20th November 2023

Bipolar and Related Disorders

Bipolar and their related disorders are characterised by the patient experiencing a manic or hypomanic episode.

A manic episode 

A manic episode must last at least one week (unless shortened by treatment) and is defined as an ‘extreme mood state’. This mood will be primarily euphoria, irritability or expansiveness. For a diagnosis of mania, the patient should be presenting with at least three of the signs below (with four required if the mood is irritable):

• Increased activity or physical restlessness.
• Increased talkativeness – This can often be referred to as pressure of speech.
• ‘Flight of ideas’ or a subjective experience of thoughts racing. Flight of ideas is a sign in which the patient rapidly switches from topic to topic continuously with minimal links between the topics.
• Loss of normal social inhibitions – This can result in behaviour that is inappropriate to the circumstances.
• Decreased need for sleep.
• Inflated self-esteem or grandiosity.
• Distractibility or constant changes in plan.
• Behaviour that is foolhardy or reckless and which the patient is unable to recognise the risk of.
• Marked sexual energy or sexual indiscretions.

If that is mania, what is hypomania?

Hypomania is very similar to the above, but as the name would suggest, it is less severe. They would still require at least three of the signs listed for a diagnosis of mania. However, the criteria do not include flight of ideas or loss of normal social inhibitions, as these are more indicative of a manic episode. A hypomanic episode should last for at least four days and must not meet the above criteria for a manic episode. A hypomanic episode should not cause a severe impairment in functioning or require hospital admission.

Bipolar type I (Manic episode +/- further episodes)

A diagnosis of bipolar type I disorder is made when the patient has had one or more manic episodes. As bipolar is an episodic disorder, patients may experience relapses. These relapses can be a manic episode (as discussed above), a depressive episode (which will be discussed below) or a mixed episode (where the patient has both prominent manic and depressive symptoms). The signs should be present for most of the time, nearly every day for two weeks.

Bipolar type II (Hypomanic episode + depressive episode +/- further episodes) 

A diagnosis of bipolar II type disorder is made when a patient has had one or more hypomanic episodes but also, crucially, at least one depressive episode. Like type I disorder, it is also an episodic mood disorder where the patient may experience hypomanic or depressive episodes. Like bipolar type I, signs should also be present for most of the time, nearly every day for two weeks.

Differences between ICD 10, ICD 11 and DSM V 

Broadly speaking, the symptomology described in these classification symptoms for bipolar are the same, but there are slight differences.

ICD-10

Classifies bipolar not by type I and type II. Instead, it uses:

• Hypomania.
• Mania +/- psychotic symptoms.
• Bipolar affective disorder – Current episode (manic / depression / mixed) +/- psychotic symptoms.
• Bipolar affective disorder – Currently in remission.

ICD-11

Does not have hypomania, and mania as separate diagnoses in and of themselves. Instead, coding these experiences under Bipolar type I or Type II.

DSM V

There is a slight alteration in the symptoms as listed above for a manic episode.

• Reckless behaviour is changed into ‘excessive involvement in pleasurable activities that have a high potential for painful consequences.’
• Increased activity is changed to ‘Increase in goal directed activity’ and includes sexual activity as opposed to being classed as a separate sign.
• Does not include loss of normal social inhibitions as a separate sign.

References

• World Health Organization. (‎2004)‎. ICD-10 : international statistical classification of Diseases and related health problems : tenth revision, 2nd ed. World Health Organization. https://apps.who.int/iris/handle/10665/42980
• International Classification of Diseases, Eleventh Revision (ICD-11), World Health Organization (WHO) 2019/2021 https://icd.who.int/browse11. Licensed under Creative Commons Attribution-NoDerivatives 3.0 IGO licence (CC BY-ND 3.0 IGO)
• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596