Bipolar Disorder Diagnosis

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Te bible for clinicians ,The Diagnostic and Statistical Manual of Mental Disorders, Fifth  Edition (DSM-5)  placed bipolar disorder in a new category—“Bipolar and Related Disorders.” Bipolar disorder involves two poles: mania and depression.  During manic episodes, people feel up or elevated, sometimes excited, happy and on top of the world. During depressive episodes, they feel down,  unhappy, and hopeless. It's not that simple though. Mania does not always feel good, and the symptoms can be more complicated. Many people feel irritable, and can have outbursts when manic, and also, the episodes are not that clear cut. They can experience what are called mixed states where they may feel manic and depressed at the same time.  This is especially true for children.  Or, they may feel anxious, along with their particular mood state.

There are many symptoms of bipolar  that overlap with other disorders, and they occur on a spectrum.  They vary in severity in different individuals and over the course of one's life.

I’ve been working with bipolar children and adults for most of my career. I run an online facebook support group that I developed as an offshoot of a local support group for parents of children with bipolar disorder.  You can find the link to this group here.

In order to understand bipolar disorder diagnosis in children, it helps to understand bipolar disorder is diagnosed in adults. 

According to the DSM V , a specific number of symptoms must occur within a specified time frame in order to be diagnosed with bipolar disorder.

It's important that we get this diagnosis right. People with bipolar disorder can wait as long as 10 years to get a correct diagnosis according to some estimates! .

The details of the diagnostic criteria and the time frames are below. Bipolar disorder in children has become a controversial diagnosis. Some of the difficulty in diagnosis of bipolar in children is that they don't have their own criteria. The difficulty with these adult criteria is that the time frames for episodes are not applicable to children. 

Children’s EPISODES may last minutes and hours instead of days.  The outward expression of depression and mania also look somewhat different in children. This is one of our core problems in diagnosing bipolar disorder in children. You can learn about this in a radio interview I did here.

 This page will explain some of the basic information necessary for understanding the diagnosis of bipolar disorder. This page is linked to many more pages about bipolar disorder in both children and adults. Scroll down to the bottom and check them all out!

 To understand how bipolar disorder diagnosis is made, it is important to understand the concept of episodes. Episodes and their length are how psychiatric professionals determine whether someone meets the criteria for bipolar disorder.

It is important to note that even with these guidelines in place, mental health professionals make mistakes all the time when diagnosing bipolar disorder. Sometimes they diagnose it when it’s not there, and sometimes they don’t see it when it is there. Other pages on the site will go into more detail describing this. The purpose of this page is simply to describe the current system mental health professionals use when diagnosing bipolar disorder. I hope it's helpful.

Episodes

Major Depressive Episode

  • All of the symptoms below must occur most of every day for two weeks
  • They musts represent a change in how you or your child has been functioning
  • the symptoms cannot be due to another medical condition

Symptoms

  • Either a depressed mood (in children this can be irritability)

or

  • No pleasure or interest in previously enjoyed activities or any activities

and

4 of the other symptoms below:

  • Weight loss or gain or decrease increase in appetite
  • Not sleeping or sleeping too much
  • Feeling restless or slowed down
  • Fatigue or loss of energy
  • Feelings of worthlessness or excessive or inappropriate guilt
  • Impaired concentration or difficulty making decisions
  • Recurrent thoughts of death , thinking of suicide with or without a plan or a suicide attempt
  • Distress or impairment in functioning
  • Cannot be due to substance use or medicine or a meidcal condition

Manic Episode

Manic Episode

Symptoms are present to a significant degree for a week.  This mood state must cause some kind of an impairment in functioning, a hospitalization or be accompanied by psychosis.

  • 3 or more of the symptoms below accompany a week of elevated or expansive mood -

or

 4 or more symptoms accompany and irritable mood

Symptoms

  • inflated self-esteem or grandiosity
  • decreased need for sleep
  • more talkative than usual or pressure to keep talking
  • flight of ideas or racing thoughts
  • easily distracted
  • increase in goal-directed activity
  • psycho-motor agitation
  • excessive involvement in pleasurable activities that have a high potential for painful consequences (gambling spending money sexual activity)

Hypomanic Episodes

At least 4 days of period of elevated, expansive, or (irritable mood if child especially), and abnormal and persistent increased activity and energy that lasts:

  • at least 4 days
  • is present most of the day and
  • nearly every day.
  • During these days also 3 of these symptoms ( 4 if only and irritable mood is present )
  • Inflated Self Esteem
  • Decreased Need for Sleep
  • More talkative than usual 
  • Flight of ideas or feeling like thoughts are racing
  • Easily dis tractable
  • Increased goal directed activity or agitated physically
  • Excessive involvement in activities that have potential for painful consequences 

This is observable by others

Indicates a departure from normal functioning

Does NOT CAUSE significant impairment in functioning to necessitate hospitalization. If there are psychotic features it is manic.

Not caused by substances or medication. If caused by treatment and persists beyond treatment it is indicative of hypomania. 


Types of Bipolar Disorder

Bipolar I

Bipolar I

Bipolar I consists of one or more manic episode.

Technically no depressive episode must be present but it almost always is.

Bipolar I = a manic episode

 

Bipolar II

Bipolar type II consists of one major depressive episode and at least one hypomanic episode.   A person cannot be diagnosed with Bipolar type II disorder if they have had a manic episode.


Bipolar II = Major Depressive Episode + Hypomania

Cyclothymia

Cyclothymia is a mood disorder that consists of two years of episodes of hypo mania and low grade depression.  To be diagnosed with cyclothymia, you cannot have had a major depressive, or manic episode during the first two year period of time.




Other Specified Bipolar and Related Disorder and Unspecified Bipolar and Related Disorder.

Specified is usually given when symptoms do not meet specific criteria but cause sufficient problems in functioning. Unspecified is usually diagnose when there is not enough information due to inadequate records or history.  

Children who don't meet episodic criteria will often carry this diagnosis

Bipolar and Related Disorder Due to Another Medical Condition

A period of elevated, expansive, or irritable mood and increased activity or energy

B. There is evidence  this is caused by another medical condition.

C. The  is not better explained by another mental health condition

D. This does not occur during delirium

E. The disturbance causes  disturbance in functioning in life, requires hospitalization or has psychotic features

Substance/Medication-Induced Bipolar and Related Disorder

1.       A disturbed mood is present that is elevated expansive or irritable with or without a depressed mood or diminished interest in all activities

2.       This occurred during or after substance intoxication or withdrawal

3.       This actual substance can produce the mood disturbance

4.       The symptoms weren’t there before the substance or medication

5.       The symptoms didn’t persist for a m month after the intoxication or withdrawal

6.       There isn’t a history of the episodes without the medication or substance

7.       The mood disturbance didn’t occur during the course of delirium

8.       The disturbance causes significant distress.

 

Specifiers

When diagnosing bipolar disorder, clinicians will use specifiers to describe more about the the particular kind of bipolar they are seeing.

These are some of the ways the describe bipolar disorder

Bipolar with:

  • Anxious Distress This specifier allows to identify anxiety symptoms that are not part of the bipolar diagnostic criteria.
  • Mixed Features This specifier allows us to categorize an episode where we see features of both  mania and depression
  • Melancholic Features. This is subtype of depression where people feel worse in the morning, early morning waking and guilt among other things.  
  • Atypical Features Mood reactivity and 2 (or more) of 4 features (increased appetite or weight gain, hypersomnia, leaden paralysis, interpersonal reaction sensitivity) predominate during the majority of days of current episode of depression.
  • Peripartum onset; Beginning  during the period of pregnancy and 4 weeks after delivery. It applies to: current or recent episode of mania, depression or hypomania in Bipolar 1 or Bipolar II
  • Psychotic Features- presence of delusions or hallucinations at any time in the episode
  • Catatonic Features -these features include rigidity staring withdrawing and immobility. 
  • Rapid cycling(for BD I or BD II)- presence of at least four mood episodes in previous 12 months that meet criteria for manic, hypomanic or depressive episode. 
  • Seasonal Pattern-  Seasonal pattern has to last at least 2 years, and the number of seasonal episodes must outnumber all nonseasonal episodes

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. 

Łojko, Dorota & Suwalska, Aleksandra & Rybakowski, Janusz. (2014). [Bipolar and related disorders and depressive disorders in DSM-5]. Psychiatria polska. 48. 245-60. 

SAMSHA Advisory. An Introduction to Bipolar Disorder and Co-Occurring Substance use Disorders ( 2016). (n.d.). Retrieved from https://store.samhsa.gov/product/Advisory-An-Introduction-to-Bipolar-Disorder-and-Co-Occurring-Substance-Use-Disorders/SMA16-4960

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