Bipolar or related disorders

Description

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 Requirements

Bipolar or Related Disorders are episodic mood disorders defined by the occurrence of Manic, Mixed or Hypomanic Episodes or symptoms. These typically alternate over the course of these disorders with Depressive Episodes or periods of depressive symptoms.

Because the symptoms of Bipolar Type I Disorder and Bipolar Type II Disorder are substantially similar apart from the occurrence of Manic or Mixed Episodes in Bipolar Type I Disorder and Hypomanic Episodes in Bipolar Type II Disorder, following a separate listing of the Essential Features for each of these disorders, the other CDDR sections (e.g., Additional Clinical Features, Boundaries with Other Disorders and Conditions) are provided for both disorders together.

For presentations characterized by manic or hypomanic symptoms (with or without depressive symptoms) that do not fulfil the diagnostic requirements for any other disorder in the Bipolar or Related Disorders grouping, the following diagnosis may be appropriate:

6A6Y Other Specified Bipolar or Related Disorders

Essential (Required) Features:

The presentation is characterized by manic or hypomanic symptoms (with or without depressive symptoms) that share primary clinical features with other Bipolar or Related Disorders (e.g., persistent elevation of mood).

The symptoms do not fulfil the diagnostic requirements for any other disorder in the Bipolar or Related Disorders grouping.

The symptoms are not better accounted for by another Mental, Behavioural or Neurodevelopmental Disorder (e.g., Schizoaffective Disorder; a Disorder Due to Addictive Behaviours; a Personality Disorder).

The symptoms and behaviours are not a manifestation of another medical condition and are not due to the effects of a substance or medication (e.g., alcohol, cocaine) on the central nervous system, including withdrawal effects.

The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

6A60 Bipolar type I disorder

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Bipolar or related disorders

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Description

Bipolar type I disorder is an 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 characterised 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 behaviour, and rapid changes among different mood states (i.e., mood lability). A mixed episode is characterised by the presence of several prominent manic and several prominent depressive symptoms consistent with those observed in manic episodes and depressive episodes, which either occur simultaneously or alternate very rapidly (from day to day or within the same day). Symptoms must include an altered mood state consistent with a manic and/or depressive episode (i.e., depressed, dysphoric, euphoric or expansive mood), and be present most of the day, nearly every day, during a period of at least 2 weeks, unless shortened by a treatment intervention. Although 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.

Exclusions

Cyclothymia (6A62)
Bipolar type II disorder (6A61)

Diagnostic Requirements

Essential Features:

A history of at least one Manic or Mixed Episode (see Essential Features for Mood Episodes). Although a single Manic or Mixed Episode is sufficient for a diagnosis of Bipolar Type I Disorder, the typical course of the disorder is characterized by recurrent Depressive and Manic or Mixed Episodes. Although some episodes may be Hypomanic, there must be a history of at least one Manic or Mixed Episode.

Type of current Mood Episode, psychotic symptoms, severity of current Depressive Episodes, and remission specifiers:

The type of current Mood Episode, the presence or absence of psychotic symptoms, the severity of current Depressive Episodes, and the degree of remission should be described in Bipolar Type I Disorder. (See descriptions of psychotic symptoms and Depressive Episode Severity in Mood Episode descriptions above.) Available categories are as follows:

6A60.0 Bipolar Type I Disorder, Current Episode Manic, without psychotic symptoms
6A60.1 Bipolar Type I Disorder, Current Episode Manic, with psychotic symptoms
6A60.2 Bipolar Type I Disorder, Current Episode Hypomanic
6A60.3 Bipolar Type I Disorder, Current Episode Depressive, Mild
6A60.4 Bipolar Type I Disorder, Current Episode Depressive, Moderate, without psychotic symptoms
6A60.5 Bipolar Type I Disorder, Current Episode Depressive, Moderate, with psychotic symptoms
6A60.6 Bipolar Type I Disorder, Current Episode Depressive, Severe, without psychotic symptoms
6A60.7 Bipolar Type I Disorder, Current Episode Depressive, Severe, with psychotic symptoms
6A60.8 Bipolar Type I Disorder, Current Episode Depressive, Unspecified Severity
6A60.9 Bipolar Type I Disorder, Current Episode Mixed, without psychotic symptoms
6A60.A Bipolar Type I Disorder, Current Episode Mixed, with psychotic symptoms
6A60.B Bipolar Type I Disorder, currently in partial remission, most recent episode Manic or Hypomanic
6A60.C Bipolar Type I Disorder, currently in partial remission, most recent episode Depressive
6A60.D Bipolar Type I Disorder, currently in partial remission, most recent episode Mixed
6A60.E Bipolar Type I Disorder, currently in partial remission, most recent episode unspecified
6A60.F Bipolar Type I Disorder, currently in full remission

Symptomatic and Course Presentation Specifiers for Mood Episodes:

Additional specifiers may be applied to describe a current mood episode in the context of Bipolar Type I Disorder (Depressive, Manic, Mixed or Hypomanic Episodes). These specifiers indicate other important features of the clinical presentation or of the course, onset, and pattern of Mood Episodes. These specifiers are not mutually exclusive, and as many may be added as apply. (Note that these same specifiers, with the exception of Rapid Cycling, may also be applied to current Depressive Episodes in the context of Depressive Disorders. The specifier Rapid Cycling is specific to Bipolar Type I and Bipolar Type II Disorders.)

Available specifiers are as follows:

with prominent anxiety symptoms (6A80.0)

This specifier can be applied if, in the context of a current Depressive, Manic, Mixed, or Hypomanic Episode, prominent and clinically significant anxiety symptoms (e.g., feeling nervous, anxious or on edge, not being able to control worrying thoughts, fear that something awful will happen, having trouble relaxing, muscle tension, autonomic symptoms) have been present for most of the time during the episode. If there have been panic attacks during the current Depressive or Mixed Episode, these should be recorded separately (see ‘with panic attacks’ specifier). This specifier may be used whether or not the diagnostic requirements for an Anxiety or Fear-Related Disorder are also met, in which case the Anxiety or Fear-Related Disorder should also be diagnosed.

with panic attacks (6A80.1)

This specifier can be applied if, in the context of a current Episode, there have been panic attacks during the past month that occur specifically in response to depressive ruminations or other anxiety-provoking cognitions. If panic attacks occur exclusively in response to such thoughts, the ‘with panic attacks’ specifier should be applied rather than an additional co-occurring diagnosis of Panic Disorder. If some panic attacks over the course of the Depressive or Mixed Episode have been unexpected and not exclusively in response to depressive or anxiety-provoking thoughts and the full diagnostic requirements for Panic Disorder are met, a separate diagnosis of Panic Disorder should be assigned.

current Depressive Episode persistent (6A80.2)

This specifier can be applied if the diagnostic requirements for Depressive Episode are currently met and have been met continuously for at least the past 2 years.

current Depressive Episode with melancholia (6A80.3)

This specifier can be applied if, in the context of a current Depressive Episode, several of the following symptoms have been present during the worst period of the current episode:
- Loss of interest or pleasure in most activities that are normally enjoyable to the individual (i.e., pervasive anhedonia).
- Lack of emotional reactivity to normally pleasurable stimuli or circumstances (i.e., mood does not lift even transiently with exposure).
- Terminal insomnia (i.e., waking in the morning 2 hours or more before the usual time).
- Depressive symptoms are worse in the morning.
- Marked psychomotor retardation or agitation.
- Marked loss of appetite or loss of weight.

with seasonal pattern of mood episode onset (6A80.4)

This specifier can be applied to Bipolar Type I Disorder if there has been a regular seasonal pattern of onset and remission of at least one type of episode (i.e., Depressive, Manic, Mixed, or Hypomanic Episodes). The other types of Mood Episodes may not follow this pattern.
A substantial majority of the relevant Mood Episodes should correspond with the seasonal pattern.
A seasonal pattern should be differentiated from an episode that is coincidental with a particular season but predominantly related to a psychological stressor that regularly occurs at that time of the year (e.g., seasonal unemployment).

with rapid cycling (6A80.5)

This specifier can be applied if the Bipolar Type I Disorder is characterized by a high frequency of Mood Episodes (at least four) over the past 12 months. There may be a switch from one polarity of mood to the other, or the Mood Episodes may be demarcated by a period of remission.
In individuals with a high frequency of Mood Episodes, some may have a shorter duration than those usually observed in Bipolar Type I Disorder. In particular, depressive periods may only last several days. However, if depressive and manic symptoms alternate very rapidly (i.e., from day to day or within the same day), a Mixed Episode should be diagnosed rather than rapid cycling.

In the context of Bipolar Type I Disorder, Mood Episodes that occur during pregnancy or commencing within about 6 weeks after delivery (referred to as the puerperium) can be identified using one of the following two additional diagnostic codes, depending on whether delusions, hallucinations, or other psychotic symptoms are present. These diagnoses should be assigned in addition to the relevant Bipolar Disorder diagnosis.

Mental or behavioural disorders associated with pregnancy, childbirth or the puerperium, without psychotic symptoms (6E20)

This additional diagnostic code should be used for Mood Episodes that arise during pregnancy or commencing within about 6 weeks after delivery that do not include delusions, hallucinations, or other psychotic symptoms. This designation should not be used to describe mild and transient depressive symptoms that do not meet the diagnostic requirements for a depressive episode, which may occur soon after delivery (so-called postpartum blues).

Mental or behavioural disorders associated with pregnancy, childbirth or the puerperium, with psychotic symptoms (6E21)

This additional diagnostic code should be used for Mood Episodes that arise during pregnancy or commencing within about 6 weeks after delivery that include delusions, hallucinations, or other psychotic symptoms. This designation should not be used to describe mild and transient depressive symptoms that do not meet the diagnostic requirements for a depressive episode, which may occur soon after delivery (so-called postpartum blues).

Note: For the following sections, see also material under Depressive Episode, Manic Episode, Mixed Episode and Hypomanic Episode. Material on Additional Clinical Features, Boundary with Normality (Threshold), Developmental Presentations, and Boundary with Other Disorders and Conditions (Differential Diagnosis) that relates specifically to the Mood Episodes is contained in these sections, whereas material focusing on Bipolar Type I Disorder overall appears below.

Additional Clinical Features:

In combination with a history of one or more Depressive Episodes, a Mixed, Manic or Hypomanic Episode arising during antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy, transcranial magnetic stimulation) is grounds for a diagnosis of Bipolar Type I Disorder if the syndrome persists after the treatment is discontinued and the full diagnostic requirements of the Mood Episode are met after the direct physiological effects of the treatment are likely to have receded.
Inter-episode periods may be characterized by complete remission of symptoms or by the presence of residual hypomanic, manic, mixed, or depressive symptoms, in which case the ‘partial remission’ specifier should be applied.
Suicide risk is significantly higher among individuals diagnosed with Bipolar Type I Disorder than among the general population, particularly during Depressive or Mixed Episodes and among individuals with rapid cycling.
Recurrent panic attacks in Bipolar Type I Disorder may be indicative of greater severity, poorer response to treatment, and greater risk for suicide.
Family history is an important factor to consider because heritability of Bipolar Disorders is the highest of all mental disorders.
Individuals initially diagnosed with Bipolar Type II Disorder are at high risk of experiencing a Manic or Mixed Episode during their lifetime. If this occurs, the diagnosis should be changed to Bipolar Type I Disorder.
Patients diagnosed with Bipolar Type I Disorder are at elevated risk for developing a variety of medical conditions affecting the cardiovascular system (e.g., hypertension) and metabolism (e.g., hyperglycemia), some of which may be due to the effects of the chronic use of medications used to treat Bipolar Disorders.
Individuals with Bipolar Type I Disorder exhibit high rates of co-occurring Mental, Behavioural or Neurodevelopmental Disorders, most commonly Anxiety or Fear-Related Disorders and Disorders Due to Substance Use.

Course Features:

Although the onset of a first Manic, Hypomanic, or Depressive Episode most often occurs during the late teen years, onset of Bipolar Type I Disorder can occur at any time through the life cycle, including in older adulthood. Late-onset mood symptoms may be more likely to be caused by the effects of medications or substances or other medical conditions.
The majority of individuals who experience a single Manic Episode will go on to develop recurrent Mood Episodes. More than half of Manic Episodes will be immediately followed by a Depressive Episode.
The risk of recurrence of Mood Episodes in Bipolar Type I Disorder increases with the number of prior Mood Episodes.
Individuals with Bipolar Type I Disorder are at increased lifetime risk of suicidality.

Culture-Related Features:

Studies indicate that the prevalence of Bipolar or Related Disorders varies across cultural, ethnic, and migrant groups, partly as a function of social stress. Symptom expression may also vary and be shaped by common cultural idioms, cultural histories or personal histories that are prominent in identity formation and expressed as grandiose ideas or beliefs. For example, grandiosity may be expressed in culturally specific ways such that a Muslim individual experiencing a Manic Episode may believe he is Muhammad, whereas a Christian individual may believe he is Jesus. Individuals from the person’s cultural group may be helpful in distinguishing normative expressions of belief or ritual from manic or psychotic experiences and behaviours.
In some cultural contexts, mood changes are more readily expressed in the form of bodily symptoms (e.g., pain, fatigue, weakness) rather than directly reported as psychological symptoms.
Some types of symptoms may be considered more shameful or severe according to cultural norms, leading to reporting biases. For example, some cultures may emphasize shame more than guilt, whereas in others suicidal behaviour and thinking may be prohibited. In some cultural groups, features such as sadness and lack of productivity may be perceived as signs of personal weakness and therefore under-reported.
The cultural salience of depressive symptoms may vary across social groups as a result of varying cultural ‘scripts’ for the disorder which make specific types of symptoms more prominent, for example: psychological (e.g., sadness, emotional numbness, rumination), moral (e.g., guilt, worthlessness), social/interpersonal (e.g., lack of productivity, conflictive relationships), hedonic (e.g., decreased pleasure), spiritual (e.g., dreams of dead relatives), or somatic symptoms (e.g., insomnia, pain, fatigue, dizziness).

Sex- and/or Gender-Related Features:

Prevalence rates for Bipolar Type I Disorder are similar between men and women with a tendency for men to exhibit earlier onset of symptoms.
Manic Episodes occur more commonly in men and are typically more severe and impairing. In contrast, women are more likely to experience Depressive Episodes, Mixed Episodes, and rapid cycling.
Disorders Due to Substance Use often co-occur with Bipolar Type I Disorder among men, whereas women are more likely to experience comorbid medical conditions including migraines, obesity, and thyroid disease as well as co-occurring mental disorders including Anxiety or Fear-Related Disorders and Eating Disorders.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

Boundary with Cyclothymic Disorder: In Cyclothymic Disorder, the number, severity and/or duration of depressive symptoms have never met the threshold required for a Depressive Episode and there is no evidence of a history of Mixed or Manic Episodes.
Boundary with Attention Deficit Hyperactivity Disorder: Although a Manic, Hypomanic, or Mixed Episode may include symptoms characteristic of Attention Deficit Hyperactivity Disorder such as distractibility, hyperactivity, and impulsivity, Bipolar Type I is differentiated from Attention Deficit Hyperactivity Disorder by its episodic nature and the accompanying elevated, euphoric or irritable mood. However, Attention Deficit Hyperactivity Disorder and Bipolar Type I Disorder can co-occur. When they do, Attention Deficit Hyperactivity Disorder symptoms tend to worsen during Hypomanic, Manic, or Mixed Episodes.
Boundary with Schizophrenia or Other Primary Psychotic Disorders: The presentation is not better accounted for by a diagnosis of Schizophrenia or Other Primary Psychotic Disorder. Individuals with Bipolar Type I Disorder can exhibit psychotic symptoms during Depressive Episodes, and individuals with Bipolar Type I Disorder can exhibit psychotic symptoms during Manic or Mixed Episodes, but these symptoms occur only during Mood Episodes. Conversely, individuals with a diagnosis of Schizophrenia or Other Primary Psychotic Disorder may experience significant depressive or manic symptoms during psychotic episodes. In such cases, if the symptoms do not meet the diagnostic requirements for a Depressive, Manic, or Mixed Episode, their presence and severity in the context of a psychotic disorder diagnosis can be denoted by applying specifier scales from ‘Symptomatic Manifestations of Primary Psychotic Disorders’, i.e., ‘with depressive symptoms in primary psychotic disorders’ or ‘with manic symptoms in primary psychotic disorders.’ If all diagnostic requirements for both a Depressive, Manic, or Mixed Episode and Schizophrenia are met concurrently or within a few days of each other and other diagnostic requirements are met, the diagnosis of Schizoaffective Disorder should be assigned rather than Bipolar Type I Disorder. A Hypomanic Episode superimposed on Schizophrenia does not qualify for a diagnosis of Schizoaffective Disorder. However, a diagnosis of Bipolar Type I Disorder can co-occur with a diagnosis of Schizophrenia or Other Primary Psychotic Disorder, and both diagnoses may be assigned if the full diagnostic requirements for both disorders are met and psychotic symptoms are present outside of Mood Episodes.
Boundary with Anxiety or Fear-Related Disorders: Symptoms of anxiety, including panic attacks, are common in Bipolar Type I Disorder, and in some individuals may be a prominent aspect of the clinical presentation. In such cases, the specifier ‘with prominent anxiety symptoms’ should be applied to the diagnosis for non-panic anxiety systems. If the anxiety symptoms meet the diagnostic requirements for an Anxiety or Fear-Related Disorder, the appropriate diagnosis from the Anxiety or Fear-Related Disorders grouping should also be assigned. For panic attacks, if these occur entirely in the context of anxiety associated with Depressive, Hypomanic, Manic, or Mixed Episodes in Bipolar Type I Disorder, they are appropriately designated using the ‘with panic attacks’ specifier. However, if panic attacks also occur outside of symptomatic Mood Episodes and other diagnostic requirements are met, a separate diagnosis of Panic Disorder should be considered. Both specifiers may be assigned if warranted.
Boundary with Personality Disorder: Individuals with a Personality Disorder may exhibit impulsivity or mood instability, but Personality Disorder does not include Depressive, Hypomanic, Manic, or Mixed Episodes. However, co-occurrence of Personality Disorder and Bipolar Type I Disorder is relatively common. Symptoms of Personality Disorder should be assessed outside the context of a Mood Episode to avoid conflating symptoms of a Mood Episode with personality traits, but both diagnoses may be assigned if the diagnostic requirements for both diagnoses are fulfilled.
Boundary with Oppositional Defiant Disorder: It is common, particularly among children and adolescents, for patterns of noncompliance and symptoms of irritability/anger to arise as part of a Mood Disorder. For example, noncompliance may be a result of depressive symptoms (e.g., diminished interest or pleasure in activities, difficulty concentrating, hopelessness, psychomotor retardation, reduced energy). During Hypomanic or Manic episodes, individuals are less likely to follow rules and comply with directions. Oppositional Defiant Disorder often co-occurs with Mood Disorders, and irritability/anger can be a common symptom across these disorders. When the behaviour problems occur primarily in the context of Hypomanic, Manic, Depressive, or Mixed Episodes, a separate diagnosis of Oppositional Defiant Disorder should not be assigned. However, both diagnoses may be given if the full diagnostic requirements for both disorders are met and the behaviour problems associated with Oppositional Defiant Disorder are observed outside the occurrence of a Mood Episode. The Oppositional Defiant Disorder specifier ‘with chronic irritability-anger’ may be used if appropriate.
Boundary with Substance-induced Mood Disorder: A Depressive, Hypomanic, Manic, or Mixed syndrome due to the effects of a substance or medication other than antidepressant medication on the central nervous system (e.g., cocaine, amphetamines), including withdrawal effects, should be diagnosed as Substance-Induced Mood Disorder rather than Bipolar Type I Disorder. The presence of continuing mood disturbance should be assessed once the physiological effects of the relevant substance subside.
Boundary with other Mental Disorders: Irritability is a symptom that is also observed in other disorders (e.g., Depressive Disorders, Generalized Anxiety Disorder). In order to attribute this symptom to a Manic, Hypomanic, or Mixed Episode, the clinician should establish the episodicity of the symptom and its co-occurrence with other symptoms consistent with a Manic, Hypomanic, or Mixed Episode.
Boundary with Secondary Mood Syndrome: A Depressive, Hypomanic, Manic, or Mixed syndrome that is a manifestation of another medical condition should be diagnosed as Secondary Mood Syndrome rather than Bipolar Type I Disorder.

6A61 Bipolar type II disorder

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Bipolar or related disorders

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Description

Bipolar type II disorder is an episodic mood disorder defined by the occurrence of one or more hypomanic episodes and at least one depressive episode. A hypomanic episode is a persistent mood state lasting for at least several days characterised by persistent elevation of mood or increased irritability as well as increased activity or a subjective experience of increased energy, accompanied by other characteristic symptoms such as increased talkativeness, rapid or racing thoughts, increased self-esteem, decreased need for sleep, distractability, and impulsive or reckless behavior. The symptoms represent a change from the individual’s typical mood, energy level, and behavior but are not severe enough to cause marked impairment in functioning. A depressive episode is characterised by a period of depressed mood or diminished interest in activities occurring most of the day, nearly every day during a period lasting at least two weeks accompanied by other symptoms such as changes in appetite or sleep, psychomotor agitation or retardation, fatigue, feelings of worthless or excessive or inappropriate guilt, feelings or hopelessness, difficulty concentrating, and suicidality. There is no history of manic or mixed episodes.

Diagnostic Requirements

Essential Features:

A history of at least one Hypomanic Episode and at least one Depressive Episode (see Essential Features for Mood Episodes). The typical course of the disorder is characterized by recurrent Depressive and Hypomanic Episodes.
There is no history of Manic or Mixed Episodes.

Type of current Mood Episode, severity and psychotic symptoms in current Depressive Episodes, and remission specifiers:

The type of current Mood Episode, the severity and presence or absence of psychotic symptoms in current Depressive Episodes, and the degree of remission should be described in Bipolar Type II Disorder. (See descriptions of psychotic symptoms and Depressive Episode Severity in Mood Episode descriptions above.) Available categories are as follows:

6A61.0 Bipolar Type II Disorder, Current Episode Hypomanic
6A61.1 Bipolar Type II Disorder, Current Episode Depressive, Mild
6A61.2 Bipolar Type II Disorder, Current Episode Depressive, Moderate, without psychotic symptoms
6A61.3 Bipolar Type II Disorder, Current Episode Depressive, Moderate, with psychotic symptoms
6A61.4 Bipolar Type II Disorder, Current Episode Depressive, Severe, without psychotic symptoms
6A61.5 Bipolar Type II Disorder, Current Episode Depressive, Severe, with psychotic symptoms
6A61.6 Bipolar Type II Disorder, Current Episode Depressive, Unspecified Severity
6A61.7 Bipolar Type II Disorder, currently in partial remission, most recent episode Hypomanic
6A61.8 Bipolar Type II Disorder, currently in partial remission, most recent episode Depressive
6A61.9 Bipolar Type II Disorder, currently in partial remission, most recent episode unspecified
6A61.A Bipolar Type II Disorder, currently in full remission

Symptomatic and Course Presentation Specifiers for Mood Episodes:

Additional specifiers may be applied to describe a current mood episode in the context of Bipolar Type II Disorder (Depressive or Hypomanic Episodes). These specifiers indicate other important features of the clinical presentation or of the course, onset, and pattern of Mood Episodes. These specifiers are not mutually exclusive, and as many may be added as apply. (Note that these same specifiers, with the exception of Rapid Cycling, may also be applied to current Depressive Episodes in the context of Depressive Disorders. The specifier Rapid Cycling is specific to Bipolar Type I and Bipolar Type II Disorders.)

Available specifiers are as follows:

with prominent anxiety symptoms (6A80.0)

This specifier can be applied if, in the context of a current Depressive, Manic, Mixed, or Hypomanic Episode, prominent and clinically significant anxiety symptoms (e.g., feeling nervous, anxious or on edge, not being able to control worrying thoughts, fear that something awful will happen, having trouble relaxing, muscle tension, autonomic symptoms) have been present for most of the time during the episode. If there have been panic attacks during the current Depressive or Mixed Episode, these should be recorded separately (see ‘with panic attacks’ specifier). This specifier may be used whether or not the diagnostic requirements for an Anxiety or Fear-Related Disorder are also met, in which case the Anxiety or Fear-Related Disorder should also be diagnosed.

with panic attacks (6A80.1)

This specifier can be applied if, in the context of a current Episode, there have been panic attacks during the past month that occur specifically in response to depressive ruminations or other anxiety-provoking cognitions. If panic attacks occur exclusively in response to such thoughts, the ‘with panic attacks’ specifier should be applied rather than an additional co-occurring diagnosis of Panic Disorder. If some panic attacks over the course of the Depressive or Mixed Episode have been unexpected and not exclusively in response to depressive or anxiety-provoking thoughts and the full diagnostic requirements for Panic Disorder are met, a separate diagnosis of Panic Disorder should be assigned.

current Depressive Episode persistent (6A80.2)

This specifier can be applied if the diagnostic requirements for Depressive Episode are currently met and have been met continuously for at least the past 2 years.

current Depressive Episode with melancholia (6A80.3)

This specifier can be applied if, in the context of a current Depressive Episode, several of the following symptoms have been present during the worst period of the current episode:
- Loss of interest or pleasure in most activities that are normally enjoyable to the individual (i.e., pervasive anhedonia).
- Lack of emotional reactivity to normally pleasurable stimuli or circumstances (i.e., mood does not lift even transiently with exposure).
- Terminal insomnia (i.e., waking in the morning 2 hours or more before the usual time).
- Depressive symptoms are worse in the morning.
- Marked psychomotor retardation or agitation.
- Marked loss of appetite or loss of weight.

with seasonal pattern (6A80.4)

This specifier can be applied to or Bipolar Type II Disorder if there has been a regular seasonal pattern of onset and remission of at least one type of episode (i.e., Depressive, Manic, Mixed, or Hypomanic Episodes). The other types of Mood Episodes may not follow this pattern.
A substantial majority of the relevant Mood Episodes should correspond with the seasonal pattern.
A seasonal pattern should be differentiated from an episode that is coincidental with a particular season but predominantly related to a psychological stressor that regularly occurs at that time of the year (e.g., seasonal unemployment).

with rapid cycling (6A80.5)

This specifier can be applied if or Bipolar Type II Disorder is characterized by a high frequency of Mood Episodes (at least four) over the past 12 months. There may be a switch from one polarity of mood to the other, or the Mood Episodes may be demarcated by a period of remission.
In individuals with a high frequency of Mood Episodes, some may have a shorter duration than those usually observed in Bipolar Type II Disorder. In particular, depressive periods may only last several days. However, if depressive and manic symptoms alternate very rapidly (i.e., from day to day or within the same day), a Mixed Episode should be diagnosed rather than rapid cycling.

In the context of Bipolar Type II Disorder, Mood Episodes that occur during pregnancy or commencing within about 6 weeks after delivery (referred to as the puerperium) can be identified using one of the following two additional diagnostic codes, depending on whether delusions, hallucinations, or other psychotic symptoms are present. These diagnoses should be assigned in addition to the relevant Bipolar Disorder diagnosis.

Mental or behavioural disorders associated with pregnancy, childbirth or the puerperium, without psychotic symptoms (6E20)

This additional diagnostic code should be used for Mood Episodes that arise during pregnancy or commencing within about 6 weeks after delivery that do not include delusions, hallucinations, or other psychotic symptoms. This designation should not be used to describe mild and transient depressive symptoms that do not meet the diagnostic requirements for a depressive episode, which may occur soon after delivery (so-called postpartum blues).

Mental or behavioural disorders associated with pregnancy, childbirth or the puerperium, with psychotic symptoms (6E21)

This additional diagnostic code should be used for Mood Episodes that arise during pregnancy or commencing within about 6 weeks after delivery that include delusions, hallucinations, or other psychotic symptoms. This designation should not be used to describe mild and transient depressive symptoms that do not meet the diagnostic requirements for a depressive episode, which may occur soon after delivery (so-called postpartum blues).

Additional Clinical Features:

In combination with a history of one or more Depressive Episodes, a Hypomanic Episode arising during antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy, transcranial magnetic stimulation) is grounds for a diagnosis of Bipolar Type II Disorder if the syndrome persists after the treatment is discontinued and the full diagnostic requirements of the Mood Episode are met after the direct physiological effects of the treatment are likely to have receded.
Inter-episode periods may be characterized by complete remission of symptoms or by the presence of residual hypomanic, manic, mixed, or depressive symptoms, in which case the ‘partial remission’ specifier should be applied.
Suicide risk is significantly higher among individuals diagnosed with Bipolar Type II Disorder than among the general population, particularly during Depressive Episodes and among individuals with rapid cycling.
Recurrent panic attacks in Bipolar Type II Disorder may be indicative of greater severity, poorer response to treatment, and greater risk for suicide.
Family history is an important factor to consider because heritability of Bipolar Disorders is the highest of all mental disorders.
When individuals with Bipolar Type II Disorder seek clinical services, they almost invariably do so during Depressive Episodes. Given that individuals experiencing a Hypomanic Episode often have a subjective experience of improved functioning (e.g., greater productivity and creativity at work), they rarely seek clinical care during such episodes. Thus, Hypomanic Episodes usually must be assessed retrospectively in individuals presenting with depressive symptoms.
Individuals initially diagnosed with Bipolar Type II Disorder are at high risk of experiencing a Manic or Mixed Episode during their lifetime. If this occurs, the diagnosis should be changed to Bipolar Type I Disorder.
Patients diagnosed with Bipolar Type II Disorder are at elevated risk for developing a variety of medical conditions affecting the cardiovascular system (e.g., hypertension) and metabolism (e.g., hyperglycemia), some of which may be due to the effects of the chronic use of medications used to treat Bipolar Disorders.
Individuals with Bipolar Type II Disorder exhibit high rates of co-occurring Mental, Behavioural or Neurodevelopmental Disorders, most commonly Anxiety or Fear-Related Disorders and Disorders Due to Substance Use.

Boundary with Normality (Threshold):

The presence or history of Hypomanic Episodes in the absence of a history of at least one Depressive Episode is not a sufficient basis for a presumptive diagnosis of Bipolar Type II Disorder.

Course Features:

Bipolar Type II Disorder has its onset most often during the mid-twenties; however, onset during late adolescence and throughout early and mid-adulthood may also occur. Initial onset of Bipolar Type II Disorder in older adults is rare.
While onset typically begins following a single Depressive Episode, some individuals experience several Depressive Episodes before occurrence of a Hypomanic Episode.
The presence of chronic and gradually worsening experiences of affective lability or mood swings, particularly during adolescence and early adulthood, has been associated with an increased risk of developing Bipolar Type II Disorder.
Up to 15% of individuals with Bipolar Type II Disorder will subsequently develop a Manic Episode resulting in a change of diagnosis to Bipolar Type I Disorder.
Spontaneous intra-episode shifts from a Depressive Episode to Hypomanic Episode are not uncommon.
Risk of recurrence increases with each subsequent Mood Episode.

Culture-Related Features:

Studies indicate that the prevalence of Bipolar or Related Disorders varies across cultural, ethnic, and migrant groups, partly as a function of social stress. Symptom expression may also vary and be shaped by common cultural idioms, cultural histories or personal histories that are prominent in identity formation and expressed as grandiose ideas or beliefs. For example, grandiosity may be expressed in culturally specific ways such that a Muslim individual experiencing a Manic Episode may believe he is Muhammad, whereas a Christian individual may believe he is Jesus. Individuals from the person’s cultural group may be helpful in distinguishing normative expressions of belief or ritual from manic or psychotic experiences and behaviours.
In some cultural contexts, mood changes are more readily expressed in the form of bodily symptoms (e.g., pain, fatigue, weakness) rather than directly reported as psychological symptoms.
Some types of symptoms may be considered more shameful or severe according to cultural norms, leading to reporting biases. For example, some cultures may emphasize shame more than guilt, whereas in others suicidal behaviour and thinking may be prohibited. In some cultural groups, features such as sadness and lack of productivity may be perceived as signs of personal weakness and therefore under-reported.
The cultural salience of depressive symptoms may vary across social groups as a result of varying cultural ‘scripts’ for the disorder which make specific types of symptoms more prominent, for example: psychological (e.g., sadness, emotional numbness, rumination), moral (e.g., guilt, worthlessness), social/interpersonal (e.g., lack of productivity, conflictive relationships), hedonic (e.g., decreased pleasure), spiritual (e.g., dreams of dead relatives), or somatic symptoms (e.g., insomnia, pain, fatigue, dizziness).

Sex- and/or Gender-Related Features:

Women are more likely to experience Hypomanic Episodes and rapid cycling. The time of greatest risk for a Hypomanic Episode is during the early postpartum period following childbirth. A specifier of ‘Current Episode Perinatal’ should be assigned under these circumstances. Approximately half of those who experience postpartum hypomanic symptoms will later develop a Depressive Disorder. Differentiating between normal experiences of mood and sleep disturbances typically associated with caring for a newborn and symptoms of Bipolar Type II disorder is challenging.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

Boundary with Cyclothymic Disorder: In Cyclothymic Disorder, the number, severity and/or duration of depressive symptoms have never met the threshold required for a Depressive Episode and there is no evidence of a history of Mixed or Manic Episodes.
Boundary with Attention Deficit Hyperactivity Disorder: Although a Hypomanic Episode may include symptoms characteristic of Attention Deficit Hyperactivity Disorder such as distractibility, hyperactivity, and impulsivity, Bipolar Type II Disorder are differentiated from Attention Deficit Hyperactivity Disorder by their episodic nature and the accompanying elevated, euphoric or irritable mood. However, Attention Deficit Hyperactivity Disorder and Bipolar Type II Disorder can co-occur. When they do, Attention Deficit Hyperactivity Disorder symptoms tend to worsen during Hypomanic Episodes.
Boundary with Schizophrenia or Other Primary Psychotic Disorders: The presentation is not better accounted for by a diagnosis of Schizophrenia or Other Primary Psychotic Disorder. Individuals with Bipolar Type II Disorder can exhibit psychotic symptoms during Depressive Episodes, but these symptoms occur only during Mood Episodes. Conversely, individuals with a diagnosis of Schizophrenia or Other Primary Psychotic Disorder may experience significant depressive or manic symptoms during psychotic episodes. In such cases, if the symptoms do not meet the diagnostic requirements for a Depressive Episode, their presence and severity in the context of a psychotic disorder diagnosis can be denoted by applying specifier scales from ‘Symptomatic Manifestations of Primary Psychotic Disorders’, i.e., ‘with depressive symptoms in primary psychotic disorders.’ If all diagnostic requirements for both a Depressive Episode and Schizophrenia are met concurrently or within a few days of each other and other diagnostic requirements are met, the diagnosis of Schizoaffective Disorder should be assigned rather than Bipolar Type II Disorder. A Hypomanic Episode superimposed on Schizophrenia does not qualify for a diagnosis of Schizoaffective Disorder. However, a diagnosis of Bipolar Type II Disorder can co-occur with a diagnosis of Schizophrenia or Other Primary Psychotic Disorder, and both diagnoses may be assigned if the full diagnostic requirements for both disorders are met and psychotic symptoms are present outside of Mood Episodes.
Boundary with Anxiety or Fear-Related Disorders: Symptoms of anxiety, including panic attacks, are common in Bipolar Type II Disorder, and in some individuals may be a prominent aspect of the clinical presentation. In such cases, the specifier ‘with prominent anxiety symptoms’ should be applied to the diagnosis for non-panic anxiety systems. If the anxiety symptoms meet the diagnostic requirements for an Anxiety or Fear-Related Disorder, the appropriate diagnosis from the Anxiety or Fear-Related Disorders grouping should also be assigned. For panic attacks, if these occur entirely in the context of anxiety associated with Depressive or Hypomanic Episodes in Bipolar Type II Disorder, they are appropriately designated using the ‘with panic attacks’ specifier. However, if panic attacks also occur outside of symptomatic Mood Episodes and other diagnostic requirements are met, a separate diagnosis of Panic Disorder should be considered. Both specifiers may be assigned if warranted.
Boundary with Personality Disorder: Individuals with a Personality Disorder may exhibit impulsivity or mood instability, but Personality Disorder does not include Depressive or Hypomanic Episodes. However, co-occurrence of Personality Disorder and Bipolar Type II Disorder is relatively common. Symptoms of Personality Disorder should be assessed outside the context of a Mood Episode to avoid conflating symptoms of a Mood Episode with personality traits, but both diagnoses may be assigned if the diagnostic requirements for both diagnoses are fulfilled.
Boundary with Oppositional Defiant Disorder: It is common, particularly among children and adolescents, for patterns of noncompliance and symptoms of irritability/anger to arise as part of a Mood Disorder. For example, noncompliance may be a result of depressive symptoms (e.g., diminished interest or pleasure in activities, difficulty concentrating, hopelessness, psychomotor retardation, reduced energy). During Hypomanic episodes, individuals are less likely to follow rules and comply with directions. Oppositional Defiant Disorder often co-occurs with Mood Disorders, and irritability/anger can be a common symptom across these disorders. When the behaviour problems occur primarily in the context of Hypomanic or Depressive Episodes, a separate diagnosis of Oppositional Defiant Disorder should not be assigned. However, both diagnoses may be given if the full diagnostic requirements for both disorders are met and the behaviour problems associated with Oppositional Defiant Disorder are observed outside the occurrence of a Mood Episode. The Oppositional Defiant Disorder specifier ‘with chronic irritability-anger’ may be used if appropriate.
Boundary with Substance-induced Mood Disorder: A Depressive or Hypomanic syndrome due to the effects of a substance or medication other than antidepressant medication on the central nervous system (e.g., cocaine, amphetamines), including withdrawal effects, should be diagnosed as Substance-Induced Mood Disorder rather than Bipolar Type II Disorder. The presence of continuing mood disturbance should be assessed once the physiological effects of the relevant substance subside.
Boundary with other Mental Disorders: Irritability is a symptom that is also observed in other disorders (e.g., Depressive Disorders, Generalized Anxiety Disorder). In order to attribute this symptom to a Hypomanic Episode, the clinician should establish the episodicity of the symptom and its co-occurrence with other symptoms consistent with a Hypomanic Episode.
Boundary with Secondary Mood Syndrome: A Depressive or Hypomanic syndrome that is a manifestation of another medical condition should be diagnosed as Secondary Mood Syndrome rather than Bipolar Type II Disorder.

6A62 Cyclothymic disorder

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Bipolar or related disorders

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Description

Cyclothymic disorder is characterised 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. 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.

Inclusions

Cycloid personality
Cyclothymic personality

Diagnostic Requirements

Essential Features:

Mood instability over an extended period of time (i.e., 2 years or more) characterized by numerous hypomanic and depressive periods. (In children and adolescents depressed mood can manifest as pervasive irritability.) Hypomanic periods may or may not have been sufficiently severe or prolonged to meet the diagnostic requirements for a Hypomanic Episode.
Mood symptoms are present for more days than not. While brief symptom-free intervals are consistent with the diagnosis, there have never been any prolonged symptom-free periods (e.g., lasting 2 months or more) since the onset of the disorder.
There is no history of Manic or Mixed Episodes.
During the first 2 years of the disorder, there has never been a 2-week period during which the number and duration of symptoms were sufficient to meet the diagnostic requirements for a Depressive Episode.
The symptoms are not a manifestation of another medical condition (e.g., hyperthyroidism) and are not due to the effects of a substance or medication on the central nervous system (e.g., stimulants), including withdrawal effects.
The symptoms result in significant distress about experiencing persistent mood instability or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

Additional Clinical Features:

In children, it may be appropriate to assign the diagnosis of Cyclothymic Disorder after a somewhat briefer period of initial symptoms (e.g., 1 year).
Individuals initially diagnosed with Cyclothymic Disorder are at high risk for developing Bipolar Type I or Bipolar Type II Disorder during their lifetime.
Individuals with Cyclothymic Disorder do not typically exhibit psychotic symptoms.

Boundary with Normality (Threshold):

Cyclothymic Disorder is distinguished from normal variations in mood by a history of distress or difficulty functioning due to repeated occurrences of mood disturbance.

Course Features

The course of Cyclothymic Disorder is often gradual and persistent. Onset of Cyclothymic Disorder commonly occurs during adolescence or early adulthood and may be difficult to differentiate from normal mood instability associated with hormonal changes that accompany puberty.

Developmental Presentations:

Onset of Cyclothymic Disorder in children typically occurs before the age of 10. Symptoms of irritability (particularly during periods of low mood) and sleep disturbance are often the prominent clinical features and reasons for consultation.
Cyclothymic Disorder is underdiagnosed in children and adolescents despite evidence for greater prevalence of this disorder in this age group as compared to Bipolar Type I and Type II Disorders. However, the most common trajectory in children and adolescents is symptom remission; only a minority will maintain the diagnosis into adulthood or be at high risk for developing Bipolar Type I or Bipolar Type II Disorder.
Co-occurrence with other Mental, Behavioural or Neurodevelopmental Disorders is common in children and adolescents with Cyclothymic Disorder, particularly with Attention Deficit Hyperactivity Disorder.

Culture-Related Features:

There is little information available about cultural influences on Cyclothymic Disorder. The information on Culture-Related Features for Bipolar Type I Disorder and Bipolar Type II Disorder may be relevant.

Sex- and/or Gender-Related Features:

There are no known differences in prevalence rates between genders for Cyclothymic Disorder.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

Boundary with Single Episode Depressive Disorder and Recurrent Depressive Disorder: During the first 2 years of the disorder, depressive periods in Cyclothymic Disorder should not be sufficient to meet the diagnostic requirements for a Depressive Episode. Outside of this 2-year period, there may be instances in which the symptoms are severe enough to constitute a Depressive Episode. In such cases, if there is no history of Hypomanic Episodes, Single Episode Depressive Disorder or Recurrent Depressive Disorder may be diagnosed along with Cyclothymic Disorder.
Boundary with Bipolar Type I Disorder: If the number and severity of symptoms reaches the diagnostic threshold for a Manic Episode or a Mixed Episode in the context of an ongoing Cyclothymic Disorder, the diagnosis should be changed to Bipolar Type I Disorder.
Boundary with Bipolar Type II Disorder: If the number and severity of symptoms reaches the diagnostic threshold for Single Episode Depressive Disorder or Recurrent Depressive Disorder in the context of an ongoing Cyclothymic Disorder and the individual has a history of Hypomanic Episodes but no history of Manic or Mixed Episodes, the diagnosis should be changed to Bipolar Type II disorder.
Boundary with Attention Deficit Hyperactivity Disorder: Although hypomanic symptoms overlap with symptoms of Attention Deficit Hyperactivity Disorder such as distractibility, hyperactivity, and impulsivity, Hypomanic Episodes are differentiated from Attention Deficit Hyperactivity Disorder by their episodic nature and the accompanying elevated, euphoric or irritable mood. Attention Deficit Hyperactivity Disorder and Cyclothymic Disorder can co-occur and, when this occurs, Attention Deficit Hyperactivity Disorder symptoms tend to worsen during Hypomanic Episodes.
Boundary with Oppositional Defiant Disorder: It is common, particularly among children and adolescents, for patterns of noncompliance and symptoms of irritability/anger to arise as part of a Mood Disorder. For example, noncompliance may be a result of depressive symptoms (e.g., diminished interest or pleasure in activities, difficulty concentrating, hopelessness, psychomotor retardation, reduced energy). Individuals may be less likely to follow rules and comply with directions when experiencing hypomanic symptoms. In contrast, individuals with Oppositional Defiant Disorder do not exhibit the episodicity characteristic of Cyclothymic Disorder. However, Oppositional Defiant Disorder often co-occurs with Mood Disorders, and irritability/anger can be a common symptom across these disorders. When the behaviour problems occur primarily in the context of mood disturbance, a separate diagnosis of Oppositional Defiant Disorder should not be assigned. However, both diagnoses may be given if the full diagnostic requirements for both disorders are met and the behaviour problems associated with Oppositional Defiant Disorder are observed outside of periods of mood disturbance. The Oppositional Defiant Disorder specifier ‘with chronic irritability-anger’ may be used if appropriate.
Boundary with Personality Disorder: Individuals with Personality Disorder may exhibit impulsivity or mood instability, but Cyclothymic Disorder does not include persistent problems in self-functioning and interpersonal dysfunction that characterize Personality Disorder. Personality Disorder should be assessed outside the context of a Mood Episode to avoid conflating symptoms of a Mood Episode with personality traits, but both diagnoses may be assigned if the diagnostic requirements for both diagnoses are fulfilled.
Boundary with Secondary Mood Syndrome: Chronic mood instability that is a manifestation of another medical condition should be diagnosed as Secondary Mood Syndrome rather than Cyclothymic Disorder.
Boundary with Substance-induced Mood Disorder: Chronic mood instability due to the effects of a substance or medication on the central nervous system (e.g., benzodiazepines), including withdrawal effects (e.g., from stimulants), should be diagnosed as Substance-Induced Mood Disorder rather than Cyclothymic Disorder.

6A6Y Other specified bipolar or related disorders

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Bipolar or related disorders

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This category is an 'other specified’ residual category

6A6Z Bipolar or related disorders, unspecified

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Bipolar or related disorders

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This category is an 'unspecified’ residual category