SYNOPSIS

Bipolar Affective Disorder F31 - ICD10 Description, World Health Organization

A disorder characterized by two or more episodes in which the patient's mood and activity
levels are significantly disturbed, this disturbance consisting on some occasions of an
elevation of mood and increased energy and activity (hypomania or mania) and on others of a
lowering of mood and decreased energy and activity (depression). Repeated episodes of
hypomania or mania only are classified as bipolar.
F31.0 Bipolar affective disorder, current episode hypomanic

The patient is currently hypomanic, and has had at least one other affective
episode (hypomanic, manic, depressive, or mixed) in the past.

F31.1 Bipolar affective disorder, current episode manic without psychotic
symptoms

The patient is currently manic, without psychotic symptoms (as in F30.1), and
has had at least one other affective episode (hypomanic, manic, depressive, or
mixed) in the past.

F31.2 Bipolar affective disorder, current episode manic with psychotic
symptoms

The patient is currently manic, with psychotic symptoms (as in F30.2), and has
had at least one other affective episode (hypomanic, manic, depressive, or
mixed) in the past.

F31.3 Bipolar affective disorder, current episode mild or moderate
depression

The patient is currently depressed, as in a depressive episode of either mild or
moderate severity (F32.0 or F32.1), and has had at least one authenticated
hypomanic, manic, or mixed affective episode in the past.

F31.4 Bipolar affective disorder, current episode severe depression
without psychotic symptoms

The patient is currently depressed, as in severe depressive episode without
psychotic symptoms (F32.2), and has had at least one authenticated
hypomanic, manic, or mixed affective episode in the past.

F31.5 Bipolar affective disorder, current episode severe depression with
psychotic symptoms

The patient is currently depressed, as in severe depressive episode with
psychotic symptoms (F32.3), and has had at least one authenticated
hypomanic, manic, or mixed affective episode in the past.

F31.6 Bipolar affective disorder, current episode mixed

The patient has had at least one authenticated hypomanic, manic, depressive,
or mixed affective episode in the past, and currently exhibits either a mixture
or a rapid alteration of manic and depressive symptoms. Excl.:single mixed
affective episode (F38.0)

F31.7 Bipolar affective disorder, currently in remission

The patient has had at least one authenticated hypomanic, manic, or mixed
affective episode in the past, and at least one other affective episode
(hypomanic, manic, depressive, or mixed) in addition, but is not currently
suffering from any significant mood disturbance, and has not done so for
several months. Periods of remission during prophylactic treatment should be
coded here.
Bipolar I Disorder - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with bipolar I disorder needs to meet all of the following criteria:
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

o A distinct period of abnormally and persistently elevated, expansive, or
irritable mood and abnormally and persistently goal-directed behavior
or energy, lasting at least 1 week and present most of the day, nearly
every day (or any duration if hospitalization is necessary).

o During the period of mood disturbance and increased energy or
activity, three (or more) of the following symptoms have persisted
(four if the mood is only irritable) are present to a significant degree
and represent a noticeable change from usual behavior:

Inflated self-esteem or grandiosity.

Decreased need for sleep (e.g., feels rested after only 3 hours of
sleep).

More talkative than usual or pressure to keep talking.

Flight of ideas or subjective experience that thoughts are
racing.

Distractibility (i.e., attention too easily drawn to unimportant or
irrelevant external stimuli), as reported or observed.

Increase in goal-directed activity (either socially, at work or
school, or sexually) or psychomotor agitation (i.e., purposeless
non-goal-directed activity).

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).

o The mood disturbance is sufficiently 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.

o The episode is not attributable to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication, or other treatment) or
another medical condition.

A full manic episode that emerges during antidepressant treatment
(e.g., medication, electroconvulsive therapy) but persists at fully
syndromal level beyond the physiological effect of that treatment is
sufficient evidence for a manic episode and therefore a bipolar I
diagnosis.

The above criteria constitute a manic episode. At least one lifetime manic
episode is required for the diagnosis of bipolar I disorder.

The occurrence of the manic and major depressive episode(s) is not better
explained by schizoaffective disorder, schizophrenia, schizophreniform
disorder, delusional disorder, or other specified or unspecified schizophrenia
spectrum and other psychotic disorder.

Bipolar I disorder is a very serious mental illness, but usually it has an excellent outcome
when treated. The average age of onset of bipolar depression is 17-18, and 30 is the average
age of onset of bipolar mania (but bipolar I disorder can start at any age). It usually starts as
repeated episodes of depression which later are followed by one or more manic (or mixed
manic and depressive) episodes. When untreated, this disorder often causes school/job
failure, relationship/marital failure, and a 15% risk of suicide.
Effective Therapies
Untreated patients often must be hospitalized to assure their safety and that of others. Most
patients respond to a combination of a mood stabilizer (lithium, valproate/divalproex, or
carbamazepine) plus an antipsychotic medication. Medication should be taken lifelong.
Clonazepam is added to treat mania. Antidepressant medication is often ineffective during
depression, and must be stopped during mania (or it will increase the mania). Clozapine and
electroconvulsive therapy (ECT) are used for treatment refractory patients. Psychological
treatments are not a substitute for medication, but are helpful for depression (but not mania).
Educating patients and their families about this disorder is always beneficial.
Ineffective Therapies
Cognitive behavioral therapy (CBT) is not effective in preventing relapse in bipolar I
disorder; however CBT is effective in reducing symptoms in major depressive episodes,
although the effect size is small. Vitamins, dietary supplements, and acupuncture are all
ineffective for mood disorders.

Summary
Bipolar I Disorder is one of the most severe
forms of mental illness and is characterized by
recurrent episodes of mania and (more often)
depression. The condition has a high rate of
recurrence and if untreated, it has an
approximately 15% risk of death by suicide. It
Pathophysiology
The pathophysiology of Bipolar I Disorder is
poorly understood. However, a variety of
imaging studies suggests the involvement of
structural abnormalities in the amygdala, basal
ganglia and prefrontal cortex. Research is now
showing that this disorder is associated with
is the third leading cause of death among
people aged 15-24 years, and is the 6th leading
cause of disability (lost years of healthy life)
for people aged 15-44 years in the developed
world.
Causation
Bipolar I Disorder is a life-long disease and
runs in families but has a complex mode of
inheritance. Family, twin and adoption studies
suggest genetic factors. The concordance rate
for monozygotic (identical) twins is 43%;
whereas it is only 6% for dizygotic
(nonidentical) twins. About half of all patients
with Bipolar I Disorder have one parent who
also has a mood disorder, usually Major
Depressive Disorder. If one parent has Bipolar
I Disorder, the child will have a 25% chance
of developing a mood disorder (about half of
these will have Bipolar I or II Disorder, while
the other half will have Major Depressive
Disorder). If both parents have Bipolar I
Disorder, the child has a 50%-75% chance of
developing a mood disorder. First-degree
biological relatives of individuals with Bipolar
I Disorder have elevated rates of Bipolar I
Disorder (4%-24%), Bipolar II Disorder (1%-
5%), and Major Depressive Disorder (4%-
24%).
The finding that the concordance rate for
monozygotic twins isn't 100% suggests that
environmental or psychological factors likely
play a role in causation. Certain environmental
factors (e.g., antidepressant medication,
antipsychotic medication, electroconvulsive
therapy, stimulants) or certain illnesses (e.g.,
multiple sclerosis, brain tumor,
hyperthyroidism) can trigger mania. Mania
can be triggered by giving birth, sleep
deprivation, and major stressful life events.
Symptoms
In adults, mania is usually episodic with an
elevation of mood and increased energy and
activity. In children, mania is commonly
chronic rather than episodic, and usually
abnormal brain levels of serotonin,
norepinephrine, and dopamine.
Prevalence
Bipolar I Disorder affects both sexes equally
in all age groups and its worldwide prevalence
is approximately 3-5%. It can even present in
preschoolers. There are no significant
differences among racial groups in the
prevalence of this disorder.
Course
The first episode may occur at any age from
childhood to old age. The average age at onset
is 21. More than 90% of individuals who have
a single Manic Episode go on to have future
episodes. Untreated patients with Bipolar I
Disorder typically have 8 to 10 episodes of
mania and depression in their lifetime. Often 5
years or more may elapse between the first
and second episode, but thereafter the episodes
become more frequent and more severe.
There is significant symptom reduction
between episodes, but 25% of patients
continue to display mood instability or mild
depression. As many as 60% of patients
experience chronic interpersonal or
occupational difficulties between acute
episodes. Bipolar I Disorder may develop
psychotic symptoms. The psychotic symptoms
in Bipolar I Disorder only occur during severe
manic, mixed or depressive episodes. In
contrast, the psychotic symptoms in
Schizophrenia can occur when there is no
mania or depression. Poor recovery is more
common after psychosis.
Manic episodes usually begin abruptly and last
for between 2 weeks and 4-5 months (median
duration about 4 months). Depressive episodes
tend to last longer (median length about 6
months), though rarely for more than a year,
except in the elderly.
Treatment And Outcome
presents in mixed states with irritability,
anxiety and depression. In adults and children,
during depression there is lowering of mood
and decreased energy and activity. During a
mixed episode both mania and depression can
occur on the same day.
Comorbidity
Comorbidity is the rule, not the exception, in
bipolar disorder. The most common mental
disorders that co-occur with bipolar disorder
are anxiety, substance use, and conduct
disorders. Disorders of eating, sexual
behavior, attention-deficit/hyperactivity, and
impulse control, as well as autism spectrum
disorders and Tourette's disorder, co-occur
with bipolar disorder. The most common
general medical comorbidities are migraine,
thyroid illness, obesity, type II diabetes, and
cardiovascular disease.
Associated Mental Disorders
Bipolar I Disorder is often associated with:
alcoholism, drug addiction, Anorexia Nervosa,
Bulimia Nervosa, Attention-Deficit
Hyperactivity Disorder, Panic Disorder, and
Social Phobia.
Diagnostic Tests
There are no diagnostic laboratory tests for
Bipolar I Disorder. Thus diagnosis is arrived
at by using standardized diagnostic criteria to
rate the patient's behavior. Onset of mania
after age 40 could signify that the mania may
be due to a general medical condition or
substance use. Current or past hypothyroidism
(or even mild thyroid hypofunction) may be
associated with Rapid Cycling.
Hyperthyroidism may precipitate or worsen
mania in individuals with a preexisting Mood
Disorder. However, hyperthyroidism in
individuals without preexisting Mood
Disorder does not typically cause manic
symptoms.
The usual treatment for Bipolar I Disorder is
lifelong therapy with a mood-stabilizer (either
lithium, carbamazepine, or divalproex /
valproic acid) often in combination with an
antipsychotic medication. Usually treatment
results in a dramatic decrease in suffering, and
causes an 8-fold reduction in suicide risk. In
mania, an antipsychotic medication and/or a
benzodiazepine medication is often added to
the mood-stabilizer. In depression, quetiapine,
olanzapine, or lamotrigine is often added to
the mood-stabilizer. Alternatively, in
depression, the mood-stabilizer can be
switched to another mood-stabilizer, or two
mood-stabilizers can be used together.
Sometimes, in depression, antidepressant
medication is used. Since antidepressant
medication can trigger mania, antidepressant
medication should always be combined with a
mood-stablizer or antipsychotic medication to
prevent mania.
Research has shown that the most effective
treatment is a combination of supportive
psychotherapy, psychoeducation, and the use
of a mood-stabilizer (often combined with an
antipsychotic medication). There is no
research showing that any form of
psychotherapy is an effective substitute for
medication. Likewise there is no research
showing that any "health food store nutritional
supplement" (e.g., vitamin, amino acid) is
effective for Bipolar I Disorder.
Since a Manic Episode can quickly escalate
and destroy a patient's career or reputation, a
therapist must be prepared to hospitalize out-
of-control manic patients before they "lose
everything". Likewise, severely depressed,
suicidal bipolar patients often require
hospitalization to save their lives.
Although the medication therapy for Bipolar I
Disorder usually must be lifelong, the majority
of bipolar patients are noncompliant and stop
their medication after one year. At 4-year
follow-up of bipolar patients, 41% have a
good overall outcome and 4% have died.
Differential Diagnosis
Bipolar I Disorder must be distinguished from:
Mood Disorder Due to a General
Medical Condition (e.g., due to
multiple sclerosis, stroke,
hypothyroidism, or brain tumor)
Substance-Induced Mood Disorder
(e.g., due to drug abuse, antidepressant
medication, or electroconvulsive
therapy)
Other Mood Disorders (e.g., Major
Depressive Disorder; Dysthymia;
Bipolar II Disorder; Cyclothymic
Disorder)
Psychotic Disorders (e.g.,
Schizoaffective Disorder,
Schizophrenia, or Delusional Disorder)
Since this disorder may be associated
with hyperactivity, recklessness,
impulsivity, and antisocial behavior;
the diagnosis of Bipolar I Disorder
must be carefully differentiated from
Attention Deficit Hyperactivity
Disorder, Conduct Disorder, Antisocial
Personality Disorder, and Borderline
Personality Disorder
Women with bipolar disorder lose, on average,
9 years in life expectancy, 14 years of lost
productivity and 12 years of normal health
Best Recoveries
The best recoveries are achieved when
individuals with Bipolar I Disorder:
1. Get the correct diagnosis (since many
are misdiagnosed as having
schizophrenia or "just borderline
personality")
2. Get effective treatment and faithfully
stay on it for a lifetime (most
individuals require the combination of
a mood-stabilizer plus an antipsychotic
medication)
3. Adopt a healthy lifestyle (regular sleep
and exercise; no alcohol or drug abuse;
low stress)
4. Regularly see a supportive physician
who is knowledgeable about the
psychiatric management of this
disorder
5. Learn which symptoms predict the
return of this illness, and what
additional "rescue" medication should
be taken
6. Learn to trust the warnings given by
family and friends when they see early
signs of relapse
7. Learn as much as possible about this
illness from therapists, the Internet,
books, or self-help groups

TREATMENT

Depressive Episode


Manic Episode

Proven (Better Than
Placebo) Treatments for
Proven (Better Than
Placebo) Treatments for
Bipolar Depression
Lithium and anticonvulsants prevent
suicide [ 1, 2, 3, 4 ]
Lithium (for prevention of future
depression and suicide)
Carbamazepine (for prevention of
future depression)
Lamotrigine (for depression)
Olanzapine (for suicidal ideation in
bipolar I manic or mixed-episode
patients)
Quetiapine (for depression)
Fluoxetine (for depression)
Imipramine (for depression but not
prevention of future depression)
Tranylcypromine (for depression)
Mania
Monotherapy (treatment with just one
medication) for Bipolar Disorder is
usually inadequate, and most patients
require a combination of a mood-
stabilizer and antipsychotic
medication
Lithium (for mania & prevention of
future mania (59% success rate), but
increases risk of diabetes insipidus
and hypothyroidism)
Carbamazepine (for mania &
prevention of future mania)
Divalproex sodium (for mania but not
prevention of future mania, but
increases risk of polycystic ovaries
and hyperinsulinemia)
No difference between in generic
valproic acid and divalproex sodium
in hospitalization
Olanzapine (for mania but increases
risk of weight gain & diabetes)
Olanzapine (for suicidal ideation in
bipolar I manic or mixed episodes)
Quetiapine (for mania)
Risperidone (for mania)
Haloperidol (for mania)
Caution: is the increased use of
atypical antipsychotic medication
(e.g., olanzapine) causing an
increased risk of stroke, heart disease
and hypertension?
Promising (But Unproven)
Treatments for Bipolar
Depression
Amitriptyline (with mood-stabilizer)
Cognitive Therapy (with mood-
stabilizer)
Electroconvulsive Therapy (no
placebo-controlled trials)
Family Psychoeducation (with mood-
stabilizer)
Group Psychoeducation (with mood-
Promising (But Unproven)
Treatments for Mania
Clozapine (but increases risk of
diabetes and agranulocytosis)
Electroconvulsive Therapy
Lamotrigine (for prevention of future
rapid-cycling)
Phenytoin (with neuroleptic for
mania}
stabilizer)
L-Sulpiride (with mood-stabilizer)
Moclobemide (with mood-stabilizer)
Paroxetine (with mood-stabilizer)
Psychotherapy (with mood-stabilizer)
Venlafaxine (with mood-stabilizer)
Ineffective Treatments for
Depression
No additional benefit of adding
antidepressant medication to a mood
stabilizer
Do certain medications for Bipolar
Disorder increase suicidal risk? [ 1, 2,
3, 4, 5, 6, 7 ]
Ineffective Treatments for
Mania
Gabapentin
Verapamil
Topiramate monotherapy or
adjunctive therapy with Topiramate
(and has serious side-effects)
Illness Course for
Depression
Bipolar Disorder and severe Major
Depressive Disorder are episodic,
life-long illnesses that need life-long
prophylactic treatment
Untreated depressive episodes usually
last 11 weeks
Usually there are multiple episodes of
depression if untreated
Suicide rate for bipolar patients is 15-
22 times the national average
Suicide rate in first year off lithium
therapy is 20 times the rate when on
lithium
Illness Course for Mania
Untreated pure manic episodes
usually last 6 weeks
Untreated mixed (manic+depressive)
episodes usually last 17 weeks
Usually there are multiple episodes of
mania if untreated
Mania usually returns 5 months after
stopping lithium therapy
Within 2-4 years of first lifetime
hospitalization for mania, 43%
achieved functional recovery, and
57% switched or had new illness
episodes