History and exam
Key diagnostic factors
common
presence of risk factors
Key factors include early age of mood disorder onset, family history of bipolar disorder or suicide, poor or limited response to traditional antidepressants, highly recurrent mood episodes, comorbid anxiety or substance misuse disorders, and a pattern of psychosocial instability.
major depressive episode(s)
Patients with bipolar I or II disorder commonly experience major depressive episodes. The DSM-5-TR criteria for a major depressive episode are identical for unipolar major depressive disorder and bipolar affective disorder. Criteria include characteristic depressed mood or anhedonia, changes in weight and libido, loss of energy, difficulty concentrating, insomnia or hypersomnia, psychomotor problems, excessive guilt, feelings of worthlessness, and suicidal ideation.[1] A depressive episode may present with mixed features, where the person concurrently experiences full criteria for a major depressive episode, plus 3 or more manic symptoms.[1]
episode(s) of mania
Bipolar I disorder is characterised by the occurrence of 1 or more manic episodes. About 35% of manic episodes have mixed features, meaning the person concurrently experiences full criteria for a manic episode, plus 3 or more depressive symptoms.[1] Patients have often also had 1 or more major depressive episodes.
episode(s) of hypomania
Bipolar II disorder is characterised by the occurrence of 1 or more hypomanic episodes. Patients also have had 1 or more major depressive episodes.[1] A hypomanic episode may occur with mixed features, where the person concurrently experiences full criteria for a hypomanic episode, plus 3 or more depressive symptoms.[1]
inflated self-esteem or grandiosity
Can be present to a significant degree during a manic or hypomanic episode.[1]
decreased need for sleep
Decreased need for sleep (e.g., feeling rested after only 3 hours of sleep) can be present to a significant degree during a manic or hypomanic episode.[1]
more talkative than usual, or feels pressure to keep talking
Can be present to a significant degree during a manic or hypomanic episode.[1]
flight of ideas, or subjective experience that thoughts are racing
Can be present to a significant degree during a manic or hypomanic episode.[1]
distractibility
Attention easily drawn to unimportant or irrelevant external stimuli.
Can be present to a significant degree during a manic or hypomanic episode.[1]
increase in goal-directed activity or psychomotor agitation
Increased goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (purposeless, non-goal-directed activity).
Can be present to a significant degree during a manic or hypomanic episode.[1]
excessive involvement in pleasurable activities that have a high potential for adverse consequences
Activities with adverse consequences may include engaging in unrestrained buying sprees, sexual indiscretions, or unwise business investments.
Can be present to a significant degree during a manic or hypomanic episode.[1]
functional impairment
Mood symptoms contribute to impairment (e.g., in social or occupational functions).
A key distinction is made between manic and hypomanic episodes: with manic episodes, marked impairment or hospitalisation results, whereas with hypomanic episodes DSM-5-TR criteria do not require marked impairment to occur but do require that the disturbance in mood and the change in functioning are observable by others.[1]
no substance misuse
According to DSM-5-TR criteria, the mood symptoms should not be due to substance misuse.[1]
For a primary bipolar diagnosis (bipolar I, bipolar II, or cyclothymia) observed manic, mixed, or hypomanic symptoms episodes must not occur in the context of a drug intoxication or withdrawal.
no underlying medical cause
Mood symptoms should not be due to a general medical condition (e.g., hyperthyroidism).[1]
not due to somatic antidepressant treatment or other prescribed medication
Manic-like or hypomanic-like episodes that are clearly caused by antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count towards a diagnosis of bipolar I or II disorder.[1] If the symptoms present for longer than the physiological period of effect of a substance, a diagnosis of bipolar disorder can be made.
Some prescribed medication (e.g., corticosteroids, levodopa, stimulants) can also produce mood disturbances. These are not counted towards a diagnosis of bipolar disorder.
Risk factors
strong
family history of bipolar disorder or schizophrenia
Family history of bipolar disorder is the strongest individual risk factor for developing bipolar disorder, with first-degree relatives having an eightfold higher risk of developing bipolar disorder compared to the baseline population risk (8% vs. 1%).[39][66][67] Twin and adoption studies suggest that the majority of this risk is genetic in nature; heritability estimates are approximately 60% to 80%.[40][41] There appears to be an element of shared genetic liability with schizophrenia and bipolar disorder, given that first-degree relatives of individuals with either schizophrenia or bipolar disorder are at increased risk of both conditions.[68]
For a patient experiencing a major depressive episode, the presence of a positive family history of bipolar disorder increases the likelihood that the depression is of the bipolar type or that a bipolar course will follow.[66][69]
onset of mood disorder prior to 20 years of age
Studies since 1990 have cited an average age at onset of between 19 years and 31 years; there is a generally accepted decline in the onset of bipolar disorder after 50 years of age.[31]
The Stanley Center Bipolar Disorder Registry has reported the median age at onset of 17.5 years and a mean age of 19.8 years.[70]
Childhood or adolescent major depression is associated with increased risk for bipolar disorder in young adulthood.[71]
adverse life events
childhood trauma and/or adversity
Exposure to childhood trauma (neglect; emotional, sexual, verbal or physical abuse) during neurodevelopmental stages earlier in life contributes to an increased risk of developing bipolar disorder.[43][44][74] A history of childhood trauma is associated with earlier onset of illness, more severe depressive symptomatology, as well as with higher rates of suicidality and of comorbidities.[45][46]
previous history of depression
One US patient survey found that 69% of people with bipolar disorder had been misdiagnosed, most frequently with unipolar depression.[27] People may also initially present with symptoms diagnostic of major depressive disorders, and only later develop mania or hypomania; although figures in the published literature vary, rates of diagnostic conversion from depression to bipolar disorder may be as high as 30% within three years.[17][18]
lifetime history of a substance use disorder
Among all serious mental health disorders, patients with bipolar disorder are known to have some of the highest rates of comorbid substance use disorders.[11] It is unknown from these studies whether this is a cause-and-effect relationship, but it is a noted comorbidity. In the US, the lifetime prevalence of any substance use disorder in people with bipolar I disorder is 5.1 times higher and in those with bipolar II disorder is 2.4 times higher than in those without the condition.[9]
presence of an anxiety disorder
In the US National Comorbidity Survey, >45% of patients with bipolar disorder met lifetime criteria for an anxiety disorder.[75]
Nearly one third of patients met current criteria for an anxiety disorder at time of entry into a large multicentre study, with social anxiety disorder and generalised anxiety disorder the 2 most common conditions (each 13.3%).[76] Whether this is a cause or an effect is unknown, but it is a noted comorbidity. Anxiety disorders may occur before the onset of mania or hypomania, suggesting the possibility that an anxiety disorder may reflect prodromal (early) symptoms of bipolar disorder.[19]
weak
obesity
Between 19% and 49% of patients with bipolar disorder, with a mean of 31%, have comorbid obesity.[77] In addition to the adverse medical consequences related to obesity, obese patients with bipolar disorder are more susceptible to relapse/recurrence (especially depression) and are more prone to suicide.[78][79]
Patients treated with antipsychotic drugs are more likely than matched population controls to develop a central body fat distribution pattern.[80] Emerging evidence suggests that some of these side effects can be corrected with lifestyle modifications.[81]
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