17 - Bipolar affective disorder (BPAD)

Bipolar affective disorder (BPAD)

© SPMM Course 5. Classification of mood disorders Depressive disorder DSM-IV Major Depressive Disorder ICD 10 Depressive disorder Duration: Most of the day, nearly every day for at least two weeks.

Duration of at least two weeks is usually required for diagnosis for depressive episodes of all three grades of severity. Five or more of following symptoms; at least one symptom is either depressed mood or loss of interest or pleasure: (1) Depressed mood (2) Loss of interest (3) Significant weight loss* or gain or decrease or increase in appetite (4) Insomnia or hypersomnia (5) Psychomotor agitation or retardation (6) Fatigue or loss of energy (7) Feelings of worthlessness or excessive or inappropriate guilt (8) Diminished ability to think or concentrate or indecisiveness (9) Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or suicide attempt or a specific plan Criterion A: Depressed mood, loss of interest and enjoyment, and reduced energy leading to increased fatigability and diminished activity

Criterion B: other common symptoms are: (1) Reduced concentration and attention (2) Reduced self-esteem and self-confidence (3) Ideas of guilt and unworthiness (4) Bleak and pessimistic views of the future (5) Ideas or acts of self-harm or suicide (6) Disturbed sleep (7) Diminished appetite

*To qualify as a diagnostic criterion, this must be an unintentional weight loss of at least 5% weight in one month. Note that reduced self-confidence is not listed in DSM.

The 4-6-8 rule for severity grading in ICD-10: For mild depressive episode at least 2 criterion A ‘core symptoms’ with four symptoms in total is required. For moderate depression, at least 2 criterion A with six symptoms in total is required. To diagnose a severe episode, at least 2 criterion A symptoms with eight symptoms in total is required.

Both DSM and ICD-10 define recurrent major depressive disorder if there is more than one episode of depression. In ICD-10, this diagnosis can be given to a patient with depression if there has been at least one previous major depressive episode separated by the current episode by at least two months.

Bipolar affective disorder (BPAD) BPAD is characterized by periods of prolonged and profound depression alternate with periods of excessively DSM-5 AND DEPRESSION In DSM-IV a diagnosis of depression cannot be given in the presence of bereavement for 2 months after the loss. This exclusion is now removed. A  specifier  “with  anxious  distress”  is added to rate the severity of bipolar or depressive disorders. This takes DSM closer  to  ICD’s  description  of  mixed   anxiety depression.

© SPMM Course elevated and irritable mood, known as mania. ICD 10 needs at least two mood episodes before a bipolar diagnosis can be considered, with complete recovery in between the episodes. The depressive episode must be present at least for 2 weeks; mania for 7 days (fewer if hospitalized); hypomania for 4 days and mixed episodes for 2 weeks before they can be diagnosed using ICD 10. In DSM, bipolar disorder can be diagnosed even with a single manic episode. BPAD is divided into two main broad types; Type 1 is characterised by full-blown mania or mixed mania and depression. Type 2 is characterised by recurrent depression and hypomania without episodes of either mania or mixed states. Except in the elderly, the natural course of mood episodes suggests that mania lasts for 4 months while depression for 6 months. This becomes longer in the elderly who show shorter periods of inter episodic remissions and more frequent episodes, which are considerably longer than those seen in working age adults.

ICD-10 bipolar affective disorder Current episode, hypomanic Current episode, manic without psychotic symptoms Current episode, manic with psychotic symptoms Current episode, mild or moderate depression Current episode, severe depression without psychotic symptoms Current episode, severe depression with psychotic symptoms Current episode, mixed Currently in remission Other bipolar affective disorders: Bipolar affective disorder, unspecified

In line with the depressive episode, a manic mood episode is also operationally defined in ICD and DSM. According to ICD, mania/manic episode is a distinct period of abnormally and persistently elevated, expansive, or irritable mood, with 3 (or more) characteristic symptoms of mania. By definition, the disturbance must be sufficiently severe to impair occupational and social functioning. Psychotic features may be present.

© SPMM Course DSM IV Manic episode ICD 10 Manic episode Duration: at least 1 week or any duration if hospitalised

Duration: Sustained for at least a week (unless it is severe enough to require hospital admission). Criterion A: Abnormally and persistently elevated, expansive, or irritable mood.

Criterion B: During the same period three (or more) of the following symptoms have persisted (four if the mood is only irritable) 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 talk (4) Flight of ideas or subjective racing of thoughts (5) Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) (6) Increase in goal-directed activity (either socially, at work or school or sexually) or psychomotor agitation (7) Excessive involvement in pleasurable activities that have a high potential for painful consequences A mood that is predominantly elevated, expansive or irritable and definitely abnormal for the individual concerned. At least three of the following must be present (four if the mood is merely irritable), leading to severe interference with personal functioning in daily living: (1) Increased activity or physical restlessness; (2) Increased talkativeness ('pressure of speech'); (3) Flight of ideas or the subjective experience of thoughts racing; (4) Loss of normal social inhibitions resulting in behaviour which is inappropriate to the circumstances; (5) Decreased need for sleep; (6) Inflated self-esteem or grandiosity; (7) Distractibility or constant changes in activity or plans; (8) Behaviour which is foolhardy or reckless and whose risks the subject does not recognize e.g. spending sprees, foolish enterprises, reckless driving; (9) Marked sexual energy or sexual indiscretions.

Psychotic symptoms: In bipolar disorder, mood symptoms are prominent. However in its more severe form, mania may be associated with psychotic symptoms (usually mood-congruent, but may also be incongruent). Delusions and hallucinations are often  ‘changeable’  in  their  quality. Grandiose and persecutory delusions are common in psychotic mania. Auditory hallucinations are usually the second person in nature and are often consistent  with  the  patient’s  mood (e.g. religious revelations). Hypomania/hypomanic episode- ICD description of hypomania is a difficult concept. By definition, hypomania shares symptoms with mania, but these are evident to a lesser degree, not severe enough to interfere with social or occupational functioning or require admission to hospital, or include psychotic features. It includes mildly elevated, expansive, or irritable mood, increased energy and activity, increased self-esteem, talkativeness, over-familiarity, reduced need for sleep and difficulty in focusing on one task alone. Mixed states are cases where manic and depressive symptoms occur simultaneously. The occurrence of both manic/hypomanic and depressive symptoms in a single episode, present every day for at least 1 week (DSM-IV) or 2 weeks (ICD-10) DSM IV course specifiers for bipolar disorder: