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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

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

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

  2. 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.

  3. Bipolar Terminology A 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.

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

  5. 296.80 Bipolar Disorder NOS The Bipolar Disorder Not Otherwise Specified category includes disorders with bipolar features that do not meet criteria for any specific bipolar disorder. Examples include: 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 Recurrent hypomanic episodes without intercurrent depressive symptoms A manic or mixed episode superimposed on delusional disorder, residual schizophrenia, or psychotic disorder not otherwise specified Hypomanic episodes, along with chronic depressive symptoms that are too infrequent to qualify for a diagnosis of cyclothymic disorder 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 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.

  6. Diagnostic Criteria for Major Affective Disorders (DSM-IV) *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.

  7. 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.

  8. The Bipolar Spectrum: Stronger Bipolar I  1 week Bipolar II  4 Days Bipolar NOS < 4 Days “Bipolar III” Antidepressant-related hypomania Adapted from Akiskal HS, Pinto O. Psychiatr Clin North Am. 1999;22:517-534.

  9. 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.

  10. 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.

  11. 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 spending • Hirschfeld RM, et al. J Clin Psychiatry. 2003;64:53-59.

  12. 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 Diagnosed withbipolar disorder 20% Neither bipolar disorder nor depression diagnosis 49% Diagnosed with depressionbut not bipolar disorder 31% 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.

  13. Unipolar Misdiagnosis May Lead to Inappropriate Treatment Bipolar disorder misdiagnosed as unipolar depression in 37% of patients (N = 85) 100 80 55% 60 Patients (%) 40 23% 20 n = 38 n = 35 0 RapidCycling Mania/Hypomania Development of mania/hypomania or rapid cycling while taking antidepressants. Ghaemi SN, et al. J Clin Psychiatry. 2000;61:804-808.

  14. 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

  15. Self-Report Diagnostic Tools For Screening Bipolar Disorder

  16. Clinician-Administered Diagnostic Tools For Screening Bipolar Disorder

  17. 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.

  18. 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.

  19. 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.

  20. Physicians Must Use Patient Perspectives to Improve Diagnosis and Care Factors Necessary for Recovery: • 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 • Treatment plans that include patient input and preferences; physician must discuss all options so patient has complete understanding of illness • 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.

  21. Take Home Messages • 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

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