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BIPOLAR DISORDERS 
 
 
 
 
 
EBM Bipolar Disorders 
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1. 
Description 
1.1 
Classifications and synonyms 
Bipolar disorders are severe mental health conditions causing significant impairment 
and disability in those affected. They are characterised by marked swings of mood, 
which are pathological, and usually recurrent. 
Typically, both depressive and manic or hypomanic (see 4.1) episodes can occur, 
but various patterns have been recorded, and subgroups recognised. 
Various terms have been used in the past, including the following: 
  Bipolar affective disorder 
  Manic depressive psychosis 
 Manic 
depression 
  Manic depressive illness 
 Mania 
 Hypomania. 
The two internationally recognised classifications of mental illness are ICD10 and 
DSM IV.  These descriptive classifications are broadly similar.  
In the UK and Europe, ICD10 is widely used, though there is a degree of overlap 
with DSM IV being used, particularly in the clinical research environment.  DSM IV is 
produced by the American Psychiatric Association, primarily for use in the USA. 
The two classifications complement each other, and to assist the understanding of 
bipolar disorders, terms from both are referred to in this protocol. 
The main similarities and differences between the two classifications are as follows: 
  Both define individual episodes and patterns of recurrence. 
  Both use severity of symptoms and impaired social functioning, to distinguish 
hypomania from mania. 
  A single episode of hypomania or mania fulfils the diagnostic criteria for bipolar 
affective disorder in DSM IV. 
  At least two episodes of mood disturbance, including one where mood has been 
elated, are required for the ICD10 criteria for bipolar affective disorder to be 
fulfilled. 
DSM IV subdivides bipolar disorder into the following: 
  Bipolar I – where an episode of mania has occurred at least once. 
  Bipolar II – where there has been hypomania, but mania has not occurred. 
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The different diagnostic codes and criteria for ICD10 relevant to this protocol, some 
further information about DSM IV, and more detail about the diagnostic 
differentiation between hypomania and mania have been included in the Appendix.  
 
 
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2.  
Aetiology 
The German psychiatrist Kraepelin first used the term manic-depressive insanity in 
the early 1920’s, highlighting in particular, the differences between these patients, 
and those with schizophrenia (then termed dementia praecox). 
The term bipolar was not introduced until the 1960’s, when clearer distinctions 
between unipolar and bipolar illness were drawn. Since that time there has been 
much research into possible aetiological factors. 
A variety of theories as to aetiology have been explored, and it seems likely that 
both disposing and precipitating factors have a role to play. 
2.1 
Genetic factors 
Of all psychiatric conditions it seems that bipolar disorders are the most genetically 
determined.  
First degree relatives of those with a bipolar disorder have elevated rates of 
developing a mood disorder themselves. The rates for some of these conditions are 
as follows:19 
  Bipolar I - 4% to 24%. 
  Bipolar II  - 1% to 5%. 
  Major depressive disorder  - 4% to 24%. 
The importance of genetic factors is also strongly supported by the twin studies that 
have been carried out. 
Twin studies have indicated a greater genetic contribution in bipolar disorder, 
compared with unipolar disorder (depression). If a monozygotic twin has bipolar 
disorder, the concordance rate for mood disorder in the other twin is 60% -70%. The 
rate is only 20% if the twins are dizygotic. 
Although genetic factors are recognised as being of importance, it is still not known 
at what aetiological level they operate.  
The search for specific causative genes continues, but has so far proved 
inconclusive. Nonetheless, it seems likely that genetic factors will prove the most 
important aetiologically, with other factors interacting to varying degrees in an 
individual. 
 
 
 
 
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2.2 
Personality 
Pre morbid personality would seem to be a relevant factor in some instances  (see 
cyclothymia  4.2). 
2.3 
Life events 
In contrast with depression, life events play a more uncertain role in the aetiology of 
mania. It does seem however that on occasion, an event such as bereavement that 
might be expected to induce low mood, may in fact induce a manic episode. Once a 
bipolar illness has become established, environmental precipitants seem to assume 
less importance than at the outset of the illness. 
2.4 
Physical illness 
Both physical illnesses and what might be termed altered physiological states, such 
as the puerperium can precipitate bipolar episodes. Endocrine changes are thought 
to be a causative factor in these circumstances. 
2.5 
Neurobiological  factors 
It has been known for some time that dopamine agonists such as bromocriptine can 
produce manic states. 
Recent studies have suggested that patients at risk of mania may in some way 
respond differently to dopamine levels in the brain, although altered dopamine levels 
have not been demonstrated experimentally. 
2.6 
Water and electrolyte changes 
Increase in the body’s residual sodium levels has been noted in both depressive and 
manic patients. This may be in some way linked to the mode of action of lithium, in 
preventing relapse in these disorders. 
2.7 
Neuroanatomical  factors 
Structural changes (‘patchy white matter lesions’, and small temporal lobes or 
caudate nuclei) have been noted experimentally in various parts of the brain. 
However, studies have been of small numbers of patients, and results inconsistent. 
No firm conclusions have been drawn to date.1 
 
  
 
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3. 
Prevalence 
Bipolar disorder can occur at any age from early adolescence to old age, and unlike 
depressive disorders, there are no gender differences evident. Childhood cases 
have been reported very occasionally. 
On average, the condition is first diagnosed during the early to mid twenties. This is 
an earlier age of onset than for major depression. 
Studies in the USA show a point prevalence of 0.4 – 1% and an incidence of 0.3%. 
Each year, some 600,000 patients are identified and treated in the USA. 
In Western countries the lifetime risk is thought to be in the order of 0.6 – 1.1%. 
If all diagnostic categories, including less severe forms are included, the lifetime risk 
is thought to be 2%.2 
Some studies have shown a higher prevalence in higher social classes. It is not 
clear whether this is a true picture or whether it simply highlights differences in 
access to mental healthcare. 
The prevalence figures at 6 months show little difference from lifetime figures, 
indicating chronicity of these conditions. 
Mania has been described in a wide range of cultures, with no obvious cross- 
cultural variations noted.2 
 
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4. 
Diagnosis 
4.1 
Clinical features 
The mood swings that characterise bipolar disorders usually include episodes of 
depression. These in their various forms are described in some detail in a separate 
protocol (Depressive Disorders). The relevant clinical features of depression will 
therefore not be described in any depth here. 
An explanation of some common terms will help in understanding the clinical 
features. 
Mood – This is a pervasive and sustained emotion. In the extreme, it markedly 
colours a person’s perception of the world. 
Elation – This is an elevated mood or exaggerated feeling of wellbeing, which is 
pathological and a feature seen in mania. 
Affect – This differs from mood in that it is much less sustained, often varying in the 
short term. It can best be described as a pattern of observable behaviours that are 
the expression of a subjectively experienced feeling state (an emotion). 
Mania and Hypomania – These represent different degrees of severity of mood 
elevation. In hypomania, the clinical features are less marked, and although day-to-
day functioning will be affected, the clinical picture is less florid than that seen in 
mania. Psychotic features such as delusions or hallucinations are not seen in 
hypomania. In mania, the clinical features are much more marked and the 
individual’s condition may rapidly decline to one of self-neglect, with features such 
as poor personal hygiene. Inattention to nutritional needs may lead to dehydration. 
Sustained physical overactivity and aggressive or violent behaviour may ensue. 
In general, patients with hypomania or mania will display the following: 
  Elevation of mood (although angry or irritable mood can also be displayed). 
 Increased 
activity. 
 Self-important 
ideas. 
Physical appearance may be unusual or altered: 
  Brightly coloured or ill-assorted clothes may be worn. 
  Appearance may be dishevelled and untidy. 
  They may appear to fluctuate between overactivity and physical exhaustion. 
Observations of speech and thought processes may highlight: 
  Rapid or copious speech, often termed ‘pressure of speech’ (‘punning’ or 
‘clanging’ may feature). 
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  Expansive or unrealistic ideas. 
  ‘Flight of ideas’. This is where thoughts follow in rapid succession and appear to 
be connected by chance, although some association can be gathered by the 
listener. 
  Extravagant or grandiose delusions. 
An example of speech with clang associations would be ‘Birmingham, Kingstanding; 
see the king he’s standing, king, king, sing, sing, bird on the wing’3. 
Flight of ideas can be so marked that speech becomes incoherent.  
In hypomania the overall train of thought is better retained, so called ‘ordered flight 
of ideas’. 
History taking or information from a third party may provide descriptions of the 
following:  
 Increased 
energy 
 Increased 
appetite 
  Loss of normal social and sexual inhibitions 
 Overspending 
 Increased 
distractibility 
  Reduced need for sleep 
  Starting many tasks or activities but failing to complete them 
  Poor attention span and ability to concentrate. 
These relevant features may not be reported by the patient, who may lack 
insight into their condition. 

As the patient deteriorates, these features may change, and delusions of 
persecution, ‘ideas of reference’ or passivity feelings may become manifest. 
10 – 20 % of manic patients will display one of Schneider’s first rank symptoms of 
schizophrenia.  These are described in a separate protocol (Schizophrenia). In such 
cases, the common perceptual disturbance is hallucinatory. 
Auditory hallucinations may be in the form of voices indicating that the patient has 
special powers. Visual hallucinations frequently have a religious content. 
It is estimated that 60% of bipolar patients will have psychotic symptoms at some 
time during their illness. 
Insight is frequently absent or variable. 
The clinical picture may be mixed, with depressive and manic symptoms occurring 
at the same time. In these cases, a rapid sequence of changes may be seen. 
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4.2 
Manic stupor 
The clinical picture of a patient presenting in a manic stupor is very rarely seen now. 
The face has an elated appearance, and although fully conscious, they remain mute, 
unresponsive and akinetic throughout. On recovery they may remember having had 
‘flight of ideas’. 
4.3 
Rapid cycling disorder 
Where the pattern of relapse and remission is frequent, (at least 4 episodes of 
illness a year), the condition is called rapid cycling disorder. The episodes may be 
manic, depressive or have a mixed picture. This variant can be triggered by anti-
depressants, is more frequently seen in women and is associated with concomitant 
hypothyroidism. Unfortunately, lithium treatment is relatively ineffective in these 
cases. 
4.4 
Bipolar III disorder 
This variant has been described by clinicians, but is not included in ICD10 or DSM 
IV.1  It is also referred to as pseudo-unipolar bipolar disorder. Individuals with this 
condition have recurrent depressive episodes, with clinical features suggesting they 
may develop a bipolar disorder. These include pre-morbid personality, family history 
of bipolar disorder, and hypomania in response to anti-depressants. 
4.5 
False unipolar disorder 
This term may be applied to recurrent depression originally classified as unipolar, 
where mania or hypomania develops subsequently. It has been estimated that 
between 10.7% and 28.4% of those diagnosed with unipolar depressive disorder are 
‘false unipolars’.1 
4.6 
Cyclothymia 
Although not included in the ICD10 classification of bipolar disorders, it is convenient 
to make mention of cyclothymia at this point. It is classified as one of the persistent 
mood (affective) disorders in ICD10. 
Other terms/synonyms for this include affective personality disorder, cycloid 
personality and cyclothymic personality. 
The disorder is of persistent instability of mood, with both episodes of elation and 
depression featuring. Episodes are neither severe enough nor of sufficient length for 
other diagnostic criteria to be satisfied. It is common in relatives of patients with 
bipolar disorders, and a significant number (30%) will at some point go on to develop 
bipolar disorder themselves. 
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4.7 
Dysthymia 
Similarly, it is convenient to make brief mention of dysthymia, also a persistent mood 
(affective) disorder at this juncture. Essentially, the relevant clinical feature here is of 
low mood which although persistent and long standing, is never (or almost never) 
severe enough to fulfil the ICD10 criteria for a recurrent depressive disorder (mild or 
moderate severity). The duration will be of years, and can last indefinitely. 
Other terms / synonyms for this include depressive neurosis, depressive personality 
disorder, neurotic depression (with more than 2 years duration) and persistent 
anxiety depression. 
There is no association with the development of a more disabling mood disorder 
later in life. 
4.8 
Investigations 
Assessment of patients with suspected bipolar disorder requires careful history 
taking and physical examination to exclude other possible causes (see 4.9). 
Information obtained from a relative or carer can prove vital, as the patient may be 
unable to recognise the extent of their abnormal behaviour. 
In mania, hospital admission is likely to be advisable, as effective care at home is 
very difficult to achieve. 
The following baseline investigations should be carried out to exclude other 
conditions such as anaemia, electrolyte disturbances or the effects of vitamin 
deficiencies. Metabolic disorders can also impact on prescribed therapy and need to 
be identified before treatment commences: 
 Full 
blood 
count 
  Urea and electrolytes 
  Thyroid function tests 
  Liver function tests 
  Vitamin B12 and serum folate levels 
 Syphilis 
serology 
  Urine tests – including a screen for illegal substances 
 EEG 
 Psychometric 
testing. 
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4.9 
Differential diagnosis 
A number of other conditions can present as hypomania or mania, and must be 
excluded by clinical assessment or the appropriate tests. 
  Organic disorders – including hyperthyroidism, anorexia nervosa and frontal lobe 
disease (tumours or HIV infection). 
  Schizophrenia / schizoaffective disorders. 
 Agitated 
depression. 
  Endocrine disturbance – idiopathic Cushing’s syndrome or steroid induced 
psychosis. 
 Epilepsy. 
  Severe physical illness (stroke in particular). 
  Psychoactive substance use disorder (amphetamines, cocaine). 
  Obsessive compulsive disorder (elation is not usually a feature here). 
  Attention deficit hyperactivity disorder (elation is not usually a feature here). 
  Transient psychoses induced by extreme stress (elation is not usually a feature 
here). 
  Dissocial personality disorder. 
4.10  Co-morbidity with other mental health conditions 
This is common and likely to increase disability significantly. Relevant conditions 
include the various anxiety disorders, alcohol dependence and substance misuse 
disorders.4 
Nearly 60% of patients with bipolar disorder are thought to have a substance misuse 
or alcohol dependence disorder at some point during their illness.1  These co-morbid 
conditions are likely to have a significant impact on factors such as response to and 
compliance with treatment, social functioning and employment prospects. 
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5. 
Treatment 
Bipolar disorders are not commonly encountered in the primary care setting. Indeed, 
most sufferers are likely to have been in contact with specialist mental health 
services. 
The management of bipolar disorders can usefully be divided into the treatment of 
acute episodes, and long-term strategies to prevent relapse. 
5.1 
Management of acute mania/hypomania 
This is best undertaken in a hospital setting. Whilst informal admission is preferable, 
compulsory admission under the Mental Health Act may be necessary if the patient’s 
wellbeing or personal safety is seriously compromised. 
The use of anti-psychotic medication has a pivotal role in the acute phase, the aim 
being to reduce both physical and mental overactivity, thus preventing the patient’s 
health from deteriorating due to exhaustion or self-neglect. Psychotic features are 
also likely to improve with such medication. 
Both  chlorpromazine and haloperidol are used in the acute situation. They are 
effective even if clear psychotic symptoms are not apparent. In general, manic 
patients are likely to be treated with fairly high doses, so extra-pyramidal side effects 
may be induced (they may be particularly susceptible to these). 
One feature of using these drugs alone is that they offer no protection against the 
depressive downswings that can often follow a manic episode. 
In the USA, guidelines advocate the use of lithium or valproate in the acute 
situation. However, scrutinising hospital prescribing records indicates that anti-
psychotics are still widely used. 
Lithium has a slower onset of action compared with anti-psychotics. It is probably 
less suitable for patients with rapid cycling disorder, or who display prominent 
depressive symptoms or psychotic features. 
Occasionally, newer atypical anti-psychotics such as olanzapine or risperidone 
may be used, but evidence to support their use preferentially is lacking.5 
Other drugs which can be used include the anti-epileptic drugs carbamazepine and 
valproate
In the short term, benzodiazepines may be added to the treatment regimen, their 
purpose being to try and restore normal sleep pattern and to reduce overactivity. 
Their use also allows lower doses of anti-psychotics to be prescribed.5 
Electroconvulsive therapy (ECT) is effective in about 80% of patients with acute 
mania. In practice, it tends to be used in patients who have failed to respond to 
medication, or those with very severe illness, rather than as a first line option. 
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5.2 
Longer term management 
The aim here is to prevent relapse or recurrence. The medications initially 
prescribed for the acute illness will usually be continued for about 6 months. Anti-
psychotic medication should be slowly withdrawn, to avoid sudden recrudescence of 
mania. 
Maintenance treatment with a mood stabilizer should be considered if there have 
been two or more episodes of illness in less than 5 years. 
Lithium is an effective prophylactic agent and remains the drug of choice for long 
term management of bipolar disorders.6 
Lithium prevents recurrences of both mania and depression. About 50% of patients 
respond well to lithium. The remainder demonstrate either no response, or only 
partial response.7 
If any of the following features are present then lithium is less likely to be effective: 
 Chronic 
depression 
  Rapid cycling disorders 
  Mixed affective states 
  Alcohol and drug misuse 
  Mood incongruent psychotic features. 
Contraindications to lithium treatment include: 
 Renal 
insufficiency 
 Cardiovascular 
insufficiency 
 Addison’s 
disease 
 Untreated 
hypothyroidism. 
Lithium is a toxic drug with a narrow therapeutic window and it can be fatal if taken 
in overdose. Patients need to have regular monitoring of blood levels whilst taking 
lithium. A blood level of 0.4-1.0 mmol/l 12 hours after the evening dose is aimed for. 
Potential side effects from lithium include: 
 Gastrointestinal 
disturbances 
 Fine 
tremor 
  Polyuria and polydipsia 
 Weight 
gain 
 Oedema 
  Subjective memory disturbances.6 
Signs of lithium intoxication include CNS disturbance, such as ataxia, coarse tremor 
and drowsiness. 
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Lithium can interact with a wide range of other prescribed drugs. Diuretics, in 
particular thiazides, should be avoided if possible. 
Many clinicians believe that lithium has a specific anti-suicidal effect therapeutically. 
This important hypothesis has not yet been confirmed by research studies.6 
Although far fewer clinical trials have been carried out, carbamazepine is thought to 
be as effective as lithium, and can be considered as an alternative in those who are 
intolerant of, or who respond poorly to lithium. 
Valproate may also be used prophylactically with seemingly good effect, either on its 
own, or in combination with lithium or other mood stabilising drugs. 
There is no evidence to date to indicate that valproate should be used in preference 
to lithium.8 
Where patients become depressed in spite of lithium treatment, an anti-depressant 
can be added to the regimen. Treatment of depressive episodes in this way carries 
with it the risk of inducing manic symptoms or rapid cycling.9  
Selective Serotonin Re-uptake Inhibitors (SSRIs) are thought to be less likely to 
induce mania or rapid cycling. 
5.3 
Cognitive behavioural therapy 
Cognitive therapy can have a useful supporting role in the treatment of bipolar 
patients.7  It focuses on helping the individual to accept the diagnosis and need for 
treatment. Patients can also be taught techniques that may avert negative thoughts 
or maladaptive beliefs. 
One experimental study carried out in the UK concluded that cognitive behaviour 
therapy was useful in helping patients to identify early signs of manic relapse,10 but 
that further studies were desirable to clarify the effect of this intervention.11 
5.4 
Compliance 
This is an important issue in the management of patients with bipolar disorders. The 
reasons for non-compliance with treatment are complex.  Some patients may be 
reluctant to stop experiencing the elevated mood swings that they perceive as being 
pleasurable. Side effects of medication may prove problematic, as may the need for 
regular blood test monitoring. 
An interesting first hand account describing what it is like to have a severe bipolar 
disorder has been written by Dr Kay Redfield Jamison, herself a respected world 
authority on the subject.12  She describes the personal dilemmas inherent in coming 
to terms with both the diagnosis and the management of the condition. It can 
certainly not be assumed that detailed knowledge of the condition will in itself ensure 
good compliance. 
For patients who are on lithium, poor compliance is a major issue, as sudden 
discontinuation can precipitate illness recurrence.13 
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6. 
Prognosis 
The average manic episode, treated or untreated, lasts 6 months. Whilst recovery 
from the acute episode is the usual outcome, the long-term prognosis is poorer than 
might be expected. The reasons for this have not been fully clarified by research 
studies. 
Functional prognosis in terms of factors such as employment is similar to other 
severe mental illnesses such as schizophrenia. 
90% of patients who have had a manic episode will have a manic or depressive 
recurrence. 
Less than 20% of bipolar patients are able to achieve a sustained period (5 years) of 
clinical stability, and social and occupational performance are both significantly 
reduced. 
Long-term follow-up studies (25 years) have shown that the average bipolar patient 
will have 10 further episodes of mood disturbance. The time interval between 
relapses tends to shorten with both increasing number of episodes and ageing. 
10% of patients diagnosed with a depressive disorder will go on to have a manic 
illness. 
The percentage of bipolar patients who attempt suicide at some point in their illness 
is estimated to be in the region of 50%. 
The suicide rate amongst bipolar patients is increased at 15%.13  Premature 
mortality is also generally increased (with the increase not just attributable to 
suicide). 
Patients with Bipolar II disorder seem to have a better prognosis (but retain the 
same suicide risk). 
Cyclothymia generally runs a chronic course, with 30% of patients going on to 
develop a full-blown bipolar disorder. 
The introduction of newer treatments has not had any measurable impact on 
prognosis.  
In conclusion, in spite of available effective treatment for bipolar disorders, the long-
term functional prognosis for these conditions remains disappointing, with high 
levels of mental health disability likely. 
 
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7. 
Main Disabling Effects 
Bipolar disorders are considered to be one of the 10 leading causes of disability 
world-wide, amongst adults aged 15-44 years.14 
In general, rates of relapse are high, and disabling mood symptoms are likely to 
persist between relapses.14 
These conditions can cause severe disruption to daily life, affecting all aspects. In 
severe cases, the ability to self-care in terms of being able to attend to personal 
hygiene and nutritional needs will be affected. 
Motivation, concentration and cognitive ability may be reduced, affecting the ability 
to complete even simple daily tasks effectively. 
Social interaction is frequently compromised, affecting relationships with others both 
in and outside the home. This feature is persistent and evident between, as well as 
during, relapses.15,16  Research has consistently shown that long term psychosocial 
functioning is poor in up to 60% of patients.14 
A study carried out in the UK, which looked at various aspects of social functioning, 
found that within the work environment, the following factors may be seriously 
affected:10 
 Timekeeping 
 Unauthorised 
absence 
  Relations with peers and supervisors 
  Quality or quantity of output. 
Despite surveys showing that most people with severe mental illness would prefer to 
be able to work, unemployment figures amongst this group remain high.  
In the USA, the figures range from 75-85%. In the UK the range is from 61-73%.17  
A survey carried out by the Manic Depression Fellowship found that whilst 69% of 
those responding wanted to work, and 40% were graduates, only 19% were in full 
time employment.14 
Recent research has indicated that supported employment, (placement in 
competitive employment whilst offering on-the-job support), is more effective than 
pre-vocational training, (a period of preparation before entering competitive 
employment), at helping those with severe mental illness to remain in the 
workplace.17 
In the USA, supported employment schemes are more widely available compared to 
the UK, where prevocational training is more likely to be offered. 
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7.1 
Assessing the Claimant  
The history obtained from the claimant should be comprehensive, with careful 
attention paid to looking for consistency between the history, and all other evidence 
available. 
Lack of insight and poor compliance are common features of these conditions, and 
although these may be obvious in some cases, may not be so apparent in others. 
Evidence for these features should therefore be actively sought. The mental state 
examination should cover these and all other relevant aspects. If mood is 
abnormally depressed or elevated, then this may well influence history features 
offered by the claimant. 
If the claimant is seen with a companion, and wishes him or her to be present during 
the assessment, it may be possible to obtain useful ‘third party’ history about both 
past and present features. This may provide vital supporting evidence about their 
disability. 
Variability is a strong feature of these conditions, and may prove difficult to address. 
Attempts to ascertain how the claimant is most of the time should be made.  
7.2 
IB-PCA Considerations 
Severe mental illness is one of the exempt categories for PCA. The definition is 
worded as follows: 
‘involving the presence of mental disease, which severely and adversely affects a 
person’s mood or behaviour, and which severely restricts his social functioning, or 
his awareness of his immediate environment’ 
Social functioning is frequently affected in those with bipolar disorders. Those with 
established conditions are likely to be taking prescribed mood modifying drugs long-
term.  
As such, many claimants who have a bipolar disorder will not present for 
assessment at an examination centre, having been exempted at an earlier stage in 
the referral process. 
The small numbers presenting for examination will require careful assessment of 
their condition. Prior study of the relevant documents should focus on the following 
features: 
  Duration and severity of the condition 
  Pattern of relapse and recurrence of symptoms 
  Any previous history of suicidal ideation or behaviour 
  Information about compliance and insight 
 Co-morbid 
conditions. 
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As with any mental health condition, a point may be reached at any stage in the 
assessment, where the examining doctor feels that giving exemption advice would 
be appropriate. Frequent and marked mood swings are likely to indicate a more 
disabling condition, and if severe, then exemption should be advised, with the usual 
procedures being followed. 
Where a full mental health test is completed, all four areas of activity are likely to be 
affected, to a greater or lesser degree. Descriptor choice should, as usual, draw on 
all available sources, including the typical day history and informal observations of 
the claimant. 
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Appendix A - Diagnostic codes and criteria 
ICD10 
Using ICD10 criteria, hypomania is diagnosed if the symptoms of abnormal mood 
and behaviour are greater than for cyclothymia, last at least several days, and are 
considerable rather than severe (in terms of how they interfere with work or social 
activity). 
For mania to be diagnosed, symptoms must be present for at least a week, and 
must be severe enough to disrupt work or social activities more or less completely. 
Mania is further classified depending on the presence or absence of psychotic 
symptoms. 
The ICD codes for the conditions discussed in this protocol are as follows: 
F30 Manic episode 
F30.0 Hypomania 
F30.1 
Mania without psychotic symptoms 
F30.2 
Mania with psychotic symptoms 
F30.8 
Other manic episodes 
F30.9 
Manic episode, unspecified 
F31 Bipolar affective disorder 
F31.0 
Bipolar affective disorder, current episode hypomanic 
F31.1 
Bipolar affective disorder, current episode manic without psychotic 
symptoms 
F31.2  Bipolar affective disorder, current episode manic with psychotic 
symptoms 
F31.3  Bipolar affective disorder, current episode mild or moderate 
depression 
 
.30 Without somatic syndrome 
 
.31 With somatic syndrome 
F31.4  
Bipolar affective disorder, current episode severe depression without 
psychotic symptoms 
F31.5 
Bipolar affective disorder, current episode severe depression with 
psychotic symptoms 
F31.6 
Bipolar affective disorder, current episode mixed 
F31.7 
Bipolar affective disorder, currently in remission 
F31.8 
Other bipolar affective disorders 
F31.9 
Bipolar affective disorder, unspecified 
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F34 Persistent mood [affective] disorders 
F34.0 Cyclothymia 
F34.1 Dysthymia 
DSM IV – TR 
For hypomania to be diagnosed using DSM IV, there has to have been elevated 
mood for at least 4 days. In addition, at least 3 additional symptoms from the 
following list must be present: 
  Inflated self esteem or grandiosity (non-delusional) 
  Decreased need for sleep 
 Pressure 
of 
speech 
  Flight of ideas 
 Distractibility 
  Increased involvement in goal-directed activities or psychomotor agitation 
  Excessive involvement in pleasurable activities that have a high potential for 
painful consequences. 
There should be no evidence of delusions or hallucinations. 
Hypomania can be diagnosed if the mood is irritable rather than elevated, but in this 
instance, 4 of the above additional symptoms are required. 
For mania to be diagnosed, the abnormal mood must last at least a week (less if the 
person is hospitalised). Again, there must also be 3 or 4 of the above symptoms 
depending on whether the mood is elevated or just irritable. There must also be 
marked impairment of social or occupational functioning, hospitalisation or the 
presence of psychotic features. 
In DSM IV, the diagnostic criteria are grouped as follows: 
Bipolar I disorder  
Single manic episode 
Most recent episode hypomanic 
Most recent episode manic 
Most recent episode mixed 
Most recent episode depressed 
Most recent episode unspecified 
Bipolar II disorder 
Specify current or most recent episode hypomanic/ depressed 
Cyclothymic disorder 
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Bipolar disorder not otherwise specified 
Numerical codes are allocated which specify one of the above conditions. Severity, 
presence and absence of clinical features, and pattern of relapse and recovery are 
also indicated by the code used. 
 
 
 
 
 
 
 
 
 
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8. 
References and bibliography 
1.  Ferrier IN, Macmillan IC et al. The search for the wandering thymostat: a review 
of some developments in bipolar disorder research. British Journal of Psychiatry 
2001;178:s103-s106. 
2.  Bandeira CA, Lima MS et al. Carbamazepine for bipolar affective disorders. 
(Protocol for a Cochrane Review). The Cochrane Library, Issue 1, 2002. Oxford: 
Update Software. 
3.  Fish’s Clinical Psychopathology. Signs and symptoms in Psychiatry. ed. by Max 
Hamilton.Bristol: John Wright 1974. 
4.  Kessler RC. The epidemiology of DSM-III-R Bipolar I disorder in a general 
population survey. Psychological Medicine 1997;  27:107989. 
5.  Cookson J. Use of antipsychotic drugs and lithium in mania. British Journal of 
Psychiatry 2001 ;178:s148-s156. 
6.  Burgess S, Geddes J et al. Lithium for maintenance treatment of mood 
disorders (Cochrane Review). The Cochrane Library, Issue 1, 2002. Oxford: 
Update Software. 
7.  Scott J. Cognitive therapy as an adjunct to medication in bipolar disorder. British 
Journal of Psychiatry 2001;178:s164-s168. 
8.  Macritchie KAN, Geddes J et al. Valproic acid, valproate and divalproex in the 
maintenance treatment of bipolar disorder (Cochrane Review).In: The Cochrane 
Library, 
Issue 1, 2002.Oxford: Update Software. 
9.  Gijsman HJ, Rendell J et al. Antidepressants for bipolar depression (Protocol for 
a Cochrane Review). In: The Cochrane Library, Issue 1, 2002. Oxford: Update 
Software.  
10.  Perry A, Tarrier N et al. Randomised controlled trial of teaching patients with 
bipolar disorder to identify early symptoms of relapse and obtain treatment. 
British Medical Journal 
1999;318:149-153. 
11.  Cates C. Teaching patients with bipolar disorder to identify early symptoms of 
relapse; Letter and author’s reply. British Medical Journal 1999;318:1557. 
12. Jamison KR. An Unquiet Mind. Picador 1995. 
13. Young AH, Macritchie KAN. Treatment of bipolar affective disorder. British 
Medical Journal 2000;321:1302-1303. 
14.  Morriss R, Marshall M et al. Bipolar affective disorder – left out in the cold. 
British Medical Journal 2002;324:61-62. 
15.  Cooke RG, Robb JC et al. Well-being and functioning in patients with bipolar 
disorder assessed using the MOS 20-ITEM short form (SF-20). Journal of 
Affective Disorders 
1996;39:93-97.  
16.  Macqueen GM, Young LT et al. A review of psychosocial outcome in patients 
with bipolar disorder. Acta Psychiatr Scand 2001;103:163-170. 
17.  Crowther RE, Marshall M et al. Helping people with severe mental illness to 
obtain work: systematic review. British Medical Journal 2001;322:204-208. 
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18.  Diagnostic and Statistical Manual of Mental Disorders (DSM–IV–TR). American 
Psychiatric Association.  
19. Gelder M, Mayou R et al. Shorter Oxford Textbook of Psychiatry. Oxford 
University Press, 2001. 
20. Puri BK, Laking PJ et al. Textbook of Psychiatry. Edinburgh: Churchill 
Livingstone, 2001. 
21.  Smith C, Sell L et al. Key Topics in Psychiatry. Bios Scientific Publishers Ltd, 
1996. 
22. Cohen RM. The Presentations of Clinical Psychiatry. Mark Allen Publishing 
Group, 2000. 
23. Katona C Robertson M. Psychiatry at a Glance. Oxford: Blackwell Science, 
2000. 
 
 
 
 
 
 
 
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