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DSM5577 - SECTION 11: ADDRESSING DIAGNOSTIC COMPLEXITIES - BIOPOLAR AND RELATED DISORDERS

Section XI: Addressing Diagnostic Complexities – Bipolar and Related Disorders

Statistic: Bipolar disorder, also known as manic-depressive illness, affects more than 2 million Americans (NIMH, 2000).

When a client enters into treatment with depression as a major component of their complaints, the assessment process will involve some complex decisions about diagnosis. There are many different reasons why clients may be depressed, some of them related to responses to difficult challenges or environments, some of them related to genetically influenced problems with neurochemistry, and always the possibility of complex interactions between the two.

In the DSM-IV TR, disorders that involved depressive symptoms were gathered together under the general category of Mood Disorders, disorders that were largely characterized by a disturbance in mood that is severe enough to require counseling. This included both disorders that presented only with symptoms of depression (unipolar mood disorder) and disorders that presented with symptoms of depression combined with symptoms of excessively elevated mood (bipolar mood disorder).

This grouping has been changed within the DSM-5. There are now separate sections covering Depressive Disorders - problems with controlling depressed mood – and Bipolar and Related Disorders, consisting of problems with controlling the combination of depressed and elevated moods. This reflects the ongoing research into the biological mechanisms responsible for bipolar disorders and unipolar depression.

Even the most recent neuroscience is not ready to declare that we have a full and exact picture of the chemistry of bipolar disorders. There are still a number of competing and overlapping theories that are being researched, each of which may offer something useful in terms of treatment options. However, we can state with increased clarity that some of the neurological changes responsible for bipolar disorder involve very different neurochemical events than what we see in unipolar depression.

This is important in terms of how we approach diagnosis and points out a logical reason why it may be useful to begin any exploration of depressive symptoms by ruling out the presence of bipolar and related disorders. We will not always sit down to evaluate a client with bipolar disorder during one of the periods where elevated mood is clearly present. Unless we are prepared to engage in a thorough assessment process – with detailed questioning about any history of excessively elevated mood – we may get the essential features of the problems wrong. This would direct us towards an erroneous diagnosis and towards treatment approaches that may not be fully appropriate to the problem.

If we view the diagnostic process as a matter of uncovering symptoms that define disorders and differentiating them from symptoms that rule out disorders, then it is prudent to head directly for the information that can do this most quickly. In the case of Bipolar and Related Disorders, this differentiation process can be most readily accomplished by ruling out the presence of excessively elevated mood, otherwise known as mania. All of the Bipolar and Related Disorders will be distinguished by a current or prior history of some degree of mania – over and above any signs of depression – and other depressive disorders will not.

This is not always as simple and straightforward as it might first appear. The neurological mechanisms that produce mania are different from the neurological mechanisms that produce anxiety. However clients who suffer from extreme anxiety can present with symptoms that can appear very similar to a manic episode, marked by nervous energy, troubles sleeping, irritability, and other things.

A client with persistent depression and a severe generalized anxiety disorder will present a diagnostic challenge in terms of differentiating these disorders from a bipolar disorder. For this reason, we will cover in this section the exact features of what constitutes mania or a manic episode. 

On the other side of the mood scale, it will also be necessary to determine that any signs and symptoms of major depression are not better explained by a schizophrenia spectrum disorder or other psychotic disorder. While both major depression disorder and Bipolar and Related Disorders can become severe enough to create thought disturbances that include psychosis, schizophrenia and other psychotic disorders will often by accompanied by a very high degree of distress and anxiety, as well as profound depression. These symptoms can be very difficult to differentiate from the kinds of problems seen with bipolar and related disorders.  

 

Key Knowledge Point to Follow:

In diagnosing mood disorders, it can be very helpful to inquire about family history, since some disorders appear to have a genetic component. We know that family history can be an indicator of the diagnosis of the individual. If the person has four people in their family who have a diagnosis of Bipolar I Disorder, you will want to first examine the person according to the criteria for Bipolar I. On the other hand, if there is a family history of schizophrenia, it may make more sense to consider that diagnosis first.

In the spectrum of disorders being studied in this section, there are three main diagnoses: Bipolar I Disorder, Bipolar II Disorder, and Cyclothymic Disorder There are also diagnoses in this category to cover situations in which the primary symptoms of a bipolar disorder are generated by a medical condition, or are not severe enough to warrant a full diagnosis of this sort. We will go into greater detail about the distinctions shortly.

A diagnosis of Bipolar I Disorder indicates a more severe presentation of problems in this area, with less severe symptoms suggesting a diagnosis of Bipolar II Disorder. Bipolar I Disorder is distinguished from Bipolar II Disorder due to the presence of at least one lifetime manic episode, defined as: 

A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently goal-directed activity or energy, lasting as least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).

 

Key Knowledge Point to Follow:

The manic episode must be sufficiently severe to cause marked impairment to social or occupational functioning, to require hospitalization, or must present with psychotic features. There are 3 or more of the following symptoms present (4 or more symptoms must be present if the mood is only “irritable”):

 - Irritability

 - Pressured speech/ feel urge to talk or keep talking

 - Decreased need for sleep

 - Inflated self esteem or grandiosity

 - Racing thoughts

 - Distractibility

 - Increased goal directed activity or psychomotor agitation

 - Excessive involvement in pleasurable activities that have a high threshold for painful consequences.

(APA, 2000)

Once a history of at least one manic episode has been established, Bipolar I Disorder can be diagnosed even when current symptomatology shows only the less severe hypomanic episodes. Hypomania, as one might infer, is a less severe form of elevated mood than mania. The essential differences between the two are: 1) the length of time the expansive (or elevated) mood exists (more than 4 days for hypomania versus more than 7 days in a full manic episode) and 2) whether the episode is (for a full manic episode) or is not (for hypomania) severe enough to create marked impairments to social or occupational functioning or require hospitalization (for a full manic episode). (DSM-5)

Bipolar II will not include a history of a full manic episode, but will instead express excessive mood through one or more hypomanic episodes. Gathering information on the symptoms listed above is crucial to making a clear diagnosis. You may want to create a checklist of patient questions to help with making a clear diagnosis between mania and hypomania, or between Bipolar I Disorder and Bipolar II Disorder. (APA, 2000).

There are a number of important specifiers for Bipolar and Related Disorders that will be incorporated into the numeric code under both ICD-9 and ICD-10. However, these specifiers should also accompany the written diagnosis in order to provide a clearer diagnostic picture. These include the following important concepts:

Specify if the current or most recent episode is:

Manic (Bipolar I Disorder only)

Hypomanic

Depressed

 

Specify if the current or most recent episode presents: 

With anxious distress

With mixed features

With rapid cycling

With melancholic features

With atypical features

With mood-congruent psychotic features

With mood-incongruent psychotic features

With catatonia

With peripartum onset

With seasonal pattern

 

Specify course if the full criteria for a bipolar episode are not currently met: 

In partial remission

In full remission

 

Specify severity if the full criteria for a bipolar episode are currently met: 

Mild

Moderate

Severe

 

The third major diagnosis in this section of the DSM is Cyclothymic disorder (ICD-10: F34)., a chronic, fluctuating mood disorder that lasts for two years or more and has various hypomanic and depressed states that do not meet the criteria for either major depression or Bipolar II Disorder. To come to a diagnosis of cyclothymic disorder, you would look for bipolar like symptoms that cause impairment in the functioning of the patient and that persist over a long period of time, but whose severity is not sufficient to warrant a Bipolar I or Bipolar II diagnosis. 

Typically, because this disorder is present with milder symptoms, there is only one specifier that would be indicated.

Specify if the current or most recent episode presents:

With anxious distress

When considering a diagnosis of Bipolar and Related Disorders, it is important to gather information about a client’s substance use history, medical history and medication use history, and to coordinate with a client’s primary care physician to make sure all this information is present and accurate. There are a number of substances and medications that can precipitate severe alterations in a client’s mood, both on the mania side and on the depression side. 

If the client presents with these severe alterations in elevated and/or depressed mood in ways consistent with the guidelines for Bipolar and Related Disorders, and it is clear that this alteration in mood has been precipitated by use of or withdrawal from one or more medications or substances, then a diagnosis of Substance/Medication-Induced Bipolar and Related Disorder may be indicated.

The coding for this disorder under ICD-10 will be complicated, identifying both the use disorder and the bipolar symptoms with a single number. This single code will also be constructed to provide information about whether the use disorder is mild, or whether the use disorder is moderate/severe. Just as is the case under ICD-9, when the diagnosis is written out in full in order to provide greater clarity, the name of the substance/medication responsible should be noted first. This disorder also requires that you specify whether the bipolar symptoms began as a result of intoxication or withdrawal. 

For example, here is how this diagnosis would be recorded under ICD-10 when the substance in question is alcohol:

Alcohol-induced Bipolar and Related Disorder, without use disorder: F10.94 

Alcohol Use Disorder, mild, with Alcohol-induced Bipolar and Related Disorder with onset during intoxication: F10.14

Alcohol Use Disorder, moderate/severe, with Alcohol-induced Bipolar and Related Disorder with onset during intoxication: F10.24

When the substance in question is cocaine, the coding would incorporate the different substance in the second digit after the ‘F’:

Cocaine-induced Bipolar and Related Disorder, without use disorder: F14.94 

Cocaine Use Disorder, mild, with Cocaine -induced Bipolar and Related Disorder with onset during intoxication: F14.14

Cocaine Use Disorder, moderate/severe, with Cocaine -induced Bipolar and Related Disorder with onset during intoxication: F14.24

There are three other diagnoses in this section that present complexities for accurate diagnosis. The first is Bipolar and Related Disorder Due to a Medical Condition (ICD-10: F06.3x). This diagnosis is used when the symptoms can be attributable to a diagnosed medical condition that can precipitate alterations in mood.

Typically, there are three specifiers used with this diagnosis:

With manic features

With manic- or hypo-manic episode

With mixed features

Under ICD-10, the first two specifiers will populate the last digit of the code with a 3 (F06.33), while mixed features will be noted with a 4 (F06.34).

Perhaps the most frequently encountered example of this is hyperthyroidism, a condition in which malfunctioning of the thyroid gland causes disturbances to the release of a hormone that is associated with metabolism. The physiological and psychological effects of these fluctuations in thyroid hormone can include wide swings in mood, creating symptoms that look very much like manic and depressive swings. 

If this diagnosis is encountered, the medical diagnosis would be listed first, followed by the psychological diagnosis, with the name of the medical condition included in the written diagnosis. The specifier will be incorporated into the written and numeric diagnosis under ICD-10. Under ICD-10, this would appear as follows, diagnostic code in parentheses: 

Hyperthyroidism: (ICD-10: E05.90)

Bipolar Disorder due to hyperthyroidism, with mixed features: (ICD-10: F06.34)

Clearly, this is another instance in which the mental health clinician would be recording a diagnosis previously made by a qualified medical professional. However, because there can be complex relationships between medical problems and psychiatric problems – and certainly that is the case where thyroid problems and bipolar disorders are concerned – it would not accurately reflect the clinical picture to omit the medical disorder from the full diagnosis. If the diagnosis helps inform the treatment, the presence of a medical issue may suggest very different kinds of conversations with the client during the counseling process.

There are two other key diagnoses to note here, Other Specified Bipolar and Related Disorders (ICD-10: F31.89) and Unspecified Bipolar and Related Disorders (ICD-10: F31.9). These are both chosen when bipolar symptoms are present, but do not meet full criteria for any of the other diagnoses in this section. The Unspecified diagnosis would be used when the clinician chooses not to specify the reason why the symptoms do not meet criteria for a specific Bipolar and Related Disorder, whereas the Other Specified would be used when the clinician elects to provide greater clarity about why criteria have not been met.

For example, if cyclothymia has been present in a client, but not for the 24 months required to meet criteria for Cyclothymia Disorder, then the diagnosis would be presented as follows: 

Other Specified Bipolar and Related Disorders, short-duration cyclothymia (less than 24 months) (ICD-10: F31.89). 

This will provide a clearer diagnostic picture of what is occurring to any other clinician who becomes involved in the case. Once a period of 24 months has passed and the symptoms remain, the diagnosis can be changed to reflect that full criteria have been met. 

Mania is a distinctly elevated, expansive or irritable mood that lasts a week or more or requires hospitalization.

There are 3 or more of the following symptoms present (4 or more symptoms must be present if the mood is only “irritable”):

 - Irritability

 - Pressured speech/ feel urge to talk or keep talking

 - Decreased need for sleep

 - Inflated self esteem or grandiosity

 - Racing thoughts

 - Distractibility

 - Increased goal directed activity or psychomotor agitation

 - Excessive involvement in pleasurable activities that have a high threshold for painful consequences.

(APA, 2013)

 

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