Bipolar Affective Disorder Clinical Presentation

Updated: Aug 10, 2017
  • Author: Stephen Soreff, MD; Chief Editor: Randon S Welton, MD  more...
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Presentation

History

Correct diagnosis of a disorder leads to proper effective treatment. No where is that more relevant than in diagnosing a patient with bipolar affective disorder, or manic-depressive illness (MDI).

Perform a thorough clinical assessment for patients with a manic, hypomanic, or mixed episode, or those with a bipolar depression episode, including information about the patient’s clinical and psychosocial status, medical and psychiatric comorbidities, current and past medications as well as medication compliance, and substance use. [3] Obtain a detailed review of symptoms, symptom severity, and their effects on daily functioning in combination with the use of a standard tool. [3]

The diagnosis of bipolar disorder type I (BPI) requires the presence of a manic episode of at least 1 week’s duration or that leads to hospitalization or other significant impairment in occupational or social functioning. The episode of mania cannot be caused by another medical illness or by substance abuse. These criteria are based on the specifications of the DSM-5. [2] The Department of Veterans Affairs and Department of Defense (VA/DOD) recommend using a standardized rating scale such as the Young Mania Rating Scale to assess the severity of a manic episode. [3]

Manic episodes are feature at least 1 week of profound mood disturbance, characterized by elation, irritability, or expansiveness (referred to as gateway criteria). At least 3 of the following symptoms must also be present [2] :

  • Grandiosity
  • Diminished need for sleep
  • Excessive talking or pressured speech
  • Racing thoughts or flight of ideas
  • Clear evidence of distractibility
  • Increased level of goal-focused activity at home, at work, or sexually
  • Excessive pleasurable activities, often with painful consequences

The mood disturbance is sufficient to cause impairment at work or danger to the patient or others. The mood is not the result of substance abuse or a medical condition.

Hypomanic episodes are characterized by an elevated, expansive, or irritable mood of at least 4 consecutive days’ duration. At least 3 of the following symptoms are also present [2] :

  • Grandiosity or inflated self-esteem
  • Diminished need for sleep
  • Pressured speech
  • Racing thoughts or flight of ideas
  • Clear evidence of distractibility
  • Increased level of goal-focused activity at home, at work, or sexually
  • Engaging in activities with a high potential for painful consequences

The mood disturbance is observable to others. The mood is not the result of substance abuse or a medical condition. The episode is not severe enough to cause social or occupational impairment.

Major depressive episodes are characterized as, for the same 2 weeks, the person experiences 5 or more of the following symptoms, with at least 1 of the symptoms being either a depressed mood or characterized by a loss of pleasure or interest [2] :

  • Depressed mood
  • Markedly diminished pleasure or interest in nearly all activities
  • Significant weight loss or gain or significant loss or increase in appetite
  • Hypersomnia or insomnia
  • Psychomotor retardation or agitation
  • Loss of energy or fatigue
  • Feelings of worthlessness or excessive guilt
  • Decreased concentration ability or marked indecisiveness
  • Preoccupation with death or suicide; patient has a plan or has attempted suicide

Symptoms cause significant impairment and distress and are not the result of substance abuse or a medical condition

The mixed symptomatology is quite common in patients presenting with bipolar symptomatology. This often causes a diagnostic dilemma [63] and has prompted a revision to the definition of bipolar disorder in DSM-5. With the aim of capturing mixed symptoms more effectively, the “mixed episode” diagnosis has been eliminated in favor of a “mixed features specifier” that could be added to any mood bipolar disorder diagnosis. [64] Other specifiers include anxious distress, rapid cycling, mood-congruent psychotic features, catatonia, peripartum onset and seasonal pattern.

Of interest, when investigating bipolar mixed states, Swann and colleagues concluded that although controversy exists regarding the definitions and properties of mixed states, the concept of mixed states and their characteristics over a range of clinical definitions and diagnostic methods has remained consistent. [65] Moreover, “distinct characteristics related to the course of illness emerge at relatively modest opposite polarity symptom levels in depressive or manic episodes.” [65]

In addition to the well-known differences between manic and hypomanic episodes, other key differences exist between BPI and BPII that may be used to help distinguish between the 2 types of conditions. Data from 1429 bipolar patients included in the National Epidemiological Survey on Alcohol and Related Conditions showed significant differences between BPI and BPII patients in unemployment, a history of a suicide attempt, depressive symptoms (eg, weight gain, feelings of worthlessness), and the presence of specific phobias. [66]

Next:

Physical Examination

Bipolar affective disorder is characterized by periods of deep, prolonged, and profound depression that alternate with periods of an excessively elevated or irritable mood known as mania.

Manic episodes are feature at least 1 week of profound mood disturbance, characterized by elation, irritability, or expansiveness (referred to as gateway criteria). At least 3 of the following symptoms must also be present [2] :

  • Grandiosity
  • Diminished need for sleep
  • Excessive talking or pressured speech
  • Racing thoughts or flight of ideas
  • Clear evidence of distractibility
  • Increased level of goal-focused activity at home, at work, or sexually
  • Excessive pleasurable activities, often with painful consequences

Hypomanic episodes are characterized by an elevated, expansive, or irritable mood of at least 4 consecutive days’ duration. The diagnosis of hypomania requires at least three of the symptoms above. The difference being that in hypomania these symptoms are not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization and are not associated with psychosis.

Major depressive episodes are characterized as, for the same 2 weeks, the person experiences 5 or more of the following symptoms, with at least 1 of the symptoms being either a depressed mood or characterized by a loss of pleasure or interest [2] :

  • Depressed mood
  • Markedly diminished pleasure or interest in nearly all activities
  • Significant weight loss or gain or significant loss or increase in appetite
  • Hypersomnia or insomnia
  • Psychomotor retardation or agitation
  • Loss of energy or fatigue
  • Feelings of worthlessness or excessive guilt
  • Decreased concentration ability or marked indecisiveness
  • Preoccupation with death or suicide; patient has a plan or has attempted suicide

See Clinical Presentation for more detail.

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