Bipolar Disorder

Understanding Abnormal behaviour

1. Bipolar Disorders

2. Bipolar disorders (BD) are a collection of heterogeneous conditions characterized by marked variations in mood . Patients with BD lie on a spectrum; according to DSM-5 those who experience manic episodes in addition to major depressive episodes (MDE) are said to suffer from BD type I. While patients who have recurrent hypomanic episodes along with MDEs are considered as having BD type II. Introduction

3. Diagnostic Criteria ( DSM 5 ) For a diagnosis of bipolar I disorder, it is necessary to meet the criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypo- manic or major depressive episodes. Bipolar I Disorder

4. A. A distinct period of abnormally and persistently elevated , expansive , or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary). B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior : Manic Episode

5. 1 . Inflated self-esteem or grandiosity. 2 . Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). 3 . More talkative than usual or pressure to keep talking. 4 . Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. 6 . Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., puφoseless non-goal- directed activity). 7. 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).

6. C . 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. D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication , other treatment) or to another medical condition . Note : Criteria A-D constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder.

7. Hypomanic Episode C . The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. D . The disturbance in mood and the change in functioning are observable by others.

8. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic . F . The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication , other treatment). Note : Criteria A-'F constitute a hypomania episode. Hypomania episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.

9. A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either ( 1) depressed mood or ( 2) loss of interest or pleasure. Major Depressive Episode

10. 1 . Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.) 2 . Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.) 4 . Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day ( observable by others ; not merely subjective feelings of restlessness or being slowed down).

11. 6 . Fatigue or loss of energy nearly every day. 7 . Feelings of worthlessness or excessive or inappropriate guilt ( which may be delusional) nearly every day (not merely self- reproach or guilt about being sick). 8 . Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others ). 9 . Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide . The symptoms cause clinically significant distress or impairment in social , occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or another medical condition. Note : Criteria A-C constitute a major depressive episode. Major depressive episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.

12. Bipolar I Disorder A. Criteria have been met for at least one manic episode (Criteria A-D under “Manic Episode” above ). B. 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.

13.   Current or Current or Current or Current or   most recent most recent most recent most recent Bipolar 1disorder episode Episode episode episode Manic Hypomania Depressed unspecified** Mild (p. 154) 296.41 ΝΑ 296.51 NA   (F31.11)   (F31.31)   Moderate (p. 154) 296.42 ΝΑ 296.52 NA   (F31.12)   (F31.32)   Severe (p. 154) 296.43 ΝΑ 296.53 NA   (F31.13)   (F31.4)   Diagnostic Code DSM V

14. Bipolar or related disorders (BlockL2‐6A6) 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. Diagnostic Criteria ICD 11

15. 6A60 Bipolar type I disorder Episodic mood disorder defined by the occurrence of one or more manic or mixed episodes . A manic episode is an extreme mood state lasting at least one week unless shortened by a treatment intervention characterized by euphoria, irritability, or expansiveness, and by increased activity or a subjective experience of increased energy. Accompanied by other characteristic symptoms such as rapid or pressured speech, flight of ideas, increased self-esteem or grandiosity, decreased need for sleep, distractibility, impulsive or reckless behavior , and rapid changes among different mood states (i.e., mood liability ). The diagnosis can be made based on evidence of a single manic or mixed episode, typically manic or mixed episodes alternate with depressive episodes over the course of the disorder.

16. 6A60.0 Bipolar type I disorder, current episode manic, without psychotic symptoms Diagnosed when the definitional requirements for Bipolar type I disorder are met. The current episode is manic. There are no delusions or hallucinations present during the episode. Manic episode is an extreme mood state.

17. 6A60.1 Bipolar type I disorder, current episode manic, with psychotic symptoms The current episode is Manic There are delusions or hallucinations present during the episode. A manic episode is an extreme mood state.

18. 6A60.2 Bipolar type I disorder, current episode hypomanic Current episode is hypomanic. A hypomanic episode is a persistent mood state lasting at least several days characterized by mild elevation of mood or increased irritability and increased activity or a subjective experience of increased energy, Accompanied by other characteristic symptoms such as rapid speech, rapid or racing thoughts, increased self-esteem, an increase in sexual drive or sociability, decreased need for sleep, distractibility, or impulsive or reckless behaviour. The symptoms are not severe enough to cause marked impairment in occupational functioning.

19. 6A60.3 Bipolar type I disorder, current episode depressive, mild Current episode is depressive at a mild level of severity. A depressive episode is characterized by a period of almost daily depressed mood or diminished interest in activities lasting at least two weeks accompanied by other symptoms such as difficulty concentrating, feelings of worthlessness or excessive or inappropriate guilt, hopelessness, recurrent thoughts of death or suicide, changes in appetite or sleep, psychomotor agitation or retardation, and reduced energy or fatigue . In a mild depressive episode, none of the symptoms are present to an intense degree. An individual with a mild depressive episode typically has some, but not considerable, difficulty in continuing with ordinary work, social, or domestic activities and there are no delusions or hallucinations.

20. 6A60.4 Bipolar type I disorder, current episode depressive, moderate without psychotic Current episode is depressive at a moderate level of severity. There are no delusions or hallucinations during the episode. In a moderate depressive episode, several symptoms of a depressive episode are present to a marked degree, or a large number of depressive symptoms of lesser severity are present overall . An individual with a moderate depressive episode typically has considerable difficulty in continuing with work, social, or domestic activities, but is still able to function in at least some areas.

21. 6A60.5 Bipolar type I disorder, current episode depressive, moderate with psychotic Current episode is depressive at a moderate level of severiy . There are delusions or hallucinations during the episode. In a moderate depressive episode, several symptoms of a depressive episode are present to a marked degree, or a large number of depressive symptoms of lesser severity are present overall. An individual with a moderate depressive episode typically has considerable difficulty in continuing with work, social, or domestic activities, but is still able to function in at least some areas.

22. 6A60.6 Bipolar type I disorder, current episode depressive, severe without psychotic Current episode is severe. There are no delusions or hallucinations during the episode. In a severe depressive episode, many or most symptoms of a depressive episode are present to a marked degree, or a smaller number of symptoms are present and manifest to an intense degree. The individual is unable to function in personal, family, social, educational, occupational, or other important domains, except to a very limited degree.

23. 6A60.7 Bipolar type I disorder, current episode depressive, severe with psychotic Current episode is severe. There are delusions or hallucinations during the episode. In a severe depressive episode, many or most symptoms of a depressive episode are present to a marked degree, or a smaller number of symptoms are present and manifest to an intense degree. The individual is unable to function in personal, family, social, educational, occupational, or other important domains, except to a very limited degree.

24. 6A60.8 Bipolar type I disorder, current episode depressive, unspecified severity Current episode is depressive, but there is insufficient information to determine the severity of the current depressive episode. The symptoms are associated with at least some difficulty in continuing with ordinary work, social, or domestic activities.

25. 6A60.9 Bipolar type I disorder, current episode mixed, without psychotic symptoms Current episode is mixed and there are no delusions or hallucinations present during the episode. A mixed episode is characterized by either a mixture or very rapid alternation between prominent manic and depressive symptoms on most days during a period of at least one week.   6A60.A Bipolar type I disorder, current episode mixed, with psychotic symptoms Current episode is mixed and there are delusions or hallucinations present during the episode. A mixed episode is characterized by either a mixture or very rapid alternation between prominent manic and depressive symptoms on most days during a period of at least one week.

26. 6A60.B Bipolar type I disorder, currently in partial remission, most recent episode The full definitional requirements for a manic or hypomanic episode are no longer met but some significant mood symptoms remain. In some cases, residual mood symptoms may be depressive rather than manic or hypomanic, but do not satisfy the definitional requirements for a depressive episode.   6A60.C Bipolar type I disorder, currently in partial remission, most recent episode The most recent episode was a depressive episode. The full definitional requirements for the episode are no longer met but some significant depressive symptoms remain.

27. 6A60.D Bipolar type I disorder, currently in partial remission, most recent episode Mixed Bipolar type I disorder, currently in partial remission, most recent episode mixed is diagnosed when the definitional requirements for Bipolar type I disorder have been met and the most recent episode was a mixed episode. The full definitional requirements for the episode are no longer met but some significant mood symptoms remain.   6A60.E Bipolar type I disorder, currently in partial remission, most recent episode Unspecified Bipolar type I disorder, currently in partial remission, most recent episode unspecified is diagnosed when the definitional requirements for Bipolar type II disorder have been met but there is insufficient information to determine the nature of the most recent mood episode. The full definitional requirements for a mood episode are no longer met but some significant mood symptoms remain.

28. 6A60.F Bipolar type I disorder, currently in full remission Bipolar type I disorder, currently in full remission is diagnosed when the full definitional requirements for Bipolar I disorder have been met in the past but there are no longer any significant mood symptoms.   6A60.Y Other specified bipolar type I disorder   6A60.Z Bipolar type I disorder, unspecified

29. 6A60 6A60.0 – 6A60.9 6A60.A – 6A60.F 6A60.Y 6A60.Z Diagnostic Code ICD 11

30. Major depressive disorder It may also be accompanied by hypomania or manic symptoms (i.e., fewer symptoms or for a shorter duration than required for mania or hypomania). When the individual presents in an episode of major depression, one must depend on corroborating history regarding past episodes of mania or hypomania. Symptoms of irritability may be associated with either major depressive disorder or bipolar disorder, adding to diagnostic complexity. Differential Diagnosis

31. Other Bipolar Disorders Diagnosis of bipolar I disorder is differentiated from bipolar II disorder by determining whether there have been any past episodes of mania. Other specified and unspecified bipolar and related disorders should be differentiated from bipolar I and II disorders by considering whether either the episodes involving manic or hypo-manic symptoms or the episodes of depressive symptoms fail to meet the full criteria for those conditions. Bipolar disorder due to another medical condition may be distinguished from bipolar I and II disorders by identifying, based on best clinical evidence, a causally related medical condition.

32. Generalized anxiety disorder, panic disorder, posttraumatic stress disorder, or other anxiety disorders These disorders need to be considered in the differential diagnosis as either the primary disorder or, in some cases, a comorbid disorder. A careful history of symptoms is needed to differentiate generalized anxiety disorder from bipolar disorder, as anxious ruminations may be mistaken for racing thoughts, and efforts to minimize anxious feelings may be taken as impulsive behaviour. Similarly, symptoms of posttraumatic stress disorder need to be differentiated from bipolar disorder. It is helpful to assess the episodic nature of the symptoms described, as well as to consider symptom triggers, in making this differential diagnosis.

33. Substance/medication-induced bipolar disorder Substance use disorders may manifest with substance medication-induced manic symptoms that must be distinguished from bipolar I disorder. Response to mood stabilizers during a substance/medication-induced mania may not necessarily be diagnostic for bipolar disorder. There may be substantial overlap in view of the tendency for individuals with bipolar I disorder to overuse substances during an episode. A primary diagnosis of bipolar disorder must be established based on symptoms that remain once substances are no longer being used.

34. Attention-deficit/hyperactivity disorder This disorder may be misdiagnosed as bipolar disorder, especially in adolescents and children. Many symptoms overlap with the symptom of mania, such as rapid speech, racing thoughts, distractibility, and less need for sleep. The "double counting" of symptoms toward both ADHD and bipolar disorder can be avoided if the clinician clarifies whether the symptom(s) represents a distinct episode.

35. Personality disorders Personality disorders such as borderline personality disorder may have substantial symptomatic overlap with bipolar disorders, since mood ability and impulsivity are common in both conditions. Symptoms must represent a distinct episode, and the noticeable increase over baseline required for the diagnosis of bipolar disorder must be present. A diagnosis of a personality disorder should not be made during an untreated mood episode.

36. Inflated self-esteem is typically present, ranging from uncritical self-confidence to marked grandiosity, and may reach delusional proportions. D ecreased need for sleep. Speech can be rapid, pressured, loud, and difficult to interrupt. Often the individual's thoughts race at a rate faster than they can be expressed through speech. Distractibility Clinical Manifestations

37. Gambling and antisocial behaviours may accompany the manic episode. Some individuals may become hostile and physically threatening to others and, when delusional, may become physically assaultive or suicidal. Loss of insight, and hyperactivity. Mood may shift very rapidly to anger or depression. Depressive symptoms may occur during a manic episode and, if present, may last moments, hours, or, more rarely, days. Etiology

38. Genetic and physiological Environmental Course Modifiers   Prognosis

39. Prevalence The 12-month prevalence estimate in the continental United States was 0.6% for bipolar I disorder as defined in DSM-IV. Twelve-month prevalence of bipolar I disorder across 11 countries ranged from 0.0% to 0.6%. The lifetime male-to-female prevalence ratio is approximately 1.1:1.

40. Outpatient treatment Inpatient treatment Dual Diagnosis treatment Treatment

41. The specific goals of drug treatment in bipolar disorder will change depending on the stage of the illness. In the acute phase, reduction of active target symptoms and overall mood stabilization are the focus. Once these occur, medications are continued to prevent future mood episodes and to enhance the chances of improved psychosocial functioning. Pharmacotherapy

42. It can provide valuable time for an individual to learn and practice effective strategies for coping with the disorder and managing symptoms. Also provide valuable psychoeducation for problem-solving, developing self-care habits, and building resilience . Cognitive behavioral therapy can help an individual challenge negative thinking patterns and the behaviors that follow. Family therapy can help family members learn to communicate calmly and effectively and reduce overall stress in relationship systems. Psychotherapy

43. Diagnostic Criteria ( DSM 5 ) Major Depressive Episode C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others. Bipolar II Disorders

44. E . The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition , manic. F . The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse , a medication or other treatment).

45. A . Criteria have been met for at least one hypomanie episode (Criteria A-F under “Hypo- manic Episode” above) and at least one major depressive episode (Criteria A-C under “Major Depressive Episode” above). B . There has never been a manic episode. Bipolar II Disorder 296.89 (F31.81 )

46. C . The occurrence of the hypomanie episode(s) 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. D . The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational , or other important areas of functioning.

47. 6A61 Bipolar type II disorder Episodic mood disorder defined by the occurrence of one or more hypomanic episodes and at least one depressive episode. The symptoms represent a change from the individual’s typical behavior and are not severe enough to cause marked impairment in functioning. Depressive episode is present.There is no history of manic or mixed Episodes. Diagnostic Criteria ICD 11

48. 6A61.0 Bipolar type II disorder, current episode hypomanic A hypomanic episode is a persistent mood state lasting at least several days characterized by mild elevation of mood or increased irritability and increased activity or a subjective experience of increased energy, accompanied by other characteristic symptoms such as rapid speech, rapid or racing thoughts, increased self-esteem, an increase in sexual drive or sociability, decreased need for sleep, distractibility, or impulsive or reckless behavior . The symptoms are not severe enough to cause marked impairment in occupational functioning or in usual social activities or relationships with others, does not necessitate hospitalization, and there are no accompanying delusions or hallucinations.

49. 6A61.1 Bipolar type II disorder, current episode depressive, mild Current episode is depressive at a mild level of severity. Depressive episode is present. In a mild depressive episode, none of the symptoms are present to an intense degree. An individual with a mild depressive episode typically has some, but not considerable, difficulty in continuing with ordinary work, social, or domestic activities and there are no delusions or hallucinations.  

50. 6A61.2 Bipolar type II disorder, current episode depressive, moderate without psychotic Current episode is depressive at a moderate level of severity and there are no delusions or hallucinations during the episode. Depressive episode is present. In a moderate depressive episode, several symptoms of a depressive episode are present to a marked degree, or a large number of depressive symptoms of lesser severity are present overall. An individual with a moderate depressive episode typically has considerable difficulty in continuing with work, social, or domestic activities, but is still able to function in at least some areas.

51. 6A61.3 Bipolar type II disorder, current episode depressive, moderate with psychotic Current episode is depressive at a moderate level of severity and there are delusions or hallucinations during the episode. Depressive episode is present. In a moderate depressive episode, several symptoms of a depressive episode are present to a marked degree, or a large number of depressive symptoms of lesser severity are present overall. An individual with a moderate depressive episode typically has considerable difficulty in continuing with work, social, or domestic activities, but is still able to function in at least some areas.

52. 6A61.4 Bipolar type II disorder, current episode depressive, severe without psychotic Current episode is severe and there are no delusions or hallucinations during the episode. Depressive episode is present. In a severe depressive episode, many or most symptoms of a depressive episode are present to a marked degree, or a smaller number of symptoms are present and manifest to an intense degree. The individual is unable to function in personal, family, social, educational, occupational, or other important domains, except to a very limited degree.

53. 6A61.5 Bipolar type II disorder, current episode depressive, severe with psychotic Current episode is severe and there are delusions or hallucinations during the episode. Depressive episode is present. In a severe depressive episode, many or most symptoms of a depressive episode are present to a marked degree, or a smaller number of symptoms are present and manifest to an intense degree The individual is unable to function in personal, family, social, educational, occupational, or other important domains, except to a very limited degree.

54. 6A61.6 Bipolar type II disorder, current episode depressive, unspecified severity Current episode is depressive, but there is insufficient information to determine the severity of the current depressive episode. Depressive episode is present. The symptoms are associated with at least some difficulty in continuing with ordinary work, social, or domestic activities.

55. 6A61.7 Bipolar type II disorder, currently in partial remission, most recent episode The most recent episode was a hypomanic episode. The full definitional requirements for a hypomanic episode are no longer met but some significant mood symptoms remain. In some cases, residual mood symptoms may be depressive rather than hypomanic, but do not satisfy the definitional requirements for a depressive episode.

56. 6A61.8 Bipolar type II disorder, currently in partial remission, most recent episode The most recent episode was a depressive episode. The full definitional requirements for the episode are no longer met but some significant depressive symptoms remain.   6A61.9 Bipolar type II disorder, currently in partial remission, most recent episode Requirements for Bipolar type II disorder have been met but there is insufficient information to determine the nature of the most recent mood episode. The full definitional requirements for a mood episode are no longer met but some significant mood symptoms remain.

57. 6A61.A Bipolar type II disorder, currently in full remission Bipolar type II disorder, currently in full remission, is diagnosed when the definitional requirements for Bipolar type II disorder have been met but there are no longer any significant mood symptoms.   6A61.Y Other specified bipolar type II disorder   6A61.Z Bipolar type II disorder, unspecified

58. Diagnostic Code ICD 11 6A61 6A61.0 – 6A61.9 6A61.A 6A61.Y 6A61.Z

59. Major depressive disorder It may be accompanied by hypomania or manic symptoms that do not meet full criteria (i.e., either fewer symptoms or a shorter duration than required for a hypomania episode). This is especially true in evaluating individuals with symptoms of irritability, which may be associated with either major depressive disorder or bipolar II disorder. Differential Diagnosis

60. Cyclothymic disorder In cyclothymic disorder, there are numerous periods of hypomanic symptoms and numerous periods of depressive symptoms that do not meet symptom or duration criteria for a major depressive episode. Bipolar II disorder is distinguished from cyclothymic disorder by the presence of one or more major depressive episodes. If a major depressive episode occurs after the first 2 years of cyclothymic disorder, the additional diagnosis of bipolar II disorder is given. Other bipolar disorders Diagnosis of bipolar II disorder should be differentiated from bipolar I disorder by carefully considering whether there have been any past episodes of mania and from other specified and unspecified bipolar and related disorders by confirming the presence of fully syndromal hypomania and depression.

61. Attention-deficit/hyperactivity disorder It may be misdiagnosed as bipolar II disorder, especially in adolescents and children. Many symptoms of ADHD, such as rapid speech, racing thoughts, distractibility, and less need for sleep, overlap with the symptoms of hypomania. The double counting of symptoms to­ ward both ADHD and bipolar II disorder can be avoided if the clinician clarifies whether the symptoms represent a distinct episode and if the noticeable increase over baseline required for the diagnosis of bipolar II disorder is present.

62. Personality disorders The same convention as applies for ADHD also applies when evaluating an individual for a personality disorder such as borderline personality disorder, since mood and impulsivity are common in both personality disorders and bi­ polar II disorder. Symptoms must represent a distinct episode, and the noticeable increase over baseline required for the diagnosis of bipolar II disorder must be present. A diagnosis of a personality disorder should not be made during an untreated mood episode unless the lifetime history supports the presence of a personality disorder.

63. A clinical course of recurring mood episodes consisting of one or more major depressive episodes (Criteria A-C under "Major Depressive Episode") and at least one hypomania episode (Criteria A-F under "Hypomania Episode"). The major depressive episode must last at least 2 weeks, and the hypomania episode must last at least 4 days, to meet the diagnostic criteria . The presence of a manic episode during the course of illness precludes the diagnosis of bipolar II disorder (Criterion B under "Bipolar II Disorder"). Clinical Manifestations

64. I mpulsivity , which can contribute to suicide at­ tempts and substance use disorders . Impulsivity may also stem from a concurrent personality disorder, substance use disorder, anxiety disorder, another mental disorder, or a medical condition. There may be heightened levels of creativity in some individuals with a bipolar disorder. Etiology

65. Genetic and physiological Course modifiers Prognosis

66. The 12-month prevalence of bipolar II disorder, internationally, is 0.3%. In the United States, 12-month prevalence is 0.8%. The prevalence rate of pediatric bipolar II disorder is difficult to establish. DSM-IV bipolar I, bipolar II, and bipolar disorder not otherwise spec­ ified yield a combined prevalence rate of 1.8% in U.S. and non-U.S. community samples, with higher rates (2.7% inclusive) in youths age 12 years or older. Prevalence

67. M ood stabilizers Antipsychotics Antidepressants Treatment

68. The specific goals of drug treatment in bipolar disorder will change depending on the stage of the illness. In the acute phase, reduction of active target symptoms and overall mood stabilization are the focus. Once these occur, medications are continued to prevent future mood episodes and to enhance the chances of improved psychosocial functioning. Pharmacotherapy

69. Psychotherapy involves counselling services. It is centered on talking through emotions and problems associated with bipolar disorder and other life issues. It may also include behavioural management, such as creating action plans on what to do during mood alterations. Psychotherapy

70. A. For at least 2 years (at least 1 year in children and adolescents) there have been nu­merous periods with hypomanie symptoms that do not meet criteria for a hypomanie episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode . B. During the above 2-year period (1 year in children and adolescents), the hypomanie and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time. Cyclothymic Disorder 301.13 (F34.0 ) Diagnostic Criteria DSM 5

71. C. Criteria for a major depressive, manic, or hypomanie episode have never been met.   D. The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia , schizophreniform disorder, delusional disorder, or other specified or un­ specified schizophrenia spectrum and other psychotic disorder. E. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse , a medication) or another medical condition ( e.g., hyperthyroidism).

72. Diagnostic Criteria ICD 11 6A62 Cyclothymic disorder Cyclothymic disorder is characterized by a persistent instability of mood over a period of at least 2 years, involving numerous periods of hypomanic (e.g., euphoria, irritability, or expansiveness, psychomotor activation) and depressive (e.g., feeling down, diminished interest in activities, fatigue) symptoms that are present during more of the time than not.

73. The hypomanic symptomatology may or may not be sufficiently severe or prolonged to meet the full definitional requirements of a hypomanic episode (see Bipolar type II disorder), but there is no history of manic or mixed episodes (see Bipolar type I disorder). The depressive symptomatology has never been sufficiently severe or prolonged to meet the diagnostic requirements for a depressive episode (see Bipolar type II disorder). The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

74. Differential Diagnosis In cyclothymic disorder, there are numerous periods of hypomanic symptoms and numerous periods of depressive symptoms that do not meet symptom or duration criteria for a major depressive episode. Bipolar II disorder is distinguished from cyclothymic disorder by the presence of one or more major depressive episodes. If a major depressive episode occurs after the first 2 years of cyclothymic disorder, the additional diagnosis of bipolar II disorder is given.

75. Mood swings between short periods of mild depression and hypomania. The highs of cyclothymia include symptoms of an elevated mood (hypomanic symptoms) The lows consist of mild or moderate depressive symptoms. Clinical Manifestations

76. The causes are unknown. It is distinguished from a mood disorder due to general medical condition. People with this disorder usually have a family history of depression, bipolar disorder, suicide, alcohol and drug dependence. There is a 15-50% chance that the person will subsequently develop Bipolar I or Bipolar II disorder. Etiology

77. Biological Psychosocial Prognosis

78. The lifetime prevalence of cyclothymic disorder is approximately 0.4%-l%. Prevalence in mood disorders clinics may range from 3% to 5%. In the general population, cyclothymic disorder is apparently equally common in males and females . In clinical settings, females with cyclothymic disorder may be more likely to present for treatment than males. Prevalence

79. Treatment usually involves counselling and therapy. In rare cases, medication may be used. Psychotherapy Cognitive Behavioral Therapy Family Therapy Treatment

80. Antipsychotics Antidepressants Pharmacotherapy

81. Also known as psychological counselling or talk therapy is a vital part of the treatment and can be provided in individual, family or group settings. Cognitive Behavioral Therapy (CBT) Interpersonal and Social Rhythm Therapy (ISRT) Psychotherapy

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