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Adult Psychopathology

Hadiqa Asif (14 SS)

Misbah Musarrat (23 SS)

Maha Sohail (30 M)

Fozia Bibi (33 M)

Inshrah Noor (12 SS)

BS (Hons) 2020-2024

Semester VI

Bipolar and Related Disorders

Mam Faiza Safdar

August 05, 2023

Centre for Clinical Psychology

University of the Punjab
Lahore
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Bipolar and Related Disorders

Diagnostic Criteria

Bipolar and related disorders include seven disorders according to the DSM-V. The disorders

include Bipolar-I, Bipolar-II, Cyclothymic disorder, Substance/Medication-Induced Bipolar and

Related disorder, Bipolar and Related Disorder due to another Medical Condition, Other

Specified Bipolar and Related disorder, and Unspecified Bipolar and Related disorder. All these

seven disorders’ DSM-V diagnostic criteria and symptoms mainly revolve around three episodes.

These three episodes are:

1. Manic Episode

2. Hypomanic Episode

3. Major Depressive Episode

Before going into each disorder’s diagnostic criteria individually, let’s first discuss these three

episodes.

Manic Episode

This episode’s duration period is at least 1 week with abnormal and persistent, elevated,

expansive, or irritable mood; and persistently increased goal directed activity or energy. The

symptoms are present most of the day, nearly every day. A manic episode's mood is frequently

described as euphoric, too much happy, high, or "feeling on top of the world." Sometimes the

mood is so contagious that it is obvious when it is out of control. In these situations, the

enthusiasm for social, sexual, or professional connection may be limitless and random. (APA,

2013). You might experience the manic phase of bipolar disorder as a joyful experience and feel

highly creative (NHS, 2019).

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During this 1-week period, out of the 7 symptoms (as presented below), at least three symptoms

(or more) must be shown by the person (APA, 2013).

This period is marked by increased self-esteem or grandiosity. Inflationary self-esteem can

range from unreflective to overt grandiosity, with delusional dimensions. It can lead to

challenging endeavors and grandiose illusions. Children often overestimate abilities and believe

they are the best in a sport or the smartest student (APA, 2013).

The person’s need for sleep is decreased, i.e., after only 3 hours of sleep, feels rested. Insomnia

is characterized by a desire for sleep but inability to achieve it, while mania is characterized by a

decreased need for sleep. Severe sleep disruption can lead to days without fatigue, and a manic

episode often begins with a decreased need for sleep (APA, 2013).

The person is more talkative than usual. Speech can be hurried, loud, difficult to interrupt, and

quick. It can be invasive or unimportant, with humor, puns, and gestures occasionally used. Loud

and firmly speaking can prioritize the message, while irritated speech may involve complaints,

rude remarks, or enraged outbursts. The person experiences a flight of ideas or racing thoughts

experience (this one if the mood is only irritable). A person's ideas rapidly flow, leading to a

flight of thoughts, causing speech fragmentation and difficulty in communication. This can be

upsetting and challenging for the speaker (APA, 2013).

The client himself may report distractibility or might be observed by others. In social

circumstances, either at school or work, the person experiences increased goal directed activity,

or the person may experience increased non-goal directed activity (psychomotor agitation).

Distractibility involves inability to censor external stimuli (e.g., the interviewer's attire,

background noises or conversations, furnishings in the room), hindering rational conversation

and instructions in individuals with mania (APA, 2013).

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The person’s goal-directed activity or psychomotor agitation is increased. Goal-directed

activity involves increased planning and involvement in various activities, including sexual,

professional, political, or religious ones. Manic episodes often involve increased sociability e.g.,

phoning or contacting friends, strangers, or reestablishing old relationships, pacing, and

psychomotor agitation. Some individuals send excessive letters, emails, and texts to friends,

celebrities, or the media without clear objectives (APA, 2013)

Lastly, the person gets involved in activities that can cause painful consequences. Excessive

optimism, grandiosity, and poor judgment often lead to reckless activities like spending, giving

away possessions, driving, and sexual promiscuity. These actions can lead to unnecessary

purchases and potential interpersonal repercussions (APA, 2013).

The disturbance in mood is very severe to cause marked impairment in social, occupational, or

other important areas of functioning. Hospitalization is necessary to prevent harm to self or

others. You can have psychotic features like hallucinations or delusions (APA, 2015).

This episode is not attributable to the physiological effects of a substance. These criteria

constitute a manic episode (APA, 2013)

Hypomanic Episode

The diagnostic criteria for hypomanic episode are same as the manic episode except it lasts for

at least 4 consecutive days (present most of the day nearly every day). The change is observable

by other people. The disturbance in mood is not severe enough to cause impairment (APA,

2013).

Major Depressive Episode

The duration period for Major Depressive Episode is 2-weeks. Out of the 9 symptoms mentioned

in the DSM-V, five (or more) should be present during this period.
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The person experiences a depressed mood (most of the day, nearly every day). This can either

be reported by the person himself, i.e., subjective report, or observable by others. A major

depressive episode often involves a mood described as melancholy, sad, hopeless, or

discouraged. Melancholy may be initially denied but later revealed during interviews. Some

people report feeling "blah," "no feelings," or "anxious" due to facial expressions. Some focus on

somatic complaints and irritability, blaming others for their problems. Markedly diminished or

loss of interest or pleasure in almost all activities (most of the day, nearly every day). People

may experience reduced engagement, less enjoyment of interests, social retreat, neglect of

pastimes e.g., a child who used to like soccer makes excuses not to practice, or a decline in

sexual activity, often attributed to family members' social retreat or neglect. At least, one of the

five symptoms should be from these two (i.e., depressed mood or loss of interest or pleasure)

(APA, 2013).

Significant weight loss or gain is seen, i.e., more 5% change in weight seen in a month.

Changes in appetite might be either an increase in appetite or reduction. Some people with

depression claim they have to push themselves to eat. Some people could eat more and have

cravings for certain meals (such sweets or other carbs). When hunger changes are large (in either

way), weight may be lost or gained significantly, or in youngsters, projected weight gains may

not be seen (APA, 2013).

Insomnia or hypersomnia is seen nearly every day. Sleep disruption can cause difficulties

falling asleep or excessive sleeping. Insomnia can manifest as middle or terminal insomnia, with

initial insomnia or difficulties falling asleep. Oversleeping can lead to extended sleep episodes or

more naps. Treatment may be sought for disturbed sleep patterns (APA, 2013).
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Psychomotor agitation or retardation is also reported. Psychomotor changes may include

agitation or retardation, affecting sitting, pacing, handwringing, and objects. These changes must

be severe enough to be observable and not subjective (APA, 2013).

Fatigue or loss of energy is reported. Common symptoms include decreased energy, tiredness,

and fatigue, even without physical exertion, and reduced efficiency in tasks like washing and

dressing.

There are feelings of worthlessness or inappropriate guilt. Major depressive episodes often

lead to feelings of worthlessness or guilt, involving unrealistic evaluations of one's worth and

guilt over past failures. This can result in exaggerated responsibility for untoward events and

delusional guilt, as individuals often blame themselves for illness and failure to meet

responsibilities (APA, 2013).

Diminished ability to think or concentrate or indecisiveness are also seen in the person, nearly

every day. They may appear easily distracted or complain of memory difficulties. Those engaged

in cognitively demanding pursuits are often unable to function. Memory difficulties affect

thinking, concentration, and decision-making, leading to cognitive decline and dementia in

elderly individuals. Treatment can resolve problems, but some may develop irreversible

dementia. (APA, 2013).

Lastly, person is occupied by recurrent thoughts of death (not just fear of dying), recurrent

suicidal ideation (without a specific plan) or suicide attempt or a specific plan for committing

suicide. Suicidal thoughts can range from passive desires to recurrent plans. Suicidal individuals

may have organized their affairs, acquired necessary materials, and chosen a location and time

for the suicide. Motivations for suicide may include giving up, ending painful emotions, or not
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being a burden. Resolving such thoughts may be a more meaningful measure of diminished

suicide risk than denial of further plans. (APA, 2013).

Like manic and hypomanic episodes, it causes significant distress or impairment, and the

disturbance is not attributable to the physiological effects of a substance.

After discussing the three episodes, we will now see the diagnostic criteria of Bipolar and

Related disorders one by one.

Bipolar-I Disorder

The criteria for bipolar-I disorder includes at least one manic episode, i.e., may be followed or

preceded by hypomanic or major depressive episodes. It causes clinically significant distress or

impairment (APA, 2013).

Note: For the diagnostic criteria of mania, hypomania, and major depressive episodes; see

above).

Bipolar-II Disorder

The criteria for bipolar-II disorder includes at least one (current or past) hypomanic episode and

at least one (current or past) major depressive episode. There has never been a manic episode. It

also causes clinically significant distress or impairment (APA, 2013).

Cyclothymic Disorder

The duration for cyclothymic disorder is at least 2 years (at least 1 year in children and

adolescents). There have been numerous episodes with hypomanic and depressive symptoms

though the full criteria for a hypomanic episode and major depressive episode have never been

met. The hypomanic and depressive symptoms are of insufficient number, severity,

pervasiveness, or duration to meet full criteria for hypomanic and major depressive episodes

respectively. The person should not be without symptoms for more than two months. None of
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the three episodes’ criteria (manic, hypomanic, and major depressive episodes) have been met

(APA, 2013).

Like Bipolar-I and Bipolar-II disorders, it also causes clinically significant distress or

impairment. Even though some people may function particularly well while experiencing periods

of hypomania, over the long course of the disorder, there must be clinically significant distress or

impairment in social, occupational, or other key areas of functioning because of the mood

disturbance. The impairment may develop because of protracted periods of cyclical, often

unpredictable mood fluctuations (e.g., the individual may be perceived as temperamental,

moody, erratic, inconsistent, or untrustworthy) (APA, 2013).

The disturbance is not attributable to the physiological effects of a substance (a drug of abuse or

medication) or any other medical condition, (e.g., hyperthyroidism).

Substance/Medication-Induced Bipolar and Related Disorder

It is marked by prominent and persistent disturbance in mood like in a manic episode, i.e.,

abnormal, and persistent, elevated, expansive, or irritable mood but here with or without

depressed mood (depressed mood isn’t present in manic episode). Secondly, markedly

diminished or loss of interest in almost all activities or all activities (APA, 2013).

After taking certain evidence from the physical examination, history, or the laboratory findings,

symptoms developed during or soon after intoxication or withdrawal or after exposure to a

medication, and that the medication can produce the symptoms. When hypomania or mania

develops with the use of antidepressants or other therapies and lasts longer than the physiological

effects of a drug, this diagnosis of substance/medication-induced bipolar disorder cannot be

made. In contrast to substance/medication-induced bipolar illness and related disorder, this

condition is thought to be a sign of real bipolar disorder (APA, 2013).

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Manic syndrome symptoms may resemble side effects of antidepressants and psychotropic

medications, but they are not sufficient for diagnosing bipolar disorder. Manic or hypomania

symptoms must be present in significant numbers and meet specific criteria. A single vague

symptom without a full manic or hypomanic state should not justify a diagnosis (APA, 2013).

The disturbance does not occur exclusively during the course of delirium. Delirium is a

disruption in attention (reduced orientation to the surroundings) and attention (lower capacity to

direct, concentrate, sustain, and transfer attention (APA, 2022). The disturbance causes clinically

significant distress or impairment and is not better explained by any other bipolar and related

disorder.

Bipolar and Related Disorder Due to Another Medical Condition

The criteria for bipolar and related disorder due to another medical condition is same as

substance/medication-induced bipolar and related disorder as here also the disturbance does not

occur exclusively during the course of a delirium, causes clinically significant distress and is not

better explained by any other bipolar and related disorder.

Dissimilarity from substance induced disorder includes, like manic episode criterion A, it

includes abnormal and persistent, elevated, expansive, or irritable mood; and persistently

increased goal directed activity or energy. After taking certain evidence from the physical

examination, history, or the laboratory findings, we find that the disturbance is a direct

pathophysiological consequence of another medical condition.

When manic or hypomanic episodes unquestionably preceded a medical condition, bipolar and

related disorders would not be diagnosed because the correct diagnosis would be bipolar disorder

(except in the unusual situation where all prior manic or hypomanic episodes—or, when only

one such episode has occurred, the prior manic or hypomanic episode—were linked to ingesting

a substance/medication) (APA, 2013).

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Other Specified Bipolar and Related disorder

The symptoms do not the full criteria for any of the previous ones. It also causes clinically

significant distress or impairment. It is used in situations in which clinician chooses to

communicate the specific reason that the presentation does not meet the full criteria for any of

the above-described disorders. For example, when short duration hypomanic episodes (2-3 days)

and short duration major depressive episode are present or hypomanic episode without prior

major depressive episode is present (APA, 2013).

Unspecified Bipolar and Related disorder

It used in situations in which clinician chooses NOT to communicate the specific reason that the

presentation does not meet the full criteria for any of the above disorders. It includes

presentations in which there is insufficient information to make a specific diagnosis, i.e., in

emergency room settings (APA, 2013).

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References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

American Psychological Association. (2015). APA Dictionary of Psychology (2nd ed.).

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental

disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

National Health Service. Overview – Bipolar

disorder. (https://www.nhs.uk/mental-health/conditions/bipolar-disorder/overview/) Acce

ssed 11/1/2021.