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Understanding bipolarity and mood disorders

Natalya Anderson reports from the Sixth National Conference on Bipolar Disorder in London, where delegates heard that better classification of bipolarity is needed to avoid misdiagnoses

An ongoing discourse between healthcare professionals and their patients may be necessary to gain a better understanding of the classification of bipolarity and to avoid misdiagnosis, according to information presented at The Sixth National Conference on Bipolar Disorder, which was held in London recently.

In his presentation, ‘Classify-ing bipolarity: from disease entity to borderline personality types,’ Dr Trevor Turner stressed the importance of continued discussion around diagnostic criteria for the highly complex mental illness.

“It’s the kind of thing that people often ask about,” said Dr Turner, Consultant Psychiatrist, Barts & Homerton University Hospital, London and the East London Foundation Trust. “There exists a difficulty of classifying modern illness traits. Sometimes it fades into personality types. Distinctions get blurred.”

It can become increasingly difficult for physicians in determining diagnosis when two types of classification language dominate, specifically the WHO’s International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD 10), and the Diagnostic and Statistical Manual of Mental Disorders (DSM IV).

“With DSM IV, there are terms used there that are not used in ICD 10,” explained Dr Turner. “The dilemma is that we have a lot of mixed presentations. For example, you could have a patient weeping in the middle of mania.”

Focusing mainly on ICD 10 ‘Chapter V: Mental and behavioural disorders’ (a manner of coding for various aspects of these disorders in accordance with the WHO), Dr Turner reviewed various diagnostic criteria for bipolar affective disorder (BPAD).

Mood disorders

BPAD in ICD 10 is classified within the codes for ‘Mood (Affective) Disorders’ (coded as F30 – F39), including manic episode (F30), bipolar affective disorder (F31), depressive episode (F32), recurrent depressive disorder (F33), and persistent mood disorders such as dysthymia and cyclothymia (F34).

Continuing in his demonstration of the complexity of classifying BPAD, Dr Turner offered a further breakdown of BPAD in ICD 10 (which can also be obtained for revision online at www.who.int/classifications/apps/icd/icd10online/).

The F30 code of manic episode is further broken down into hypomania (.0), mania without psychotic symptoms (.1), mania with psychotic symptoms (.2), other (.8) and unspecified (.9).

BPAD in ICD 10 also details the F31 code for BPAD itself, including hympomanic (.0), manic without psychotic symptoms (.1), manic with psychotic symptoms (.2) and mild or moderate depression without .30 or with 0.31 somatic symptoms. These were noted as all current episodes. The F31 category is continued as severe depression without psychotic symptoms (.4), severe depression with psychotic symptoms (.5), mixed (.6), in remission (.7) and other and unspecified again (.8, .9, respectively).
Dr Turner focused on a few of the important definitions outlined for BPAD in ICD 10. Hypomania, for example, is stipulated as a persistent elevation of mood or energy, without severe social disruption and without hallucinations or delusions.

Mania without psychotic symptoms has been defined by the WHO as characterised by elevated mood, overactivity, pressure of speech, short attention span, over-inflated self-esteem, ‘grandiose’ gestures and extravagance.

Mania with psychotic symptoms encapsulates the characteristics of mania without psychotic symptoms, but with the addition of delusion and hallucinations. Dr Turner highlighted the fact that many diagnostic categories exist because of an arbitrary number of diagnostic symptoms. He added that a great debate still resurfaces among professionals regarding dysthymia and cyclothymia and whether they are ‘personality styles’ or mood disorders.

He highlighted in his presentation that bipolar indications in depression might include onset of symptoms at an early age, strong family history of depression, psychotic or atypical features, illness at post-partum and brief, recurrent episodes.

“We try to classify BPAD within various degrees of highness and lowness,” explained Dr Turner. “It’s an attempt to put some structure on facets of the illness. Discussion of classification is important in the case of junior doctors. They may assume that if someone’s got a persecutory delusion, that must mean that they’re suffering from paranoia.”

Furthering the complexity of diagnosis, comorbidity of BPAD can include alcohol and/or drug abuse, panic disorder, obsessive compulsive disorder, eating disorders and other personality disorders.

Dr Turner suggested that discussion with some groups of patients could be crucial to improving diagnostic criteria in the future. He offered examples of patients who could insightfully describe to him the colours, shapes or specific types of light patterns that they saw during a shift from mania to depression, or vice versa.

“With our more intelligent patients, it may be worth exploring the changeability they feel inside them,” he explained.

In his presentation, ‘Under-standing mood states: aetiology, diagnostic pitfalls and differential diagnosis’, Dr Mark Slater, Consultant Psychiatrist at Barts & Homerton University Hospital, London, echoed Dr Turner’s suggestion that distinctions between mood disorders are still very blurred. He suggests that a challenge is also posed to psychiatrists treating patients with mood disorders.

“Clinical practice pays scant regard to what we have learnt about emotion,” Dr Slater explained during his presentation. “Our current diagnostic approach to mood disorders is based entirely upon clinical description. We need to be rigorous in our attempts at description.”

Dr Slater also examined differential diagnosis criteria for schizophrenia, anxiety, borderline personality disorder, drug-induced abnormal mood and ‘normality’.

Schizophrenia

In the area of schizophrenia, he explained that mood symptoms are common and that psychotic symptoms are common in BPAD. The form and content of hallucinations and delusions should be ‘scoured’ for ‘mood congruence’, according to Dr Slater. Family history and the quality of a patient’s thought disruption should also be considered.

Points to consider in examining differential diagnosis for anxiety include very high levels of anxiety in BPAD, with special attention during early episodes. Dr Slater also looked at the question of whether or not a symptom is part of differential diagnosis, comorbidity or an integral part of the patient’s anxiety – again, adding weight to the argument for clear description from patients who are able to define some of their mood changes clearly. Also integral to differential diagnosis of anxiety is inarticulacy or learning difficulty, according to Dr Slater’s presentation. Physicians should attempt to define whether a patient is exhibiting signs of apprehension and calamity, as opposed to signs of euphoria and irritability. “Look for clear autonomic overarousal,” explained Dr Slater.

Differential diagnosis in the area of borderline personality disorder (BPD) might include deciphering short but intense mood changes, which are common in BPD. “The ‘personality disorder’ label encourages us to overlook other diagnoses,” said Dr Slater. “Consider early life and constitution and explore motives and beliefs behind behaviours and relationships.”

Dr Slater warned that BPAD has high comorbidity for drug abuse, and that mania can be very similar to stimulant intoxication. The difference with mania is that it takes longer to settle than drug reaction. A thorough examination of the patient’s drug history is essential, he added.

Emotional constitution

There exists an assumption that BPAD sufferers ‘have an ‘emotional constitution’, according to Dr Slater’s presentation. He stressed, however, that a patient with BPAD may have a different cognitive style than that of a ‘normal’ individual. He suggested that isolated hypomania is important in examining differential diagnosis in this area, and that a ‘normal mood between unipolar lows may be misinterpreted as high’.

Again illustrating the varying diagnostic codes for mood disorders, Dr Slater briefly reviewed schizoaffective disorder as defined by DSM IV (further information can be found at www.dsmivtr.org/). Within that context, schizoaffective disorder is defined as a period of illness that is uninterrupted, and during which a manic, depressive or mixed affective episode occurs ‘concurrent with criterion symptoms for schizophrenia’.

Additionally, throughout that period of illness, there should be a two-week duration of delusions or hallucinations without prominent mood symptoms. Symptoms that meet criteria for a mood disorder should furthermore be ‘present for a substantial portion of the total duration of the active and residual periods of the illness’, Dr Slater summarised in his presentation.

“The gulf between our understanding and treatment of mood disorders is unnecessarily wide,” concluded Dr Slater. “Until we bridge this gulf, we must rely on descriptive precision. Epidemiologic, cognitive, genetic and neurologic progress is being made. The borderlands of normality, psychosis, drug misuse and mood disorder need greater exploration.”

Posted in Mental Health & CNS on 11 March 2009
Tags: bipolar disorder

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abortion, accupuncture, ACE inhibitors, acne, ADHD, alcohol, allergies, Alzheimer's, anaemia, anaethesia, anorexia, antibiotics, antidepressants, antihistamine, anxiety, appetite control, arthritis, ASCOT, aspirin, asthma, atherosclerosis, autism, autoantibodies, back pain, beta carotene, beta-blockers, bipolar disorder, birth, bleeding, blindness, blood pressure, body dysmorphic disorder, body mass, breast cancer, breast feeding, bronchitis, Caesarean section, calcium, cancer, carcinogens, carcinoma, cardiac syncope, cardiolgy, cataracts, cervical cancer, chemotherapy, child psychiatry, children, cholesterol, clinical trial, clopidogrel, Clostridium difficile, cognitive behavioural therapy, colectomy, colic, colorectal cancer, complementary and alternative therapies, contraception, COPD, coronary care, coronary stents, Crohn's, cystic fibrosis, defibrillator, dementia, depression, dermatology, diabetes management, diet, disability, DNA, Down's syndrome, eating disorders, echinacea, ECT, eczema, elderly people, endoscopy, epilepsy, erectile dysfunction, euthanasia, exercise, fat, fertility, fitness, flu pandemic, fluoxetine, folic acid, food labelling, fracture, fragile X syndrome, general surgery, genetics, gerontology, GIK infusion therapy, GORD, gout, haemodialysis, hearing, heart attack, heart disease, heart failure, heart health, hepatitis, HIV, hospital care, HPV, HRT, hyperglycaemia, hypertension, hypoglycaemia, IBD, ICU, incontinence, infant, infant mortality, infection, inflammatory bowel disease, influenza, invasive candidiasis, IQ, Irish Heart Foundation, irritable bowel syndrome, keyhole surgery, kidney disease, laser, learning difficulties, leukaemia, liver disease, lumbar disk herniation, lung cancer, lung disease, lymph nodes, macular degeneration, macular oedema, magnetic resonance imaging (MRI), malaria, malnutrition, Marfan syndrome, media, medical ethics, medical research, medication, meningitis, mental illness, metabolic syndrome, migraine, miscarriage, mortality rate, MRSA, multiple sclerosis (MS), NCHDs, nephrology, neurology, OAB, obesity, obstetrics, occupational health, ocular medicine, omega-3, opthalmology, oral cancer, organ transplantation, orthopaedics, osteoporosis, otolaryngology, ovarian cancer, paediatrics, pain management, pancreatic cancer, panic, Parkinson’s disease, patient safety, patient-physician communication, personality disorders, physiotherapy, plastic surgery, polio, practice, pre-eclampsia, pregnancy, preventative health care, probiotics, prostate cancer, psoriasis, psychiatric admission, psychiatry, psychotherapy, PTSD, public health, quality of life, radiology, radiotherapy, rectal cancer, reproductive health, research, resuscitation, rheumatoid arthritis, rheumatology, rhinitis, salt, SARS, schizophrenia, screening, seizures, self harm, sexual abuse, sexual health, sexually transmitted infections, SGA, sinusitis, skin cancer, sleep disorders, smoking, smoking ban, spinal injury, sports medicine, statins, stress, stroke, substance abuse, suicide, supplement, surgery, syncope, technology, teenagers, testosterone, thoracic surgery, thrombosis, thyroid cancer, tonsillectomy, tonsillitis, Tourette's syndrome, toxicology, travel medicine, tuberculosis, tumour angiogenesis, type 1 diabetes, type 2 diabetes, ulcer, ulcerative colitis, urinary incontinence, vaccine, vitamins, weight, WHO, women's health, World Health Assembly

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Understanding bipolarity and mood disorders

Natalya Anderson reports from the Sixth National Conference on Bipolar Disorder in London, where delegates heard that better classification of bipolarity is needed to avoid misdiagnoses

An ongoing discourse between healthcare professionals and their patients may be necessary to gain a better understanding of the classification of bipolarity and to avoid misdiagnosis, according to information presented at The Sixth National Conference on Bipolar Disorder, which was held in London recently.

In his presentation, ‘Classify-ing bipolarity: from disease entity to borderline personality types,’ Dr Trevor Turner stressed the importance of continued discussion around diagnostic criteria for the highly complex mental illness.

“It’s the kind of thing that people often ask about,” said Dr Turner, Consultant Psychiatrist, Barts & Homerton University Hospital, London and the East London Foundation Trust. “There exists a difficulty of classifying modern illness traits. Sometimes it fades into personality types. Distinctions get blurred.”

It can become increasingly difficult for physicians in determining diagnosis when two types of classification language dominate, specifically the WHO’s International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD 10), and the Diagnostic and Statistical Manual of Mental Disorders (DSM IV).

“With DSM IV, there are terms used there that are not used in ICD 10,” explained Dr Turner. “The dilemma is that we have a lot of mixed presentations. For example, you could have a patient weeping in the middle of mania.”

Focusing mainly on ICD 10 ‘Chapter V: Mental and behavioural disorders’ (a manner of coding for various aspects of these disorders in accordance with the WHO), Dr Turner reviewed various diagnostic criteria for bipolar affective disorder (BPAD).

Mood disorders

BPAD in ICD 10 is classified within the codes for ‘Mood (Affective) Disorders’ (coded as F30 – F39), including manic episode (F30), bipolar affective disorder (F31), depressive episode (F32), recurrent depressive disorder (F33), and persistent mood disorders such as dysthymia and cyclothymia (F34).

Continuing in his demonstration of the complexity of classifying BPAD, Dr Turner offered a further breakdown of BPAD in ICD 10 (which can also be obtained for revision online at www.who.int/classifications/apps/icd/icd10online/).

The F30 code of manic episode is further broken down into hypomania (.0), mania without psychotic symptoms (.1), mania with psychotic symptoms (.2), other (.8) and unspecified (.9).

BPAD in ICD 10 also details the F31 code for BPAD itself, including hympomanic (.0), manic without psychotic symptoms (.1), manic with psychotic symptoms (.2) and mild or moderate depression without .30 or with 0.31 somatic symptoms. These were noted as all current episodes. The F31 category is continued as severe depression without psychotic symptoms (.4), severe depression with psychotic symptoms (.5), mixed (.6), in remission (.7) and other and unspecified again (.8, .9, respectively).
Dr Turner focused on a few of the important definitions outlined for BPAD in ICD 10. Hypomania, for example, is stipulated as a persistent elevation of mood or energy, without severe social disruption and without hallucinations or delusions.

Mania without psychotic symptoms has been defined by the WHO as characterised by elevated mood, overactivity, pressure of speech, short attention span, over-inflated self-esteem, ‘grandiose’ gestures and extravagance.

Mania with psychotic symptoms encapsulates the characteristics of mania without psychotic symptoms, but with the addition of delusion and hallucinations. Dr Turner highlighted the fact that many diagnostic categories exist because of an arbitrary number of diagnostic symptoms. He added that a great debate still resurfaces among professionals regarding dysthymia and cyclothymia and whether they are ‘personality styles’ or mood disorders.

He highlighted in his presentation that bipolar indications in depression might include onset of symptoms at an early age, strong family history of depression, psychotic or atypical features, illness at post-partum and brief, recurrent episodes.

“We try to classify BPAD within various degrees of highness and lowness,” explained Dr Turner. “It’s an attempt to put some structure on facets of the illness. Discussion of classification is important in the case of junior doctors. They may assume that if someone’s got a persecutory delusion, that must mean that they’re suffering from paranoia.”

Furthering the complexity of diagnosis, comorbidity of BPAD can include alcohol and/or drug abuse, panic disorder, obsessive compulsive disorder, eating disorders and other personality disorders.

Dr Turner suggested that discussion with some groups of patients could be crucial to improving diagnostic criteria in the future. He offered examples of patients who could insightfully describe to him the colours, shapes or specific types of light patterns that they saw during a shift from mania to depression, or vice versa.

“With our more intelligent patients, it may be worth exploring the changeability they feel inside them,” he explained.

In his presentation, ‘Under-standing mood states: aetiology, diagnostic pitfalls and differential diagnosis’, Dr Mark Slater, Consultant Psychiatrist at Barts & Homerton University Hospital, London, echoed Dr Turner’s suggestion that distinctions between mood disorders are still very blurred. He suggests that a challenge is also posed to psychiatrists treating patients with mood disorders.

“Clinical practice pays scant regard to what we have learnt about emotion,” Dr Slater explained during his presentation. “Our current diagnostic approach to mood disorders is based entirely upon clinical description. We need to be rigorous in our attempts at description.”

Dr Slater also examined differential diagnosis criteria for schizophrenia, anxiety, borderline personality disorder, drug-induced abnormal mood and ‘normality’.

Schizophrenia

In the area of schizophrenia, he explained that mood symptoms are common and that psychotic symptoms are common in BPAD. The form and content of hallucinations and delusions should be ‘scoured’ for ‘mood congruence’, according to Dr Slater. Family history and the quality of a patient’s thought disruption should also be considered.

Points to consider in examining differential diagnosis for anxiety include very high levels of anxiety in BPAD, with special attention during early episodes. Dr Slater also looked at the question of whether or not a symptom is part of differential diagnosis, comorbidity or an integral part of the patient’s anxiety – again, adding weight to the argument for clear description from patients who are able to define some of their mood changes clearly. Also integral to differential diagnosis of anxiety is inarticulacy or learning difficulty, according to Dr Slater’s presentation. Physicians should attempt to define whether a patient is exhibiting signs of apprehension and calamity, as opposed to signs of euphoria and irritability. “Look for clear autonomic overarousal,” explained Dr Slater.

Differential diagnosis in the area of borderline personality disorder (BPD) might include deciphering short but intense mood changes, which are common in BPD. “The ‘personality disorder’ label encourages us to overlook other diagnoses,” said Dr Slater. “Consider early life and constitution and explore motives and beliefs behind behaviours and relationships.”

Dr Slater warned that BPAD has high comorbidity for drug abuse, and that mania can be very similar to stimulant intoxication. The difference with mania is that it takes longer to settle than drug reaction. A thorough examination of the patient’s drug history is essential, he added.

Emotional constitution

There exists an assumption that BPAD sufferers ‘have an ‘emotional constitution’, according to Dr Slater’s presentation. He stressed, however, that a patient with BPAD may have a different cognitive style than that of a ‘normal’ individual. He suggested that isolated hypomania is important in examining differential diagnosis in this area, and that a ‘normal mood between unipolar lows may be misinterpreted as high’.

Again illustrating the varying diagnostic codes for mood disorders, Dr Slater briefly reviewed schizoaffective disorder as defined by DSM IV (further information can be found at www.dsmivtr.org/). Within that context, schizoaffective disorder is defined as a period of illness that is uninterrupted, and during which a manic, depressive or mixed affective episode occurs ‘concurrent with criterion symptoms for schizophrenia’.

Additionally, throughout that period of illness, there should be a two-week duration of delusions or hallucinations without prominent mood symptoms. Symptoms that meet criteria for a mood disorder should furthermore be ‘present for a substantial portion of the total duration of the active and residual periods of the illness’, Dr Slater summarised in his presentation.

“The gulf between our understanding and treatment of mood disorders is unnecessarily wide,” concluded Dr Slater. “Until we bridge this gulf, we must rely on descriptive precision. Epidemiologic, cognitive, genetic and neurologic progress is being made. The borderlands of normality, psychosis, drug misuse and mood disorder need greater exploration.”

Posted in Mental Health & CNS on 11 March 2009
Tags: bipolar disorder