4%-24%), Bipolar II Disorder (1%-5%), and Major Depressive Disorder (4%-24%). Those individuals with Mood Disorder in their first-degree biological relatives are more likely to have an earlier age at onset. Twin and adoption studies provide strong evidence of a genetic influence for Bipolar I Disorder.

Differential Diagnosis

Major Depressive, Manic, Mixed, and Hypomanic Episodes in Bipolar I Disorder must be distinguished from episodes of a Mood Disorder Due to a General Medical Condition. The diagnosis is Mood Disorder Due to a General Medical Condition for episodes that are judged to be the direct physiological consequence of a specific general medical condition (e.g., multiple sclerosis, stroke, hypothyroidism) (see p. 401 ). This determination is based on the history, laboratory findings, or physical examination.

A Substance-Induced Mood Disorder is distinguished from Major Depressive, Manic, or Mixed Episodes that occur in Bipolar I Disorder by the fact that a substance (e.g., a drug of abuse, a medication, or exposure to a toxin) is judged to be etiologically related to the mood disturbance (see p. 405). Symptoms like those seen in a Manic, Mixed, or Hypomanic Episode may be part of an intoxication with or withdrawal from a drug of abuse and should be diagnosed as a Substance-Induced Mood Disorder (e.g., euphoric mood that occurs only in the context of intoxication with cocaine would be diagnosed as Cocaine-Induced Mood Disorder, With Manic Features, With Onset During Intoxication). Symptoms like those seen in a Manic or Mixed Episode may also be precipitated by antidepressant treatment such as medication, electroconvulsive therapy, or light therapy. Such episodes may be diagnosed as a Substance-Induced Mood Disorder (e.g., Amitriptyline-Induced Mood Disorder, With Manic Features; Electroconvulsive Therapy-Induced Mood Disorder, With Manic Features) and would not count toward a diagnosis of Bipolar I Disorder. However, when the substance use or medication is judged not to fully account for the episode (e.g., the episode continues for a considerable period autonomously after the substance is discontinued), the episode would count toward a diagnosis of Bipolar I Disorder.

Bipolar I Disorder is distinguished from Major Depressive Disorder and Dysthymic Disorder by the lifetime history of at least one Manic or Mixed Episode. Bipolar I Disorder is distinguished from Bipolar II Disorder by the presence of one or more Manic or Mixed Episodes. When an individual previously diagnosed with Bipolar II Disorder develops a Manic or Mixed Episode, the diagnosis is changed to Bipolar I Disorder.

In Cyclothymic Disorder, there are numerous periods of hypomanic symptoms that do not meet criteria for a Manic Episode and periods of depressive symptoms that do not meet symptom or duration criteria for a Major Depressive Episode. Bipolar I Disorder is distinguished from Cyclothymic Disorder by the presence of one or more Manic or Mixed Episodes. If a Manic or Mixed Episode occurs after the first 2 years of Cyclothymic Disorder, then Cyclothymic Disorder and Bipolar I Disorder may both be diagnosed.

The differential diagnosis between Psychotic Disorders (e.g., Schizoaffective Disorder, Schizophrenia, and Delusional Disorder) and Bipolar I Disorder may be difficult (especially in adolescents) because these disorders may share a number of presenting symptoms (e.g., grandiose and persecutory delusions, irritability, agitation, and catatonic symptoms), particularly cross-sectionally and early in their course. In contrast to Bipolar I Disorder, Schizophrenia, Schizoaffective Disorder, and Delusional Disorder are all characterized by periods of psychotic symptoms that occur in the absence of prominent mood symptoms. Other helpful considerations include the accompanying symptoms, previous course, and family history. Manic and depressive symptoms may be present during Schizophrenia, Delusional Disorder, and Psychotic Disorder Not Otherwise Specified, but rarely with sufficient number, duration, and pervasiveness to meet criteria for a Manic Episode or a Major Depressive Episode. However, when full criteria are met (or the symptoms are of particular clinical significance), a diagnosis of Bipolar Disorder Not Otherwise Specified may be made in addition to the diagnosis of Schizophrenia, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

If there is a very rapid alternation (over days) between manic symptoms and depressive symptoms (e.g., several days of purely manic symptoms followed by several days of purely depressive symptoms) that do not meet minimal duration criteria for a Manic Episode or Major Depressive Episode, the diagnosis is Bipolar Disorder Not Otherwise Specified.

Diagnostic criteria for 296.0x Bipolar I Disorder, Single Manic Episode

  1. Presence of only one Manic Episode (see p. 362) and no past Major Depressive Episodes.

    Note: Recurrence is defined as either a change in polarity from depression or an interval of at least 2 months without manic symptoms.

  2. The Manic Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Specify if:

Mixed: if symptoms meet criteria for a Mixed Episode (see p. 365)

If the full criteria are currently met for a Manic, Manic, or Major Depressive Episode, specify its current clinical status and/or features:

If the full criteria are not currently met for a Manic, Mixed, or Major Depressive Episode, specify the current clinical status of the Bipolar I Disorder or features of the most recent episode:

Diagnostic criteria for 296.40 Bipolar I Disorder, Most Recent Episode Hypomanic

  1. Currently (or most recently) in a Hypomanic Episode (see p. 368).
  2. There has previously been at least one Manic Episode (see p. 362) or Mixed Episode (see p. 365).
  3. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  4. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
Specify:

Diagnostic criteria for 296.4x Bipolar I Disorder, Most Recent Episode Manic

  1. Currently (or most recently) in a Manic Episode (see p. 362).
  2. There has previously been at least one Major Depressive Episode (see p. 356), Manic Episode (see p. 362), or Mixed Episode (see p. 365).
  3. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

If the full criteria are currently met for a Manic Episode, specify its current clinical status and/or features:

If the full criteria are not currently met for a Manic Episode, specify the current clinical status of the Bipolar I Disorder and/or features of the most recent Manic Episode:

Specify:

Diagnostic criteria for 296.6x Bipolar I Disorder, Most Recent Episode Mixed

  1. Currently (or most recently) in a Mixed Episode (see p. 365).
  2. There has previously been at least one Major Depressive Episode (see p. 356), Manic Episode (see p. 362), or Mixed Episode (see p. 365).
  3. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

If the full criteria are currently met for a Mixed Episode, specify its current clinical status and/or features:

If the full criteria are not currently met for a Mixed Episode, specify the current clinical status of the Bipolar I Disorder and/or features of the most recent Mixed Episode:

Specify:

Diagnostic criteria for 296.5x Bipolar I Disorder, Most Recent Episode Depressed

  1. Currently (or most recently) in a Major Depressive Episode (see p. 356).
  2. There has previously been at least one Manic Episode (see p. 362) or Mixed Episode (see p. 365).
  3. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

If the full criteria are currently met for a Major Depressive Episode, specify its current clinical status and/or features:

If the full criteria are not currently met for a Major Depressive Episode, specify the current clinical status of the Bipolar I Disorder and/or features of the most recent Major Depressive Episode:

Specify:

Diagnostic criteria for 296.7 Bipolar I Disorder, Most Recent Episode Unspecified

  1. Criteria, except for duration, are currently (or most recently) met for a Manic (see p. 362), a Hypomanic (see p. 368), a Mixed (see p. 365), or a Major Depressive Episode (see p. 356).
  2. There has previously been at least one Manic Episode (see p. 362) or Mixed Episode (see p. 365).
  3. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  4. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
  5. The mood symptoms in Criteria A and B are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
Specify:
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text RevisionTM. Copyright 2000 American Psychiatric Association. All Rights Reserved.