Download Bipolar I Disorder

DSM-5 in Action:
™
Diagnostic and Treatment Implications
Section 2, Chapters 5–13
PART 1 of Section 2
Chapters 1–7
by Sophia F. Dziegielewski, PhD, LCSW
© 2014 S. Dziegielewski
After completion of this section, participants will be
able to:
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Identify the major diagnostic categories and the
criteria needed for proper diagnostic assessment.
Utilize the dimensional assessment strategy
outlined in DSM-5 for two disorders.
Utilize this information to complete the diagnostic
assessment.
© 2014 S. Dziegielewski
DSM-5 Chapters
20 Disorder Categories
Neurodevelopmental Disorders
Sleep-Wake Disorders
Schizophrenia Spectrum and the Other
Psychotic Disorders
Sexual Dysfunctions
Bipolar and the Related Disorders
Gender Dysphoria
Depressive Disorders
Disruptive, Impulse Control, and Conduct Disorders
Anxiety Disorders
Substance-Related and Addictive Disorders
Obsessive-Compulsive and the Related
Disorders
Neurocognitive Disorders
Trauma and Stressor-Related Disorders
Personality Disorders
Dissociative Disorders
Paraphilic Disorders
Somatic Symptom and Related Disorders
Other Mental Disorders
Feeding and Eating Disorders
Medication-Induced Movement Disorders and Other
Adverse Effects of Medication
Elimination Disorders
Other Conditions That May Be a Focus of Clinical
Attention
© 2014 S. Dziegielewski
(2 additional categories)
© 2014 S. Dziegielewski
© 2014 S. Dziegielewski
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Mood disorders no longer a combined
chapter.
Bipolar disorders now in the middle as a
bridge between:
schizophrenia spectrum disorders and depressive disorders
© 2014 S. Dziegielewski
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Bipolar I disorder,
Bipolar II disorder,
Cyclothymic disorder,
Substance/medication-induced bipolar and
related disorder,
Bipolar disorder due to another medical
condition,
Other specified bipolar and the related
disorders, and
Unspecified bipolar and the related disorders.
© 2013 S. Dziegielewski
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Bipolar disorder due to another
medical condition
When listing this as a principal
diagnosis, according to the ICD, which
should be listed first—the medical or
the mental health condition?
© 2014 S. Dziegielewski
Manic episode
 Hypomanic episode
 Depressive episode
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© 2014 S. Dziegielewski
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Present mood is persistently elevated, irritable, and
expansive, with severe mood disturbance, leading to impaired
functioning.
At least THREE symptoms:
pressured speech,
increased psychomotor agitation,
flight of ideas,
decreased need for sleep,
increased involvement in goal-oriented activities,
distractibility, and
inflated self-esteem or grandiosity.
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© 2014 S. Dziegielewski
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Excessive involvement in pleasurable
activities that have the potential for high
risk and negative consequences.
The time frame for the episode is at least 1
week.
When hospitalized to control or address
behaviors occurs, the 1-week time frame is
NOT NEEDED.
© 20134 S. Dziegielewski
Similar to manic, LESS SEVERE features and
symptoms
 Interfere with functioning.
Criteria for hypomanic includes a distinct
period of:
 persistently expansive,
 irritable,
 elevated mood that
Lasts at least 4 days but less than 1 week.
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© 2014 S. Dziegielewski
At least THREE symptoms (four symptoms
required if predominantly irritable mood):
 Pressured speech
 Increased involvement in goal-oriented
activities
 Psychomotor agitation
 Distractibility
 Decreased need for sleep
 Inflated self-esteem or grandiosity
© 2014 S. Dziegielewski
Similar to MANIC
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May be excessive involvement in
pleasurable activities that have the potential
for high risk and negative consequences.
© 2014 S. Dziegielewski
 Depressed
mood LASTS at least 2
weeks
 OR a loss of interest or pleasure
in nearly all activities
 Plus at least 5 additional
symptoms
 Experienced almost daily for the
same 2-week period
© 2014 S. Dziegielewski
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Sleeping
Appetite disturbances
Fatigue or decreased energy
Changes in sleep
Changes in psychomotor activity
Reduced ability to think, concentrate, or make
decisions
Feelings of worthlessness or guilt
Morbid ideation or suicidal ideation, plans, or
attempts
Irritable mood
© 2014 S. Dziegielewski
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Gather information from collateral sources such as
family and friends.
In the bipolar and related disorders, similar to most
of the other disorders, in the DSM-5, a disorder
may not clearly fit into distinct diagnostic
categories.
A course specifier may be warranted.
© 2014 S. Dziegielewski
 No
subtypes
 No subtypes to clarify a diagnosis
as mutually exclusive and
exhaustive.
 A subtype is used for
schizoaffective disorder
© 2014 S. Dziegielewski
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Allows the crosscutting of core anxiety-related
symptoms characteristic of the episode of mania,
hypomania, or depression.
Requires 2 or more of the symptoms—feeling
keyed up, unusually restless, difficulty
concentrating because of worry, fearing something
awful might happen, and feeling the loss of
control.
Occurs most days during the mood episode.
© 2014 S. Dziegielewski
Mixed features can be further divided into two
types:
manic or hypomanic episode with
mixed features
depressive episode with mixed
features.
© 2014 S. Dziegielewski
Can be used with both bipolar I and
bipolar II disorder
 Rapid cycling is the switch to an
opposite episode (e.g., major
depressive episode to a manic
episode)
 Only difference between rapid cycling
and other episodes is the frequency of
the episodes
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© 2013 S. Dziegielewski
There needs to have been at least four
mood episodes within the past 12
months.
 Same duration criteria/symptom
numbers for a major depressive,
manic, or hypomanic episode.
 Can have a period of remission or a
switch to an opposite episode.
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© 2014 S. Dziegielewski
 To
distinguish rapid cycling from
episodes caused by a substance,
consider:
Medical history,
Laboratory tests,
Medical physical
© 2014 S. Dziegielewski
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Characterized by a loss of pleasure in activities previously considered
pleasurable.
The loss or lack of pleasure needs to be present during the most severe
period of the episode.
In addition, three or more of the following six symptoms must be present: a
distinct depressed mood or empty mood, depression that is worse in the
mornings, early-morning awakening (at least 2 hours earlier than usual),
psychomotor retardation or agitation, significant weight loss or anorexia,
and excessive guilt. Melancholic features are noted at the most severe stage
of the episode, where there is almost a complete absence of pleasure, and
even in positive circumstances, the mood does not improve.
These features are seen most frequently in the inpatient setting because of
the severe loss of pleasure in almost all activities.
The numbness often experienced is more characteristic of the most severe
stages of the disorder and is more likely in individuals with psychotic
features.
© 2014 S. Dziegielewski
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Atypical features are more common than the name implies.
The mood is brightened with the occurrence of positive
events and may stay that way for an extended period of time.
Characteristic of at least two of the following symptoms:
significant weight gain or increase in appetite, hypersomnia
(increase in sleep), leaden paralysis (heavy feelings in arms or
legs), and sensitivity to interpersonal rejection that affects
social or occupational functioning.
There can be an increase in food intake that leads to weight
gain.
There may also be leaden paralysis, which is characterized by
a heavy sensation in the arms or legs.
Sensitivity to rejection from others is present even when the
client is not in a depressed episode.
© 2014 S. Dziegielewski
The specifier with psychotic features is characterized by
delusions or hallucinations during the episode.
There are two types: mood-congruent and mood-incongruent
features.
 With mood-congruent features, the content of the delusions
and hallucinations is consistent with the manic episode of
grandiosity and invulnerability and may also include paranoia.
 With mood-incongruent features, the content of the delusions
and hallucinations is inconsistent with the themes of the
episode, or there is a mixture of mood-congruent and moodincongruent features.
© 2014 S. Dziegielewski
With Catatonic Features
 The specifier with catatonic features can be
present in either a manic or a depressive
episode.
With Peripartum Features
 The specifier with peripartum onset is applied
if symptoms occur during pregnancy or 4
weeks postdelivery. This specifier is used for
manic, hypomanic, or major depressive
episodes in both bipolar I and bipolar II
disorders.
© 2014 S. Dziegielewski
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Involves depressive, hypomanic, or manic episodes
and the criteria for each.
The expected course results in a clearly defined
manic episode that comes as the first episode, and
it can be followed by hypomanic or depressive
episodes (APA, 2013).
To diagnose bipolar 1 disorder, however, according
to DSM-5 there are two criteria that must be met
(A-B).
REMEMBER— MUST MEET THE CRITERIA FOR
THE EPISODE !
© 2013 S. Dziegielewski
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Criterion A requires that at least one manic episode be
present.
Criterion B— the potential for hypomanic and depressive
episodes exists, but the full criteria for the manic and major
depressive episodes must be met and are not better
explained by another mental disorder such as selected
schizophrenia spectrum and the psychotic disorders.
Time frame: Has lasted least one week, and is present almost
every day.
The exact time frame is not given in DSM-5 as to what
constitutes almost all day, every day but approximately 75%
to 100% of the time appears to be a safe estimate.
© 20134 S. Dziegielewski
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Characterized by one or more depressive
episodes with at least one hypomanic
episode.
Hypomanic episode involves a period of
elevated or irritable mood with increased
activity, lasting at least 4 consecutive days
and present throughout each day most of the
time.
© 2014 S. Dziegielewski
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This disorder is characterized by a persistent
mood disturbance lasting at least 2 years (1
year in children and adolescents), and the
individual must not be without the symptoms
for 2 months.
This disorder, although considered more
chronic because of the duration of the
symptoms, is less severe because the
symptoms experienced do not meet the
criteria for either the full hypomanic or
depressive episodes.
© 2014 S. Dziegielewski
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Characterized by a disturbance in mood, including
symptoms of elevated or irritable mood, occurring
with or without depressed mood, or diminished
interest or pleasure in all or most activities.
A physical exam and laboratory tests are needed to
confirm that the symptoms developed during or
soon after substance intoxication or withdrawal or
after taking a medication as evidence that the
substance/medication produces the mood
symptoms.
© 2014 S. Dziegielewski
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Not better explained by a bipolar or related
disorder that is not induced by
substances/medications, does not occur only
during a delirium.
Causes significant impairment in social,
occupational, or other areas of functioning.
Categories of the substances include alcohol,
phencyclidine, other hallucinogen, sedative,
hypnotic or anxiolytic, amphetamine or other
stimulant, cocaine, other, or unknown substance.
© 2014 S. Dziegielewski
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Characterized by a period of elevated or irritable
mood with extreme increased activity or energy.
Results from laboratory tests and physical exams
show evidence of another medical disorder.
The disturbance is not explained by another mental
disorder and does not occur exclusively during a
delirium.
Causes significant impairment in social,
occupational, or other areas of functioning.
Specify with manic features, with manic or
hypomanic features, or with mixed features.
© 2014 S. Dziegielewski
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Characterized by impairment in social,
occupational, or other significant areas of
functioning but does not meet full criteria for any
of the other categories of bipolar and related
disorders.
Can apply to the following four clinical
presentations: short-duration hypomanic episodes
(2–3 days) and major episodes, hypomanic
episodes with insufficient symptoms and major
depressive episodes, hypomanic episode without
prior major depressive episode, and short-duration
cyclothymia (less than 24 months).
© 2014 S. Dziegielewski
Characteristic of bipolar and related
disorder.
 Does not meet the full criteria for any
of the BP and related disorders.
 Used with insufficient information to
place a more formal diagnosis and
used in settings such as emergency
rooms.
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© 2014 S. Dziegielewski
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Bipolar I: Anxiety disorders, ADHD and
disruptive impulse control disorders
Bipolar I: Alcohol use disorder (half have
symptoms of both)
Medical Conditions:
Bipolar I: Metabolic syndrome and migraines;
Bipolar II: Eating disorders—BED binge eating
disorder
Cyclothymic substance and sleep-related
disorders
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© 2014 S. Dziegielewski
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How to document in DSM-5
© 2014 S. Dziegielewski
AXIS I:
296.6 Bipolar I Disorder, Most Recent Episode
Depressed
AXIS II: None
AXIS III: Deferred
AXIS IV: Occupational Problems: Discord as Boss With
Coworkers; Economic Problems: Overspending
and Impulsive Buying Resulting in Large Debt
AXIS V: GAF (current/highest in past year) = 30/70
© 2014 S. Dziegielewski
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Type of most current episode (Mild, Moderate,
Severe): Does it meet the criteria for the episode?
Does it meet more than the criteria?
With Psychotic Features (mood congruent [matches
manic episode] or mood incongruent [delusions
don’t match manic episode)
Partial Remission (less than 2 months without
symptoms of that presenting episode)
Full Remission (during the last 2 months without
symptoms of the presenting episode)
© 2014 S. Dziegielewski
Bipolar I Disorder (principal diagnosis)
Current Episode Manic 296.41 (F31.11) Mild
With Psychotic Features 296.54 (F31.5) Mood
Congruent
In Full Remission 296.56 (F31.76) (e.g., 2
months)
© 2014 S. Dziegielewski