| 1.
Differential Diagnosis
Manic symptoms can occur in association
with known organic disorders, but in such cases should be diagnosed
as a mood disorder due to a general medical condition (ie, "secondary
mania") rather than as bipolar disorder. There appear to be no
clinical characteristics that might distinguish the two diagnoses,
and it is probable that future research will result in the shifting
of many manic diagnoses from a primary to a secondary category. The
list of known causal agents is long and includes drugs (eg, corticosteroids,
levodopa, stimulants), metabolic disturbances (such as those associated
with hemodialysis), infections, neoplastic diseases, and epilepsy
(particularly partial complex seizures).
In manic patients presenting with prominent delusions
and hallucinations, the differential diagnosis is likely to include
schizophrenia, paranoid type. Both syndromes can present with identical
clinical symptoms, which means that the diagnosis can be based only
on the clinical course or on secondary features such as the presence
of a family history of mood disorder, the level of premorbid adjustment,
a history of manic symptoms, or a prior response to treatment. The
diagnosis of schizoaffective disorder is available for cases in which
the clinician is unable to choose between manic episode and schizophrenia.
Unfortunately, there is at present no agreement on how this category
should be defined or on its etiological or prognostic relationship
to schizophrenia or mood disorder.
2. DSM IV Criteria
Table 20-1. DSM-IV
criteria for manic episode and bipolar disorders.
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Manic episode
A. A distinct period of abnormally and persistently elevated, expansive,
or irritable mood, lasting at least 1 week (or any duration if hospitalization
is necessary).
B. During the period of mood disturbance, three (or more) of the following
symptoms have persisted (four if the mood is only irritable) and have
been present to a significant degree: (1) inflated self-esteem or
grandiosity, (2) decreased need for sleep (eg, feels rested after
only 3 hours of sleep), (3) more talkative than usual or pressure
to keep talking, (4) flight of ideas or subjective experience that
thoughts are racing, (5) distractibility (ie, attention too easily
drawn to unimportant or irrelevant external stimuli), (6) increase
in goal-directed activity (either socially, at work or school, or
sexually) or psychomotor agitation, (7) excessive involvement in pleasurable
activities that have a high potential for painful consequences (eg,
engaging in unrestrained buying sprees, sexual indiscretions, or foolish
business investments).
C. The symptoms do not meet criteria for a mixed episode.
D. The mood disturbance is sufficiently severe to cause marked impairment
in occupational functioning or in usual social activities or relationships
with others or to necessitate hospitalization to prevent harm to self
or others or there are psychotic features.
E. The symptoms are not due to the direct physiological effects of
a substance (eg, a drug of abuse, a medication, or other treatment)
or a general medical condition (eg, hyperthyroidism).
Note: Manic-like episodes that are clearly caused
by somatic antidepressant treatment (eg, medication, electroconvulsive
therapy, light therapy) should not count toward a diagnosis of bipolar
disorder.
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Bipolar I disorder, single manic episode
A. Presence of only one manic episode and no past major depressive
episodes.
Note: Recurrence is defined as either a change in
polarity from depression or an interval of at least 2 months without
manic symptoms.
B. The manic episode is not better accounted for by schizoaffective
disorder and is not superimposed on schizophrenia, schizophreniform
disorder, delusional disorder, or psychotic disorder not otherwise
specified.
Specify if:
Mixed: if symptoms meet criteria for a mixed episode
Specify (for current or most recent episode):
Severity/Psychotic/Remission Specifiers
With Catatonic Features
With Postpartum Onset
_______________________________________________________
Bipolar I disorder, most recent episode hypomanic
A. Currently (or most recently) in a hypomanic episode.
B. There has previously been at least one manic episode or mixed episode.
C. The mood symptoms cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
D. The mood episodes in Criteria A and B are not better accounted
for by schizoaffective disorder and are not superimposed on schizophrenia,
schizophreniform disorder, delusional disorder, or psychotic disorder
not otherwise specified.
Specify:
Longitudinal Course Specifiers (With and Without Interepisode
Recovery)
With Seasonal Pattern (applies only to the pattern
of major depressive episodes)
With Rapid Cycling
______________________________________________________
Bipolar I disorder, most recent episode manic
A. Currently (or most recently) in a manic episode.
B. There has previously been at least one major depressive episode,
manic episode, or mixed episode.
C. The mood episodes in Criteria A and B are not better accounted
for by schizoaffective disorder and are not superimposed on schizophrenia,
schizophreniform disorder, delusional disorder, or psychotic disorder
not otherwise specified.
Specify (for current or most recent episode):
Severity/Psychotic/Remission Specifiers
With Catatonic Features
With Postpartum Onset
Specify:
Longitudinal Course Specifiers (With and Without Interepisode
Recovery)
With Seasonal Pattern (applies only to the pattern
of major depressive episodes)
With Rapid Cycling
_______________________________________________________
Bipolar I disorder, most recent episode mixed
A. Currently (or most recently) in a mixed episode.
B. There has previously been at least one major depressive episode,
manic episode, or mixed episode.
C. The mood episodes in Criteria A and B are not better accounted
for by schizoaffective disorder and are not superimposed on schizophrenia,
schizophreniform disorder, delusional disorder, or psychotic disorder
not otherwise specified.
Specify (for current or most recent episode):
Severity/Psychotic/Remission Specifiers
With Catatonic Features
With Postpartum Onset
Specify:
Longitudinal Course Specifiers (With and Without Interepisode
Recovery)
With Seasonal Pattern (applies only to the pattern
of major depressive episodes)
With Rapid Cycling
_______________________________________________________
Bipolar I disorder, most recent episode depressed
A. Currently (or most recently) in a major depressive episode.
B. There has previously been at least one manic episode or mixed episode.
C. The mood episodes in Criteria A and B are not better accounted
for by schizoaffective disorder and are not superimposed on schizophrenia,
schizophreniform disorder, delusional disorder, or psychotic disorder
not otherwise specified.
Specify (for current or most recent episode):
Severity/Psychotic/Remission Specifiers
Chronic
With Catatonic Features
With Melancholic Features
With Atypical Features
With Postpartum Onset
Specify:
Longitudinal Course Specifiers (With and Without Interepisode
Recovery)
With Seasonal Pattern (applies only to the pattern
of major depressive episodes)
With Rapid Cycling
_______________________________________________________
Bipolar I disorder, most recent episode unspecified
A. Criteria, except for duration, are currently (or most recently)
met for a manic, a hypomanic, a mixed, or a major depressive episode.
B. There has previously been at least one manic episode or mixed episode.
C. The mood symptoms cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
D. The mood symptoms in Criteria A and B are not better accounted
for by schizoaffective disorder and are not superimposed on schizophrenia,
schizophreniform disorder, delusional disorder, or psychotic disorder
not otherwise specified.
E. The mood symptoms in Criteria A and B are not due to the direct
physiological effects of a substance (eg, a drug of abuse, a medication,
or other treatment) or a general medical condition (eg, hyperthyroidism).
Specify:
Longitudinal Course Specifiers (With and Without Interepisode
Recovery)
With Seasonal Pattern (applies only to the pattern
of major depressive episodes)
With Rapid Cycling
_______________________________________________________
Bipolar II disorder
A. Presence (or history) of one or more major depressive episodes.
B. Presence (or history) of at least one hypomanic episode.
C. There has never been a manic episode or a mixed episode.
D. The mood symptoms in Criteria A and B are not better accounted
for by schizoaffective disorder and are not superimposed on schizophrenia,
schizophreniform disorder, delusional disorder, or psychotic disorder
not otherwise specified.
E. The symptoms cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
Specify (for current or most recent episode):
Hypomanic: if currently (or most recently) in a hypomanic
episode
Depressed: if currently (or most recently) in a major
depressive episode
Specify (for current or most recent major depressive episode only
if it is the most recent type of mood episode):
Severity/Psychotic/Remission Specifiers
Chronic
With Catatonic Features
With Melancholic Features
With Atypical Features
With Postpartum Onset
Specify:
Longitudinal Course Specifiers (With and Without Interepisode
Recovery)
With Seasonal Pattern (applies only to the pattern
of major depressive episodes)
With Rapid Cycling
3. Diagnostic Tools:
Reference:
American Psychiatric Association: Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition, Text Revision. Washington, DC,
American Psychiatric Association, 2000.
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