Bipolar and Related Disorders

ABNORMAL PSYCHOLOGY C-PSYM311A 1ST SEMESTER – FINALS MODULE 9: BIPOLAR AND RELATED DISORDERS A BIPOLAR DISORDERS ●​ Bipolar disorders are a group of conditions characterized by episodes of hypomania and mania that may alternate with episodes of depression. ●​ Although depressive symptoms occur in bipolar disorders, bipolar and depressive disorders are distinct conditions. ●​ Bipolar disorders have a strong genetic basis, with evidence of shared biological features with schizophrenia, a severe disorder involving loss of contact with reality. ●​ Individuals with bipolar disorders also respond to medications that are generally less effective for depressive disorders. ●​ ●​ B ●​ ●​ ●​ ●​ In addition, bipolar disorders tend to have an earlier peak age of onset, typically during the teenage years or early twenties, compared with depressive disorders, which more often begin in the late twenties. Lastly, bipolar disorders are much less common than depressive disorders. DIAGNOSIS AND CLASSIFICATION OF BIPOLAR DISORDERS Bipolar disorders are diagnosed through careful assessment that confirms the presence of hypomanic or manic symptoms. Clinicians also evaluate the severity and pattern of depressive symptoms, as depression is often the most disabling aspect of bipolar disorders. While periods of normal mood are also considered, diagnostic distinctions among bipolar disorders are made primarily by examining the intensity of depressive and hypomanic or manic symptoms and the overall pattern of mood changes over time. The three types of bipolar disorders are bipolar I, bipolar II, and cyclothymic disorder. PAGE 1 CREATED BY JEMS C BIPOLAR 1 DISORDER C1 DIAGNOSTIC CRITERIA ●​ To be diagnosed with Bipolar I Disorder, a person must have experienced at least one manic episode at some point in their life. This manic episode may occur before or after hypomanic or major depressive episodes. ★​ Manic Episode A.​ A clear period of abnormally high, excited, or very irritable mood, along with unusually increased energy or activity, lasting at least 1 week and present most of the day, nearly every day. (If hospitalization is needed, the duration can be shorter.) B.​ During this period, three or more of the following symptoms must be present (four if the mood is only irritable), and they must show a clear change from the person’s usual behavior: 1.​ Very high self-confidence or feeling overly important or powerful (Grandiosity). 2.​ Needing much less sleep and still feeling rested. 3.​ Talking much more than usual or feeling pressured to keep talking. 4.​ Racing thoughts or ideas moving very quickly. 5.​ Being easily distracted by unimportant things. 6.​ Increased goal-focused activity (socially, at work, school, or sexually) or restless, purposeless movement. 7.​ Taking part in risky activities that can lead to serious negative consequences (such as reckless spending, unsafe sex, or poor business decisions). C.​ The mood change is serious enough to cause major problems at work or socially, require hospitalization to prevent harm, or include psychotic symptoms. ABNORMAL PSYCHOLOGY C-PSYM311A 1ST SEMESTER – FINALS D.​ The episode is not caused by drugs, medications, or another medical condition. F.​ ➔​ Note: Criteria A–D defines a manic episode. Having at least one manic episode in a lifetime is required for a diagnosis of Bipolar I Disorder. ➔​ Note: Criteria A–F define a hypomanic episode. Hypomanic episodes are common in Bipolar I Disorder but are not required for its diagnosis. ★​ Hypomanic Episode ★​ Major Depressive Episode A.​ A clear period of unusually elevated, excited, or irritable mood, with increased energy or activity, lasting at least 4 consecutive days and present most of the day, nearly every day. A.​ A person has five or more of the following symptoms during the same 2-week period, showing a clear change from how they usually function. At least one symptom must be either depressed mood or loss of interest/pleasure. B.​ During this period, three or more of the following symptoms must be present (four if the mood is only irritable). These symptoms represent a clear change from the person’s usual behavior and are noticeable: 1.​ Very high self-confidence or feeling overly important. 2.​ Needing much less sleep and still feeling rested. 3.​ Talking much more than usual or feeling pressured to keep talking. 1.​ The episode is not caused by substances, medications, or another medical condition. Feeling sad, empty, or hopeless most of the day, nearly every day (in children or teens, this may appear as irritability). 2.​ Losing interest or enjoyment in almost all activities most of the day, nearly every day. 3.​ Noticeable weight loss or gain, or major changes in appetite nearly every day (in children, failure to gain expected weight). 4.​ Trouble sleeping or sleeping too much nearly every day. 4.​ Racing thoughts or rapidly shifting ideas. 5.​ Being easily distracted by unimportant things. 5.​ Moving or speaking much slower or faster than usual, observable by others. 6.​ Increased goal-directed activity (social, work, school, or sexual) or restless movement. 6.​ Feeling tired or having very low energy nearly every day. 7.​ 7.​ Engaging in risky behaviors that can lead to negative consequences (such as reckless spending, unsafe sex, or poor business decisions). C.​ The episode involves a clear change in how the person functions that is different from how they usually are when not experiencing symptoms. D.​ The mood and behavior changes are noticeable to other people. E.​ The episode is not severe enough to cause major problems at work or socially and does not require hospitalization. ➔​ Note: If psychotic symptoms are present, the episode is considered manic, not hypomanic. PAGE 2 CREATED BY JEMS Strong feelings of worthlessness or excessive guilt that may be unrealistic. 8.​ Difficulty thinking, concentrating, or making decisions nearly every day. 9.​ Repeated thoughts about death or suicide, suicidal thoughts without a plan, a suicide attempt, or having a specific plan. B.​ These symptoms cause serious distress or interfere with work, social life, or other important areas of functioning. C.​ The episode is not caused by substances, medications, or another medical condition. ➔​ Note: Criteria A–C define a major depressive episode. Major depressive episodes are common ABNORMAL PSYCHOLOGY C-PSYM311A 1ST SEMESTER – FINALS in Bipolar I Disorder but are not required for its diagnosis. C2 ●​ ●​ Bipolar 1 disorder involves a pattern of recurring mood episodes that may include mania, depression, or hypomania, but a diagnosis requires that the person has experienced at least one manic episode. A manic episode is defined by a clearly noticeable period of abnormally elevated, expansive, or irritable mood along with increased energy or activity. ★​ Expansive: Extremely talkative and familiar with others. ●​ In children, being happy, silly, or playful can be normal, but if it happens too often, in the wrong situations, is much more than usual for that child, and comes with unusually high energy or activity, it may meet the mood criteria for a manic episode. ●​ For a child to be diagnosed with mania, these behaviors must also match the other symptoms of a manic episode and be clearly different from how the child normally behaves. ●​ During a manic episode, a person often starts multiple new projects at the same time, usually without much knowledge or preparation. ●​ They may feel capable of anything, taking on tasks that seem unrealistic or impossible. ●​ Their high energy may show at unusual times, such as staying active during normal sleeping hours. ●​ Inflated self-esteem is common, ranging from strong confidence to extreme grandiosity, and can even reach delusional levels. A person might attempt things like writing a book or seeking attention for an impractical invention. DIAGNOSTIC FEATURES ★​ Elevated: Abnormally cheerful or euphoric mood that is more intense than normal happiness and inappropriate for the situation. ●​ ●​ These changes are present for most of the day, nearly every day, for at least one week, or for a shorter time if hospitalization is required. ●​ During this period, the individual must also show several additional symptoms, such as changes in thinking, behavior, or activity level. ●​ Grandiose beliefs in children, like thinking they are the best at a sport or the smartest in class, are normal to an extent, but if these beliefs are clearly unrealistic, dangerous, and a change from their usual behavior, it may meet the grandiosity criterion. ●​ A hallmark symptom is a decreased need for sleep, which differs from insomnia. ●​ Individuals may sleep very little or wake unusually early but still feel energized, sometimes going days without sleep yet not feeling tired. ●​ If the mood is mainly irritable rather than elevated or expansive, a higher number of these additional symptoms must be present to meet the criteria. ●​ In a manic episode, a person’s mood is often extremely happy, excited, or “on top of the world.” ●​ This strong mood can be very obvious and contagious, sometimes leading the person to act impulsively or do things without thinking, like talking for a long time with strangers. ●​ ●​ Sometimes, irritability is more noticeable than happiness, especially if the person is frustrated or using substances. This reduced need for sleep often signals the start of a manic episode. ●​ Mood can also change quickly, swinging between feeling very happy, very irritable, or very upset. During a manic episode, a person’s speech can become very rapid, loud, and difficult to interrupt. ●​ They may talk constantly, often ignoring whether others want to speak, and may say things that are irrelevant, intrusive, or ●​ PAGE 3 CREATED BY JEMS ABNORMAL PSYCHOLOGY C-PSYM311A theatrical, using jokes, exaggerated gestures. 1ST SEMESTER – FINALS puns, singing, or experiencing onset slightly earlier (21.5 years) than men (23 years). ●​ In some cases, the volume and force of speech become more noticeable than the content itself. ●​ International studies show a similar pattern, with a median onset around 24 years. ●​ If the mood is more irritable than euphoric, speech may include complaints, hostile remarks, or angry outbursts, especially when someone tries to interrupt them. ●​ Diagnosing bipolar 1 disorder in children requires special care because children of the same age may be at very different developmental stages. ●​ At the same time, thoughts may race so quickly that the person struggles to keep up with their own ideas, resulting in a nearly nonstop flow of conversation that jumps abruptly from topic to topic. ●​ Clinicians need to compare behaviors to the child’s own baseline to determine whether they represent typical development or a manic episode. ●​ ●​ In severe cases, speech can become disorganized or incoherent, which can be very distressing. ●​ Distractibility is common, with attention easily pulled by irrelevant external stimuli like background noises, clothing, or objects, making it hard to focus on conversations or follow instructions. Although first onset can occur in older adults, such as in their 60s or 70s, the appearance of manic symptoms at a later age—like unusual sexual or social behavior—should prompt evaluation for medical conditions, including frontotemporal neurocognitive disorders, as well as the effects of substances or withdrawal. ●​ Manic symptoms caused directly by drugs, medications, or medical conditions do not count toward a bipolar I disorder diagnosis. ●​ However, if a full manic episode emerges during treatment and persists beyond the effects of the inducing agent, it is considered sufficient evidence for a manic episode due to bipolar I disorder. ●​ Clinicians exercise caution to avoid diagnosing mania based on one or two symptoms, like irritability or agitation after antidepressant use. ●​ Hypomanic or depressive episodes often precede or follow a manic episode but are not required for a bipolar I disorder diagnosis. C3 ●​ ●​ DEVELOPMENT AND COURSE Bipolar 1 disorder most often begins between the ages of 20 and 30, although it can start at any point in life. In the United States, the average age at onset is about 22 years, with women typically PAGE 4 CREATED BY JEMS D BIPOLAR 2 DISORDER D1 DIAGNOSTIC CRITERIA ●​ To be diagnosed with Bipolar 2 Disorder, a person must have both a hypomanic episode and a major depressive episode at some point in their life. ★​ Hypomanic Episode A.​ A clear period of unusually elevated, excited, or irritable mood, with increased energy or activity, lasting at least 4 consecutive days and present most of the day, nearly every day. B.​ During this period, three or more of the following symptoms must be present (four if the mood is only irritable) and represent a noticeable change from usual behavior: 1.​ Very high self-confidence or feeling overly important. 2.​ Needing much less sleep and still feeling rested. 3.​ Talking more than usual or feeling pressured to keep talking. ABNORMAL PSYCHOLOGY C-PSYM311A 1ST SEMESTER – FINALS 4.​ Racing thoughts or quickly jumping from one idea to another. 6.​ Feeling tired or having very low energy nearly every day. 7.​ 5.​ Being easily distracted by unimportant things. Strong feelings of worthlessness or excessive guilt that may be unrealistic. 6.​ Increased goal-directed activity (social, work, school, or sexual) or restless movement. 8.​ Difficulty thinking, concentrating, or making decisions nearly every day. 7.​ 9.​ Repeated thoughts about death or suicide, suicidal thoughts without a plan, a suicide attempt, or having a specific plan. Engaging in risky activities that could have serious negative consequences (reckless spending, unsafe sex, or poor business decisions). C.​ The episode shows a clear change in functioning that is different from the person’s usual behavior. B.​ These symptoms cause serious distress or interfere with work, social life, or other important areas of functioning. D.​ The mood and behavior changes are noticeable to others. C.​ The episode is not caused by substances, medications, or another medical condition. E.​ The episode is not severe enough to cause major problems at work or socially and does not require hospitalization. ➔​ Note: If psychotic symptoms are present, the episode is considered manic, not hypomanic. F.​ The episode is not caused by drugs, medications, or another medical condition. ★​ Major Depressive Episode A.​ A person has five or more of the following symptoms during the same 2-week period, showing a clear change from how they usually function. At least one symptom must be either depressed mood or loss of interest/pleasure. 1.​ Feeling sad, empty, or hopeless most of the day, nearly every day (in children or teens, this may appear as irritability). 2.​ Losing interest or enjoyment in almost all activities most of the day, nearly every day. Bipolar 2 Disorder A.​ The person must have experienced at least one hypomanic episode and at least one major depressive episode. B.​ The person has never had a full manic episode. C.​ The hypomanic and depressive episodes are not better explained by schizoaffective disorder and are not part of schizophrenia, schizophreniform disorder, delusional disorder, or other psychotic disorders. D.​ The depressive symptoms or the effects of frequently alternating between depression and hypomania cause significant distress or problems in work, social life, or other important areas. D2 ●​ Bipolar 2 disorder involves recurring mood episodes that include at least one major depressive episode and at least one hypomanic episode. ●​ A major depressive episode in this context requires a period of depressed mood or, alternatively, a marked loss of interest or pleasure for most of the day, nearly every day, lasting at least 2 weeks. 3.​ Noticeable weight loss or gain, or major changes in appetite nearly every day (in children, failure to gain expected weight). 4.​ Trouble sleeping or sleeping too much nearly every day. 5.​ Moving or speaking much slower or faster than usual, observable by others. PAGE 5 CREATED BY JEMS DIAGNOSTIC FEATURES ABNORMAL PSYCHOLOGY C-PSYM311A ●​ ●​ ●​ ●​ 1ST SEMESTER – FINALS This depressed mood or reduced interest must be accompanied by additional symptoms—such as changes in sleep, psychomotor agitation or slowing, fatigue, feelings of worthlessness, difficulty concentrating, or thoughts of death—so that a total of at least five symptoms are present nearly every day. A hypomanic episode happens when a person has a clearly noticeable period of unusually high, expansive, or irritable mood along with extra energy or activity, lasting most of the day, nearly every day, for at least 4 straight days. During this period, the person must also show at least three other symptoms (or four if the mood is only irritable), such as feeling overly confident, needing less sleep, or being easily distracted, and these changes must be clearly different from their usual behavior. Hypomanic episodes do not include psychotic symptoms, and the major depressive episodes in bipolar II disorder usually have fewer psychotic features than those in bipolar I disorder. ●​ If the person ever has a full manic episode, bipolar II disorder cannot be diagnosed. ●​ For a diagnosis, at least one depressive episode and one hypomanic episode must not be caused by drugs, medication, or another medical condition. ●​ ●​ ●​ ●​ Hypomanic episodes that appear during antidepressant treatment can count toward the diagnosis if they last at least 4 days at full intensity after the treatment’s effects have worn off. People with bipolar II disorder usually seek help during a major depressive episode and may not recognize or report hypomanic episodes, sometimes even finding them enjoyable. Hypomanic episodes do not cause major impairment, but depressive episodes or ongoing unpredictable mood swings often do, leading to problems in relationships, work, or daily functioning. Input from friends or family is often important to confirm the diagnosis. PAGE 6 CREATED BY JEMS ●​ It is important not to confuse hypomania with the normal increase in energy and mood that can follow recovery from depression. ●​ Bipolar II disorder is not simply a milder version of bipolar I disorder; in fact, individuals with bipolar II often experience more chronic illness and spend more time in depressive states, which can be severe and disabling. D3 DEVELOPMENT AND COURSE ●​ Bipolar 2 disorder usually begins in late adolescence or adulthood, with the average age of onset in the mid-20s, which is slightly later than bipolar I disorder but earlier than major depressive disorder. ●​ Age at onset alone does not reliably distinguish bipolar I from bipolar II. ●​ The disorder often starts with a depressive episode and may not be recognized as bipolar II until a hypomanic episode occurs; this happens in about 12% of individuals initially diagnosed with major depressive disorder. ●​ Anxiety, substance use, or eating disorders may appear first, making diagnosis more challenging. ●​ Many people experience several major depressive episodes before their first hypomanic episode, often with a delay of over 10 years between illness onset and correct diagnosis. ●​ Bipolar II disorder is highly recurrent, with more than half of individuals experiencing a new episode within a year of their first. ●​ Mood changes tend to show more seasonal variation than in bipolar I disorder. ●​ The total number of lifetime episodes, including both hypomanic and major depressive episodes, is generally higher in bipolar II disorder than in bipolar I or major depressive disorder. ●​ Interestingly, individuals with bipolar I disorder are more likely to experience hypomanic symptoms than those with bipolar II disorder. ●​ Over time, the intervals between episodes in bipolar II disorder tend to shorten. ABNORMAL PSYCHOLOGY C-PSYM311A 1ST SEMESTER – FINALS ●​ Although the hypomanic episode is what defines bipolar II disorder, the depressive episodes are typically longer lasting and more disabling. ●​ Despite the prominence of depression, once a hypomanic episode occurs, the diagnosis becomes bipolar II disorder and does not revert to major depressive disorder. E E1 C.​ The person has never had a full manic, hypomanic, or major depressive episode. D.​ The symptoms are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other psychotic disorders. E.​ The symptoms are not caused by drugs, medications, or another medical condition (e.g., hyperthyroidism). ●​ ●​ During the first 2 years (or 1 year for children and adolescents), these symptoms must be present more days than not, and any breaks without symptoms should last no longer than 2 months. ●​ The diagnosis is only made if the person has never met the criteria for a full major depressive, manic, or hypomanic episode. ●​ If, after this initial period, the individual experiences a full episode of depression or mania, the diagnosis changes to major depressive disorder, bipolar I disorder, or another specified bipolar-related disorder, and the cyclothymic disorder diagnosis is no longer applied. ●​ The diagnosis of cyclothymic disorder is not made if the mood swings are better explained by a psychotic disorder. ●​ The mood disturbance also cannot be caused by the effects of substances, like drugs or medications, or by a medical condition, such as hyperthyroidism. ●​ While some individuals may appear to function well during periods of hypomania, over time the disorder must cause clinically significant distress or difficulties in social, work, or other important areas of life. ●​ The long-term pattern of repeated, often unpredictable mood changes can lead to impairment both from the symptoms themselves and from the negative impact that the unpredictability has on relationships and fulfilling roles at home, work, or school. DIAGNOSTIC CRITERIA B.​ During this period, the symptoms have been present for at least half the time, and the person has never been symptom-free for more than 2 months at a time. E2 The hypomanic symptoms are not enough in number, intensity, or duration to qualify as a full hypomanic episode, and the depressive symptoms are similarly insufficient to meet the criteria for a major depressive episode. CYCLOTHIMIC DISORDER A.​ For at least 2 years (or 1 year in children and adolescents), a person has had many periods of hypomanic symptoms that don’t fully meet criteria for a hypomanic episode, and many periods of depressive symptoms that don’t fully meet criteria for a major depressive episode. F.​ ●​ The symptoms cause significant distress or problems in work, social life, or other important areas. DIAGNOSTIC FEATURES Cyclothymic disorder is mainly defined by a long-term, shifting mood pattern that includes repeated periods of hypomanic symptoms and periods of depressive symptoms. PAGE 7 CREATED BY JEMS E3 ●​ DEVELOPMENT AND COURSE Cyclothymic disorder most often starts in adolescence or early adulthood and is sometimes seen as reflecting a natural temperament that increases vulnerability to other mood disorders. ABNORMAL PSYCHOLOGY C-PSYM311A 1ST SEMESTER – FINALS ●​ Most young people with cyclothymic disorder begin showing mood symptoms before age 10. ●​ The disorder usually continues over time. ●​ Between 15% and 50% of individuals with cyclothymic disorder eventually develop bipolar I or bipolar II disorder, with youth having a higher risk of this progression than adults. ●​ If fluctuating hypomanic and depressive symptoms appear later in adulthood, it is important to rule out bipolar or depressive disorders caused by medical conditions, such as multiple sclerosis, before diagnosing cyclothymic disorder. PAGE 8 starts CREATED BY JEMS gradually and