Bipolar Disorders I & II

Bipolar Disorders I & IIUniversity of Massachusetts, Amherst

Nursing 690M

Donna Petko, MSN, RN, APN, FNP-BC

April 7, 2015

Objective

• prevalence

• diagnostic criteria

• development

• functional consequences

• cultural issues

• measurements

• diagnostic features

• specifiers

• severity levels

• differential diagnoses

• ICD-10 coding

To increase understanding of Bipolar Disorders I & II listed in the DSM-5 (APA, 2013):

Bipolar Disorders I & II

Bipolar I Disorder

Prevalence (APA, 2013):

• 12-month prevalence estimate in US is 0.6%

• Lifetime male-to-female ratio is 1.1:1

Bipolar I Disorder Cont.

Diagnostic Criteria (APA, 2013):

• At least one lifetime manic episode required for diagnosis

• Manic episode may be preceded/followed by hypomanic or major depressive episode

• Specific criteria must be met for a current/past hypomanic episode and current/past major depressive episode


Manic Episode (APA, 2013):

• Distinct period of abnormally and persistently elevated, expansive, or irritable mood

• Increased energy or activity

• Lasting at least 1 week and present most of the day, nearly every day


Manic Episode cont. (APA, 2013):

• 3 or more of the following (4 if mood is only irritable):• Inflated self-esteem or grandiosity

• Decreased need for sleep

• More talkative than usual

• Flight of ideas

• Distractibility

• Increase in goal-directed activity

• Excessive involvement in risk taking activities

• Spending sprees

• Sexual indiscretions


Manic Episode cont. (APA, 2013):

• Mood disturbance is severe to cause marked impairment in social/occupational functioning or requires hospitalization

• Episode not attributable to the physiological effects of a substance or another medical condition


Hypomanic Episode (APA, 2013):


• Increased activity or energy

• Lasting at least 4 consecutive days and present most of the day, nearly every day


Hypomanic Episode cont. (APA, 2013):




• Flight of ideas

• Distractibility



• Spending sprees




• Episode associated with change in functioning• Uncharacteristic when asymptomatic

• Disturbance in mood/change in functioning observed by others

• Not severe enough to cause impairment in social/occupational functioning• Not requiring hospitalization

• Not attributable to the physiological effects of a substance

• Are common in bipolar I but not required for diagnosis


Major Depressive Disorder (APA, 2013):

• 5 or more of the following symptoms during the same 2-week period and represent change from prior functioning:• 1 symptom must be (1) depressed mood or (2) loss of

interest/pleasure

• Depressed mood most of the day, nearly every day per subjective report or observation

• Diminished interest, pleasure in all, or most, activities

• Significant weight-loss or weight-gain

• Insomnia or hypersomnia

• Psychomotor agitation

• Fatigue


Major Depressive Disorder cont. (APA, 2013):• Feelings of worthlessness

• Diminished ability to think/concentrate

• Recurrent thoughts of death, suicidal ideation

• Symptoms cause clinically significant distress/impairment in social, occupational functioning

• Not attributable to the physiological effects of a substance or another medication

• Are common in bipolar I but not required for diagnosis


Development and Course (APA, 2013):

• Mean age of onset: 18 years

• Onset may occur throughout the life cycle• Manic symptoms later in life may indicate medical conditions

• > 90% of individuals who have 1 episode experience recurrent

• Approx. 60% of manic episodes occur immediately before a major depressive episode

• Rapid cycling occurs when individuals experience 4 or more mood episodes in 1 year


Functional Consequences (APA, 2013):

• Approx. 30% of individuals experience severe impairment in work role function

• Functional recovery may be slow

• Cognitive impairments may occur

Cultural issues (APA, 2013):

• Little data exists on specific cultural differences

• Lack of transcultural validation

• One U.S. study shows 12-month prevalence significantly lower in Afro-Caribbeans than African Americans and Whites


Measurements (STABLE, 2007):

• The Mood Disorder Questionnaire (MDQ)• Screening tool: present and past episodes of mania/hypomania.

• Includes 13 questions associated with the symptoms of bipolar disorder

• Plus items assessing clustering of symptoms and functional impairment

• May be used in primary care settings

• Efficient way to identify patients most likely to have a bipolar disorder


Measurements cont. (STABLE, 2007):

• The Composite International Diagnostic Interview (CIDI) Bipolar Disorder Screening Scale• Can accurately identify threshold/sub-threshold bipolar disorder

• Scale detected between 67-96% of true cases in clinical studies

• Compares favorably with the MDQ screening scale


Diagnostic Features (APA, 2013):

• Manic Episode:• Euphoric: “feeling on top

of the world”

• Increased activity

• Irritable

• Grandiose delusions


• Rapid, pressured speech

• Racing thoughts

• Distractibility

• Marked impairment in social/occupational function

• Rapidly shifting mood to anger or depression

• Depressive symptoms may occur during a manic episode

Brief I Disorder Cont.

Specifiers (APA, 2013):

• 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

Bipolar I Disorder Cont.ICD-10 Coding and severity (APA, 2013):

Bipolar I

disorder

Current/most recent

episode manic

Current/most recent

episode hypomanic*

Current/most recent

episode depressed

Current/most recent

episode unspecified**

Mild 296.41

(F31.11)

NA 296.51

(F31.31)

NA

Moderate 296.42

(F31.12)

NA 296.52

(F31.32)

NA

Severe 296.43

(F31.13)

NA 296.53

(F31.4)

NA

With psychotic

features***

296.44

(F31.2)

NA 296.54

(F31.5)

NA

In partial

remission

296.45

(F31.73)

296.45

(F31.73)

296.55

(F31.75)

NA

In full

remission

296.46

(F31.74)

296.46

(F31.74)

296.56

(F31.76)

NA

Unspecified 296.40

(F31.9)

296.40

(F31.9)

296.50

(F31.9)

NA

*Severity & psychotic specifiers do not apply; code 296.40 (F31.0) for cases not in remission.

**Severity, psychotic, and remission specifiers do not apply; code 296.7 (F31.9).

***If psychotic features are present, code “with psychotic features.”


Differential Diagnoses (APA, 2013):

• Major depressive disorder

• Other bipolar disorders

• Generalized anxiety disorder, panic disorder, posttraumatic stress disorder, or other anxiety disorders

• Substance/medication-induced bipolar disorder

• Attention-deficit/hyperactivity disorder

• Personality disorders

• Disorders with prominent irritability

Bipolar II Disorder

Prevalence (APA, 2013):

• 12-month prevalence estimate in US is 0.8%• Internationally 0.3%

Diagnostic Criteria (APA, 2013):

• One hypomanic and one major depressive episode

• Never experienced a manic episode

• Specific criteria must be met for a current/past hypomanic episode and current/past major depressive episode:

Bipolar II Disorder Cont.

Hypomanic Episode (APA, 2013):


• Increased activity or energy

• Lasting at least 4 consecutive days and present most of the day, nearly every day






• Flight of ideas

• Distractibility



• Spending sprees




• Episode associated with change in functioning• uncharacteristic when asymptomatic

• Disturbance in mood and change in functioning observed by others

• Not severe enough to cause impairment in social/occupational functioning

• Not requiring hospitalization

• Not attributable to the physiological effects of a substance


Major Depressive Disorder (APA, 2013):

• 5 or more of the following symptoms during the same 2-week period and represent change from prior functioning:• 1 symptom must be (1) depressed mood or (2) loss of

interest/pleasure

• Depressed mood most of the day, nearly every day per subjective report or observation

• Diminished interest, pleasure in all, or most, activities

• Significant weight-loss or weight-gain

• Insomnia or hypersomnia

• Psychomotor agitation

• Fatigue


Major Depressive Disorder cont. (APA, 2013):• Feelings of worthlessness

• Diminished ability to think/concentrate

• Recurrent thoughts of death, suicidal ideation

• Symptoms cause clinically significant distress/impairment in social, occupational functioning

• Not attributable to the physiological effects of a substance or another medication


Development and Course (APA, 2013):

• Can begin in late adolescence

• Average age of onset in mid-20s• Slightly later than bipolar I

• Most often begins with depressive episode and not recognized until hypomanic episode occurs

• May be preceded by anxiety, substance use, or eating disorders

• Lifetime episodes of hypomanic and depressive episodes greater than in bipolar I


Functional Consequences (APA, 2013):

• Most individuals return to fully functional state between episodes

• 15% may continue to have some inter-episode dysfunction

• 20% transition directly into another mood episode without inter-episode recovery

• Functional recovery may be slow

• Cognitive impairments may occur


Cultural Issues (APA, 2013):

• Little data exists on specific cultural differences• Lack of transcultural validation


Measurements (STABLE, 2007):

• The Mood Disorder Questionnaire (MDQ)• Screening tool: present and past episodes of mania/hypomania.

• Includes 13 questions associated with the symptoms of bipolar disorder

• Plus items assessing clustering of symptoms and functional impairment

• May be used in primary care settings

• Efficient way to identify patients most likely to have a bipolar disorder


Measurements cont. (STABLE, 2007):

• The Composite International Diagnostic Interview (CIDI) Bipolar Disorder Screening Scale• Can accurately identify threshold/sub-threshold bipolar disorder

• Scale detected between 67-96% of true cases in clinical studies

• Compares favorably with the MDQ screening scale


Diagnostic Features (APA, 2013):

• Recurring mood episodes:• 1 or more major depressive episodes

• Episode lasting at least 2 weeks

• At least 1 hypomanic episode

• Episode lasting at least 4 days

• During episode(s), required number of symptoms must be present most of the day, nearly every day

• A manic episode precludes the diagnosis of bipolar II

• Individuals typically present for treatment during major depressive episode


Specifiers and Severity(APA, 2013):

• Specify current or most recent episode:• Hypomanic

• Depressed

• Specify if (APA, 2013):• With anxious distress

• With mixed features

• With rapid cycling

• With mood-congruent psychotic features

• With mood-incongruent psychotic features

• With catatonia

• With peripartum onset

• With seasonal pattern


• Specify course if full criteria for a mood episode not currently met (APA, 2013):• In partial remission

• In full remission

• Specify severity if full criteria for a mood episode are currently met (APA, 2013):• Mild

• Moderate

• Severe


Differential diagnoses (APA, 2013):

• Major depressive disorder

• Cyclothymic disorder

• Schizophrenia spectrum and other related psychotic disorders

• Panic disorder or other related anxiety disorders

• Substance use disorders

• Attention-deficit/hyperactivity disorder

• Personality disorders

• Other bipolar disorders


ICD-10 (APA, 2013, p. 111):

• Bipolar II disorder has only one diagnostic code:• 296.89 (F31.81)

• Severity, presence of psychotic features, course, and other specifiers cannot be coded but should be indicated in writing

Differences Between Bipolar I & II

Bipolar I• At least 1 manic or mixed

episode

Bipolar II• Never had a manic episode

• At least 1 hypomanic episode

• At least 1 major depressive episode

Bipolar Disorders I & II Cont.

Bipolar Disorders I & II Cont.

Treatment Options for Bipolar I & II (Epocrates, 2015):

• Pharmacologic:• Mood stabilizers

• Atypical antipsychotic

• Typical antipsychotic

• Alternative antipsychotic

• Neuroleptic

• Other neurologic

• Benzodiazepine

• Antidepressants

Bipolar I & II Disorders Cont.

Treatment cont. (Epocrates, 2015):

• Education to recognize and manage early symptoms

• Psychotherapies:• Cognitive behavioral therapy

• Family-focused therapy

• Interpersonal social rhythm therapy

• Psychoeducation

• Electroconvulsive therapy (ECT)

Case Study

(Novac, 1998, p. 108)

Case Study Cont.

(Novac, 1998, p. 108)

Case Study Cont.

Did you recognize the symptoms of Bipolar I Disorder?

• Mania:• Insomnia

• Rapid speech

• Euphoria

• Intermittent irritability

• Hospitalized for a previous manic episode

• Depression 2 months prior and treated with SSRI• Antidepressants can worsen mania and cause rapid cycling

• Rapid cycling

The End

References

American Psychiatric Association. (2013). Clinician-rated dimensions of psychosis symptom severity. Retrieved from http://www.psychiatry.org /File%20Library/ Practice/DSM/DSM-5/ClinicianRatedDimensionsOf

PsychosisSymptomSeverity.pdf

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington D.C.: Author.

Epocrates. (2015). Bipolar disorder in adults. Retrieved from https://online.epocrates.com/u/2942488/Bipolar+disorder+in+adults/Treatment/Tx+Details

References Cont.

Novac, A. (1998). Atypical antipsychotics as enhancement therapy in rapid cycling mood states: A case study. Retrieved from http://link.springer.com/article/ 10.1023/A%3A1022398104353

Stable National Coordinating Council. (2007). Stable resource toolkit. Retrieved from http://www.integration.

samhsa.gov/images/res/STABLE_toolkit.pdf

Health & Medicine

Bipolar Disorders I & II