ICD-10
Criteria for Bipolar Affective Disorder
- F31 Bipolar Affective Disorder
-
F31.6 Bipolar Affective Disorder,
Current Episode Mixed - F30 Manic Episode
- F30.0 Hypomania
- F30.1 Mania Without Psychotic Symptoms
- F30.2 Mania With Psychotic Symptoms
- F32 Depressive Episode
- F32.0 Mild Depressive Episode
- F32.1 Moderate Depressive Episode
-
F32.2 Severe Depressive Episode
Without Psychotic Symptoms -
F32.3 Severe Depressive Episode
With Psychotic Symptoms
F31 Bipolar Affective Disorder
This disorder is characterized by repeated (i.e.
at least two) 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 (mania or hypomania),
and on others of a lowering of mood and decreased energy and activity (depression).
Characteristically, recovery is usually complete between episodes, and
the incidence in the two sexes is more nearly equal than in other mood
disorders. As patients who suffer only from repeated episodes of mania
are comparatively rare, and resemble (in their family history, premorbid
personality, age of onset, and long-term prognosis) those who also have
at least occasional episodes of depression, such patients are classified
as bipolar.
Manic episodes usually begin abruptly and last
for between 2 weeks and 4-5 months (median duration about 4 months). Depressions
tend to last longer (median length about 6 months), though rarely for more
than a year, except in the elderly. Episodes of both kinds often follow
stressful life events or other mental trauma, but the presence of such
stress is not essential for the diagnosis. The first episode may occur
at any age from childhood to old age. The frequency of episodes and the
pattern of remissions and relapses are both very variable, though remissions
tend to get shorter as time goes on and depressions to become commoner
and longer lasting after middle age.
Although the original concept of “manic-depressive
psychosis” also included patients who suffered only from depression, the
term “manic-depressive disorder or psychosis” is now used mainly as a synonym
for bipolar disorder.
Includes:
- manic-depressive illness, psychosis or reaction
Excludes:
- bipolar disorder, single manic episode
- cyclothymia
F31.6 Bipolar Affective Disorder,
Current Episode Mixed
The patient has had
at least one manic, hypomanic, or mixed affective episode in the past and
currently exhibits either a mixture of a rapid alternation of manic, hypomanic,
and depressive symptoms.
Diagnostic Guidelines
Although the most typical form of bipolar disorder
consists of alternating manic and depressive episodes separated by periods
of normal mood, it is not uncommon for depressive mood to be accompanied
for days or weeks on end by overactivity and pressure of speech, or for
a manic mood and grandiosity to be accompanied by agitation and loss of
energy and libido. Depressive symptoms and symptoms of hypomania or mania
may also alternate rapidly, from day to day or even from hour to hour.
A diagnosis of mixed bipolar affective disorder should be made only if
the two sets of symptoms are both prominent for the greater part of the
current episode of illness, and if that episode has lasted for a least
2 weeks.
Excludes:
-
single mixed affective
episode
F30 Manic Episode
Three degrees of severity are specified here, sharing
the common underlying characteristics of elevated mood, and an increase
in the quantity and speed of physical and mental activity. All the subdivisions
of this category should be used only for a single manic episode. If previous
or subsequent affective episodes (depressive, manic, or hypomanic), the
disorder should be coded under bipolar affective disorder.
Includes:
- bipolar disorder, single manic episode
F30.0 Hypomania
Hypomania is a lesser degree of mania, in which abnormalities
of mood and behaviour are too persistent and marked to be included under
cyclothymia but are not accompanied by hallucinations or delusions. There
is a persistent mild elevation of mood (for at least several days on end),
increased energy and activity, and usually marked feelings of well-being
and both physical and mental efficiency. Increased sociability, talkativeness,
overfamiliarity, increased sexual energy, and a decreased need for sleep
are often present but not to the extent that they lead to severe disruption
of work or result in social rejection. Irritability, conceit, and boorish
behaviour may take the place of the more usual euphoric sociability.
Concentration and attention may be impaired, thus
diminishing the ability to settle down to work or to relaxation and leisure,
but this may not prevent the appearance of interests in quite new ventures
and activities, or mild over-spending.
Diagnostic Guidelines
Several of the features mentioned above, consistent
with elevated or changed mood and increased activity, should be present
for at least several days on end, to a degree and with a persistence greater
than described for cyclothymia. Considerable interference with work or
social activity is consistent with a diagnosis of hypomania, but if disruption
of these is severe or complete, mania should be diagnosed.
Differential Diagnosis
Hypomania covers the range of disorders of mood
and level of activities between cyclothymia and mania. The increased activity
and restlessness (and often weight loss) must be distinguished from the
same symptoms occurring in hyperthyroidism and anorexia nervosa; early
states of “agitated depression”, particularly in late middle-age, may bear
a superficial resemblance to hypomania of the irritable variety. Patients
with severe obsessional symptoms may be active part of the night completing
their domestic cleaning rituals, but their affect will usually be the opposite
of that described here.
When a short period of hypomania occurs as a prelude
to or aftermath of mania, it is usually not worth specifying the hypomania
separately.
F30.1 Mania Without Psychotic
Symptoms
Mood is elevated out of keeping with the individual’s
circumstances and may vary from carefree joviality to almost uncontrollable
excitement. Elation is accompanied by increased energy, resulting in overactivity,
pressure of speech, and a decreased need for sleep. Normal social inhibitions
are lost, attention cannot be sustained, and there is often marked distractability.
Self-esteem is inflated, and grandiose or over-optimistic ideas are freely
expressed.
Perceptual disorders may occur, such as the appreciation
of colours as especially vivid (and usually beautiful), a preoccupation
with fine details of surfaces or textures, and subjective hyperacusis.
The individual may embark on extravagant and impractical schemes, spend
money recklessly, or become aggressive, amorous, or facetious in inappropriate
circumstances. In some manic episodes the mood is irritable and suspicious
rather than elated. The first attack occurs most commonly between the ages
of 15 and 30 years, but may occur at any age from late childhood to the
seventh or eighth decade.
Diagnostic Guidelines
The episode should last for at least 1 week and
should be severe enough to disrupt ordinary work and social activities
more or less completely. The mood change should be accompanied by increased
energy and several of the symptoms referred to above (particularly pressure
of speech, decreased need for sleep, grandiosity, and excessive optimism).
F30.2 Mania With Psychotic Symptoms
The clinical picture is that of a more severe form
of mania as described above. Inflated self-esteem and grandiose ideas may
develop into delusions, and irritability and suspiciousness into delusions
of persecution. In severe cases, grandiose or religious delusions of identity
or role may be prominent, and flight of ideas and pressure of speech may
result in the individual becoming incomprehensible. Severe and sustained
physical activity and excitement may result in aggression or violence,
and neglect of eating, drinking, and personal hygiene may result in dangerous
states of dehydration and self-neglect. If required, delusions or hallucinations
can be specified as congruent or incongruent with the mood. “Incongruent”
should be taken as including affectively neutral delusions and hallucinations;
for example, delusions of reference with no guilty or accusatory content,
or voices speaking to the individual about events that have no special
emotional significance.
Differential Diagnosis
One of the commonest problems is differentiation
of this disorder from schizophrenia, particularly if the stages of development
through hypomania have been missed and the patient is seen only at the
height of the illness when widespread delusions, incomprehensible speech,
and violent excitement may obscure the basic disturbance of affect. Patients
with mania that is responding to neuroleptic medication may present a similar
diagnostic problem at the stage when they have returned to normal levels
of physical and mental activity but still have delusions or hallucinations.
Occasional hallucinations or delusions as specified for schizophrenia may
also be classed as mood-incongruent, but if these symptoms are prominent
and persistent, the diagnosis of schizoaffective disorder is more likely
to be appropriate.
Includes:
- manic stupor
F32 Depressive Episode
In typical depressive episodes of all three varieties
described below (mild, moderate, and severe), the individual usually suffers
from depressed mood, loss of interest and enjoyment, and reduced energy
leading to increased fatiguability and diminished activity. Marked tiredness
after only slight effort is common. Other common symptoms are:
- reduced concentration and attention;
- reduced self-esteem and self-confidence;
-
ideas of guilt and unworthiness (even in a
mild type of episode); - bleak and pessimistic views of the future;
- ideas or acts of self-harm or suicide;
- disturbed sleep;
- diminished appetite.
The lowered mood varies little from day to
day, and is often unresponsive to circumstances, yet may show a characteristic
diurnal variation as the day goes on. As with manic episodes, the clinical
presentation shows marked individual variations, and atypical presentations
are particularly common in adolescence. In some cases, anxiety, distress,
and motor agitation may be more prominent at times than the depression,
and the mood change may also be masked by added features such as irritability,
excessive consumption of alcohol, histrionic behaviour, and exacerbation
of pre-existing phobic or obsessional symptoms, or by hypochondriacal preoccupations.
For depressive episodes of all three grades of severity, a duration of
at least 2 weeks is usually required for diagnosis, but shorter periods
may be reasonable if symptoms are unusually severe and of rapid onset.
Some of the above symptoms may be marked and develop
characteristic features that are widely regarded as having special clinical
significance. The most typical examples of these “somatic” symptoms are:
loss of interest or pleasure in activities that are normally enjoyable;
lack of emotional reactivity to normally pleasurable surroundings and events;
waking in the morning 2 hours or more before the usual time; depression
worse in the morning; objective evidence of definite psychomotor retardation
or agitation (remarked on or reported by other people); marked loss of
appetite; weight loss (often defined as 5% or more of body weight in the
past month); marked loss of libido. Usually, this somatic syndrome is not
regarded as present unless about four of these symptoms are definitely
present.
The categories of mild, moderate and severe depressive
episodes described in more detail below should be used only for a single
(first) depressive episode. Further depressive episodes should be classified
under one of the subdivisions of recurrent depressive disorder.
These grades of severity are specified to cover
a wide range of clinical states that are encountered in different types
of psychiatric practice. Individuals with mild depressive episodes are
common in primary care and general medical settings, whereas psychiatric
inpatient units deal largely with patients suffering from the severe grades.
Acts of self-harm associated with mood (affective)
disorders, most commonly self-poisoning by prescribed medication, should
be recorded by means of an additional code from Chapter XX of ICD-10 (X60-X84).
These codes do not involve differentiation between attempted suicide and
“parasuicide”, since both are included in the general category of self-harm.
Differentiation between mild, moderate, and severe
depressive episodes rests upon a complicated clinical judgement that involves
the number, type, and severity of symptoms present. The extent of ordinary
social and work activities is often a useful general guide to the likely
degree of severity of the episode, but individual, social, and cultural
influences that disrupt a smooth relationship between severity of symptoms
and social performance are sufficiently common and powerful to make it
unwise to include social performance amongst the essential criteria of
severity.
The presence of dementia or mental retardation
does not rule out the diagnosis of a treatable depressive episode, but
communication difficulties are likely to make it necessary to rely more
than usual for the diagnosis upon objectively observed somatic symptoms,
such as psychomotor retardation, loss of appetite and weight, and sleep
disturbance.
Includes:
-
single episodes
of depression (without psychotic symptoms), psychogenic depression or reactive
depression)
F32.0 Mild Depressive Episode
Diagnostic Guidelines
Depressed mood, loss of interest and enjoyment,
and increased fatiguability are usually regarded as the most typical symptoms
of depression, and at least two of these, plus at least two of the other
symptoms described above should usually be present for a definite diagnosis.
None of the symptoms should be present to an intense degree. Minimum duration
of the whole episode is about 2 weeks.
An individual with a mild depressive episode is
usually distressed by the symptoms and has some difficulty in continuing
with ordinary work and social activities, but will probably not cease to
function completely.
A fifth character may be used to specify the presence
of the somatic syndrome:
F32.00 Without somatic symptoms
The criteria for mild depressive episode are
fulfilled, and there are few or none of the somatic symptoms present.
F32.01 With somatic symptoms
The criteria for mild depressive episode are
fulfilled, and four or more of the somatic symptoms are also present. (If
only two or three somatic symptoms are present but they are unusually severe,
use of this category may be justified.)
F32.1 Moderate Depressive Episode
Diagnostic Guidelines
At least two of the three most typical symptoms
noted for mild depressive episode should be present, plus at least three
(and preferably four) of the other symptoms. Several symptoms are likely
to be present to a marked degree, but this is not essential if a particularly
wide variety of symptoms is present overall. Minimum duration of the whole
episode is about 2 weeks.
An individual with a moderately severe depressive
episode will usually have considerable difficulty in continuing with social,
work or domestic activities.
A fifth character may be used to specify the occurrence
of somatic symptoms:
F32.10 Without somatic symptoms
The criteria for moderate depressive episode
are fulfilled, and few if any of the somatic symptoms are present.
F32.11 With somatic symptoms
The criteria for moderate depressive episode
are fulfilled, and four or more or the somatic symptoms are present. (If
only two or three somatic symptoms are present but they are unusually severe,
use of this category may be justified.)
F32.2 Severe Depressive Episode
Without Psychotic Symptoms
In a severe depressive episode, the sufferer usually
shows considerable distress or agitation, unless retardation is a marked
feature. Loss of self-esteem or feelings of uselessness or guilt are likely
to be prominent, and suicide is a distinct danger in particularly severe
cases. It is presumed here that the somatic syndrome will almost always
be present in a severe depressive episode.
Diagnostic Guidelines
All three of the typical symptoms noted for mild
and moderate depressive episodes should be present, plus at least four
other symptoms, some of which should be of severe intensity. However, if
important symptoms such as agitation or retardation are marked, the patient
may be unwilling or unable to describe many symptoms in detail. An overall
grading of severe episode may still be justified in such instances. The
depressive episode should usually last at least 2 weeks, but if the symptoms
are particularly severe and of very rapid onset, it may be justified to
make this diagnosis after less than 2 weeks.
During a severe depressive episode it is very
unlikely that the sufferer will be able to continue with social, work,
or domestic activities, except to a very limited extent.
This category should be used only for single episodes
of severe depression without psychotic symptoms; for further episodes,
a subcategory of recurrent depressive disorder should be used.
Includes:
- single episodes of agitated depression
-
melancholia or vital depression without psychotic
symptoms
F32.3 Severe Depressive Episode
With Psychotic Symptoms
Diagnostic Guidelines
A severe depressive episode which meets the criteria
given for severe depressive episode without psychotic symptoms and in which
delusions, hallucinations, or depressive stupor are present. The delusions
usually involve ideas of sin, poverty, or imminent disasters, responsibility
for which may be assumed by the patient. Auditory or olfactory hallucinations
are usually of defamatory or accusatory voices or of rotting filth or decomposing
flesh. Severe psychomotor retardation may progress to stupor. If required,
delusions or hallucinations may be specified as mood-congruent or mood-incongruent.
Differential Diagnosis
Depressive stupor must be differentiated from
catatonic schizophrenia, from dissociative stupor, and from organic forms
of stupor. This category should be used only for single episodes of severe
depression with psychotic symptoms; for further episodes a subcategory
of recurrent depressive disorder should be used.
Includes:
-
single episodes of major depression with psychotic
symptoms, psychotic depression, psychogenic depressive psychosis, reactive
depressive psychosis
-
Thanks to Internet Mental Health
for their text.
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