CLASSIFICATION OF BIPOLAR AFFECTIVE DISORDERS

Chairperson: Dr. K. Krishnamurthy Presenter: Dr. Wilona

Introduction
Mood disorders are among the most frequent psychiatric illnesses both in the community and in psychiatric settings Patients commonly present with features of either mania or depression and sometimes both These disorders virtually always result in impaired interpersonal, social, and occupational functioning

Introduction
After relative neglect in the age of melancholy during the 1970s and 1980s there has been a renaissance of bipolar disorder during the last decade of the 20th century Recent survey of the members of the depressive and Manic- Depressive Association in the united states found that early misdiagnosis was common, and often a decade elapsed before the correct diagnosis

Introduction
The signs and symptoms of the classical cyclical illness are unmistakable However, very often an insiduous onset or subthreshold symptoms may present a diagnostic challenge What has emerged from recent studies is that bipolar disorders consist of a group of overlapping clinical sub-types

History
A state of raving madness with exalted mood Greeks Hippocrates Used the term mania and melancholia to describe mental illness. Believed that the illness often arose from the substrate of the melancholic temperaments, which under the influence of planet Saturn made the spleen secrete black bile, ultimately leading to mood darkening , through its influence on the brain.

History
Aulus Corneleus described melancholia as depression caused by black bile. Bonet described a mental illness called manico melancholicus. Soranus described mania as remitting illness which in some patients had a admixture of melancholia: continual wakefulness, and fluctuating states of anger and merriment, sometimes of sadness and futility during the same episode

History
Aretaeus of Cappadocia is credited with explicitly stating the connection between the two major mood states and described the cardinal features of mania. States that melancholy is the commencement and a part of mania Mania- a disease of adolescent & young men given intermittently to active habits, drunkenness & lechery Also reported of secondary personality changes Exacerbation more frequent in spring

History
Jules Falret coined folie circulaire described patient who became depressed and elated in cyclic fashion.
Jules Baillarger coined folie a double forme, - in which the patients became deeply depressed and feel into a stupurous state from which he would eventually recover. Karl Ludwig Kahlaum The episodes of mania and melancholia were different stages of the same disease process, called cyclothymia.

History
Emil Kraeplin Grouped mania & melancholia together Concluded that all of the mood disorder are identical in certain ways , this formulation of a single underlying disorder was widely accepted for several decades. Also termed the involutional melancholia Observed that manic depressive psychosis was a separate entity from schizophrenia.

History
Kraeplins principle Various forms had a common heredity Frequent transitions from depression to mania or vice versa Superimposed episodes opposite to habitual temperaments Depression and manic episodes could intermix during the same episode Recurrent course with illness free intervals

Kraeplins Concept of mixed states in contemporary practice.

Type of mixed state

Anxious depressive mania Excited depression Depression with flight of ideas

mood thinking activity

History
Karl Abraham accepted Kraeplins notion of single mood illness.

Sigmund Freud emphasized the importance of loss in depression. Anger is turned inwards in depressed individuals Determined that some depression are psychogenic and others are biological.

History
Unipolar bipolar distinction The proposal to divide manic depressive illness into separate bipolar and unipolar first brought by Leonhard. Angst produced convincing evidence Perris showed that bipolar started on an average fifteen years earlier than depression and recurred more frequently

History
Henry Maudsley coined the term affective disorder Pope Lipinski explained schizophrenia symptoms in manic depressive psychosis

Akiskal - 1983 broadened the bipolar spectrum.

Contemporary classificatory approaches

Unipolar Bipolar Distinction Many researchers working independently in different continents found there is a difference between Unipolar and Bipolar depression Observation in past two decades have found an overlap between those extremes Pseudounipolar

Differences between the two

Feature
Mania / Hypomania Sex ratio Age at onset Post partum episodes Onset of episode

Bipolar
Present Equal Teens, 20s,30s More common Often abrupt

Unipolar
Absent More in women 30s,40s,50s Less common More insidious

Anti depressants
Lithium

Induced hypomania/ Mania

Acute Anti depressant effect

Rare
Generally ineffective

Probabilistic approach
Unipolar depression more likely if 4 Bipolar depression more likely if 4 Symptomatology

Insomnia Decreased appetite

Psychomotor agitation Somatic complaints

Hypersomnia Hyperphagia
Psychomotor retardation Other atypical symptoms Psychosis and/ or pathological guilt Mood lability or manic symptoms Course of illness

Later onset > 25 yrs Long current depression > 6 months No bipolar disorder

Earlier onset < 25 yrs Multiple depressions 5 episodes Family history Bipolar disorder
Proposed by Task Force on Diagnostic Guidelines of the International Society For Bipolar Disorders

The overlap
Firstly there are depressive patients who experience very brief hypomanic episodes Secondly 10-20% patients with MDD subsequently develop hypo or manic episodes and have to reclassified bipolar I or II . Average latency of 6 years noticed from first depressive episode Thirdly there are unipolar patients in Bipolar Pedigree common genetic linkage

So
This overlap explains why some apparently unipolar patients respond to lithium monotherapy or augmentation Kraeplin declared that the illness pursued an indefinite number of courses but he was sceptical of subdivisions since it would undermine his concept of manic depressive illness The question is whether there are validated clinical subtypes ?

Bipolar Subtypes - general

Bipolar I Bipolar II Bipolar III Bipolar IV

Bipolar I
Teenage years the 20s or 30s First episode can be manic, depressive or mixed Common mode of onset is mild retarded depression or hypersomnia for few weeks or months which often switches to manic episode In others several depressive episodes occur before first mania Secondary manias occur in association with cerebral, endocrine, and other systemic medical conditions. Irritable mood prevails

Bipolar II
Typically present with MDD and upon enquiry history of hypomanic episodes elicited Rates were underestimated till recently Documenting hypomania among subjects suspected of cyclothymia Complexity is less severe symptom intensity but more severe course Mood lability is a most specific predictor for switch Diagnosis is crucial for prognosis High suicidality

Bipolar III
Antidepressant mobilised switch These hypomanic episodes are somewhat milder and less likely with SSRI than TCA MAOI induce euphoric while TCA induce dysphoric hypomania Probing may reveal hypomanic episodes in the past Can occur in patients with dysthymia as well as ocd, social phobia and panic disorders

Bipolar IV
Experience cycles of depression and hyperthymia Hyperthymia is characterised by lifelong traits of upbeat, energy driven and overconfident disposition Hyperthymic traits precede manic episodes

Klerman classification
Bipolar I - same Bipolar II same Bipolar III Cyclothymia Bipolar IV Hypomania or mania precipitated by medication Bipolar V Depressed patient with Bipolar relatives Bipolar VI Mania without Depression

Cyclothymia
Individuals In whom Low grade affective manifestations of a subdepressive and mild hypomanic nature oscillated over long periods of life span Could occur throughout life without progression to major affective episodes and if episodes do occur they return to their cyclothymic baseline Biphasic shifts lasts typically no more than a few days Strong familial association with Bipolar disorder. Linked more to Bipolar II than I Occurs in 6% of general population

Are there only 4 or 6 subtypes?

A strong case can be made for Bipolar I, II, III, IV. However Kraeplin after charting 18 patterns of affective phases in his large manic-depressive sample found that there were so many other patterns that the task of delineating specific course patterns could not be achieved Therefore Akiskal brought about the intermediary subtypes

Akiskal classification
Bipolar I: full blown mania -manic depressive illness has an explosive manic onset with psychosis while some have mixture of depression and mania

Bipolar I1/2
Depression with protracted hypomania -where hypomania ends and mania starts is not clearly demarcated -patients exist between these extremes with protracted hypomanic periods which cause some trouble to the patient and significant others without reaching the destructive potential of mania

Bipolar II
Depression with hypomania -moderately to severely impairing major depressions, interspersed with hypomanic periods of at least 4 days duration without marked impairment -signs and symptoms of hypomanic episode represent a departure from the patients habitual baseline -although behavior is colored by elated mood, confidence and optimism ,judgement is relatively preserved compared with mania

- The cyclic mood changes permit normal to supernormal periods of functioning - A considerable number of patients are able to rebound from their difficult periods to attain new conjugal or occupational status sunny bipolar IIs

Bipolar II 1/2
Cyclothymic depressions - Many soft bipolar patients do not meet criteria for Bipolar II due hypomanic episodes being in range of 1 to 3 days compared to criteria which exists for 4 days - Patients with short hypomania often have a recurrent pattern of periods of excitement which are followed by minidepressions thereby fulfilling criteria for cyclothymia

- When a major depressive episode is superimposed on this baseline , the diagnosis of bipolar may be completely missed because the instability in the life of a cyclothymic may be of such a degree that these patients meet criteria for axis II cluster B personality disorder at the trait level - They are more prone to be labelled borderline than affectively ill - Mood lability represents the most powerful predictor of which depressive patient would develop frank hypomania

- The mood lability in this bipolar shown that most cyclothymic individuals do not exhibit clearcut hypomanic features but instead give evidence of depressive moodiness characterised by brief depressive mood swings . Such moodiness unfortunately gets classified as borderline personality by DSM IV

Bipolar III
Antidepressant associated hypomania

Bipolar III 1/2

Bipolarity masked and unmasked- by stimulant abuse - Patients whose periods of excitement are so closely linked with substance or alcohol use and abuse that it is not always easy to decide whether these periods would have occurred in the absence of such use or abuse - Possible benefit of mood stabilisation is given to these patients who would otherwise be classified as substance induced or withdrawal induced mood disorders

Bipolar IV
Hyperthymic depression - Clinical depression that occurs later in life and superimposed on a lifelong hyperthymic temperament - Many hyperthymics seem protected from depression and if they succumb it is usually later in life - Variant is a pattern whereby the temperament lead to a great deal of trouble in their lives often associated with recurrent depression

- When hyperthymic individuals become depressed the initial episode is hypersomnic retarded - The use of antidepressants tends to destabilise the underlying hyperthymic temperament - Eventually the elements of temperament appear in the depression include increased sexuality and racing thoughts these are depressive mixed states - Hence patients who meet criteria for MDD plus have intrusions of hypomanic signs and symptoms excited depressives

A proposed broad spectrum of bipolar disorders by Akiskal and Pinto.

unstable form of unipolar depression, responding rapidly but in unsustained manner to antidepressants schizobipolar disorder I manic depressive illness I depression with protracted hypomania

 II depression with spontaneous discrete hypomanic episodes II depression superimposed on cyclothymia

III depression + hypomania occurring in association with anti depressants or other somatic treatment III prominent mood swings association with substance &/or alcohol abuse. IV depression superimposed on hyperthymia.

 V recurrent depressions that are admixed with dysphoric hypomania VI late onset depression with mixed mood features, progressing to a dementia like syndrome

ICD 10 classification
F31.0 BPAD, current episode hypomanic F31.1 BPAD, current episode manic without psychotic symptoms F31.2 BPAD, current episode manic with psychotic symptoms F31.3 BPAD, current episode mild or moderate depression .30 without somatic syndrome .31 with somatic syndrome

 F31.4 BPAD, current episode severe depression without psychotic symptoms F31.5 BPAD, current episode severe depression with psychotic symptoms F31.6 BPAD, current episode mixed F31.7 BPAD, currently in remission F31.8 Other BPAD F31.9 BPAD, unspecified

Evolution of bipolar in DSM

DSM-III(1980) - the term 'bipolar disorder' replaced the older term 'manic depressive disorder'. Also, the diagnostic distinction between adult and pediatric bipolar disorder was indicated for the first time. In the DSM-III-R (1987)- diagnoses supplemented with subtyping classifications such as - Bipolar Disorder-Mixed - Bipolar Disorder-Manic - Bipolar Disorder-Depressed - Bipolar Disorder-Not Otherwise Specified - Cyclothymia.

 DSM-IV (1994) and DSM-IV TR-The definition of bipolar disorders has evolved from a monolithic disorder with a single set of criteria, to a more nuanced subtype system, where Bipolar I and Bipolar II forms of the disorder are recognized and differentiated

DSM IV TR classification
Bipolar disorders 296.XX Bipolar I Disorder .0X Single Manic Episode
Specify if: Mixed

.40 Most recent episode Hypomanic .4X Most recent episode Manic .6X Most recent episode Mixed .5X Most recent episode Depressed .7 Most recent episode Unspecified

296.89 Bipolar II Disorder

Specify (current or most recent episode) : Hypomanic / Depressed

301.13 Cyclothymic Disorder 296.80 Bipolar Disorder NOS

Prevalence rate lifetime prevalence rates

Bipolar I 0 2.4% Bipolar II 0.3 4.8% Cyclothymia 0.5 6.8 % Hypomania 2.6 7.8% Full term spectrum 2.6% - 7.8%

BARCELONA INTERNATIONAL CONSENSUS ON BIPOLAR SUB-TYPES BEYOND DSM IV AND ICD 10.
Mood incongruent bipolar psychosis Bipolar I (mania) Mixed mania (>/= 2 depressive symptoms) Bipolar II (hypomania >/= 2 days) Somatic treatment induced hypomania Rapid cycling Cyclothymia Recurrent brief hypomania

The Controversies
The unipolar-bipolar distinction left undefined many affective conditions lying between ,which are encountered in pedigrees of bipolar probands Based on clinical intuition it was argued that phenotypically Unipolar relatives of bipolar probands are genotypically Bipolar Hence 4 5% of general population belongs to broad bipolar spectrum with predominantly depressive phenomenology and muted bipolar features

 Dunner et al - identified these less than manic patients as bipolar II Diagnosis of Bipolar I for those requiring hospitalisation whether it can be a criteria? Akiskal and Mallya soft Bipolar Spectrum How to subdivide the broad clinical terrain of bipolarity on genetic terms? Cassano et al argue that bipolar spectrum is a clinical reality but in search of diagnosis and assessment methodology

DSM Vs ICD concepts

Unipolar disorder is avoided because of risk of conversion to bipolar ICD 10 is less committed to the concept of spectrum Cyclothymia recognised with bipolar in DSM while classified with dysthymia under persistent affective disorder in ICD 10 ICD 10 does not recognise Bipolar II as a category but an example of nondescript other category ICD allows RDD to be diagnosed inspite of hypomanic episodes during recovery

 Both dont include antidepressant induced switch in bipolar rubric Both accept mixed states ICD does not have provision for rapid cycling though

Overall
ICD 10 definition of bipolar phases and subtypes pay greater attention to phenomenology and less attention to arbitrary cut offs on the number of symptoms and their duration with which DSM IV is burdened

DSM 5 and Bipolar disorder

There have been proposals to include further and more accurate subtyping for bipolar disorder (Akiskal and Ghaemi, 2006) More stringent criteria for the diagnosis of bipolar disorder in children. A new diagnosis Temper Dysregulation Disorder with Dysphoria proposed

Conclusions
The clinical phenomenology of bipolar subtypes has remissions and exacerbations and it is not possible to divorce the clinical picture from treatments received As practising clinicians extending the concept of bipolar spectrum to include what others might consider unipolar territory, substance abuse or axis II pathology would help in the cause of shielding these patients from possible negative effects of antidepressants unprotected by mood stabilisers

Conclusions
But there are many controversies regarding this and many researchers may not agree with these The literature is got from patients who are not representative of patients seen in contemporary clinical practise The challenge is to make sense of this larger universe of patients who do not become research subjects