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Bipolar I Disorders

Suggested Diagnostic Criteria For Bipolar I Disorders In Children



The two most common documents used for the diagnosis of Bipolar I Disorders are the DSM IV and ICD 10. The DSM IV is used mostly in the United States though it has been used elsewhere, including the U.K., whereas the ICD 10 is more commonly used in Europe. We have included the descriptions of both, as below.

DSM IV
ICD 10 (European Description)


Note: Consider a criterion met only if the behaviour is considerably more frequent than that of most people of the same mental age.



DSM IV (Diagnostic & Statistical Manual) Bipolar I Disorders Diagnostic Criteria:

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.

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 is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

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 is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

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 is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

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 is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

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 episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is 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 (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Criteria For Mood Episodes Major Depressive Episode

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

A. depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.

B. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

C. significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.

D. insomnia or hypersomnia nearly every day

E. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

F. fatigue or loss of energy nearly every day

G. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

H. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

I. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

B. The symptoms do not meet criteria for a Mixed Episode

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

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:

A. inflated self-esteem or grandiosity
B. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
C. more talkative than usual or pressure to keep talking
D. flight of ideas or subjective experience that thoughts are racing
E. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
F. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
G. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., 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 (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Mixed Episode

A. The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.

B. 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.

C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Hypomanic Episode

A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.

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:

A. inflated self-esteem or grandiosity
B. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
C. more talkative than usual or pressure to keep talking
D. flight of ideas or subjective experience that thoughts are racing
E. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
F. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
G. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.

D. The disturbance in mood and the change in functioning are observable by others.

E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.

F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II Disorder.

Differential Diagnosis

Mood Disorder Due to a General Medical Condition; Substance-Induced Mood Disorder; Major Depressive Disorder; Dysthymic Disorder; Bipolar II Disorder; Cyclothymic Disorder; Psychotic Disorders (e.g., Schizoaffective Disorder, Schizophrenia, and Delusional Disorder).

Bipolar Disorder - European Description:

The ICD-10 Classification of Mental and Behavioural Disorders World Health Organization, Geneva, 1992

F42 Obsessive-Compulsive Disorder

Contents F31 Bipolar Affective Disorder
F31.6 Bipolar Affective Disorder, Current Episode Mixed
F30 Manic Episode
F30.0 Hypomania
F30.1 Mania Without Psychotic Symptoms
F30.2 Mania With Psychotic Symptoms
F32 Depressive Episode
F32.0 Mild Depressive Episode
F32.1 Moderate Depressive Episode
F32.2 Severe Depressive Episode Without Psychotic Symptoms
F32.3 Severe Depressive Episode With Psychotic Symptoms

F31 Bipolar Affective Disorder

This disorder is characterized by repeated (i.e. at least two) episodes in which the patient's mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of an elevation of mood and increased energy and activity (mania or hypomania), and on others of a lowering of mood and decreased energy and activity (depression).

Characteristically, recovery is usually complete between episodes, and the incidence in the two sexes is more nearly equal than in other mood disorders. As patients who suffer only from repeated episodes of mania are comparatively rare, and resemble (in their family history, premorbid personality, age of onset, and long-term prognosis) those who also have at least occasional episodes of depression, such patients are classified as bipolar.

Manic episodes usually begin abruptly and last for between 2 weeks and 4-5 months (median duration about 4 months). Depressions tend to last longer (median length about 6 months), though rarely for more than a year, except in the elderly. Episodes of both kinds often follow stressful life events or other mental trauma, but the presence of such stress is not essential for the diagnosis. The first episode may occur at any age from childhood to old age. The frequency of episodes and the pattern of remissions and relapses are both very variable, though remissions tend to get shorter as time goes on and depressions to become commoner and longer lasting after middle age.

Although the original concept of "manic-depressive psychosis" also included patients who suffered only from depression, the term "manic-depressive disorder or psychosis" is now used mainly as a synonym for bipolar disorder.

Includes:
* manic-depressive illness, psychosis or reaction

Excludes:
* bipolar disorder, single manic episode
* cyclothymia

F31.6 Bipolar Affective Disorder, Current Episode Mixed

The patient has had at least one manic, hypomanic, or mixed affective episode in the past and currently exhibits either a mixture of a rapid alternation of manic, hypomanic, and depressive symptoms.

Diagnostic Guidelines

Although the most typical form of bipolar disorder consists of alternating manic and depressive episodes separated by periods of normal mood, it is not uncommon for depressive mood to be accompanied for days or weeks on end by overactivity and pressure of speech, or for a manic mood and grandiosity to be accompanied by agitation and loss of energy and libido. Depressive symptoms and symptoms of hypomania or mania may also alternate rapidly, from day to day or even from hour to hour. A diagnosis of mixed bipolar affective disorder should be made only if the two sets of symptoms are both prominent for the greater part of the current episode of illness, and if that episode has lasted for a least 2 weeks.

Excludes:
* single mixed affective episode F30 Manic Episode

Three degrees of severity are specified here, sharing the common underlying characteristics of elevated mood, and an increase in the quantity and speed of physical and mental activity. All the subdivisions of this category should be used only for a single manic episode. If previous or subsequent affective episodes (depressive, manic, or hypomanic), the disorder should be coded under bipolar affective disorder.

Includes:
* bipolar disorder, single manic episode

F30.0 Hypomania

Hypomania is a lesser degree of mania, in which abnormalities of mood and behaviour are too persistent and marked to be included under cyclothymia but are not accompanied by hallucinations or delusions. There is a persistent mild elevation of mood (for at least several days on end), increased energy and activity, and usually marked feelings of well-being and both physical and mental efficiency. Increased sociability, talkativeness, overfamiliarity, increased sexual energy, and a decreased need for sleep are often present but not to the extent that they lead to severe disruption of work or result in social rejection. Irritability, conceit, and boorish behaviour may take the place of the more usual euphoric sociability. Concentration and attention may be impaired, thus diminishing the ability to settle down to work or to relaxation and leisure, but this may not prevent the appearance of interests in quite new ventures and activities, or mild over-spending.

Diagnostic Guidelines

Several of the features mentioned above, consistent with elevated or changed mood and increased activity, should be present for at least several days on end, to a degree and with a persistence greater than described for cyclothymia. Considerable interference with work or social activity is consistent with a diagnosis of hypomania, but if disruption of these is severe or complete, mania should be diagnosed.

Differential Diagnosis

Hypomania covers the range of disorders of mood and level of activities between cyclothymia and mania. The increased activity and restlessness (and often weight loss) must be distinguished from the same symptoms occurring in hyperthyroidism and anorexia nervosa; early states of "agitated depression", particularly in late middle-age, may bear a superficial resemblance to hypomania of the irritable variety. Patients with severe obsessional symptoms may be active part of the night completing their domestic cleaning rituals, but their affect will usually be the opposite of that described here. When a short period of hypomania occurs as a prelude to or aftermath of mania, it is usually not worth specifying the hypomania separately.

F30.1 Mania Without Psychotic Symptoms

Mood is elevated out of keeping with the individual's circumstances and may vary from carefree joviality to almost uncontrollable excitement. Elation is accompanied by increased energy, resulting in overactivity, pressure of speech, and a decreased need for sleep. Normal social inhibitions are lost, attention cannot be sustained, and there is often marked distractability. Self-esteem is inflated, and grandiose or over-optimistic ideas are freely expressed.

Perceptual disorders may occur, such as the appreciation of colours as especially vivid (and usually beautiful), a preoccupation with fine details of surfaces or textures, and subjective hyperacusis. The individual may embark on extravagant and impractical schemes, spend money recklessly, or become aggressive, amorous, or facetious in inappropriate circumstances. In some manic episodes the mood is irritable and suspicious rather than elated. The first attack occurs most commonly between the ages of 15 and 30 years, but may occur at any age from late childhood to the seventh or eighth decade.

Diagnostic Guidelines

The episode should last for at least 1 week and should be severe enough to disrupt ordinary work and social activities more or less completely. The mood change should be accompanied by increased energy and several of the symptoms referred to above (particularly pressure of speech, decreased need for sleep, grandiosity, and excessive optimism).

F30.2 Mania With Psychotic Symptoms

The clinical picture is that of a more severe form of mania as described above. Inflated self-esteem and grandiose ideas may develop into delusions, and irritability and suspiciousness into delusions of persecution. In severe cases, grandiose or religious delusions of identity or role may be prominent, and flight of ideas and pressure of speech may result in the individual becoming incomprehensible. Severe and sustained physical activity and excitement may result in aggression or violence, and neglect of eating, drinking, and personal hygiene may result in dangerous states of dehydration and self-neglect. If required, delusions or hallucinations can be specified as congruent or incongruent with the mood.

"Incongruent" should be taken as including affectively neutral delusions and hallucinations; for example, delusions of reference with no guilty or accusatory content, or voices speaking to the individual about events that have no special emotional significance.

Differential Diagnosis

One of the commonest problems is differentiation of this disorder from schizophrenia, particularly if the stages of development through hypomania have been missed and the patient is seen only at the height of the illness when widespread delusions, incomprehensible speech, and violent excitement may obscure the basic disturbance of affect. Patients with mania that is responding to neuroleptic medication may present a similar diagnostic problem at the stage when they have returned to normal levels of physical and mental activity but still have delusions or hallucinations. Occasional hallucinations or delusions as specified for schizophrenia may also be classed as mood-incongruent, but if these symptoms are prominent and persistent, the diagnosis of schizoaffective disorder is more likely to be appropriate.

Includes:
* manic stupor

F32 Depressive Episode

In typical depressive episodes of all three varieties described below (mild, moderate, and severe), the individual usually suffers from depressed mood, loss of interest and enjoyment, and reduced energy leading to increased fatiguability and diminished activity. Marked tiredness after only slight effort is common. Other common symptoms are:

(a) reduced concentration and attention;
(b) reduced self-esteem and self-confidence;
(c) ideas of guilt and unworthiness (even in a mild type of episode);
(d) bleak and pessimistic views of the future;
(e) ideas or acts of self-harm or suicide;
(f) disturbed sleep;
(g) diminished appetite.

The lowered mood varies little from day to day, and is often unresponsive to circumstances, yet may show a characteristic diurnal variation as the day goes on. As with manic episodes, the clinical presentation shows marked individual variations, and atypical presentations are particularly common in adolescence. In some cases, anxiety, distress, and motor agitation may be more prominent at times than the depression, and the mood change may also be masked by added features such as irritability, excessive consumption of alcohol, histrionic behaviour, and exacerbation of pre-existing phobic or obsessional symptoms, or by hypochondriacal preoccupations. For depressive episodes of all three grades of severity, a duration of at least 2 weeks is usually required for diagnosis, but shorter periods may be reasonable if symptoms are unusually severe and of rapid onset.

Some of the above symptoms may be marked and develop characteristic features that are widely regarded as having special clinical significance. The most typical examples of these "somatic" symptoms are: loss of interest or pleasure in activities that are normally enjoyable; lack of emotional reactivity to normally pleasurable surroundings and events; waking in the morning 2 hours or more before the usual time; depression worse in the morning; objective evidence of definite psychomotor retardation or agitation (remarked on or reported by other people); marked loss of appetite; weight loss (often defined as 5% or more of body weight in the past month); marked loss of libido. Usually, this somatic syndrome is not regarded as present unless about four of these symptoms are definitely present.

The categories of mild, moderate and severe depressive episodes described in more detail below should be used only for a single (first) depressive episode. Further depressive episodes should be classified under one of the subdivisions of recurrent depressive disorder.

These grades of severity are specified to cover a wide range of clinical states that are encountered in different types of psychiatric practice. Individuals with mild depressive episodes are common in primary care and general medical settings, whereas psychiatric inpatient units deal largely with patients suffering from the severe grades.

Acts of self-harm associated with mood (affective) disorders, most commonly self-poisoning by prescribed medication, should be recorded by means of an additional code from Chapter XX of ICD-10 (X60-X84). These codes do not involve differentiation between attempted suicide and "parasuicide", since both are included in the general category of self-harm.

Differentiation between mild, moderate, and severe depressive episodes rests upon a complicated clinical judgement that involves the number, type, and severity of symptoms present. The extent of ordinary social and work activities is often a useful general guide to the likely degree of severity of the episode, but individual, social, and cultural influences that disrupt a smooth relationship between severity of symptoms and social performance are sufficiently common and powerful to make it unwise to include social performance amongst the essential criteria of severity.

The presence of dementia or mental retardation does not rule out the diagnosis of a treatable depressive episode, but communication difficulties are likely to make it necessary to rely more than usual for the diagnosis upon objectively observed somatic symptoms, such as psychomotor retardation, loss of appetite and weight, and sleep disturbance.

Includes:
* single episodes of depression (without psychotic symptoms), psychogenic depression or reactive depression)

F32.0 Mild Depressive Episode

Diagnostic Guidelines

Depressed mood, loss of interest and enjoyment, and increased fatiguability are usually regarded as the most typical symptoms of depression, and at least two of these, plus at least two of the other symptoms described above should usually be present for a definite diagnosis. None of the symptoms should be present to an intense degree. Minimum duration of the whole episode is about 2 weeks.

An individual with a mild depressive episode is usually distressed by the symptoms and has some difficulty in continuing with ordinary work and social activities, but will probably not cease to function completely.

A fifth character may be used to specify the presence of the somatic syndrome:

F32.00 Without somatic symptoms

The criteria for mild depressive episode are fulfilled, and there are few or none of the somatic symptoms present.

F32.01 With somatic symptoms

The criteria for mild depressive episode are fulfilled, and four or more of the somatic symptoms are also present. (If only two or three somatic symptoms are present but they are unusually severe, use of this category may be justified.)

F32.1 Moderate Depressive Episode

Diagnostic Guidelines

At least two of the three most typical symptoms noted for mild depressive episode should be present, plus at least three (and preferably four) of the other symptoms. Several symptoms are likely to be present to a marked degree, but this is not essential if a particularly wide variety of symptoms is present overall. Minimum duration of the whole episode is about 2 weeks.

An individual with a moderately severe depressive episode will usually have considerable difficulty in continuing with social, work or domestic activities.

A fifth character may be used to specify the occurrence of somatic symptoms:

F32.10 Without somatic symptoms

The criteria for moderate depressive episode are fulfilled, and few if any of the somatic symptoms are present.

F32.11 With somatic symptoms

The criteria for moderate depressive episode are fulfilled, and four or more or the somatic symptoms are present. (If only two or three somatic symptoms are present but they are unusually severe, use of this category may be justified.)

F32.2 Severe Depressive Episode Without Psychotic Symptoms

In a severe depressive episode, the sufferer usually shows considerable distress or agitation, unless retardation is a marked feature. Loss of self-esteem or feelings of uselessness or guilt are likely to be prominent, and suicide is a distinct danger in particularly severe cases. It is presumed here that the somatic syndrome will almost always be present in a severe depressive episode.

Diagnostic Guidelines

All three of the typical symptoms noted for mild and moderate depressive episodes should be present, plus at least four other symptoms, some of which should be of severe intensity. However, if important symptoms such as agitation or retardation are marked, the patient may be unwilling or unable to describe many symptoms in detail. An overall grading of severe episode may still be justified in such instances. The depressive episode should usually last at least 2 weeks, but if the symptoms are particularly severe and of very rapid onset, it may be justified to make this diagnosis after less than 2 weeks.

During a severe depressive episode it is very unlikely that the sufferer will be able to continue with social, work, or domestic activities, except to a very limited extent.

This category should be used only for single episodes of severe depression without psychotic symptoms; for further episodes, a subcategory of recurrent depressive disorder should be used.

Includes:
* single episodes of agitated depression
* melancholia or vital depression without psychotic symptoms

F32.3 Severe Depressive Episode With Psychotic Symptoms

Diagnostic Guidelines

A severe depressive episode which meets the criteria given for severe depressive episode without psychotic symptoms and in which delusions, hallucinations, or depressive stupor are present. The delusions usually involve ideas of sin, poverty, or imminent disasters, responsibility for which may be assumed by the patient. Auditory or olfactory hallucinations are usually of defamatory or accusatory voices or of rotting filth or decomposing flesh. Severe psychomotor retardation may progress to stupor. If required, delusions or hallucinations may be specified as mood-congruent or mood-incongruent.

Differential Diagnosis

Depressive stupor must be differentiated from catatonic schizophrenia, from dissociative stupor, and from organic forms of stupor. This category should be used only for single episodes of severe depression with psychotic symptoms; for further episodes a subcategory of recurrent depressive disorder should be used.

Includes:
* single episodes of major depression with psychotic symptoms, psychotic depression, psychogenic depressive psychosis, reactive depressive psychosis



ICD-10 copyright 1992 by World Health Organization. Internet Mental Health (www.mentalhealth.com) copyright 1995-1997 by Phillip W. Long, M.D.

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