Bipolar Disorder in DSM-IV

Bipolar I disorder: manic episode(s)

or mixed episode(s) plus MDE(s)
Bipolar II disorder: major depressive
episode(s) plus hypomanic episode(s)
Cyclothymia: hypomanic symptoms
plus depressive symptoms

Bipolar Disorders: DSM-IV Nosology

BPD I

BPD II

Cyclothymia

Mania

Required

No

No

Hypomania

Possible

Required

No

Major depression

Possible

Required

No

Mixed state

Possible

No

No

Criteria

Manic Episode: Diagnostic Criteria

Elevated, expansive, or irritable mood for
1 week or longer, plus 3 or more of the
following

Inflated self-esteem or grandiosity

Decreased need for sleep
Pressured speech
Racing thoughts/flight of ideas
Distractibility
Psychomotor agitation/increased goal-directed
activity
Excessive involvement in high-risk activities

Manic Episode:
Differential Diagnoses
Differential diagnosis
Mood disorder due to a
general medical
condition
Substance-induced
mood disorder

Consider if . . .
Major medical condition present
First episode at >50 years of age
Symptoms in context of intoxication
or withdrawal
History of treatment for depression

Hypomanic episode

Mood disturbance not severe

enough to require hospitalization
or impair functioning

Mixed episode

Manic episode and MDE in 1 week

Manic Episode:
Differential Diagnoses (cont.)
Differential diagnosis

AD/HD

Consider if . . .
Early childhood mood disturbance onset
Chronic rather than episodic course
No clear onsets and offsets
No abnormally elevated mood
No psychotic features

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders

(DSM-IV). 4th ed. 1994.

Major Depressive Episode:

DSM-IV Criteria
Depressed mood and/or loss of interest
or pleasure 2 weeks duration
Associated symptoms
Physical: insomnia/hypersomnia,
appetite/weight change, decreased energy,
psychomotor change
Psychological: feelings of guilt or
worthlessness, poor
concentration/indecisiveness, thoughts
of death/suicidal intentions (SI)

and 4 of the following symptoms

Physical

Sleep disorder
Appetite change
Fatigue
Psychomotor
retardation

Psychological
Low self
esteem/guilt
Poor concentration/
indecisiveness
Thoughts of
death/SI

Mixed Episode: Diagnostic Criteria

Criteria met for both manic episode + MDE
for 1 week
Symptoms
Are sufficient to impair functioning
or
Necessitate hospitalization
or
Are accompanied by psychotic features

Bipolar Disorders: Epidemiology

Characteristics

BPD I

BPD II

Prevalence

1.6%

0.5%

Ethnic/racial
differential

None

None

Gender
differential

M=F

FM (?)

Bipolar Disorders: Epidemiology

Characteristics

Course

Familial
pattern

BPD I
Recurrent in
>90% of cases

First-degree
relatives have
increased rates of
BPD I, BPD II,
and MDD

BPD II
Hypomanic episodes
in BPD II immediately
precede or follow
MDEs in 60% to
70% of cases

First-degree relatives
may have increased
rates of BPD I, BPD
II, and MDD

Epidemiology
Peak age of onset: adolescence through early
20s
Onset of first manic episode after age 40 years is
red flag to consider substance use or general
medical condition

Seasonal variation
Depression more common in spring and autumn
Mania more common in summer

Diagnostic Dilemmas:
Unipolar Versus Bipolar
Unipolar
BPD I
BPD II

BPD NOS

No evidence of hypomania,
cyclothymia, hyperthymic personality,
or family history of BPD
1 manic episode
Recurrent major depression with
hypomania and/or cyclothymic
temperament
Recurrent major depression without
spontaneous hypomania but often
with hyperthymic temperament
and/or family history of BPD

Etiology

Heritability
Evidence for heritability is much stronger
for bipolar than for unipolar disorders
Specific genetic association has not been
consistently replicated

EVIDENCE FOR HERITABILITY OF

BIPOLAR DISORDER
Family Studies- First degree relatives are 8
to 18 times more likely to have Bipolar I

2 to 10 times to have MDD.

Risk is 25% if one parent has illness, and
50% to 75% with both parents affected

FAMILY STUDIES
The majority of individuals with bipolar disorder
have a positive family history of some type of
mood disorder
About 50% of all bipolar I patients have at least
one parent with a mood disorder

ADOPTION STUDIES
Prevalence of bipolar disorder in adopted away
offspring corresponds to rates in biological, but
not adoptive relatives

Twin Studies- Concordance rate in MZ

twins is 33 to 90%, in DZ is 5 to 25%

Cognitive Deficits

Working memory
Sustained attention
Abstract reasoning
Visuomotor skills
Verbal memory
Verbal fluency
Cognitive flexibility
General cognitive functioning

Potential Explanations
for Cognitive Deficits

Iatrogenic or Alcohol use

Temporary functional changes
Degenerative brain changes
Permanent structural lesions
Permanent functional alterations of neural
networks underlying affect and cognition

Alcohol Use
Alcohol use occurs in 30-50% of cases
Impairs memory and executive functioning
Gorp et al (1998)
Compared BP only, BP + AD, Control
BP + AD > BP only for cognitive impairment
No difference between Control and BP only

Other studies have reported cognitive

deficits in non substance abusing BP
patients

Iatrogenic
Lithium
Memory and psychomotor functioning

Valproate and Carbemazepine

Attentional deficitis

Neuroleptics
Sustained attention
Visuomotor speed deficits

Benzodiazapines
Memory

Crews et al.
Performance on WCST negatively related to years of exposure
to antipsychotic drugs

Questions
Some evidence indicates that Lithium exerts a
neuroprotective effect on neuronal tissue
Are studies indicating adverse effects of lithium not
accounting for complex combinations of meds?

Could we even study this issue empirically??

Ethics
Generalizability

Temporal Functional Deficits

Are cognitive deficits specific to depressive or manic states?
Depression
Decreased dorsal prefrontal cortex and anterior cingulate gyrus
activation
Increased ventral prefrontal cortex activation
Reductions in left hemisphere activity

Mania
Opposite pattern
Decreased ventral and increased dorsal activity of the prefrontal cortex
Reductions in right hemisphere activity

Remission of depressive symptoms associated with increased blood

flow to dorsolateral and medial prefrontal cortex

 Distractibility and behavioral dysregulation

during mania
Heightened left hemisphere prefontal corticol activity

Attentional deficits accompanying depression

Right hemisphere disturbance of dorsal prefrontal
cortex, cingulate gyrus, parlimbic cortex

Summary
Authors contend (Savitz et al, 2005) that
functional disturbances have a
neurodevelopmental and possibly genetic
etiology that may be exacerbated by mood
disturbances