Bipolar and Related Disorders

Manic, Hypomanic, Mixed and Depressive episodes

Bipolar was previously known as "manic depression" and is a mood"Pervasive and sustained emotion" which affects a person's perception of the world.{{Rp|6}} disorder. This page will concentrate on bipolar disorders as they relate to trauma and stressor-related and dissociative disorders.

A manic episode is an extreme persistent mood state lasting at least one week characterized by euphoria, irritability, or expansiveness, and excessive psychomotor activation or increased energy, accompanied by other characteristic symptoms such as grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, and impulsive or reckless behavior."^[3]

A hypomanic episode is an persistent mood state characterized by similar symptoms to a manic episode (but less severe), and lasting at least four days. It may accompany a heightened level of creativity. The symptoms represent a change from the individual’s typical behavior and are not severe enough to cause marked impairment in functioning.^[3] The person's mood may be described as "hyper".^[4]:2

A Mixed episode is characterized by either a mixture or very rapid alternation between prominent manic and depressive symptoms on most days during a period of at least 2 weeks. "^[3]

A Depressive episode is characterized by a period of almost daily depressed mood or diminished interest in activities lasting at least two weeks accompanied by other symptoms such as changes in appetite or sleep, psychomotor agitation or retardation, fatigue, feelings of worthless or excessive or inappropriate guilt, feelings or hopelessness, difficulty concentrating, and suicidality."^[3]

Different types of Mixed Episodes

Kraepelin (1921) originally investigated mixed episodes. Characteristics can include opposite moods (anxious vs sad, or euphoric vs irritable), thoughts changing between racing and slow, thoughts changing between depressive and expansive thoughts, and disturbed perceptions (depression vs expansive), or movements changing between quicker and slower. Mixed disorders can be difficult to characterize or describe because symptoms can be either a mixture of depression and manic symptoms occurring simultaneously, or rapidly moving between depressive and manic symptoms.

Some examples identified by Perugi et al. ⁽¹⁹⁹⁷⁾ and Kraepelin include:

• Dysphoric mixed mania
• Inhibited mania (also known as unproductive-inhibited manic) - with fatigue and indecisiveness
• Mixed agitated psychoticA person experiencing psychosis, or a characteristic of psychosis. {{Rp|24}} depressive states or Agitated depression - with irritable mood and flight of ideas
• Dysphoric mixed mania (as described in the DSMPublished by the American Psychiatric Association as the standard classification of mental disorders used by US mental health professionals. It consists of diagnostic classification, the diagnostic criteria sets, and descriptive text. The DSM-II listed multiple personality disorder as a symptom of hysterical neurosis, dissociative type. The DSM-III (1980) moved Multiple Personality Disorder from a symptom to its own disorder. The DSM-IV changed the name to dissociative identity disorder (1994) and the DSM-5 (May 2013) updated the listing to current standards. {{Rp|384}}-III-R)

A review of a large number of studies compared people often experiencing mixed episodes with those experiencing different forms of bipolar disorder; the people with mixed episodes had more episodes, increased suicidality, higher rates of co-occurring conditions, and also a poorer response to treatments. ^[5]:6

Rapid Cycling

Rapid cycling within bipolar disorders refers to at least four episodes within a single year, this could be a combination of depressive and hypomanic episodes, or many be several manic episodes occurring between periods of normal mood.^[2]:6 Rapid cycling is not a separate diagnosis, but can be specified within any bipolar-related disorder.

Bipolar and Related Disorders in the ICD-11

The ICD-11 is currently a beta version, but is expected to be published in 2017.^[6] The proposed disorders and descriptions are listed below.

Bipolar type I disorder

• An episodic mood disorder defined by the occurrence of one or more Manic or Mixed episodes
• typically manic or mixed episodes alternate with Depressive episodes over the course of the disorder, although a single or recurrent Manic or Mixed episode is enough for diagnosis
• can occur with or without psychotic symptoms

Exclusions: cannot be diagnosed alongside bipolar disorder, single manic episode or Cyclothymia.

Impacts can include:

• family and intimate relationships
• life management, e.g.; carrying out daily routines, handling stress
• work activities/employment
• self care (looking after one's health)
• problems solving skills

Bipolar type I is also known as manic-depressive psychosis"Mental disorder in which thoughts, affective response, ability to recognize reality, and the ability to communicate and relate to others are sufficiently impaired to interfere grossly with the capacity to deal with reality." Impaired reality testing, hallucinations, delusions, and illusions are classic characteristics. {{Rp|24}}"Mental disorder in which thoughts, affective response, ability to recognize reality, and the ability to communicate and relate to others are sufficiently impaired to interfere grossly with the capacity to deal with reality." Impaired reality testing, hallucinations, delusions, and illusions are classic characteristics. {{Rp|24}}, reaction or illness.^[3]

Bipolar type II disorder

• An episodic mood disorder defined by the occurrence of one or more hypomanic episodes and at least one depressive episode.
• can occur with or without psychotic symptoms ^[3]

Cyclothymic disorder

• characterized by a persistent instability of mood over a period of 'several years (e.g., at least 2)
• involves having numerous periods of hypomanic (e.g., euphoria, irritability, or expansiveness, psychomotor activation) and depressive (e.g., feeling down, diminished interest in activities, fatigue) symptoms which occur during more of the time than not
• Most of the time, the number or duration of depressive symptoms is not sufficient to meet the requirements of a Depressive episode.
• Symptoms result in significant distress or significant impairment in important areas of functioning

Cyclothymic is also known as Affective personality disorder/trait, Affective personalityEvery individual has a personality that is composed of many diverse, fragmentary and generally illusory images of [[Personality|self]]. (see multiples) The DSM-IV uses the term identity in its definition of dissociation. (see identity) {{Rp|127}}, Cycloid/Cyclothymic personality, Cyclothymic personality disorder, Tends to be unstable in affect"a person's present emotional responsiveness, which can be inferred from facial expressions" including both the degree and range of expressive behavior. This can also be shown in tone of voice, hand and body movements. {{Rp| 6}}, Unstable personality trait, Hyperthymic personality/personality disorder.^[3]

Substance-induced mood disorder

Substances which can cause mood disorders include alcohol, opioids (for example, heroin), sedativesA hypnotic/sedative is a substance which is a central nervous system depressant with the capacity to relieve anxiety, induce calmness and sleep. Some hypnotics cause amnesia and muscle relaxation. Examples include alcohol, buspirone, benzodiazepines and barbiturates. Sometimes this term is used to refer to drugs to calm anxiety in order to differentiate them from minor tranquillizers. Long term use can cause impairments in memory, learning, speed and coordination which last after detoxification, and can result in a permanent amnestic disorder. {{Rp|57-58}}/hypnoticsA hypnotic/sedative is a substance which is a central nervous system depressant with the capacity to relieve anxiety, induce calmness and sleep. Some hypnotics cause amnesia and muscle relaxation. Examples include alcohol, buspirone, benzodiazepines and barbiturates. Sometimes this term is used to refer to drugs to calm anxiety in order to differentiate them from minor tranquillizers. Long term use can cause impairments in memory, learning, speed and coordination which last after detoxification, and can result in a permanent amnestic disorder. {{Rp|57-58}}, cocaine, stimulant-indiced, hallucinofen, ecstasy, Ketamine, volatile inhalantsThese are substances inhaled for psychoative effects, including organic solvents (e.g., glue, aerosol, paints and gasoline), and aliphatic nitrites such as amyl nitrite. Some are directly toxic to the heart, kidney or liver and can produce progressive brain degeneration. These vaporize at ambient temperatures. Also known as a volatile substance. {{Rp|63}}. A detailed description is available yet. Last updated 7 May 2014.^[3]

Bipolar disorder Not Otherwise Specified

This is not officially recognized in the ICD-11 beta version.

Bipolar and Related Disorders in the DSM-5

Manic episode in the DSM-5

A Abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased goal-directed energy or activity. This lasts at least 1 week and is present most of the day, nearly every day (or less if hospitalization is needed).

B During this period, three or more of the following symptoms are present, significant and demonstrate a change from usual behavior.

1. Inflated self-esteem or grandiosity
2. Reduced need for sleep (feeling rested after 3 hours sleep)
3. More talkative or feeling pressure to keep talking
4. Flight of ideas (or the person feels their thoughts are racing)
5. Very distractable (either reported by the person or observed), e.g. distracted by irrelevant external stimuli.
6. Increased goal-directed activity (can be social, work/school-focused, or sexual) or psychomotor agitation (non-goal-directed activity without a purpose)

Note: if mood is irritable rather than elevated or expansive, then at least four symptoms must be present.

C Mood"Pervasive and sustained emotion" which affects a person's perception of the world.{{Rp|6}} disturbance impairs social or occupational functioning, or hospitalization is needed to prevent harm to self or others (or if there are psychotic features)

D Not caused by physiological effects of a substance or another medical condition (including medication and drug abuse"interactions in which one person behaves in a violent, demeaning or invasive manner towards another person (e.g. child or partner)" )

A full manic episode which emerges during anti-depressant treatment but goes beyond the level of physiological effect that the treatment may cause is also sufficient for a manic episode.

An episode which only partially meets these criteria but includes psychotic features is classed as manic. ^[7]:65-67

Hypomanic episode in the DSM-5

Symptoms are the same as those for a manic episode with the following exceptions:

• the mood disturbance lasts a minimum of 4 days
• hospitalization is not necessary
• there is an unequivocal change in functioning, which is uncharacteristic of that person
• the mood disturbance and change in functioning are noticable to others
• it is not severe enough for marked impairment in social or occupational functioning
• there are no psychotic features
• often occur in bipolar I as well as other forms

Note: One or two symptoms (such as increase irritability, edginess, or agitation) which occur following after antidepressant use are not necessaily indicators of a hypomanic epidsode or bipolar disorder.

^[7]:66-67

Major Depressive episode within Bipolar Disorder

^[7]:67-67

Mixed episode in the DSM-5

This is now classified using one of the following:

• Manic episode with depressive features
• Hypomanic episode with depressive features
• Depressive episode with manic/hypomanic features

The criteria for both types of episode no longer need to be fully met.^[8]:4

Bipolar I disorder

This "represents classic manic depressive disorder, with the exception that neither a depressive episode nor psychosis has to be present for diagnosis)."^[4]:1

To be completed shortly.

Bipolar II disorder

To be updated shortly.

Other Specified Bipolar and Related Disorder

This was previously known as Bipolar Disorder Not Otherwise Specified (BP-NOS).^[7] Stahl ⁽²⁰⁰⁸⁾ stated that more people experienced this type of bipolar spectrum disorder than any other,^[2]{{Rp|16} however, the broadening of the diagnostic criteria for Bipolar I and Bipolar II in the DSM-5 should reduce the number in this category.^[4]

Examples:

1. A history of a major depressive disorder, meeting all criteria for hypomania but with shorter duration (under 4 consecutive days)
2. A history of a major depressive disorder with an episode which lasts at least 4 days but does not fully meet criteria for hypomania (so not quite Bipolar II Disorder).^[8]:4
3. Cyclothymia^[9]

Manic-like phenomena

"Manic-like phenomena" can be recognized as being associated the use of substances (either substances of abuse or prescribed medications) or with medical conditions.

Changes since the DSM-IV

Bipolar and Related Disorders are now in their own chapter in the DSM,^[4]:1 rather than grouped with mood disorders. The first criteria for both manic and hypomanic episodes now emphasizes the changes in activity and energy, as well as mood.^[8]:4 "Persistently increased (goal-directed) activity or energy" must be present nearly every day, and for most of the day.^[4]:1

Other Specified Bipolar and Related Disorder has been added.^[8]:4

An Anxious Distress Specifier can be used to identify patients with anxiety symptoms that do not fit within the bipolar diagnostic criteria.^[8]:4

Manic features can also be specified within Major Depressive Disorder (unipolar depression).^[8]:4

Treatment for Bipolar related disorders

The Bipolar treatment guidelines focus mostly on medication,^[10] but note that psychoeducation (learning about the illness and its treatment), cognitive-behavioral therapy, and family intervention have been shown to improve the outcome (when used in additional to medication).^[10]:9 Typical treatment may involve medication, for example a mood stabilizer (known as prophylactic antimanic agents), possibly in combination with anti-depressant medication. ^[4] Some anti-depressants may cause hypomania in some people, which can complicate a bipolar diagnosis.^[4]

Comparison with Dissociative Identity DisorderPrior to the DSM-IV, dissociative identity disorder was known as multiple personality disorder, which was from 1980-1994. The International Classification of Diseases,(ICD) still uses this label, even though the ICD-11 is expected to change it. The term is misleading. No one can have more than one personality, nor is the disorder a personality disorder. {{See also| Multiple Personality Disorder}} and Other Specified Dissociative Disorder

Physical illnesses and symptoms

Dissociative Identity Disorder and similar presentations of Other Specified Dissociative Disorder (OSDD, formerly known as DDNOS) are commonly misdiagnosed as Bipolar disorder,^[11] although they can be cormorbid. Physical symptoms caused by somatoform dissociation are more common in Dissociative Identity Disorder and OSDD,^[12][13] for example multiple medical illnesses, headaches, fibromyalgia, and GI and gynecological problems.^[14]:67 The SDQ-20The Somatoform disorders questionnaire in available in a 20 question or 5 question format and measures somatoform dissociation. {{See also | Somatoform Disorders}} screening tool can be used to assess these symptoms.^[15]

Trauma history and Dissociative/psychotic-like symptoms

People with Bipolar disorder and no cormorbid dissociative disorder may also have a history of early childhood traumaThe most fundamental effect of trauma is dissociation, so we define trauma as the event(s) that cause dissociation. {{Rp|75}} The original trauma in those with dissociative identity disorder was failure of secure attachment with a primary attachment figure in early childhood. {{Rp|83}}, but this is less likely to be severe and chronic trauma, and no identity alternations will occur. Identity alternations may feel as though the person has different identities, for example sometimes feeling like a scared child but at other times being highly critical, possibly like a former abuser.^[14]:66 Some dissociative symptoms may be present, but they will not be moderate or severe when assessed with with Dissociative Experience Scale self-screening tool. Most people with Dissociative Identity Disorder score over 44 on the DES, and people with Borderline personality disorder score around 20, so scores would be expected to be below that range.^[14]:66

During periods of psychotic mania or psychotic depression a person with a bipolar disorder may experience hallucinationsThe DSM-IV-TR psychiatric manual defined hallucinations as a "sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ. Auditory hallucinations are common both in schizophrenia and dissociative identity disorder. {{Rp|525}}Hallucinations can be auditory (voices, noises or other sounds), voices commenting on the person's behavior or thoughts, voices conversing, somatic or tactile (peculiar physical sensations), olfactory (unusual smells), visual (shapes or people that are not present). {{Rp|45}}Visual hallucinations are the most common type of hallucination and are often in geometric forms and figures {{Rp|127}} Illusions are similar to visual hallucinations but are based on real images or sensations., such as hearing voices (auditory hallucinations) but these voices are typically persecutory voices (no encouraging or child voices); voices will also not be in conflict with one another (arguing) as they often are in Dissociative Identity Disorder. In DID some people also see alter identities, but like the voices they will be aware these are not "real".^[14]:66

Since Dissociative Identity Disorder and OSDD usually occur with Posttraumatic stress disorder hallucinations may also include periods of "seeing" past traumatic events in the form of a flashbackA flashback is a reactivated traumatic memory experienced as intrusive thoughts, feelings, or images associated with past trauma, but lacking a sense of being from the past. {{Rp|30}} It is experienced by the state referred to as the EP. {{See also | Grounding techniques}}. Similar flashbacks are likely to occur in a person with both PTSD and Bipolar disorder. There is no significant amnesia present in bipolar disorders, but this is a key requirement in the diagnosis of Dissociative Identity Disorder (but not OSDD).

Mood changes

Mood changes in DID and OSDD typically occur several times a day, and are often inexplicable and rapid changes (eg, sad to angry to helpless and afraid); in bipolar disorder mood changes take at least 12 hours to occur, usually much longer.^[14]:67 disorders, and somatoformSomatoform Dissociation - refers to dissociative symptoms that involve the body; these symptoms are characteristic of dissociative disorders. {{Rp| 9}}Somatoform or somatic symptoms are physical symptoms that resemble, but cannot be explained by, a medical symptom or the direct effects of a substance. {{Rp| 9}} These include bodily sensations such as numbness/loss of sensation, inability to feel pain and dizziness. They are strongly linked to past trauma. {{See also | Somatoform Disorders}} disorder, as well as usually meet BPD criteria when severely decompensated or having overwhelming PTSD/dissociative disorder symptoms; The SCID-D and Dissociative Disorders Interview Schedule are structured clinical interviews which are also helpful in differentiating between DID and Bipolar disorder.^[16],^[11]

References

1. ^ Perugi, Giulio; Akiskal, Hagop S, Micheli, Claudia, Musetti, Laura, Paiano, Antonio, Quilici, Cinzia, Rossi, Luciano, Cassano, Giovanni B (1997). Clinical subtypes of bipolar mixed states:: Validating a broader European definition in 143 cases. Journal of Affective Disorders, volume 43, issue 3, 1 May 1997, page 169-180.
2. ^ a b c Stahl, Stephen M. (2008). . Cambridge University Press..
3. ^ a b c d e f g h World Health Organization World Health Organization: ICD-11 Beta. retrieved on 17 April 2014
4. ^ a b c d e f g Severus, Emanuel; Bauer, Michael (2013). Diagnosing bipolar disorders in DSM-5. International Journal of Bipolar Disorders, volume 1, issue 14. (doi:10.1186/2194-7511-1-14)
5. ^ Swann, Alan C.; Lafer, Beny, Perugi, Giulio, Frye, Mark A., Bauer, Michael, Bahk, Won-Myong, Scott, Jan, Ha, Kyooseob, Suppes, Trisha (2013). http://ajp.psychiatryonline.org/data/Journals/AJP/926192/31.pdf. American Journal of Psychiatry, volume 170, issue 1, page 31-42.
6. ^ World Health Organisation http://www.who.int: ICD-11 Factsheet. retrieved on 19 February 2014
7. ^ a b c d American Psychiatric Association, (2013). . APA.
8. ^ a b c d e f American Psychiatric Association DSM5.org: Highlights of Changes from DSM-IV-TR to DSM-5. retrieved on 17 April 2014
9. ^ Angst, Jules. Bipolar disorders in DSM-5: strengths, problems and perspectives. International Journal of Bipolar Disorders, volume 1, 23 August 2013, page 1-3. (doi:10.1186/2194-7511-1-12)
10. ^ a b Fountoulakis, K. N.; Vieta, E.,Sanchez-Moreno, J., Kaprinis, S.G., Goikolea, J.M. Kaprinis, G.S. (2005). Treatment guidelines for bipolar disorder: A critical review. Journal of Affective Disorders, volume 86, issue 1, page 1-10. (doi:10.1016/j.jad.)
11. ^ a b International Society for the Study. Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision. Journal of Trauma & Dissociation, volume 12, issue 2, 28 February 2011, page 115–187. (doi:10.1080/152947)
12. ^ ERS, Nijenhuis; Spinhoven, P, van Dyck, R, Van der Hart, O, Vanderlinden, J. (1998). Degree of somatoform and psychological dissociation in dissociative disorder is correlated with reported trauma.. J TraumaStress, volume 11, page 711-30.
13. ^ Sar, V; Kundakci T, Kiziltan E, Bakim B, Bozkurt O (2000). Differentiating dissociative disorders from other diagnostic groups through somatoform dissociation in Turkey. Journal of Trauma and Dissociation, volume 4, issue 1, page 67-80.
14. ^ a b c d e Brand, BL; Loewenstein, RJ (2010). Dissociative Disorders: An Overview of Assessment, Phenomenology and Treatment. Psychiatric Times, volume 27, issue 10, page 62-69.
15. ^ Nijenhuis, Ellert R.S.. European Society for Trauma and Dissociation: The scoring and interpretation of the SDQ-20 AND SDQ-5:Update. retrieved on 17 January 2014
16. ^ Colin A. Ross Institute for Psychological Trauma, The. . retrieved on January 9, 2014