Bipolar II Disorder


As I wrote recently, I am in the strange position of boning up on the soon-to-be-obsolete diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders IV-TR.

The DSM-IV-TR devotes 84 pages to how to diagnose Mood Disorders. It’s a complex business, and something diagnosticians can take extremely seriously. The criteria for the actual disorders (Depressive Disorders and Bipolar Disorders) are like recipes. The ingredients for those recipes are Mood Episodes (Depressive, Manic, Mixed, or Hypomanic) and “specifiers.” The following are the criteria for the specifiers, which are about severity, accompanying symptoms, and timing aspects. The Criteria for Severity/Psychotic/Remission Specifiers for the Mood Episodes are quoted from the DSM-IV-TR:

Major Depressive Episodes, p. 413

Manic Episodes, p. 415

Mixed Episodes, p. 416

Hypomanic Episodes, p. 417

And the criteria for other Mood Disorder specifiers:

Chronic Specifier, p. 417

Catatonic Features Specifier is from p. 418

Melancholic Features Specifier is from p. 420

Atypical Features Specifier is from p. 422

Postpartum Onset Specifier is from p. 423

Criteria for Longitudinal Course Specifier is from p. 425

Seasonal Pattern Specifier is from p. 427

Rapid-Cycling Specifier is from p. 428

Criteria for Severity/Psychotic/Remission Specifiers for current (or most recent) Major Depressive Episodes

Note: Code in fifth digit. Mild, Moderate, Severe Without Psychotic Features, and Severe With Psychotic Features can be applied only if the criteria are currently met for a Major Depressive Episode. In Partial Remission and In Full Remission can be applied to the most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode.

.x1–Mild: Few, if any, symptoms in excess of those required to make the diagnosis and symptoms result in only minor impairment in occupational functioning or in usual social activities or relationships with others.

.x2–Moderate: Symptoms between “mild” and “severe.”

.x3–Severe Without Psychotic Features: Several symptoms in excess of those required to make the diagnosis, and symptoms markedly interfere with occupational functioning or with usual social activities or relationships with others.

.x4–Severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-incongruent:

Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment.

Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Included are such symptoms as persecutory delusions (not directly related to grandiose ideas or themes), thought insertion, and delusions of being controlled.

.x5–In Partial Remission: Symptoms of a Major Depressive Episode are present but full criteria are not met, or there is a period without any significant symptoms of a Major Depressive Episode lasting less than 2 months following the end of the Major Depressive Episode. (If the Major Depressive Episode was superimposed on Dysthymic Disorder, the diagnosis of Dysthymic Disorder alone is given once the full criteria for a Major Depressive Episode are no longer met.)

.x6–In Full Remission: During the past 2 months no significant signs or symptoms of the disturbance were present.

.x0–Unspecified.

 

Criteria for Severity/Psychotic/Remission Specifiers for current (or most recent) Manic Episodes

Note: Code in fifth digit. Mild, Moderate, Severe Without Psychotic Features, and Severe With Psychotic Features can be applied only if the criteria are currently met for a Manic Episode. In Partial Remission and In Full Remission can be applied to the most recent Manic Episode in Bipolar I Disorder only if it is the most recent type of mood episode.

.x1–Mild: Minimum symptoms criteria are met for a Manic Episode

.x2–Moderate: Extreme increase in activity or impairment in judgement.

.x3–Severe Without Psychotic Features: Almost continual supervision required to prevent physical harm to self or others.

.x4–Severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-incongruent:

Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with the typical manic themes of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person.

Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve typical manic themes  of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person. Included are such symptoms as persecutory delusions (not directly related to grandiose ideas or themes), thought insertion, and delusions of being controlled.

.x5–In Partial Remission: Symptoms of a Manic Episode are present but full criteria are not met, or there is a period without any significant symptoms of a Manic Episode lasting less than 2 months following the end of the Manic Episode.

.x6–In Full Remission: During the past 2 months no significant signs or symptoms of the disturbance were present.

.x0–Unspecified.

Criteria for Severity/Psychotic/Remission Specifiers for current (or most recent) Mixed Episodes

Note: Code in fifth digit. Mild, Moderate, Severe Without Psychotic Features, and Severe With Psychotic Features can be applied only if the criteria are currently met for a Mixed Episode. In Partial Remission and In Full Remission can be applied to a Mixed Episode  in Bipolar I Disorder only if it is the most recent type of mood episode.

.x1–Mild: No more than minimum symptom criteria are met for both a Manic Episode and a Major Depressive Episode.

.x2–Moderate: Symptoms or functional impairment between “mild” and “severe.”

.x3–Severe Without Psychotic Features: Almost continual supervision required to prevent physical harm to self or others.

.x4–Severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-incongruent:

Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with the typical manic or depressive themes.

Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve typical manic or depressive themes. of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person. Included are such symptoms as persecutory delusions (not directly related to grandiose ideas or themes), thought insertion, and delusions of being controlled.

.x5–In Partial Remission: Symptoms of a Mixed Episode are present but full criteria are not met, or there is a period without any significant symptoms of a Mixed Episode lasting less than 2 months following the end of the Mixed Episode.

.x6–In Full Remission: During the past 2 months no significant signs or symptoms of the disturbance were present.

.x0–Unspecified.

Criteria for Chronic Specifier

Specify if:

Chronic (can be applied to the current or most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode)

Full criteria for a Major Depressive Episode have been met continuously for at least the past 2 years.

Criteria for Catatonic Features Specifier

Specify if:

With Catatonic Features (can be applied to the current or most recent Major Depressive Episode, Manic Episode, or Mixed Episode in Major Depressive Disorder, Bipolar Disorder, or Bipolar II Disorder)

The clinical picture is dominated by at least two of the following:

(1) motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor

(2) excessive motor activity (that is apparently purposeless and not influenced by external stimuli)

(3) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism

(4) peculiarities of voluntary movements as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing

(5) echolalia or echopraxia

Criteria for Melancholic Features Specifier

Specify if:

With Melancholic Features (can be applied to the current or most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode)

A. Either of the following, occurring during the most severe period of the current episode:

(1) loss of pleasure in all, or almost all, activities

(2) lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens)

B. Three (or more) of the following:

(1) distinct quality of depressed mood (i.e., the depressed mood is experienced as distinctly different from the kind of feeling experienced after the death of a loved one)

(2) depression regularly worse in the morning

(3) early morning awakening (at least 2 hours before usual time of awakening)

(4) marked psychomotor retardation or agitation

(5) significant anorexia or weight loss

(6) excessive or inappropriate guilt

Criteria for Atypical Features Specifier

Specify if:

With Atypical Features (can be applied when these features predominate during the most recent 2 weeks of a current Major Depressive Episode in Major Depressive Disorder or in Bipolar I or Bipolar II Disorder when a current Major Depressive Episode is the most recent type of mood episode, or when these features predominate during the most recent 2 years of Dysthymic Disorder; if the Major Depressive Episode is not current, it applies if the feature predominates during any 2-week period)

A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events)

B. Two (or more) of the following features:

(1) significant weight gain or increase in appetite

(2) hypersomnia

(3) leaden paralysis (i.e., heavy, leaden feelings in arms or legs)

(4) long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment

C. Criteria are not met for With Melancholic Features or With Catatonic Features during the same episode.

Criteria for Postpartum Onset Specifier

Specify if:

With Postpartum Onset (can be applied to the current or most recent Major Depressive, Manic, or Mixed Episode in Major Depressive Disorder, Bipolar I Disorder, or Bipolar II Disorder)

Onset of episode within 4 weeks postpartum

Criteria for Longitudinal Course Specifiers

Specify if (can be applied to Recurrent Major Depressive Disorder or Bipolar I or II Disorder):

With Full Interepisode Recovery: if full remission is attained between the two most recent Mood Episodes

Without Full Interepisode Recovery: if full remission is not attained between the two most recent Mood Episodes

Criteria for Seasonal Pattern Specifier

Specify if:

With Seasonal Pattern (can be applied to the pattern of Major Depressive Episodes in Bipolar I disorder, Bipolar II Disorder, or Major Depressive Disorder, Recurrent)

A.      There has been a regular temporal relationship between the onset of Major Depressive Episodes in Bipolar I or Bipolar II Disorder or Major Depressive Disorder, Recurrent, and a particular time of the year (e.g., regular appearance of the Major Depressive Episode in the fall or winter).

Note: Do not include cases in which there is an obvious effect of seasonal related psychosocial stressors (e.g., regularly unemployed every winter).

B.      Full remissions (or a change from depression to mania or hypomania) also occur at a characteristic time of the year (e.g., depression disappears in the spring).

C.      In the last 2 years, two Major Depressive Episodes have occurred that demonstrate the temporal seasonal relationships defined in Criteria A and B, and no nonseasonal Major Depressive Episodes have occurred during that same period.

D.      Seasonal Major Depressive Episodes (as described above) substantially outnumber the nonseasonal Major Depressive episodes that may have occurred over the individual’s lifetime.

Criteria for Rapid-Cycling Specifier

Specify if:

With Rapid Cycling (can be applied to Bipolar I Disorder or Bipolar II Disorder)

At least four episodes of a mood disturbance in the previous 12 months that meet criteria for a Major Depressive, Manic, Mixed, or Hypomanic Episode.

Note: Episodes are demarcated either by partial or full remission for at least 2 months or a switch to an episode of opposite polarity (e.g., Major Depressive Episode to Manic Episode).

As I wrote recently, I am in the strange position of boning up on the soon-to-be-obsolete diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders IV-TR.

I usually post a prevalence-rate map from Wikipedia along with diagnostic criteria. For Bipolar Disorder, though, Wikipedia currently has a map of “age-standardised disability-adjusted life year (DALY) rates.” (Yellow countries have something like two-thirds the DALY rates from Bipolar Disorder of the red countries.)

Bipolar_disorder_world_map_-_DALY_-_WHO2002

DALY is basically trying to measure how costly an affliction is, as opposed to just how many people experience it. Perhaps this is why it looks so much worse in poorer countries than rich ones, quite the opposite of how Major Depressive Disorder prevalence map looks. I’d still like to look at prevalence. Can anyone point me to a good prevalence map?

As you will see, there are a bunch of versions of Bipolar Disorder. The basic ingredients of them are called Mood Episodes (which I have here): Depressive, Manic, Mixed, and Hypomanic Episodes. There are also a whole bunch of “specifiers,” which are used to describe severity, extra features, and timing (which I will link to at some point). The criteria quoted in this post are basically recipes of Episodes and specifiers.

Here are the diagnostic criteria, directly quoted from the DSM-IV-TR, for Bipolar I Disorders (pp. 388-392), Bipolar II Disorder (p. 397),  and Cyclothymic Disorder (p. 400). There is a final Bipolar Disorder Not Otherwise Specified available to diagnosticians who suspect a Bipolar Disorder in a client that doesn’t fit any of the diagnostic criteria. I can’t post criteria for BD NOS, though, because there aren’t any.

Diagnostic criteria for 296.0x Bipolar I Disorder, Single Manic Episode

A. Presence of only one Manic Episode (see p. 362) 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 Mixed Episode (see p. 365)

If the full criteria are currently met for a Manic, Mixed, or Major Depressive Episodespecify its current clinical status and/or features:

Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a Manic, Mixed, or Major Depressive Episodespecify the current clinical status of the Bipolar I Disorder or features of the most recent episode:

In Partial Remission, In Full Remission (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

Diagnostic criteria for 296.40 Bipolar I Disorder, Most Recent Episode Hypomanic

A. Currently (or most recently) in a Hypomanic Episode (see p. 368).

B. There has previously been at least one Manic Episode (see p. 362) or Mixed Episode (see p. 365).

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 is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 242)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 296.4x Bipolar I Disorder, Most Recent Episode Manic

A. Currently (or most recently) in a Manic Episode (see p. 362)

B. There has previously been at least one Major Depressive Episode (see p. 356), Manic Episode (see p. 362) or Mixed Episode (see p. 365).

C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

If the full criteria are currently met for a Manic Episodespecify its current clinical status and/or features:

Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a Manic Episodespecify the current clinical status of the Bipolar I Disorder and/or features of the most recent Manic Episode:

In Partial Remission, In Full Remission (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 242)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 296.6x Bipolar I Disorder, Most Recent Episode Mixed

A. Currently (or most recently) in a Mixed Episode (see p. 365).

B. There has previously been at least one Major Depressive Episode (see p. 365), Manic Episode, (see p. 362) or Mixed Episode (see p. 365).

C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

If the full criteria are currently met for a Mixed Episodespecify its current clinical status and/or features:

Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a Mixed Episodespecify the current clinical status of the Bipolar I Disorder and/or features of the most recent Mixed Episode:

In Partial Remission, In Full Remission (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 242)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 296.5x Bipolar I Disorder, Most Recent Episode Depressed

A. Currently (or most recently) in a Major depressive Episode (see p. 365).

B. There has previously been at least one Manic Episode (see p. 362) or Mixed Episode (see p. 365).

C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

If the full criteria are currently met for a Major Depressive Episodespecify its current clinical status and/or features:

Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 412)

Chronic (see p. 417)

With Catatonic Features (p. 417)

With Melancholic Features (see p. 419)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a Major Depressive Episodespecify the current clinical status of the Bipolar I Disorder and/or features of the most recent Major Depressive Episode:

In Partial Remission, In Full Remission (see p. 414)

Chronic (see p. 417)

With Catatonic Features (p. 417)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 242)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

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 (see p. 362), a Hypomanic (see p. 368), a Mixed (see p. 365), or a Major Depressive Episode (see p. 356).

B. There has previously been at least on Manic Episode (see p. 362) or Mixed Episode (see p. 365).

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 is 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 abus, a medication) or a general medical condition (e.g., hypothyroidism).

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 424)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 296.89 Bipolar II Disorder

A. Presence (or history) of one or more Major Depressive Episodes (seep. 356).

B. Presence (or history) of at least one Hypomanic Episode (see p. 368).

C. There has never been a Manic Episode (see p. 362) or a Mixed Episode (see p. 365).

D. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and is 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 (see p. 362)

Depressed:  if currently (or most recently) in a Major Depressive Episode (see p. 356)

If the full criteria are currently met for a Major Depressive Episodespecify its current clinical status and/or features:

Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 412)     Note: Fifth-digit codes specified on p. 413 cannot be used here because the code for Bipolar II Disorder already uses the fifth digit.

Chronic (see p. 417)

With Catatonic Features (p. 417)

With Melancholic Features (see p. 419)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a Hypomanic or Major Depressive Episodespecify the current clinical status of the Bipolar II Disorder and/or features of the most recent Major Depressive Episode (only if it is the most recent type of mood episode):

In Partial Remission, In Full Remission (see p. 414)     Note: Fifth-digit codes specified on p. 413 cannot be used here because the code for Bipolar II Disorder already uses the fifth digit.

Chronic (see p. 417)

With Catatonic Features (p. 417)

With Melancholic Features (see p. 419)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 242)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 301.13 Cyclothymic Disorder

A. For at least 2 years, the presence of numerous periods with hypomanic symptoms (see p. 368) and numerous periods with depressive symptoms that do not meet criteria for a Major Depressive Episode.     Note: In children and adolescents, the duration must be at least 1 year.

B. During the above 2-year period (1 year in children and adolescents), the person has not been without the symptoms in Criterion A for more than 2 months at a time.

C. No Major Depressive Episode (p. 356), Manic Episode (p. 362), or Mixed Episode (see p. 365) has been present during the first 2 years of the disturbance.

Note: After the initial 2 years (1 year in children and adolescents) of Cyclothymic Disorder, there may be superimposed Manic or Mixed Episodes (in which case both Bipolar I Disorder and Cyclothymic Disorders may be diagnosed) or Major Depressive Episodes (in which case both Bipolar II Disorder and Cyclothymic Disorder may be diagnosed).

D. The symptoms in Criterion A are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.