Bipolar type I disorder (6A60)
Description
Bipolar type I disorder is an episodic
mood disorder defined by the occurrence of one or more manic or mixed episodes.
A manic episode is an extreme mood state lasting at least one week unless
shortened by a treatment intervention characterised by euphoria, irritability,
or expansiveness, and by increased activity or a subjective experience of
increased energy, accompanied by other characteristic symptoms such as rapid or
pressured speech, flight of ideas, increased self-esteem or grandiosity,
decreased need for sleep, distractibility, impulsive or reckless behaviour, and
rapid changes among different mood states (i.e., mood lability). A mixed
episode is characterised by the presence of several prominent manic and several
prominent depressive symptoms consistent with those observed in manic episodes
and depressive episodes, which either occur simultaneously or alternate very
rapidly (from day to day or within the same day). Symptoms must include an
altered mood state consistent with a manic and/or depressive episode (i.e.,
depressed, dysphoric, euphoric or expansive mood), and be present most of the
day, nearly every day, during a period of at least 2 weeks, unless shortened by
a treatment intervention. Although the diagnosis can be made based on evidence
of a single manic or mixed episode, typically manic or mixed episodes alternate
with depressive episodes over the course of the disorder.
Exclusions
·
Cyclothymia (6A62)
·
Bipolar type II disorder (6A61)
Diagnostic Requirements
Essential Features:
- A
history of at least one Manic or Mixed Episode (see Essential Features for
Mood Episodes). Although a single Manic or Mixed Episode is sufficient for
a diagnosis of Bipolar Type I Disorder, the typical course of the disorder
is characterized by recurrent Depressive and Manic or Mixed Episodes.
Although some episodes may be Hypomanic, there must be a history of at
least one Manic or Mixed Episode.
Type of current Mood Episode, psychotic symptoms, severity of current
Depressive Episodes, and remission specifiers:
The type of current Mood Episode, the presence or absence of psychotic
symptoms, the severity of current Depressive Episodes, and the degree of
remission should be described in Bipolar Type I Disorder. (See descriptions of
psychotic symptoms and Depressive Episode Severity in Mood Episode descriptions
above.) Available categories are as follows:
- 6A60.0 Bipolar Type I Disorder, Current Episode Manic, without psychotic symptoms
- 6A60.1 Bipolar Type I Disorder, Current Episode Manic, with psychotic symptoms
- 6A60.2 Bipolar Type I Disorder, Current Episode Hypomanic
- 6A60.3 Bipolar Type I Disorder, Current Episode Depressive, Mild
- 6A60.4 Bipolar Type I Disorder, Current Episode Depressive, Moderate, without psychotic symptoms
- 6A60.5 Bipolar Type I Disorder, Current Episode Depressive, Moderate, with psychotic symptoms
- 6A60.6 Bipolar Type I Disorder, Current Episode Depressive, Severe, without psychotic symptoms
- 6A60.7 Bipolar Type I Disorder, Current Episode Depressive, Severe, with psychotic symptoms
- 6A60.8 Bipolar Type I Disorder, Current Episode Depressive, Unspecified Severity
- 6A60.9 Bipolar Type I Disorder, Current Episode Mixed, without psychotic symptoms
- 6A60.A Bipolar Type I Disorder, Current Episode Mixed, with psychotic symptoms
- 6A60.B Bipolar Type I Disorder, currently in partial remission, most recent episode Manic or Hypomanic
- 6A60.C Bipolar Type I Disorder, currently in partial remission, most recent episode Depressive
- 6A60.D Bipolar Type I Disorder, currently in partial remission, most recent episode Mixed
- 6A60.E Bipolar Type I Disorder, currently in partial remission, most recent episode unspecified
- 6A60.F Bipolar Type I Disorder, currently in full remission
Symptomatic and Course Presentation Specifiers for Mood Episodes:
Additional specifiers may be applied to describe a current mood episode
in the context of Bipolar Type I Disorder (Depressive, Manic, Mixed or
Hypomanic Episodes). These specifiers indicate other important features of the
clinical presentation or of the course, onset, and pattern of Mood Episodes.
These specifiers are not mutually exclusive, and as many may be added as apply.
(Note that these same specifiers, with the exception of Rapid Cycling, may also
be applied to current Depressive Episodes in the context of Depressive
Disorders. The specifier Rapid Cycling is specific to Bipolar Type I and
Bipolar Type II Disorders.)
Available specifiers are as follows:
with prominent anxiety symptoms (6A80.0)
- This
specifier can be applied if, in the context of a current Depressive,
Manic, Mixed, or Hypomanic Episode, prominent and clinically significant
anxiety symptoms (e.g., feeling nervous, anxious or on edge, not being
able to control worrying thoughts, fear that something awful will happen,
having trouble relaxing, muscle tension, autonomic symptoms) have been
present for most of the time during the episode. If there have been panic
attacks during the current Depressive or Mixed Episode, these should be
recorded separately (see ‘with panic attacks’ specifier). This specifier
may be used whether or not the diagnostic requirements for an Anxiety or
Fear-Related Disorder are also met, in which case the Anxiety or
Fear-Related Disorder should also be diagnosed.
with panic attacks (6A80.1)
- This
specifier can be applied if, in the context of a current Episode, there
have been panic attacks during the past month that occur specifically in
response to depressive ruminations or other anxiety-provoking cognitions.
If panic attacks occur exclusively in response to such thoughts, the ‘with
panic attacks’ specifier should be applied rather than an additional
co-occurring diagnosis of Panic Disorder. If some panic attacks over the
course of the Depressive or Mixed Episode have been unexpected and not
exclusively in response to depressive or anxiety-provoking thoughts and
the full diagnostic requirements for Panic Disorder are met, a separate
diagnosis of Panic Disorder should be assigned.
current Depressive Episode persistent (6A80.2)
- This
specifier can be applied if the diagnostic requirements for Depressive
Episode are currently met and have been met continuously for at least the
past 2 years.
current Depressive Episode with melancholia (6A80.3)
- This
specifier can be applied if, in the context of a current Depressive
Episode, several of the following symptoms have been present during the
worst period of the current episode:
- Loss
of interest or pleasure in most activities that are normally enjoyable to
the individual (i.e., pervasive anhedonia).
- Lack
of emotional reactivity to normally pleasurable stimuli or circumstances
(i.e., mood does not lift even transiently with exposure).
- Terminal
insomnia (i.e., waking in the morning 2 hours or more before the usual
time).
- Depressive
symptoms are worse in the morning.
- Marked
psychomotor retardation or agitation.
- Marked
loss of appetite or loss of weight.
with seasonal pattern (6A80.4)
- This
specifier can be applied to Bipolar Type I Disorder if there has been a
regular seasonal pattern of onset and remission of at least one type of
episode (i.e., Depressive, Manic, Mixed, or Hypomanic Episodes). The other
types of Mood Episodes may not follow this pattern.
- A
substantial majority of the relevant Mood Episodes should correspond with
the seasonal pattern.
- A
seasonal pattern should be differentiated from an episode that is
coincidental with a particular season but predominantly related to a
psychological stressor that regularly occurs at that time of the year
(e.g., seasonal unemployment).
with rapid cycling (6A80.5)
- This
specifier can be applied if the Bipolar Type I Disorder is characterized
by a high frequency of Mood Episodes (at least four) over the past 12
months. There may be a switch from one polarity of mood to the other, or
the Mood Episodes may be demarcated by a period of remission.
- In
individuals with a high frequency of Mood Episodes, some may have a
shorter duration than those usually observed in Bipolar Type I Disorder.
In particular, depressive periods may only last several days. However, if
depressive and manic symptoms alternate very rapidly (i.e., from day to
day or within the same day), a Mixed Episode should be diagnosed rather
than rapid cycling.
In the context of Bipolar Type I Disorder, Mood Episodes that occur
during pregnancy or commencing within about 6 weeks after delivery (referred to
as the puerperium) can be identified using one of the following two additional
diagnostic codes, depending on whether delusions, hallucinations, or other
psychotic symptoms are present. These diagnoses should be assigned in addition
to the relevant Bipolar Disorder diagnosis.
Mental or behavioural disorders associated with pregnancy, childbirth or
the puerperium, without psychotic symptoms (6E20)
- This
additional diagnostic code should be used for Mood Episodes that arise
during pregnancy or commencing within about 6 weeks after delivery that do
not include delusions, hallucinations, or other psychotic symptoms. This
designation should not be used to describe mild and transient depressive
symptoms that do not meet the diagnostic requirements for a depressive
episode, which may occur soon after delivery (so-called postpartum blues).
Mental or behavioural disorders associated with pregnancy, childbirth or
the puerperium, with psychotic symptoms (6E21)
- This
additional diagnostic code should be used for Mood Episodes that arise
during pregnancy or commencing within about 6 weeks after delivery that
include delusions, hallucinations, or other psychotic symptoms. This
designation should not be used to describe mild and transient depressive
symptoms that do not meet the diagnostic requirements for a depressive
episode, which may occur soon after delivery (so-called postpartum blues).
Note: For the following sections, see also material under Depressive
Episode, Manic Episode, Mixed Episode and Hypomanic Episode. Material on
Additional Clinical Features, Boundary with Normality (Threshold),
Developmental Presentations, and Boundary with Other Disorders and Conditions
(Differential Diagnosis) that relates specifically to the Mood Episodes is
contained in these sections, whereas material focusing on Bipolar Type I
Disorder overall appears below.
Additional Clinical Features:
- In
combination with a history of one or more Depressive Episodes, a Mixed,
Manic or Hypomanic Episode arising during antidepressant treatment (e.g.,
medication, electroconvulsive therapy, light therapy, transcranial
magnetic stimulation) is grounds for a diagnosis of Bipolar Type I
Disorder if the syndrome persists after the treatment is discontinued and
the full diagnostic requirements of the Mood Episode are met after the
direct physiological effects of the treatment are likely to have receded.
- Inter-episode
periods may be characterized by complete remission of symptoms or by the
presence of residual hypomanic, manic, mixed, or depressive symptoms, in
which case the ‘partial remission’ specifier should be applied.
- Suicide
risk is significantly higher among individuals diagnosed with Bipolar Type
I Disorder than among the general population, particularly during
Depressive or Mixed Episodes and among individuals with rapid cycling.
- Recurrent
panic attacks in Bipolar Type I Disorder may be indicative of greater
severity, poorer response to treatment, and greater risk for suicide.
- Family
history is an important factor to consider because heritability of Bipolar
Disorders is the highest of all mental disorders.
- Individuals
initially diagnosed with Bipolar Type II Disorder are at high risk of
experiencing a Manic or Mixed Episode during their lifetime. If this
occurs, the diagnosis should be changed to Bipolar Type I Disorder.
- Patients
diagnosed with Bipolar Type I Disorder are at elevated risk for developing
a variety of medical conditions affecting the cardiovascular system (e.g.,
hypertension) and metabolism (e.g., hyperglycemia), some of which may be
due to the effects of the chronic use of medications used to treat Bipolar
Disorders.
- Individuals
with Bipolar Type I Disorder exhibit high rates of co-occurring Mental,
Behavioural or Neurodevelopmental Disorders, most commonly Anxiety or
Fear-Related Disorders and Disorders Due to Substance Use.
Course Features:
- Although
the onset of a first Manic, Hypomanic, or Depressive Episode most often
occurs during the late teen years, onset of Bipolar Type I Disorder can
occur at any time through the life cycle, including in older adulthood.
Late-onset mood symptoms may be more likely to be caused by the effects of
medications or substances or other medical conditions.
- The
majority of individuals who experience a single Manic Episode will go on
to develop recurrent Mood Episodes. More than half of Manic Episodes will
be immediately followed by a Depressive Episode.
- The
risk of recurrence of Mood Episodes in Bipolar Type I Disorder increases
with the number of prior Mood Episodes.
- Individuals
with Bipolar Type I Disorder are at increased lifetime risk of
suicidality.
Culture-Related Features:
- Studies
indicate that the prevalence of Bipolar or Related Disorders varies across
cultural, ethnic, and migrant groups, partly as a function of social
stress. Symptom expression may also vary and be shaped by common cultural
idioms, cultural histories or personal histories that are prominent in
identity formation and expressed as grandiose ideas or beliefs. For
example, grandiosity may be expressed in culturally specific ways such
that a Muslim individual experiencing a Manic Episode may believe he is
Muhammad, whereas a Christian individual may believe he is Jesus.
Individuals from the person’s cultural group may be helpful in
distinguishing normative expressions of belief or ritual from manic or
psychotic experiences and behaviours.
- In
some cultural contexts, mood changes are more readily expressed in the
form of bodily symptoms (e.g., pain, fatigue, weakness) rather than
directly reported as psychological symptoms.
- Some
types of symptoms may be considered more shameful or severe according to
cultural norms, leading to reporting biases. For example, some cultures
may emphasize shame more than guilt, whereas in others suicidal behaviour
and thinking may be prohibited. In some cultural groups, features such as
sadness and lack of productivity may be perceived as signs of personal
weakness and therefore under-reported.
- The
cultural salience of depressive symptoms may vary across social groups as
a result of varying cultural ‘scripts’ for the disorder which make
specific types of symptoms more prominent, for example: psychological
(e.g., sadness, emotional numbness, rumination), moral (e.g., guilt,
worthlessness), social/interpersonal (e.g., lack of productivity,
conflictive relationships), hedonic (e.g., decreased pleasure), spiritual
(e.g., dreams of dead relatives), or somatic symptoms (e.g., insomnia,
pain, fatigue, dizziness).
Sex- and/or Gender-Related Features:
- Prevalence
rates for Bipolar Type I Disorder are similar between men and women with a
tendency for men to exhibit earlier onset of symptoms.
- Manic
Episodes occur more commonly in men and are typically more severe and
impairing. In contrast, women are more likely to experience Depressive
Episodes, Mixed Episodes, and rapid cycling.
- Disorders
Due to Substance Use often co-occur with Bipolar Type I Disorder among
men, whereas women are more likely to experience comorbid medical
conditions including migraines, obesity, and thyroid disease as well as
co-occurring mental disorders including Anxiety or Fear-Related Disorders
and Eating Disorders.
Boundaries with Other Disorders and Conditions (Differential Diagnosis):
- Boundary
with Cyclothymic Disorder: In
Cyclothymic Disorder, the number, severity and/or duration of depressive
symptoms have never met the threshold required for a Depressive Episode
and there is no evidence of a history of Mixed or Manic Episodes.
- Boundary
with Attention Deficit Hyperactivity Disorder: Although a Manic, Hypomanic, or Mixed
Episode may include symptoms characteristic of Attention Deficit
Hyperactivity Disorder such as distractibility, hyperactivity, and
impulsivity, Bipolar Type I is differentiated from Attention Deficit
Hyperactivity Disorder by its episodic nature and the accompanying
elevated, euphoric or irritable mood. However, Attention Deficit Hyperactivity
Disorder and Bipolar Type I Disorder can co-occur. When they do, Attention
Deficit Hyperactivity Disorder symptoms tend to worsen during Hypomanic,
Manic, or Mixed Episodes.
- Boundary
with Schizophrenia or Other Primary Psychotic Disorders: The presentation is not better accounted
for by a diagnosis of Schizophrenia or Other Primary Psychotic Disorder.
Individuals with Bipolar Type I Disorder can exhibit psychotic symptoms
during Depressive Episodes, and individuals with Bipolar Type I Disorder
can exhibit psychotic symptoms during Manic or Mixed Episodes, but these
symptoms occur only during Mood Episodes. Conversely, individuals with a
diagnosis of Schizophrenia or Other Primary Psychotic Disorder may
experience significant depressive or manic symptoms during psychotic
episodes. In such cases, if the symptoms do not meet the diagnostic
requirements for a Depressive, Manic, or Mixed Episode, their presence and
severity in the context of a psychotic disorder diagnosis can be denoted
by applying specifier scales from ‘Symptomatic Manifestations of Primary
Psychotic Disorders’, i.e., ‘with depressive symptoms in primary psychotic
disorders’ or ‘with manic symptoms in primary psychotic disorders.’ If all
diagnostic requirements for both a Depressive, Manic, or Mixed Episode and
Schizophrenia are met concurrently or within a few days of each other and
other diagnostic requirements are met, the diagnosis of Schizoaffective
Disorder should be assigned rather than Bipolar Type I Disorder. A
Hypomanic Episode superimposed on Schizophrenia does not qualify for a
diagnosis of Schizoaffective Disorder. However, a diagnosis of Bipolar
Type I Disorder can co-occur with a diagnosis of Schizophrenia or Other
Primary Psychotic Disorder, and both diagnoses may be assigned if the full
diagnostic requirements for both disorders are met and psychotic symptoms
are present outside of Mood Episodes.
- Boundary
with Anxiety or Fear-Related Disorders: Symptoms of anxiety, including panic
attacks, are common in Bipolar Type I Disorder, and in some individuals
may be a prominent aspect of the clinical presentation. In such cases, the
specifier ‘with prominent anxiety symptoms’ should be applied to the
diagnosis for non-panic anxiety systems. If the anxiety symptoms meet the
diagnostic requirements for an Anxiety or Fear-Related Disorder, the
appropriate diagnosis from the Anxiety or Fear-Related Disorders grouping
should also be assigned. For panic attacks, if these occur entirely in the
context of anxiety associated with Depressive, Hypomanic, Manic, or Mixed
Episodes in Bipolar Type I Disorder, they are appropriately designated
using the ‘with panic attacks’ specifier. However, if panic attacks also
occur outside of symptomatic Mood Episodes and other diagnostic
requirements are met, a separate diagnosis of Panic Disorder should be
considered. Both specifiers may be assigned if warranted.
- Boundary
with Personality Disorder: Individuals
with a Personality Disorder may exhibit impulsivity or mood instability,
but Personality Disorder does not include Depressive, Hypomanic, Manic, or
Mixed Episodes. However, co-occurrence of Personality Disorder and Bipolar
Type I Disorder is relatively common. Symptoms of Personality Disorder
should be assessed outside the context of a Mood Episode to avoid conflating
symptoms of a Mood Episode with personality traits, but both diagnoses may
be assigned if the diagnostic requirements for both diagnoses are
fulfilled.
- Boundary
with Oppositional Defiant Disorder: It is common, particularly among
children and adolescents, for patterns of noncompliance and symptoms of
irritability/anger to arise as part of a Mood Disorder. For example,
noncompliance may be a result of depressive symptoms (e.g., diminished
interest or pleasure in activities, difficulty concentrating,
hopelessness, psychomotor retardation, reduced energy). During Hypomanic
or Manic episodes, individuals are less likely to follow rules and comply
with directions. Oppositional Defiant Disorder often co-occurs with Mood
Disorders, and irritability/anger can be a common symptom across these
disorders. When the behaviour problems occur primarily in the context of
Hypomanic, Manic, Depressive, or Mixed Episodes, a separate diagnosis of
Oppositional Defiant Disorder should not be assigned. However, both diagnoses
may be given if the full diagnostic requirements for both disorders are
met and the behaviour problems associated with Oppositional Defiant
Disorder are observed outside the occurrence of a Mood Episode. The
Oppositional Defiant Disorder specifier ‘with chronic irritability-anger’
may be used if appropriate.
- Boundary
with Substance-induced Mood Disorder: A Depressive, Hypomanic, Manic, or Mixed
syndrome due to the effects of a substance or medication other than
antidepressant medication on the central nervous system (e.g., cocaine,
amphetamines), including withdrawal effects, should be diagnosed as
Substance-Induced Mood Disorder rather than Bipolar Type I Disorder. The
presence of continuing mood disturbance should be assessed once the
physiological effects of the relevant substance subside.
- Boundary
with other Mental Disorders: Irritability
is a symptom that is also observed in other disorders (e.g., Depressive
Disorders, Generalized Anxiety Disorder). In order to attribute this
symptom to a Manic, Hypomanic, or Mixed Episode, the clinician should
establish the episodicity of the symptom and its co-occurrence with other
symptoms consistent with a Manic, Hypomanic, or Mixed Episode.
- Boundary
with Secondary Mood Syndrome: A
Depressive, Hypomanic, Manic, or Mixed syndrome that is a manifestation of
another medical condition should be diagnosed as Secondary Mood Syndrome
rather than Bipolar Type I Disorder.
Copyright Notice
ICD-11 is licensed under the Creative Commons Attribution-NoDerivs 3.0 IGO license (CC BY-ND 3.0 IGO, or the “ICD-11 License”) available at: https://creativecommons.org/licenses/by-nd/3.0/igo/).
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