Chapter 4 Bipolar refers to fluctuations of a good or irritable mood (APA, 2013a; NIMH, 2012). The swings between mania and depression can sometimes be quite severe. Although bipolar was not officially included in the DSM until the third edition (APA, 1980), writers as far back as the ancient Greeks referred to melancholia and mania related to behavior. Aretaeus of Cappadocia wrote of individuals who displayed high levels of energy and euphoria followed by periods of melancholy (Burton, 2012). During the 19th century, psychiatric professionals used terms such as manic-depressive and affective psychosis as descriptive for this phenomenon (APA, 2013a). Kraepelin (1921) theorized that these symptoms were separate from psychosis and conceptualized them on a spectrum, emphasizing outcome as a criterion. Originally termed manic depressive illness in the first DSM, the diagnosis was renamed bipolar disorder in the DSM-III because of the stigma associated with manic depression and the attempt to explain the polarity of disorder rather than simply focus on symptomatology. Currently, theorists debate the need for conceptualization of bipolar disorder on a spectrum (Merikangas et al., 2007; Paris, 2009). Since the DSM-III, the diagnosis of bipolar disorder has increased rapidly, particularly for adolescents, for whom claims of increase fall between 10% and 40% (Jenkins, Youngstrom, Washburn, & Youngstrom, 2011). CNN (see Gardner, 2011) reported that 4.4% of individuals in the United States will be diagnosed on the bipolar spectrum in their lifetimes, making the United States the highest in the world for bipolar disorder diagnosis. NIMH (2012) reported bipolar disorder as the sixth leading cause of disability worldwide. Individuals diagnosed with bipolar disorder have the highest rates of suicide and premature death related to medical disorders (Merikangas et al., 2007), with a 10–20 times increased risk of suicide compared with the U.S. population in general (Jenkins et al., 2011). The major changes to the Bipolar and Related Disorders chapter in the DSM-5 include its strategic location. Whereas in the DSM-IV-TR bipolar disorders were presented within the mood disorders section, the DSM-5 includes bipolar and related disorders as a stand-alone chapter, located between schizophrenia spectrum and other psychotic disorders and depressive disorders (APA, 2013a). In addition, the mixed episode criteria have been discontinued and reorganized into a new specifier. Bipolar II is no longer considered a milder diagnosis than Bipolar I, because of the intensity of the impairment experienced by clients with this disorder and the length of time depressive symptoms are experienced. Both mania and hypomania criteria now emphasize changes in activity or energy, and other specified bipolar and related disorders have been added as a category (APA, 2013c). As with depressive disorders, comorbidity seems to be the rule rather than the exception for bipolar and related disorders. Because individuals tend to seek treatment more frequently when they are experiencing depression, bipolar and related disorders are frequently mistaken for depression or anxiety. Furthermore, symptoms consistent with hypomania are often unreported or misdiagnosed as anxiety. Together, it is estimated that between 20% and 30% of individuals being treated for depression and anxiety symptoms have a bipolar disorder (Manning, 2010). In other cases, bipolar disorder may go completely unrecognized. Das et al. (2005) screened individuals at a primary care facility for bipolar disorder. Of the 81 individuals who qualified for a bipolar disorder diagnosis, just 9% had been diagnosed with bipolar or related disorders. Remaining participants were undiagnosed or carried depressive, substance use, and anxiety disorder diagnoses. Manning (2010) posited that thorough history, accurate assessments, and a good therapeutic alliance, including multiple contacts with the client, might be key to accurately diagnosing bipolar and related disorders. Although no one single explanation can be given, researchers and theorists posit a variety of contributors to bipolar disorder, including life stress, genetic predisposition, neurobiological factors, psychosocial factors, environmental issues, brain structure, ion activity, and impaired executive functioning (Alloy, Abramson, Urosevic, Bender, & Wagner, 2009; R. J. Comer, 2013; Hankin, 2009). Understanding the factors that contribute to bipolar symptoms can inform well-rounded, evidence-based treatments. Traditionally recommended treatment for bipolar and related disorders includes psychotherapy in conjunction with mood-stabilizing medication. Psychoeducation, CBT, family-focused therapy, and interpersonal and social rhythm therapy have been shown to be effective in treating the symptoms of bipolar disorder (Steinkuller & Rheineck, 2009). Lithium and other mood stabilizers have had high success rates in decreasing manic episodes and symptoms; however, individuals who discontinue medication are at very high risk of relapse (R. J. Comer, 2013). Psychoeducation can emphasize the importance of lifestyle management and regular medication use and assist with social skills and relationship building (R. J. Comer, 2013). Because of the impact of bipolar disorder on the individual, family, and community, it is critical that counselors are able to recognize the disorder. Individuals who experience bipolar disorder tend to have more health problems, experience relationship issues, and are at risk for suicidal ideation and attempts (R. J. Comer, 2013; Steinkuller & Rheineck, 2009). Because of issues with comorbidity, many clients in mental health centers may not be fully treated for the symptoms of bipolar disorder (Manning, 2010). Rather than attend solely to initial presenting problems (which may be depressive or anxious in nature), counselors need to attend to the possibility of bipolar disorder through a full and complete assessment, which may be over several sessions. To help readers better understand changes from the DSM-IV-TR to the DSM-5, the rest of this chapter outlines each disorder within the Bipolar and Related Disorders chapter of the DSM-5. Readers should note that we have focused on major changes from the DSM-IV-TR to the DSM-5; however, this is not a stand-alone resource for diagnosis. Although a summary and special considerations for counselors are provided for each disorder, when diagnosing clients, counselors need to reference the DSM-5. It is essential that the diagnostic criteria and features, subtypes and specifiers (if applicable), prevalence, course, and risk and prognostic factors for each disorder are clearly understood prior to diagnosis. The constant energy was amazing. It felt like I was connected to everything and everyone all at once. Everything I saw was beautiful, and I bought everything I wanted. But after about a week or so, the crash would come and I would be miserable. The misery would increase over time until I didn’t want to live anymore. No one understood. My wife eventually left, and I can’t pay for all things that I bought. —Richard With a lifetime prevalence of 0.8% (Merikangas et al., 2007), Bipolar I disorder is characterized by the presence of at least one manic episode. This episode can precede or follow major depressive or hypomanic episodes. Most individuals who meet full criteria for manic episodes also experience major depressive episodes. Although major depressive episodes are not required for diagnosis, it is atypical for manic episodes to occur without a history of depression (APA, 2013a). At least one episode of mania is required for a Bipolar I disorder diagnosis. Symptoms of a manic episode will occur for at least a week, almost every day, with symptoms being present most of the day. During this time, the individual will experience abnormally increased goal-directed activity or heightened energy levels along with persistently elevated, irritable, or expansive mood (APA, 2013a). The individual will experience some additional symptoms that represent a noticeable change from usual behavior. If the mood is irritable only, he or she will experience at least four of the following symptoms (for other mood presentations, three or more of the following are required): exaggerated self-esteem or grandiosity; limited need for sleep; pressured speech or abnormally talkative self-report of racing thoughts or flight of ideas; inability to concentrate or easily distractible as indicated by self or others; significant increase in psychomotor agitation or goal-directed activity that is often social, work, or sexually related; and increased involvement in high-risk behavior or activities that could result in painful consequences (APA, 2013a). In addition to current or historical presence of a manic episode, individuals with Bipolar I disorder often have histories involving major depressive and hypomanic episodes. Contrary to popular belief regarding the nature of bipolar disorder as involving rapid mood swings, mood episodes may go on for weeks or months at a time, resolve, and then be followed several months (or more) later with another mood episode. As with MDD, Bipolar I disorder is associated with high rates of lethality. Some researchers speculate that between 25% and 50% of individuals suffering from this disorder attempt suicide (Jamison, 2000), and APA (2013a) estimates the suicide risk to be 15 times that of the general population. The length of depressive episodes and previous suicide attempts are related to elevated risk. In addition, individuals who are experiencing a manic episode often engage in risky, even life-threatening, behaviors as part of the course. Counselors need to be particularly aware of these risk factors and engage clients who have bipolar disorder in risk assessments and crisis planning. Counselors also need to be aware of the impact of Bipolar I disorder on the family system. R. J. Comer (2013) noted that the “roller coaster ride” (p. 224) of bipolar emotions results in dramatic impact on the individual’s friends and family. Health care costs for an individual with Bipolar I disorder are 3 times higher than costs for other individuals because there are significantly more hospital visits, doctor visits, and medications (Chatterton, Ke, Lewis, Rajagopalan, & Lazarus, 2008). As a result of their symptoms, individuals with this disorder experience higher divorce rates and chronic relationship instability. Because of this disruption and the impact on functioning, family members should be included in the therapeutic process whenever possible (Steinkuller & Rheineck, 2009). Although it may require lifelong management, there are effective treatments for Bipolar I disorder. Mood-stabilizing medications have been shown to be effective for treatment, and many researchers agree that a combination of psychotherapy and medications is the most effective treatment (R. J. Comer, 2013; Culver, Amow, & Ketter, 2007; Steinkuller & Rheineck, 2009). Evidence-based interventions for treating Bipolar I disorder include psychoeducation, CBT, family-focused therapy, and interpersonal and social rhythm therapy (Steinkuller & Rheineck, 2009). Counselors can use these interventions for assisting clients with Bipolar I disorder. Although Bipolar I disorder occurs as frequently in women as in men, women tend to experience more rapid cycling and depressive episodes than men (R. J. Comer, 2013; Ketter, 2010). Concurrent with Bipolar I, women also experience higher rates of eating disorders and substance use disorders (APA, 2013a). In terms of cultural variation, individuals diagnosed with Bipolar I disorder often have lower socioeconomic status, higher rates of disability, and lower life expectancy (R. J. Comer, 2013; Ketter, 2010). Despite being one of the most distinct diagnoses in mental health treatment, there is sparse information on how Bipolar I disorder manifests in different populations (APA, 2013a; Belmaker, 2004). Some studies have indicated higher levels of prevalence in African American and Caucasian samples (APA, 2013a), whereas other studies have claimed little variation in rates of bipolar disorder across cultures (R. J. Comer, 2013; Ketter, 2010). This discrepancy is most easily explained by the hallmark symptom of Bipolar I disorder, mania, which varies significantly according to culture, country of residence, and socioeconomic class. More research on the cultural presentation of this disorder is needed. For Bipolar I disorder diagnosis, the manic episodes cannot be better explained by substance use or a medical condition and must be severe enough to result in significant impairment in functioning, include psychotic features, or require hospitalization. The APA (2013a) notes that if an individual experiences a manic episode while receiving antidepressant treatment, the diagnosis is warranted as long as the episode continues with full criteria met after the effects of the treatment are over. Symptoms of Bipolar I disorder must present in an episode and represent a marked difference in one’s baseline functioning, thus differentiating Bipolar I disorder from symptoms of a personality disorder. A personality disorder should never be diagnosed during a manic episode (APA, 2013a). Moreover, symptoms of mania or hypomania can occur along with MDD. If the episodes are shorter in duration than required or have fewer symptoms than is necessary for a Bipolar I disorder diagnosis to be given, MDD or Bipolar II disorder can be diagnosed. Anxiety disorder and panic symptoms should be explored through careful determination of the episodic nature of the client’s symptoms. Gathering a thorough history of symptoms can be crucial to helping differentiate panic or anxiety from a true experience of mania (APA, 2013a). Because onset for this disorder usually occurs between 15 and 44 years of age (R. J. Comer, 2013), counselors will need to differentiate between mania and ADHD, especially in adolescents (APA, 2013a). Whereas ADHD symptoms are continuous, Bipolar I symptoms should be episodic, which will help counselors to differentiate between the two. Severe irritability can present a similar challenge, particularly in children; a diagnosis of DMDD may be more appropriate if an episode of mania is not clearly present (APA, 2013a). The diagnostic code for Bipolar I disorder is 296. _ _ (F31._ _). Coding for Bipolar I disorder is based on the current or most recent episode only. Counselors must also specify severity, whether psychotic features are present, and whether the client is in partial or full remission. If psychosis is present, the specifier with psychotic features is given. If the episode includes psychotic features, that code is given rather than specifying severity. Severity indicators are listed as mild, moderate, or severe. Remission status includes in partial remission or in full remission. An unspecified episodes specifier may also be given (APA, 2013a). As shown in the table on pages 126–127 of the DSM-5, all coding numbers for these specifiers are based on whether the most recent or current episode is manic, hypomanic, or depressed. When the name of the diagnosis is given, Bipolar I is stated or written first, followed by the type of episode (i.e., manic, hypomanic, or depressed), and finally any and all the noncoded specifiers that apply. We discuss additional specifiers for bipolar and related disorders at the end of this chapter. Readers can also see pages 149–154 in the DSM-5 for more information regarding specifiers for bipolar and related disorders. Counselors should note that the DSM-5 incorrectly published coding numbers for Bipolar I disorder, current or most recent episode hypomanic, with the in partial remission and in full remission specifiers. As published, the second decimal point of the ICD-10-CM code is incorrect. For the Bipolar I disorder, current or most recent episode hypomanic, in partial remission, the diagnostic code is published as F31.73 but should be F31.71. For the Bipolar I disorder, current or most recent episode hypomanic, in full remission, the diagnostic code is published as F31.74 but should be F31.72. The accurate diagnostic codes for this disorder with these specifiers should be: Vincent is a 28-year-old African American man who has just completed a major work project. He and his team were contracted to complete the project within a 2-month timeframe. Vincent bragged, however, that he is good enough to get the work done in half the time. About 2 weeks into the project, his energy level “went on high” as it has done in the past. Vincent states that he slept a couple of hours a day, working at fevered pitch. He states that he was the best contractor ever hired and that, even though his colleagues told him he was edgy and difficult most of the time, he knew this was not the case because women were “all over him.” In fact, he bragged about taking a different woman home almost every night. After a little over a week, his energy level slowly returned to normal and the work was completed early, as he predicted, making his employer very happy.
Bipolar and Related Disorders
Major Changes From DSM-IV-TR to DSM-5
Differential Diagnosis
Etiology and Treatment
Implications for Counselors
296. _ _ Bipolar I Disorder (F31._ _)
Essential Features
Special Considerations
Cultural Considerations
Differential Diagnosis
Coding, Recording, and Specifiers
Case Example
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
