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BIPOLAR DISORDERS 
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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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9. References and bibliography 
                                                 
1 World Health Organisation. The International Statistical Classification of Diseases and Related 
Health Problems, Tenth Revision. (ICD–10). Section V. Mental and behavioral disorders. Geneva: 
World Health Organisation; 1992. 
2 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Text 
Revision (DSM-IV-TR). 4th ed. Washington DC: American Psychiatric Association; 2000. 
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. 
Schizophr Bull 2009;35(6):1045-56. 
6 Miklowitz DJ, Chang KD. Prevention of bipolar disorder in at-risk children: theoretical assumptions 
and empirical foundations. Dev Psychopathol 2008;20(3):881-97. 
7 Levin FR, Hennessy G. Bipolar disorder and substance abuse. Biol Psychiatry 2004;56(10):738-48. 
8 Francis-Raniere EL, Alloy LB et al. Depressive personality styles and bipolar spectrum disorders: 
prospective tests of the event congruency hypothesis. Bipolar Disord 2006;8(4):382-99. 
9 Fajutrao L, Locklear J et al. A systematic review of the evidence of the burden of bipolar disorder in 
Europe. Clin Pract Epidemol Ment Health 2009;5:3. 
10 Sanches M, Jorge MR.Transcultural aspects of bipolar disorder. Rev Bras Psiquiatr 2004;26 Suppl 
3:54-6. 
11 Ferrier IN, MacMillan IC et al. The search for the wandering thymostat: a review of some 
developments in bipolar disorder research. Br J Psychiatry Suppl 2001;41:s103-6. 
12 Krishnan KR. Psychiatric and medical comorbidities of bipolar disorder. Psychosom Med 
2005;67(1):1-8. 
13 Brousse G, Garay RP et al. Management of comorbid bipolar disorder and alcohol dependence. 
Presse Med 2008;37(7-8):1132-7. 
14 Cookson J. Use of antipsychotic drugs and lithium in mania. Br J Psychiatry Suppl 2001;41:s148-56. 
15 Harel EV, Levkovitz Y. Effectiveness and safety of adjunctive antidepressants in the treatment of 
bipolar depression: a review. Isr J Psychiatry Relat Sci 2008;45(2):121-8. 
16 Hausmann A, Hörtnagl C et al. Are there substantial reasons for contraindicating antidepressants in 
bipolar disorder? Part II: facts or artefacts? Neuropsychiatr 2007;21(2):131-58. 
17 Malhi GS, Adams D et al. Is lithium in a class of its own? A brief profile of its clinical use. Aust N Z J 
Psychiatry 2009;43(12):1096-104. 
18 Grof P, Müller-Oerlinghausen B. A critical appraisal of lithium's efficacy and effectiveness: the last 
60 years. Bipolar Disord 2009;11 Suppl 2:10-9. 
19 Cipriani A, Pretty H et al. Lithium in the prevention of suicidal behavior and all-cause mortality in 
patients with mood disorders: a systematic review of randomized trials. Am J Psychiatry 
2005;162(10):1805-19. 
20 Miklowitz DJ, Scott J. Psychosocial treatments for bipolar disorder: cost-effectiveness, mediating 
mechanisms, and future directions. Bipolar Disord 2009;11 Suppl 2:110-22. 
21 Jamison KR. An Unquiet Mind. Picador 1995. 
22 Young AH, Macritchie KA et al. Treatment of bipolar affective disorder. BMJ 2000;321(7272):1302-3. 
23 Pompili M, Rihmer Z et al. Assessment and treatment of suicide risk in bipolar disorders. Expert Rev 
Neurother 2009;9(1):109-36. 
24 Roshanaei-Moghaddam B et al. Premature mortality from general medical illnesses among persons 
with bipolar disorder: a review. Psychiatr Serv 2009;60(2):147-56. 
25 Morriss R, Marshall M et al. Bipolar affective disorder-left out in the cold. Too late for the national 
service framework but local initiatives may be possible. BMJ 2002;324(7329):61-2. 
26 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). J Affect Disord 1996;39(2):93-7. 
27 MacQueen GM, Young LT et al. A review of psychosocial outcome in patients with bipolar disorder. 
Acta Psychiatr Scand 2001;103(3):163-70. 
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28 Perry A, Tarrier N et al. Randomised controlled trial of efficacy of teaching patients with bipolar 
disorder to identify early symptoms of relapse and obtain treatment. BMJ 1999;318(7177):149-53. 
29 Bowden CL. Bipolar disorder and work loss. Am J Manag Care 2005;11(3 Suppl):S91-4. 
30 Crowther RE, Marshall M et al. Helping people with severe mental illness to obtain work: systematic 
review. BMJ 2001;322(7280):204-8. 
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