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BIPOLAR DISORDERS
Version 2 Final
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Document control
Version history
Version Date
Comments
2 Final
6 Sept 2011
Signed off by CMMS
2c draft
12 Sept 2011
Comments for HWWD incorporated
2b draft
03 April 2011
External QA by Specialist Registrar
2a draft
Int. Q.A.
Changes since last version
Section 2.2 - Non-Genetic Factors
Section
4.0
Diagnosis
Section 5 Treatment
Section 7.2 ESA Considerations
Appendix A – ICD-10
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1. Description
1.1. Classifications and synonyms
Bipolar disorders are recurrent affective disorders characterised by episodes of
mania or hypomania. They are usually separated by periods of depression but the
term is now used even in cases where a depressive episode has not occurred, on
the grounds that most patients with recurrent mania will also experience episodes of
depression in time.
Various patterns have been recorded, and subgroups recognised.
The term bipolar disorder is now preferred to previously used labels such as manic
depressive psychosis or manic depressive illness.
The two internationally recognised classifications of mental illness are ICD-101 and
DSM-IV.2 These descriptive classifications are broadly similar.
In the UK and Europe, ICD-10 is widely used, though there is a degree of overlap
with DSM-IV, 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 ICD-10 criteria for bipolar affective disorder
DSM-IV subdivides bipolar disorders into the following subgroups:
Bipolar I – where an episode of mania has occurred at least once
Bipolar II – where there has been hypomania, but mania has not occurred
The different diagnostic codes and criteria for ICD-10 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 on aetiology have been explored, and it seems likely that
genetic and environmental factors combine to induce the psychological and
biological features that underlie bipolar disorders.
2.1.
Genetic
factors
Of all psychiatric conditions it seems that bipolar disorders are amongst the most
genetically determined.3
Many family studies have shown that the risk of a first-degree relative of a patient
with a bipolar disorder developing the condition is approximately 9%. This is
substantially greater than the risk in the general population. Non-genetic factors
could contribute to these risks, but the importance of genetics is strongly supported
by evidence from twin studies indicating that monozygotic twins exhibit a
concordance rate of approximately 40% while the rate for dizygotic twins is much
less at approximately 5%.4
Whether bipolar l and bipolar II are genetically separate entities is not clear.4
Although genetic factors are recognised as being of importance, the mechanisms
are still unclear. The search for specific genes associated with bipolar disorders is
progressing,3 but since concordance in monozygotic twins is not 100%, it is clear
that non-genetic factors must contribute, and the possibility that they may do so
through their effects on gene expression is gaining favour.5
2.2. Non-genetic factors
Early environment
Childhood experience of relationship difficulties, abuse, and neglect appears to be
associated with increased risk of bipolar disorder later in life, especially in the
genetically vulnerable.6
Ongoing environment and life events
A wide range of circumstances may trigger bipolar episodes in predisposed
individuals. There may be ongoing vulnerability factors such as lack of a confiding
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relationship, poor social support, not working outside the home, or having the care of
young children. There may also be stressful factors such as problems with housing,
in marriage, or at work. Adverse life events such as bereavement may contribute.
However in all of the above examples, triggering of depression rather than mania is
more likely. Manic symptoms may be triggered by a disruption in a person’s sleep
pattern e.g. following a long haul flight or by doing shift work. They may even arise
when an important goal has been achieved; illness triggered by positive rather than
negative circumstances.
Altered physiology and physical disease
Childbirth is one of the most wellknown triggers of mania with between 25-50% of
women with bipolar becoming unwell in the immediate postpartum period. Other
alterations in physiological states such as endocrine disorders (e.g. Cushing’s
disease, Addison’s disease, hypothyroidism, and hyperparathyroidism), some
infections, prescribed medication (e.g. steroids) and some diseases of the brain may
also precipitate affective illnesses, including bipolar disorders, the condition then
being referred to as an organic mood disorder.
Substance abuse
Abuse of substances, including alcohol, occurs more often in individuals with a
bipolar disorder than in the general population. However, it is not clear whether such
abuse may contribute to the development of the disorder or whether proneness to
bipolar disorders may underlie a tendency to substance abuse.7
Psychological factors
Genetics, early environment, and the growing experiences of life mould an
individual’s personality, cognitive style, and range of strategies for coping with
problems of both short and long duration. Certain variants of these attributes can be
associated with development of bipolar symptoms. For example, individuals who
focus excessively on their performance, set themselves high standards, are self
critical, and who tend to dwell on negative thoughts appear to be vulnerable to
development of bipolar symptoms when confronted by events that they perceive to
be adverse, or when experiencing ongoing mental stress.8
Neurobiological factors
Brain imaging techniques have shown that bipolar disorders are associated with
structural alterations and dysfunction in areas of the brain. It remains uncertain
whether such changes are genetically determined or develop in response to adverse
factors arising as life progresses, or both.
It has been known for some time that dopamine agonists such as bromocriptine can
produce manic states, but it is not clear whether this is due to localised increase in
levels of dopamine or to increased sensitivity to its actions. Certainly there is now
evidence that some of the medications used to treat mania act on the dopaminergic
system.
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3. Prevalence
Bipolar disorders can occur at any age from early adolescence to old age, and
unlike depressive disorders, there are no evident gender differences. Childhood
cases have been reported very occasionally.
On average, the condition is first diagnosed during the late teens to early to mid
twenties. This is an earlier age of onset than for major depression.
In European countries both the point prevalence and lifetime prevalence are
approximately 1%; an indication of the chronic nature of the disorder.9
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.
Mania has been described within a wide range of cultures, with little cross-cultural
variation.10
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4. Diagnosis
4.1. Clinical features
The mood changes 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 is 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 emotional state.
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:
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Rapid or copious speech, often termed ‘pressure of speech’, (‘punning’ [word
play] or ‘clanging’ [selecting words because of sound or rhyming rather than
meaning] may feature)
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 (mania only)
Extravagant or grandiose delusions (mania only)
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’.
Flight of ideas can be so marked that speech becomes incoherent. In hypomania the
overall train of thought is better retained.
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. At this
point the patient is described as experiencing “mania with psychotic symptoms”. It is
estimated that 60% of bipolar patients will have psychotic symptoms at some time
during their illness.
In such cases, hallucinations are common. Auditory hallucinations may be in the
form of voices indicating that the patient has special powers. Visual hallucinations
frequently have a religious content. 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, referred to as being in a “mixed affective state”, a
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rapid sequence of changes in symptoms may be seen.
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, the patient
remains mute, unresponsive and akinetic [motor and psychic hypoactivity]
throughout. On recovery he or she 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 can be associated with
concomitant hypothyroidism. Unfortunately, lithium treatment is relatively ineffective
in these cases.
4.4. Bipolar III disorder
This controversial subtype with varying definitions has been described by clinicians,
but is not included in ICD-10 or DSM-IV.11 It is also referred to as bipolar spectrum
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’.11
4.6.
Cyclothymia
Although not included in the ICD-10 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 ICD-10.
The disorder is characterised by persistent instability of mood, featuring episodes of
both mild elation and depression. Episodes are neither severe enough nor of
sufficient length for diagnostic criteria of other conditions 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 a bipolar disorder themselves.
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4.7.
Dysthymia
It is also convenient at this juncture to make brief mention of dysthymia, another
persistent mood (affective) disorder. Essentially, the relevant clinical feature here is
a low mood which although persistent and long standing, is never (or almost never)
severe enough to fulfil the ICD-10 criteria for a recurrent depressive disorder (mild or
moderate severity). The duration will be of years, and can last indefinitely.
Other 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 a suspected bipolar disorder requires careful history
taking and physical examination to exclude other possible conditions (see
4.
9).
Information obtained from a relative or carer can prove vital, as the patients may be
unable to recognise the extent of their own 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 features suggestive of hypomania or
mania, and must be excluded by clinical assessment and appropriate tests.
Organic
disorders:
Delirium/ acute confusional state
Frontal lobe disease (dementia, tumour or HIV infection)
Other neurological cause (epilepsy, post CVA, MS)
endocrine disorder (hyperthyroidism, Cushing’s syndrome)
secondary to prescribed medication (corticosteroids, L-dopa, anti-
depressants)
Psychoactive substance use disorder (alcohol, amphetamines, cocaine)
Schizophrenia / schizoaffective disorders
Acute and transient psychotic disorder
Agitated
depression
Obsessive compulsive disorder (elation is not usually a feature here)
Personality disorder (emotionally unstable or dissocial)
Attention deficit hyperactivity disorder (elation is not usually a feature here)
4.10. Comorbidity with other mental health conditions
This is common and likely to increase disability significantly. Relevant conditions
include abuse of alcohol and other substances, anxiety disorders, social phobias,
and post-traumatic stress disorder.12
Alcohol abuse is 3 to 4 times more likely to occur during the lifetime of patients with
a bipolar disorder than in the general population, and mood disorders are
approximately 10 times more likely during the lifetime of those with an alcohol
dependence problem.13
Comorbid 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
People with bipolar disorders are commonly encountered in the primary care setting,
although most are likely to be in contact with specialist mental health services and
care is usually provided by both.
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.
Drug treatment forms the backbone of therapy in the acute phase. If the patient is
already on an antidepressant this should be stopped. If not on any anti-manic
medication the first drug of choice would be an antipsychotic. Antipsychotics act not
just to treat psychotic symptoms but variably have sedative, anxiolytic, anti-manic
and anti-depressant properties, therefore treating multiple aspects of a bipolar
illness.
Atypical antipsychotics (olanzapine, risperidone, quetiapine and aripiprazole) are
preferable to typical antipsychotics (haloperidol and chlorpromazine) due to their
better side effect profile and the fact that manic patients may be particularly
susceptible to extrapyramidal side effects.
The
mood stabilising drugs lithium or valproate may also be used first line,
particularly if the person has shown a previous good response to these drugs and if
the illness is a little less acute. Combining one of the mood stabilisers with an
atypical antipsychotic gives better results than a mood stabiliser alone, especially if
there had been only partial response to one drug.
If use of one drug alone proves ineffective, a combination of a mood stabiliser and
an antipsychotic or 2 mood stabilisers may be tried.
In the short term,
benzodiazepines may be added to restore normal sleep pattern
and to reduce agitation. Their use also allows lower doses of other antipsychotic
drugs to be prescribed.14
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 option.
5.2. Management of bipolar depression
A person with a bipolar illness will spend approximately 50% of the time with clinical
symptoms, and of these the vast majority will be depressive symptoms. It is
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therefore very important to recognise and treat a bipolar depression. Although
clinically a bipolar depressive episode presents in largely the same way as a
unipolar depression, the treatment is not the same. Unfortunately there is not a good
body of evidence for the treatment of bipolar depression.
Antidepressants should not be used alone due to the risk of triggering a switch to a
manic state15. Better first line options are mood stabilisers (lamotrigine may be better
than valproate and lithium) or antipsychotics (the best evidence base currently being
for quetiapine). In patients who do not respond, an antidepressant (SSRI class is
considered least likely to provoke a manic episode16) in combination with an anti-
manic drug may be used. ECT should also be considered if symptoms are severe.
5.3. Longer term management
The aim here is to prevent relapse or recurrence. Long term treatment should be
offered after one severe episode of mania or after 2 less severe episodes of illness
and should be offered for at least 2 years. Even then, given the risk of relapse
remains constant , there should be good reason for stopping treatment.
The drugs available for long term use tend to be better at preventing relapse of
either mania or depression. The choice of drug should therefore depend on whether
the patient tends to experience more manic or more depressive episodes. Lithium,
olanzapine, risperidone, aripiprazole and valproate seem better at preventing mania
while lamotrigine protects against depression. Quetiapine may be good at
preventing both.
Lithium is an effective prophylactic agent and remains one of the drugs of choice for
long term management of bipolar disorders.17,18
Experience with it has resulted in its
use as first line therapy but certain factors may favour one of the alternatives.
It is
effective in preventing recurrences of mania but less effective for depression,
although it may significantly reduce suicide rates.19
If any of the following features are present then an alternative may be preferred:
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
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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. The target blood level is 0.4-1.0 mmol/l 12 hours after the evening dose.
Potential side effects from lithium include:
Gastrointestinal
disturbances
Fine
tremor
Polyuria and polydipsia
Weight
gain
Oedema
Subjective memory disturbances
Signs of lithium intoxication include CNS disturbances, such as ataxia, coarse
tremor and drowsiness.
Lithium can interact with a wide range of other prescribed drugs. Diuretics, in
particular thiazides, should be avoided if possible.
All the alternatives have their own reported side effects and the benefit – side effect
balance has to be tailored to the individual. MIMS or the BNF should be consulted
for guidance on potential side effects.
5.4. Cognitive behavioural therapy
Cognitive therapy can have a useful supporting role in the treatment of bipolar
patients.20 It may help the individual to understand the illness, the need for
treatment, and how to resist negative thoughts or maladaptive beliefs. It may also
help patients to identify early signs of manic relapse.
5.5.
Compliance
Compliance 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.21 She describes the personal dilemmas inherent in coming
to terms with both the diagnosis and the management of the condition. It can
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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.22
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6. Prognosis
The average manic episode, treated or untreated, lasts 6 months.
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 5-year period 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.
It is estimated that 10% of patients diagnosed with a depressive disorder will go on
to have a manic illness.
There is a substantially higher suicide rate amongst bipolar patients than in the
general population,23
and the percentage of bipolar patients who attempt suicide at
some point in their illness is estimated to be in the region of 50%.
In addition to suicide risk, there is an increased premature mortality rate due to
medical conditions, and unhealthy lifestyle and adverse effects from drugs may be
contributory factors.24
Patients with Bipolar II disorder seem to have a better general prognosis (but retain
the same suicide risk).
Cyclothymia usually runs a chronic course, with 30% of patients going on to develop
a full-blown bipolar disorder.
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 amongst the 10 leading causes of disability
world-wide, in adults aged 15-44 years.25
In general, rates of relapse are high, and disabling mood symptoms are likely to
persist between relapses.27
These conditions can cause severe disruption to daily life, affecting all aspects.
In severe cases, the ability 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
inside and outside the home. This feature is persistent, and evident both between
and during relapses.26,27 Research has consistently shown that long term
psychosocial functioning is poor in up to 60% of patients.27
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:28
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.29
In the USA, the unemployment figures range from 75-85%. In the UK the range is
from 61-73%.30
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.27
In order to help those with severe mental illness to remain in the workplace it is
thought 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).32
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. ESA Considerations
As noted because of the lack of insight appropriate consideration must be given to
the evidence of accompanying friends, relatives or carers. Elements or
inconsistencies in the typical day may reflect this.
Mental state examination may give an indication of memory and concentration
problems, while elation affect and speech may indicate that mania should be clearly
considered and addressed.
Aggression may be observed and considered appropriately in line with accepted
diagnoses. Aggression may have to be addressed within appropriateness of
behaviour.
Where mania is a component the recognised effects of lack of attention to personal
hygiene and ability to maintain nutrition may indicate consideration be given to
personal action descriptors.
As noted concurrent depression and other mental health problems are frequently
present and the co-morbid effects may form part of the justification of other
appropriate advised descriptors.
Hallucinations and extremes of elation of mood may suggest that consideration be
given to the non-functional descriptor of “substantial risk to any person”.
In most instances episodes last for 6 months or more and prognostic advice should
reflect this.
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Appendix A - Diagnostic codes and criteria
ICD-10
Using ICD-10 criteria, hypomania is diagnosed if mood is elevated or irritable to an
abnormal degree for that individual and is sustained for at least 4 consecutive days.
Three of the following must be present, leading to some interference with personal
functioning:
Increased activity or physical restlessness
Increased
talkativeness
Difficulty in concentration or distractability
Decreased need for sleep
Increased sexual energy
Mild overspending, or other types of reckless or irresponsible behaviour
Increased sociability or overfamiliarity
For mania to be diagnosed, mood must be abnormally elevated or irritable and be
prominent and present for at least a week. Symptoms must be severe enough to
disrupt work or social activities more or less completely. At least three of the
following must be present:
Increased activity or physical restlessness
Increased
talkativeness
Flight of ideas
Loss of normal social inhibitions, resulting in behaviour that is inappropriate to
circumstances
Decreased need for sleep
Inflated self-esteem or grandiosity
Distractibility or constant changes in activity or plans
Behaviour that is foolhardy or reckless and whose risks the individual does not
recognise, e.g. spending sprees
Marked sexual energy or sexual indiscretions
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Mania is further classified depending on the presence or absence of psychotic
symptoms.
The ICD-10 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
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:
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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
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. Additional sources
1 Gelder M, Harrison P et al.
Shorter Oxford Textbook of Psychiatry. Oxford:
Oxford
University Press; 2006
.
2 Jones SH, Bentall RP.
The Psychology of Bipolar Disorder. Oxford: Oxford University Press;
2006
.
3 Puri BK, Laking PJ et al.
Textbook of Psychiatry. Edinburgh: Churchill Livingstone; 2002.
4 Katona C, Robertson M.
Psychiatry at a Glance. Oxford: Blackwell Science; 2005.
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3 O'Donovan MC, Craddock NJ et al. Genetics of psychosis; insights from views across the genome.
Hum Genet 2009;126(1):3-12.
4 Barnett JH, Smoller JW. The genetics of bipolar disorder. Neuroscience 2009;164:331-43.
5 Rutten BP, Mill J. Epigenetic mediation of environmental influences in major psychotic disorders.
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