CLASSIFICATION AND

SPECTRUM OF BIPOLAR
DISORDER
MODERATOR: DR. NAVKIRAN S. MAHAJAN

REFERENCES:
• SYNOPSIS 12TH EDITION
• STAHL’S ESSENTIAL PSYCHOPHARMACOLOGY
• CTP 10TH EDITION
• ICD 11
 INTRODUCTION

 Bipolar and related disorders are episodic mood disorders defined by the occurrence of
Manic, Mixed or Hypomanic episodes or symptoms.

 These episodes typically alternate over the course of these disorders with Depressive
episodes or periods of depressive symptoms.

(ICD 11 )
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.

 Observed that manic depressive psychosis was a separate entity from schizophrenia.
HISTORY

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.
SPECTRUM CONCEPT

 The spectrum concept includes the broad areas of psychiatric phenomenology relating to
a given ‘classical’ form of disorder , but in addition, also goes on to include:
 Core, subthreshold and subclinical symptoms of the classically described disorder
 Atypical symptoms related to the prototypic configuration
 Associated features including signs, isolated symptoms, symptom clusters & behavioral
patterns related to core symptoms
 Temperamental and/or personality traits
 BIPOLAR SPECTRUM
 Broader concept, which questions the strict dichotomous categorical division of erstwhile
manic-depressive illness into two discrete categories viz. bipolar disorder and major
depressive disorder, thereby overlooking a wide ‘spectrum’ of patients which lie ‘in between’
the two extremes.
 Presence of underlying bipolar ‘spectrum’ or ‘soft bipolarity’ often goes undetected in
patients presenting with major depression. This sub-group of patients may not stabilize with
indiscriminate use of anti-depressant drugs, and without proper management, it may be
associated with continued nonresponsive symptoms, increased suicidality and poorer
prognosis.
 Need to suspect and identify such cases of soft bipolarity/spectrum by early screening of
patients with major depression presenting to medical settings.
BIPOLAR SPECTRUM

Bipolar spectrum : encompasses

 sub-threshold, short duration hypomanic symptoms, or
 depression arising in the background of cyclothymia,
 hyperthymic temperament,
 familial bipolarity
 hypomania arising due to treatment.
Depressed patients often fail to report past history of subthreshold hypomanic
symptoms that are usually associated with intact, or even enhanced functioning.
 Manic Episode :
 Major Depressive Episode
 Hypomanic Episode a milder form of mania usually lasts few days with
no marked dysfunction.
 Mixed Episode Meets criteria for both a manic episode and a major
depressive episode
TERMS

 Dysthymia is a less severe form of depression than major depression, but

long-lasting (over 2 years in duration) and often unremitting.
 Cyclothymic disorder is characterized by mood swings between
hypomania and dysthymia but without any full manic or major depressive
episodes
 Hyperthymic temperament: Mood is above normal but not pathological,
stable characteristics such as extroversion, optimism, exuberance,
impulsiveness, overconfidence, grandiosity, and lack of inhibition.
 Depressive temperament : consistently sad or apathetic but do not meet
the criteria for dysthymia
CLINICAL SIGNS POINTING
TOWARDS SOFT BIPOLARITY
 Four or more recurrent episodes of major depression
 Psychosis during major depression
 Post partum depression
 First episode of major depression before 25 years of age
 Multiple, brief (less than 3months) depressive episodes
 Atypical depressive symptoms
 First-degree relative has diagnosis of bipolar disorder
 Hyperthymic personality
 Onset of hypomania after antidepressants
 Loss of response on antidepressant drugs
 3 or more Antidepressants tried; none worked
 Highly seasonal mood shifts
 Prevalence of ‘Spectrum’/‘Soft’
Bipolarity
 The life time prevalence of Bipolar disorder:
 I (BP-I; defined as presence of depression and atleast one manic episode) is 1% in general
population surveys.
 However, when we focus on the entire spectrum of bipolar disorders, the prevalence is much
higher.
 The prevalence for the bipolar disorder II (BP-II; defined as presence of depression and
atleast a hypomania) was found to be 1.67% in a largescale epidemiological survey in U.S.
 The secondary analyses from these landmark studies revealed that if we consider the
prevalence of entire bipolar ‘spectrum’ disorders, it was found to be about 6.4% in the
community setting implying that the sub threshold cases are atleast five times more common
than BP-I and BP-II.
Prevalence of ‘Spectrum’/‘Soft’
Bipolarity
 In terms of clinic prevalence, on applying the broader criteria for
‘spectrum’ bipolarity, it was seen that upto half of the patients with current
diagnosis of depression may be bipolar spectrum disorders.Timely and
accurate diagnosis may facilitate improved management and outcome for
these patients.

(Concept and Identification of “Soft Bipolarity” in Patients presenting with

Depression: Need for Careful Screening by Physicians)
Prevalence of ‘Spectrum’/‘Soft’
Bipolarity
 Antidepressants being widely prescribed without the consultation of
mental health specialists.
 the propensity of antidepressants causing a “ switch ” to mania in persons
with underlying predisposition to bipolarity, leading to significant socio
occupational dysfunction.
 promote judicious use of antidepressants
 PREVALENCE OF BIPOLAR
SPECTRUM DISORDER
• 2.4% overall lifetime prevalence of bipolar spectrum disorders, across 11 countries
• World Mental Health Survey:
• 0.6% for bipolar type 1
• 0.4% for bipolar type 2
• 6 to 7.8% experience hypomania; of that, 0.5 to 6.3% is cyclothymia

 Sources: NIMH. Bipolar Disorder; Jain A, Mitra P. Bipolar Affective Disorder. February 27, 2021.
COURSE OF BIPOLAR
SPECTRUM DISORDER
 Bipolar I disorder most often starts with depression (75 percent of the
time in women, 67 percent in men) and is a recurring disorder.
 Most patients experience both depressive and manic episodes, although
10 to 20 percent experience only manic episodes.
 Bipolar II disorder is a chronic disease that warrants long-term
treatment strategies.
 COURSE OF BIPOLAR
SPECTRUM DISORDER
 Although the median age of onset for Bipolar I and II disorders ranges from 17-31, the first peak
in rates of BSDs is between ages 15 and 19.
 BSDs have shown that although rates of recovery from index episodes are high, in the range of
70-100%, of those who recover, majority will experience one or more syndromal recurrences over
a period of 2-5 years.
 Factors associated with worse longitudinal outcome includes:
 Early age of onset
 Cyclothymic temperament
 Rapid cycling
 Psychosis
 Low socio-economic status
DURATION OF BIPOLAR
DISORDER
 The manic episodes typically have a rapid onset (hours or days) but may
evolve over a few weeks.
 An untreated manic episode lasts about 3 months; therefore, clinicians
should not discontinue giving drugs before that time.
 Depressive episodes are generally similar to those for depressive
disorders.
DURATION OF BIPOLAR
DISORDER
 Of persons who have a single manic episode, 90 percent are likely to
have another.
 As the disorder progresses, the time between episodes often decreases.
 After about five episodes, however, the interepisode interval often
stabilizes at 6 to 9 months.
 Of persons with bipolar disorder, 5 to 15 percent have four or more
episodes per year and are classified as rapid cyclers

SYNOPSIS 12TH
EDITION
KLERMAN
CLASSIFICATION(1981)
 Bipolar I: Mania and depression
Bipolar II: Hypomania and depression
Bipolar III: Cyclothymia
Bipolar IV: Medication induced hypomania\mania
Bipolar V: Depression with bipolar relatives
Bipolar VI: Mania without depression
AKISKAL CLASSIFICATION
(1999)
Bipolar ¼-
unipolar depression, responding rapidly but in unsustained manner to
antidepressants

Bipolar ½-
schizobipolar disorder
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
AKISKAL CLASSIFICATION

 Bipolar I ½- 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
AKISKAL CLASSIFICATION

 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
 AKISKAL CLASSIFICATION

 Bipolar II ½- Cyclothymic depressions

 Many bipolar patients do not meet criteria for Bipolar II due to 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 mini depressions thereby fulfilling criteria for cyclothymia
 The mood lability in this bipolar shown that most cyclothymic individuals do not exhibit
clearcut hypomanic features but instead give evidence of depressive mood
characterised by brief depressive mood swings
AKISKAL CLASSIFICATION

BipolarIII: hypomania due to

antidepressant drugs
AKISKAL CLASSIFICATION

Bipolar III ½: hypomania and/or depression

associated with substance use
 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
AKISKAL CLASSIFICATION

Bipolar IV: hyperthymic depression-

 Clinical depression that occurs later in life and superimposed on a lifelong
hyperthymic temperament
 Variant is a pattern whereby the temperament lead to a great deal of
trouble in their lives often associated with recurrent depression
 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
AKISKAL CLASSIFICATION

Bipolar V-
recurrent depressions with dysphoric hypomania

Bipolar VI-
late onset depression with mixed mood features, progressing to a
dementia like syndrome
 DSM-5 AND ICD-11
DSM-5 ICD-11
Name Bipolar and related disorders Bipolar and related disorders

DISORDERS Bipolar 1 disorder Bipolar 1 disorder

Bipolar II disorder Bipolar II disorder
Cyclothymic Disorder Cyclothymic Disorder
Substance/Medication Induced Bipolar and Related Disorder Other specified Bipolar and
Bipolar and Related Disorder Due to Another Medical Condition Related Disorder
Other specified Bipolar and Related Disorder
1. Short duration hypomanic episodes (2-3 days ) and major depressive
episodes
2. Hypomanic episodes with insufficient symptoms and major depressive
episodes
3. Hypomanic episode without prioir major depressive episode
4. Short duration Cyclothymia (less than 24 months)
 DSM-5 ICD-11
SPECIFICATIONS Single episode of mania Occurrence of manic, mixed or
hypomanic episodes or symptoms
typically alternating with depressive
episodes or symptoms

Bipolar I- mania+/- depression Bipolar II Bipolar type I – one or more manic or

-hypomania and depression mixed episodes Bipolar type II- one or
more hypomanic and atleast one
depressive.

Single manic episode enough to diagnose as Single episode is diagnosed as bipolar type I
bipolar disorder disorder

SYMPTOMS Abnormally and persistently elevated, Euphoria, irritability or expansiveness and by

expansive or irritable mood and increased goal increased activity and a subjective experience
directed activity of increased energy

DURATION 1 week or less if hospitalization is necessary Last at least 1 week

3 or more of 7 other symptoms (4 if irritable Accompanied by other characteristic

mood) symptoms
 DSM-5 ICD-11

DEPRESSIVE SYMPTOMS 5 or more of 9 symptoms with at least one Depressed mood or loss of interest in
is either depressed mood or loss of daily activities
interest

DURATION 2 weeks 2 weeks

SEVERITY Severity based on no of criterion Severity determination is subjective

symptoms

No somatic syndrome No somatic syndrome

Psychotic features coded irrespective of Psychotic symptoms in moderate and

episode severity severe episodes
This Photo by Unknown Author is licensed under CC BY-NC-ND
MEDICAL COMORBIDITIES

 Many neurological disorders can cause “secondary mania,” including

strokes, tumors, head trauma, CNS infection, and degenerative
disorders.
Medical Disorders Comorbid
With Bipolar Disorder
 Migraine : 3.7%
 Velocardiofacial Syndrome
 Multiple Sclerosis