psychology 101 class, 9wks tasks

̂ ~ Bipolar and Related Disorders

B i p o l s r S n d r G lâ t e d disorders are separated from the depressive disorders in DSM-5 and placed between the chapters on schizophrenia spectrum and other psychotic disorders and depressive disorders in recognition of their place as a bridge between the two diagnostic classes in terms of symptomatology, family history, and genetics. The di­ agnoses included in this chapter are bipolar I disorder, bipolar II disorder, cyclothymic disorder, substance/medication-induced bipolar and related disorder, bipolar and relat­ ed disorder due to another medical condition, other specified bipolar and related disor­ der, and unspecified bipolar and related disorder.

The bipolar I disorder criteria represent the modern understanding of the classic manic-depressive disorder or affective psychosis described in the nineteenth century, dif­ fering from that classic description only to the extent that neither psychosis nor the lifetime experience of a major depressive episode is a requirement. However, the vast majority of individuals whose symptoms meet the criteria for a fully syndromal manic episode also experience major depressive episodes during the course of their lives.

Bipolar II disorder, requiring the lifetime experience of at least one episode of major de­ pression and at least one hypomanie episode, is no longer thought to be a "milder" condition than bipolar I disorder, largely because of the amount of time individuals with this con­ dition spend in depression and because the instability of mood experienced by individuals with bipolar II disorder is typically accompanied by serious impairment in work and social functioning.

The diagnosis of cyclothymic disorder is given to adults who experience at least 2 years (for children, a full year) of both hypomanie and depressive periods without ever fulfilling the criteria for an episode of mania, hypomania, or major depression.

A large number of substances of abuse, some prescribed medications, and several medical conditions can be associated with manic-like phenomena. This fact is recognized in the diagnoses of substance/medication-induced bipolar and related disorder and bipo­ lar and related disorder due to another medical condition.

The recognition that many individuals, particularly children and, to a lesser extent, ad­ olescents, experience bipolar-like phenomena that do not meet the criteria for bipolar I, bi­ polar II, or cyclothymic disorder is reflected in the availability of the other specified bipolar and related disorder category. Indeed, specific criteria for a disorder involving short-duration hypomania are provided in Section III in the hope of encouraging further study of this disorder.

Bipolar I Disorder Diagnostic Criteria

For a diagnosis of bipolar I disorder, it is necessary to meet tlie following criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypo- manic or major depressive episodes.

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 hospi­ talization is necessary).

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 sig­ nificant 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 or subjective experience that thoughts are racing. 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external

stimuli), as reported or observed. 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or

psychomotor agitation (i.e., puφoseless non-goal-directed activity). 7. Excessive involvement in activities that have a high potential for painful conse­

quences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

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 oth­ ers, 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. Note: A full manic episode that emerges during antidepressant treatment (e.g., medi­ cation, 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 re­ quired for the diagnosis of bipolar I disorder.

Hypomanie 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 consec­ utive days and present most of the day, nearly every day.

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, rep­ resent 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 (e.g., feels rested after only 3 hours of sleep). 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external

stimuli), as reported or observed. 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or

psychomotor agitation. 7. Excessive involvement in activities that have a high potential for painful conse­

quences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

C. The episode is associated with an unequivocal change in functioning that is uncharac­ teristic 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 occupa­

tional 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). Note: A full hypomanie 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 hypomanie episode diagnosis. However, caution is indicated so that one or two symptoms (particularly in­ creased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanie episode, nor necessarily indicative of a bi­ polar diathesis.

Note: Criteria A-'F constitute a hypomanie episode. Hypomanie episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.

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 condi­ tion. 1. Depressed mood most of the day, nearly every day, as indicated by either subjec­

tive report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., 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 (as indicated by either subjective account or observation).

3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), 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. 5. Psychomotor agitation or retardation nearly every day (observable by others; not

merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delu­

sional) nearly every day (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (ei­

ther by subjective account or as observed by others). 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation with­

out a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms cause clinically significant distress or impairment in social, occupa­

tional, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or another

medical condition. 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 Cri­ terion A, which may resemble a depressive episode. Although such symptoms may be un­ derstandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.̂

Bipolar I Disorder A. Criteria have been met for at least one manic episode (Criteria A-D under “Manic Ep­

isode” above). B. The occurrence of the manic and major depressive episode(s) is not better explained

by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional dis­ order, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

Coding and Recording Procedures The diagnostic code for bipolar I disorder is based on type of current or most recent epi­ sode and its status with respect to current severity, presence of psychotic features, and remission status. Current severity and psychotic features are only indicated if full criteria are currently met for a manic or major depressive episode. Remission specifiers are only indicated if the full criteria are not currently met for a manic, hypomanie, or major depres­ sive episode. Codes are as follows:

Bipolar 1 disorder

Current or most recent

episode manic

Current or most recent

episode hypomanie*

Current or most recent

episode depressed

Current or most recent

episode unspecified**

Mild (p. 154) 296.41 ΝΑ 296.51 NA (F31.11) (F31.31)

Moderate (p. 154) 296.42 ΝΑ 296.52 NA (F31.12) (F31.32)

Severe (p. 154) 296.43 ΝΑ 296.53 NA (F31.13) (F31.4)

̂In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in grief the predominant affect is feelings of emptiness and loss, while in MDE it is persistent depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is likely to decrease in intensity over days to Wfeeks and occurs in waves, the so-called pangs of grief. These waves tend to be associated with thoughts or reminders of the deceased. The depressed mood of a MDE is more persistent and not tied to specific thoughts or preoccupations. The pain of grief may be accompanied by positive emotions and humor that are uncharacteristic of the pervasive unhappiness and misery characteristic of a major depressive episode. The thought content associated with grief generally features a preoccupation with thoughts and memories of the deceased, rather than the self-critical or pessimistic ruminations seen in a MDE. In grief, self-esteem is generally preserved, whereas in a MDE, feelings of worthlessness and self­ loathing are common. If self-derogatory ideation is present in grief, it typically involves per­ ceived failings vis-à-vis the deceased (e.g., not visiting frequently enough, not telling the deceased how much he or she was loved). If a bereaved individual thinks about death and dying, such thoughts are generally focused on the deceased and possibly about "joining" the deceased, whereas in a major depressive episode such thoughts are focused on ending one's own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression.