Download Bipolar Disorder and Mood Disorders

Bipolar Disorder and Mood Disorders
DSM IV TR Criteria
Diagnostic criteria for 296.0x Bipolar I Disorder, Single Manic Episode:
A. Presence of only one Manic Episode and no past Major Depressive Episodes.
Note: Recurrence is defined as either a change in polarity from depression or an
interval of at least 2 months without manic symptoms.
B. The Manic Episode is not better accounted for by Schizoaffective Disorder and
is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional
Disorder, or Psychotic Disorder Not Otherwise Specified.
Specify if:
Mixed: if symptoms meet criteria for a Mixed Episode
Specify (for current or most recent episode):
Severity/Psychotic/Remission Specifiers
With Catatonic Features
With Postpartum Onset
Diagnostic criteria for 296.40 Bipolar I Disorder, Most Recent Episode
Hypomanic:
A. Currently (or most recently) in a Hypomanic Episode.
B. There has previously been at least one Manic Episode or Mixed Episode.
C. The mood symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
D. The mood episodes in Criteria A and B are not better accounted for by
Schizoaffective Disorder and are not superimposed on Schizophrenia,
Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not
Otherwise Specified.
Specify:
Longitudinal Course Specifiers (With and Without Interepisode Recovery)
With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)
With Rapid Cycling
Diagnostic criteria for 296.4x Bipolar I Disorder, Most Recent Episode
Manic:
A. Currently (or most recently) in a Manic Episode.
B. There has previously been at least one Major Depressive Episode, Manic
Episode, or Mixed Episode.
C. The mood episodes in Criteria A and B are not better accounted for by
Schizoaffective Disorder and are not superimposed on Schizophrenia,
Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not
Otherwise Specified.
Specify (for current or most recent episode):
Severity/Psychotic/Remission Specifiers
With Catatonic Features
With Postpartum Onset
Specify:
Longitudinal Course Specifiers (With and Without Interepisode Recovery)
With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)
With Rapid Cycling
Diagnostic criteria for 296.6x Bipolar I Disorder, Most Recent Episode
Mixed:
A. Currently (or most recently) in a Mixed Episode.
B. There has previously been at least one Major Depressive Episode, Manic
Episode, or Mixed Episode.
C. The mood episodes in Criteria A and B are not better accounted for by
Schizoaffective Disorder and are not superimposed on Schizophrenia,
Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not
Otherwise Specified.
Specify (for current or most recent episode):
Severity/Psychotic/Remission Specifiers
With Catatonic Features
With Postpartum Onset
Specify:
Longitudinal Course Specifiers (With and Without Interepisode Recovery)
With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)
With Rapid Cycling
Diagnostic criteria for 296.5x Bipolar I Disorder, Most Recent Episode
Depressed:
A. Currently (or most recently) in a Major Depressive Episode.
B. There has previously been at least one Manic Episode or Mixed Episode.
C. The mood episodes in Criteria A and B are not better accounted for by
Schizoaffective Disorder and are not superimposed on Schizophrenia,
Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not
Otherwise Specified.
Specify (for current or most recent episode):
Severity/Psychotic/Remission Specifiers
Chronic
With Catatonic Features
With Melancholic Features
With Atypical Features
With Postpartum Onset
Specify:
Longitudinal Course Specifiers (With and Without Interepisode Recovery)
With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)
With Rapid Cycling
Diagnostic criteria for 296.7 Bipolar I Disorder, Most Recent Episode
Unspecified:
A. Criteria, except for duration, are currently (or most recently) met for a Manic, a
Hypomanic, a Mixed, or a Major Depressive Episode.
B. There has previously been at least one Manic Episode or Mixed Episode.
C. The mood symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
D. The mood symptoms in Criteria A and B are not better accounted for by
Schizoaffective Disorder and are not superimposed on Schizophrenia,
Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not
Otherwise Specified.
E. The mood symptoms in Criteria A and B are not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a
general medical condition (e.g., hyperthyroidism).
Specify:
Longitudinal Course Specifiers (With and Without Interepisode Recovery)
With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)
With Rapid Cycling
Diagnostic criteria for 296.89 Bipolar II Disorder:
A. Presence (or history) of one or more Major Depressive Episodes.
B. Presence (or history) of at least one Hypomanic Episode.
C. There has never been a Manic Episode or a Mixed Episode.
D. The mood symptoms in Criteria A and B are not better accounted for by
Schizoaffective Disorder and are not superimposed on Schizophrenia,
Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not
Otherwise Specified.
E. The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Specify current or most recent episode:
Hypomanic: if currently (or most recently) in a Hypomanic Episode
Depressed: if currently (or most recently) in a Major Depressive Episode
Specify (for current or most recent Major Depressive Episode only if it is the most
recent type of mood episode):
Specify:
Longitudinal Course Specifiers (With and Without Interepisode Recovery)
With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)
With Rapid Cycling
Definition
Bipolar disorder is a medical condition in which people have mood swings
unrelated to things going on in their lives. These swings affect thoughts, feelings,
physical health, behavior, and functioning.
Statistics
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Almost 1/3 of 6-to-12-year-old children diagnosed with major depression
will develop bipolar disorder within a few years
32% will be diagnosed with bipolar disorder at an average age of 11 years
Bipolar disorder affects approximately 2.3 million American adults
Bipolar disorder affects 1.2 percent of the U.S. population age 18 and older
in a given year
More than 50% of those with bipolar disorder abuse alcohol or drugs
during their illness
Causes
There is no single cause for bipolar disorder, but different factors can act together
to produce the illness:
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Lack of stability in the transmission of nerve impulses in the brain
Different genes may occur together and in combination with other factors
of the person's environment
Symptoms
Signs and symptoms of mania (or a manic episode) include:
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Increased energy, activity, and restlessness
Excessively "high," overly good, euphoric mood
Extreme irritability
Racing thoughts and talking very fast, jumping from one idea to another
Distractibility, lack of concentration
Little sleep needed
Unrealistic beliefs in one's abilities and powers
Poor judgment
Spending sprees
A lasting period of behavior that is different from usual
Increased sexual drive
Abuse of drugs, particularly cocaine, alcohol, and sleeping medications
Provocative, intrusive, or aggressive behavior
Denial that anything is wrong
Signs and symptoms of hypomania (or a hypomanic episode) include:
Hypomania is a milder form of mania with similar but less severe symptoms and
less impairment. In hypomanic episodes, the individual may have an elevated
mood, feel better than usual, and be more productive. However, this may result in
either escalation to mania or a crash to depression.
Signs and symptoms of depression (or a depressive episode) include:
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Lasting sad, anxious, or empty mood
Feelings of hopelessness or pessimism
Feelings of guilt, worthlessness, or helplessness
Loss of interest or pleasure in activities once enjoyed, including sex
Decreased energy, a feeling of fatigue or of being "slowed down"
Difficulty concentrating, remembering, making decisions
Restlessness or irritability
Sleeping too much, or can't sleep
Change in appetite and/or unintended weight loss or gain
Chronic pain or other persistent bodily symptoms that are not caused by
physical illness or injury
Thoughts of death or suicide, or suicide attempts
Signs and symptoms of Mixed Episode include:
Perhaps the most disabling episodes are those that involve symptoms of both
mania and depression occurring at the same time or alternating frequently during
the day. The person is excitable or agitated as in mania but also feels irritable and
depressed, instead of feeling on top of the world.
Course of Illness
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Bipolar disorder typically begins in adolescence or early adulthood and
continues throughout life.
Episodes of mania and depression typically recur across the life span.
Between episodes, most people with bipolar disorder are free of symptoms,
but as many as one-third of people have some residual symptoms. A small
percentage of people experience chronic unremitting symptoms despite
treatment.
Without treatment, however, the natural course of bipolar disorder tends to
worsen. Over time a person may suffer more frequent (more rapid-cycling)
and more severe manic and depressive episodes than those experienced
when the illness first appeared. But in most cases, proper treatment can
help reduce the frequency and severity of episodes and can help people
with bipolar disorder maintain good quality of life.
Diagnosis
The diagnosis of bipolar disorder is made on the basis of symptoms, course of
illness, and, when available, family history. The diagnostic criteria for bipolar
disorder is described in the Diagnostic and Statistical Manual for Mental
Disorders, fourth edition (DSM IV TR).
**see DSM IV TR criteria section above
Treatment
Stages of Treatment
Acute treatment: Treatment is aimed at ending the current manic, hypomanic,
depressive, or mixed episode.
Preventive treatment: Medication is continued on a long-term basis to prevent
future episodes.
Components of Treatment:
Medication: prescribed for nearly all patients during acute and preventive phases.
Education: crucial in helping patients and families learn how to best manage
bipolar disorder and prevent its complications.
Psychotherapy: helpful for many patients and families in solving problems and
dealing with stress; should not be used alone, but rather should be combined with
medication (except in special situations such as pregnancy).
Medications:
1) Mood Stabilizers:
Mood stabilizers are used to improve symptoms during acute manic, hypomanic,
and mixed episodes; they may sometimes also reduce symptoms of depression.
They are the mainstay of long-term preventive treatment for both mania and
depression. Three mood stabilizers are widely used in the United States:
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Lithium (Eskalith, Lithobid, Lithonate, and other brands)
Valproate (most commonly used as divalproex [Depakote])
Carbamazepine (Tegretol)
2) Antidepressants:
Although mood stabilizers by themselves, especially lithium, can sometimes
pull the person out of a depression, he/she may also need to take a specific
antidepressant medication to treat the depressive episode. However, if given alone,
antidepressants can sometimes cause a major problem in bipolar disorder by
pushing one's mood up too high (causing hypomania, mania, or even rapid
cycling). Therefore, in bipolar disorder, antidepressants are given together with a
mood stabilizer to prevent an "overshoot." All can be effective, but most common
types are:
 Bupropion (Wellbutrin)
 Selective serotonin reuptake inhibitors: fluoxetine (Prozac), fluvoxamine
(Luvox), paroxetine (Paxil), sertraline (Zoloft)
Electroconvulsive therapy
Electroconvulsive therapy (ECT) can be a life-saver and is often the safest and
most effective treatment for psychotic depression. ECT may also be needed if the
person is severely ill and cannot wait for medicines to work, he/she has had
several unsuccessful trials of antidepressant medications, or if the person has
medical conditions that make drug therapy less safe.
Hospitalization
Treatment in the hospital is sometimes needed but is usually brief (1-2 weeks).
Hospitalization is essential to prevent self-destructive, impulsive, or aggressive
behavior that the person will later regret. Hospitalization is also used for
individuals who have medical complications that make it harder to monitor
medication and for people who cannot stop using drugs or alcohol.
Accommodations
Maintaining Stamina during the Workday (e.g. – restlessness, increased or
decreased energy):
Flexible scheduling
Allow longer or more frequent breaks
Provide additional time to learn new responsibilities
Provide self-paced work load
Provide backup coverage for when the employee needs to take breaks
Allow for time off for counseling
Allow for use of supportive employment and job coaches
Allow employee to work from home during part of the day or week
Part time work schedules
Maintaining Concentration (e.g. – restlessness, distractibility, racing thoughts):
Reduce distractions in the work area
Provide space enclosures or private office
Allow for use of white noise or environmental sound machines
Increase natural lighting or provide full spectrum lighting
Allow the employee to work form home and provide necessary equipment
Plan for uninterrupted work time
Allow for frequent breaks
Divide large assignments into smaller tasks and goals
Restructure job to include only essential functions
Difficulty Staying Organized and Meeting Deadlines (e.g.- racing thoughts,
difficulty making decisions):
Make daily TO-DO lists and check items off as they are completed
Use several calendars to mark meetings and deadlines
Remind employee of important deadlines
Use electronic organizers
Divide large assignments into smaller tasks and goals
Working Effectively with Supervisors (e.g. – provocative or aggressive
behavior):
Provide positive praise and reinforcement
Provide written job instructions
Develop written work agreements including the agreed upon accommodations,
clear expectations of responsibilities and the consequences of not meeting
performance standards
Allow for open communication to managers and supervisors
Establish written long term and short term goals
Develop strategies to deal with problems before they arise
Develop a procedure to evaluate the effectiveness of the accommodation
Difficulty Handling Stress and Emotions (e.g. – poor judgment, irritability):
Provide praise and positive reinforcement
Refer to counseling and employee assistance programs
Allow telephone calls during work hours to doctors and others for needed support
Provide sensitivity training to coworkers and supervisors
Allow the presence of a support animal
Reinforce peer supports
Attendance Issues (e.g. – loss of interest):
Provide flexible leave for health problems
Provide a self-paced work load and flexible hours
Allow employee to work from home
Provide part-time work schedule
Allow the employee to make up time missed
Additional General Information on Mood Disorders
Mood disorders, which can be viewed as a continuum, predominantly include
Unipolar Depression, Bipolar, and Panic/Anxiety Disorders.
The two principal classifications for mood disorders are bipolar (also known as
manic-depression) and depression alone. Bipolarity is characterized by wild mood
swings ranging from deep sadness and depression to euphoric and manic type
behavior. Depression is defined as a deep overriding sadness and feelings of
despair. These feelings are all pervasive and don't disappear in time.
For further information on Anxiety Disorders please refer to the Anxiety Disorders
Module that will be presented next week.
Recommended Readings
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Job Accommodations Network (JAN) The Job Accommodation Network (JAN) is a free consulting service that
provides information about job accommodations, the Americans with
Disabilities Act (ADA), and the employability of people with disabilities.
http://www.jan.wvu.edu/links/
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Psychiatric Disabilities: Reasonable Accommodations: This on-line resource provides information about reasonable
accommodations for people with psychiatric disabilities, specifically in
order to aid employers and educators. Reasonable accommodations are
those adjustments within a work or school site that allow an otherwise
qualified employee or student with a disability to perform the tasks
required.
http://www.bu.edu/cpr/reasaccom/
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Mental Health Matters Mental Health Matters, was founded to supply information and resources
to mental health consumers, professionals, students and supporters. While
the percentage of people facing a diagnosable Mental Disorder in any
given year is substantial, the acceptance of these problems can be hard to
come by. Essentially, Mental Health Issues are hidden illnesses. The main
purpose is to provide a structured source of information about mental
health issues. To this end, Mental Health Matters will offer detailed
technical briefs on disorders, symptoms, treatment modes, and in time, a
"comparison engine" that allows users to compare different aspects of
disorders. With this information, we hope to educate consumers and guide
them towards intelligent decisions in their pursuit of Mental Health.
http://www.mental-health-matters.com/disorders/index.php
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Research Article - Tse, S. & Yeats, M. (2002). What helps people with
bipolar affective disorder succeed in employment: A grounded theory
approach. Work, 19 (1), 47-62.