BIPOLAR I & II DISORDER

SITI NURFATHINI BINTI MUHAMMAD AZRIE (MP2212101T)

MP16C SECTION 9
FACULTY OF PSYCHOLOGY AND EDUCATION
PK6353: PSYCHOPATHOLOGY
DR. NUR FARHANA ARDILLAH BTE AFTAR
MARCH 28, 2023

INTRODUCTION (SEMPLE & SMYTH, 2013)

- Bipolar a ective disorder (commonly known as manic

depression) is one of the most common, severe, and
persistent psychiatric illnesses.
- It is associated with notions of ‘creative madness’, and
indeed it has a ected many creative people—both past
and present
- Most people who battle with the e ects of the disorder
would rather live a normal life, free from the
unpredictability of mood swings, which most of us take for
granted.
- The symptoms may vary from one patient to the next, and
from one episode to the next within the same patient.
- More than other psychiatric disorders, the clinician needs
to pay attention to the life history of the patient, and to
third-party information from family and friends.

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HISTORY (CLARK, 2016)

Figure 1. The History of Bipolar Disorder. Adapted from “The History of

Bipolar Disorder" by M. Clark, 2016, Bipolar Bandit (Michelle Clark).
Retrieved from https://bipolarbandit.wordpress.com/2016/04/01/the-history-
of-bipolar-disorder-infographic/. Copyright 2016 by Bipolar Bandit.
BIPOLAR I DISORDER
 DIAGNOSTIC CRITERIA (5TH ED.; DSM-5; AMERICAN PSYCHIATRIC ASSOCIATION, 2013)

- For a diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a manic episode.
- The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes.

- Manic Episode (At least one lifetime manic episode is required for the diagnosis of bipolar I disorder.)
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or
energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present
to a signi cant degree and represent a noticeable change from usual behavior:
1. In ated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., 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 (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity).
7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions,
or foolish business investments).
C. The mood disturbance is su ciently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm
to self or others, or there are psychotic features.
D. The episode is not attributable to the physiological e ects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition.
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 DIAGNOSTIC CRITERIA (5TH ED.; DSM-5; AMERICAN PSYCHIATRIC ASSOCIATION, 2013)

- Hypomanic Episode (Common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.)
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity
or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.
B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is
only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a signi cant degree:
1. In ated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., 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 (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.
7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging 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 individual 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. If
there are psychotic features, the episode is, by de nition, manic.
F. The episode is not attributable to the physiological e ects of a substance (e.g., a drug of abuse, a medication, other treatment).
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 DIAGNOSTIC CRITERIA (5TH ED.; DSM-5; AMERICAN PSYCHIATRIC ASSOCIATION, 2013)

- Major Depressive Episode (common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.)
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 attributable to another medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation
made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
2. 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).
3. Signi cant 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 gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about
being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a speci c plan, or a suicide attempt or a speci c plan for
committing suicide.
B. The symptoms cause clinically signi cant distress or impairment in social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological e ects of a substance or another medical condition.
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BIPOLAR II DISORDER
 DIAGNOSTIC CRITERIA (5TH ED.; DSM-5; AMERICAN PSYCHIATRIC ASSOCIATION, 2013)

- For a diagnosis of bipolar II disorder, it is necessary to meet the following criteria for a current or past hypomanic episode and the following
criteria for a current or past major depressive episode:

- Hypomanic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4
consecutive days and present most of the day, nearly every day.
B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms have persisted (four if the mood is only irritable),
represent a noticeable change from usual behavior, and have been present to a signi cant degree:
1. In ated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., 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 (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.
7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging 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 individual 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. If there are psychotic features, the
episode is, by de nition, manic.
F. The episode is not attributable to the physiological e ects of a substance (e.g., a drug of abuse, a medication or other treatment).
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 DIAGNOSTIC CRITERIA (5TH ED.; DSM-5; AMERICAN PSYCHIATRIC ASSOCIATION, 2013)

- 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 attributable to a medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation
made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
2. 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).
3. Signi cant 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 gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about
being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a speci c plan, a suicide attempt, or a speci c plan for
committing suicide.
B. The symptoms cause clinically signi cant distress or impairment in social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological e ects of a substance or another medical condition.
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DIAGNOSTIC CRITERIA (5TH ED.; DSM-5; AMERICAN PSYCHIATRIC ASSOCIATION, 2013)

A.Criteria have been met for at least one hypomanic episode and at least one major
depressive episode.
B.There has never been a manic episode.
C.The occurrence of the hypomanic episode(s) and major depressive episode(s) is not
better explained by schizoa ective disorder, schizophrenia, schizophreniform disorder,
delusional disorder, or other speci ed or unspeci ed schizophrenia spectrum and other
psychotic disorder.
D.The symptoms of depression or the unpredictability caused by frequent alternation
between periods of depression and hypomania causes clinically signi cant distress or
impairment in social, occupational, or other important areas of functioning.

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PREVALENCE (5TH ED.; DSM-5; AMERICAN PSYCHIATRIC ASSOCIATION, 2013; MALAYSIA PSYCHIATRY ASSOCIATION, N.D.)

- The 12-month prevalence estimate in the continental United States was 0.6% for bipolar
I disorder as de ned in DSM-IV. Twelve-month prevalence of bipolar I disorder across 11
countries ranged from 0.0% to 0.6%.
- The lifetime male-to-female prevalence for bipolar I disorder ratio is approximately 1.1:1.
- The 12-month prevalence of bipolar II disorder, internationally, is 0.3%. In the United
States, 12-month prevalence is 0.8%.
- Some, but not all, clinical samples suggest that bipolar II disorder is more common in
females than in males, which may re ect gender di erences in treatment seeking or
other factors.
- In Malaysia, it is estimated that about 1% of the population su ers from bipolar disorder
i.e. there are about 250,000 people with bipolar disorder in the country

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RISK FACTORS (5TH ED.; DSM-5; AMERICAN PSYCHIATRIC ASSOCIATION, 2013)

- Environmental
- More common in high-income than in low-income countries (1.4 vs. 0.7%). Separated,
divorced, or widowed individuals have higher rates of bipolar I disorder than do individuals
who are married or have never been married, but the direction of the association is unclear.
- Genetic and Physiological
- Family history of bipolar disorders
- There is an average 10-fold increased risk among adult relatives of individuals with bipolar I
and bipolar II disorders.
- Magnitude of risk increases with degree of kinship.
- Schizophrenia and bipolar disorder likely share a genetic origin, re ected in familial co-
aggregation of schizophrenia and bipolar disorder.
- There may be genetic factors in uencing the age at onset for bipolar disorders.

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RISK FACTORS (NHS, 2023)

- Triggers
- A stressful circumstance or situation often triggers the symptoms of bipolar
disorder.
- Physical illness
- Sleep disturbances
- Overwhelming problems in everyday life, such as problems with money, work or
relationships

- Chemical imbalance in the brain

- There's some evidence that if there's an imbalance in
the levels of 1 or more neurotransmitters, a person
may develop some symptoms of bipolar disorder.
- There's evidence that episodes of mania may occur
when levels of noradrenaline are too high, and
episodes of depression may be the result of
noradrenaline levels becoming too low.

COURSE AND PROGNOSIS (5TH ED.; DSM-5; AMERICAN PSYCHIATRIC ASSOCIATION, 2013; GANTI ET. AL, 2019)

- Bipolar I Disorder
- After an individual has a manic episode with psychotic features, subsequent manic episodes
are more likely to include psychotic features.
- Untreated manic episodes generally last several months.
- Incomplete inter-episode recovery is more common when the current episode is accompanied
by mood-incongruent psychotic features.
- The course is usually chronic with relapses; as the disease progresses, episodes may occur
more frequently.
- Ninety percent of individuals after one manic episode will have a repeat mood episode within
5 years.
- Bipolar disorder has a poorer prognosis than MDD.
- Maintenance treatment with mood stabilizing medications between episodes helps to ↓ the
risk of relapse

COURSE AND PROGNOSIS (5TH ED.; DSM-5; AMERICAN PSYCHIATRIC ASSOCIATION, 2013; GANTI ET. AL, 2019)

- Bipolar II Disorder
- Early and insidious onset, with a chronic course.
- Depressive symptoms much less likely to resolve than in MDD.
- A rapid-cycling pattern is associated with a poorer prognosis.
- Return to previous level of social function for individuals with bipolar II disorder is more likely
for individuals of younger age and with less severe depression, suggesting adverse e ects of
prolonged illness on recovery.
- More education, fewer years of illness, and being married are independently associated with
functional recovery in individuals with bipolar disorder, even after diagnostic type (I vs. II),
current depressive symptoms, and presence of psychiatric comorbidity are taken into
account.

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SUICIDE RISK (5TH ED.; DSM-5; AMERICAN PSYCHIATRIC ASSOCIATION, 2013)

- The prevalence rates of lifetime attempted suicide in bipolar II and bipolar I disorder
appear to be similar (32.4% and 36.3%, respectively)
- Bipolar I Disorder
- Estimated to be at least 15 times that of the general population.
- Bipolar disorder may account for one-quarter of all completed suicides.

- Bipolar II Disorder
- Approximately one-third of individuals with bipolar II disorder report a lifetime history of suicide
attempt.
- The lethality of attempts, as de ned by a lower ratio of attempts to completed suicides, may be
higher in individuals with bipolar II disorder compared with individuals with bipolar I disorder
- There may be an association between genetic markers and increased risk for suicidal behavior
in individuals with bipolar disorder, including a 6.5-fold higher risk of suicide among rst-degree
relatives of bipolar II probands compared with those with bipolar I disorder.

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DIFFERENTIAL DIAGNOSIS (5TH ED.; DSM-5; AMERICAN PSYCHIATRIC ASSOCIATION, 2013)

- Major Depressive Disorder

- Cyclothymic Disorder
- Schizophrenia spectrum and other related
psychotic disorders
- Panic disorder or other anxiety disorders
- Attention-de cit/hyperactivity disorder
- Personality disorders
- Substance/medication-induced bipolar disorder
- Disorders with prominent irritability
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 COMORBIDITY (5TH ED.; DSM-5; AMERICAN PSYCHIATRIC ASSOCIATION, 2013)

- Anxiety disorder (e.g., panic attacks, social anxiety disorder [social phobia], speci c
phobia) - occurring in approximately three-fourths of individuals
- Children and adolescents with bipolar II disorder have a higher rate of co-occurring
anxiety disorders compared with those with bipolar I disorder, and the anxiety
disorder most often predates the bipolar disorder.
- ADHD
- Any disruptive, impulse-control, or conduct disorder (e.g., intermittent explosive disorder,
oppositional de ant disorder, conduct disorder)
- Substance use disorder (e.g., alcohol use disorder) occur in over half of individuals with
bipolar I disorder.
- Approximately 14% of individuals with bipolar II disorder have at least one lifetime eating
disorder, with binge-eating disorder being more common than bulimia nervosa and
anorexia nervosa.
- Adults has high rates of serious and/or untreated co-occurring medical conditions
- Metabolic syndrome
- Migraine
- Approximately 60% of individuals with bipolar II disorder have three or more co-occurring
mental disorders; 75% have an anxiety disorder; and 37% have a substance use disorder

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ASESSMENT (MILLER ET. AL., 2009; NEURA, 2021; SEMPLE & SMYTH, 2013)

Diagnostic Assessment
- Mood Disorder Questionnaire (MDQ)
- Self-rated screen for bipolar disorder.
- 13 yes/no questions, and two others.
- Positive screen is ‘yes’ 7/13, and ‘yes’ to question 2, moderate/serious to
question 3.
- Young Mania Rating Scale (YMRS)
- Assesses mania symptoms and weighted severity over the past 48 hr.
- Schedule for A ective Disorders and Schizophrenia (SADS)
- Interview probes, symptom thresholds, and information about exclusion criteria
(i.e., medical or pharmacological conditions that may induce mania)
- Psychotic symptoms are more likely to yield a diagnosis of schizoa ective
disorder
- Focus on the symptoms for the most recent episode and then capture a broad
overview of past episodes.

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 ASESSMENT (MILLER ET. AL., 2009; NEURA, 2021; SEMPLE & SMYTH, 2013)

Self-report Measures
- General Behavior Inventory (GBI)
- Cover the core symptoms of bipolar disorder
- Hypomanic Personality Scale (HPS)
- Predicted the development of manic episodes at 13-year follow-up in
undergraduates
- Altman Self-Rating Mania Scale (ASRM)
- Quick Inventory of Depressive Symptomatology–Self Report (QIDS – SR)
- Internal State Scale (ISS)
Outcome Assessment Tools
- Bech-Rafaelsen Mania Rating Scale (MAS)
- Quick Inventory of Depressive Symptomatology (QIDS)
- Bipolar Inventory of Symptoms Scale (BISS).

 TREATMENT (GANTI ET. AL, 2019)

- Pharmacotherapy
- Lithium is a mood stabilizer; 50–70% treated with lithium show partial reduction of
mania. Long-term use reduces suicide risk. Acute overdose can be fatal due to its low
therapeutic index.
- The anticonvulsants carbamazepine and valproic acid are also mood stabilizers. They
are particularly useful for rapid cycling bipolar disorder and those with mixed features.
- Atypical antipsychotics (e.g., risperidone, olanzapine, quetiapine, ziprasidone) are
e ective as both monotherapy and adjunct therapy for acute mania. In fact, many
patients (especially with severe mania and/or with psychotic features) are treated with
a combination of a mood stabilizer and antipsychotic; studies have shown a greater
and faster response with combination therapy.
- Antidepressants are discouraged as monotherapy due to concerns of activating mania
or hypomania. They are occasionally used to treat depressive episodes when patients
concurrently take mood stabilizers.
- Psychotherapy
- Supportive psychotherapy, family therapy, group therapy (may prolong remission once
the acute manic episode has been controlled).
- ECT
- Works well in treatment of manic episodes.
- Some patients require more treatments (up to 20) than for depression.
- Especially e ective for refractory or life-threatening acute mania or depression.
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REFERENCES
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Clark, M. (2016). The History of Bipolar Disorder. https://bipolarbandit.wordpress.com/2016/04/01/the-history-of-
bipolar-disorder-infographic/
Ganti, L., Kaufman, M. S., & Blitzstein, S. (2019). First aid for the psychiatry clerkship (Fifth Edition). McGraw-Hill
Education.
Malaysian Psychiatric Association. (n.d.). Bipolar Disorder – About: What is Bipolar Disorder?. https://psychiatry-
malaysia.com/public/public-education/mental-disorders/bipolar-disorder/bipolar-disorder-about/
Miller, C. J., Johnson, S. L., & Eisner, L. (2009). Assessment Tools for Adult Bipolar Disorder. Clinical psychology : a
publication of the Division of Clinical Psychology of the American Psychological Association, 16(2), 188. https://
doi.org/10.1111/j.1468-2850.2009.01158.x
NHS. (2023). Causes - Bipolar Disorder. https://www.nhs.uk/mental-health/conditions/bipolar-disorder/causes/
Neura. (2021). Bipolar disorder assessment tools. https://library.neura.edu.au/bipolar-disorder/assessment-and-
diagnosis/outcome-assessment-tools-2/
Semple, D., & Smyth, R. (2013). Oxford Handbook of Psychiatry (Third Edition). Oxford University Press.

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