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Diagnostic Features
The essential feature of Bipolar I Disorder is a clinical course that
is characterized by the occurrence of one or more Manic Episodes...or
Mixed Episodes... Often individuals have also had one or more Major
Depressive Episodes...Episodes of Substance-Induced Mood Disorder
(due to the direct effects of a medication, other somatic treatments
for depression, a drug of abuse, or toxin exposure) or of Mood
Disorder Due to a General Medical Condition do not count toward a
diagnosis of Bipolar I Disorder. In addition, the episodes are not
better accounted for by Schizoaffective Disorder and are not
superimposed on Schizophrenia, Schizophreniform Disorder, Delusional
Disorder, or Psychotic Disorder Not Otherwise Specified. Bipolar I
Disorder is subclassified in the fourth digit of the code according
to whether the individual is experiencing a first episode (i.e.,
Single Manic Episode) or whether the disorder is recurrent.
Recurrence is indicated by either a shift in the polarity of the
episode or an interval between episodes of at least 2 months without
manic symptoms. A shift in polarity is defined as a clinical course
in which a Major Depressive Episode evolves into a Manic Episode or a
Mixed Episode or in which a Manic Episode or a Mixed Episode evolves
into a Major Depressive Episode. In contrast, a Hypomanic Episode
that evolves into a Manic Episode or a Mixed Episode, or a Manic
Episode that evolves into a Mixed Episode (or vice Versa), is
considered to be only a single episode. For recurrent Bipolar I
Disorders, the nature of the current (or most recent) episode can be
specified (Most Recent Episode Hypomanic, Most Recent Episode Manic,
Most Recent Episode Mixed, Most Recent Episode Depressed, Most Recent
Episode Unspecified).
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Specifiers
The following specifiers for Bipolar I Disorder can be used to
describe the current Manic, Mixed, or Major Depressive Episode (or,
if criteria are not currently met for a Manic, Mixed, or Major
Depressive Episode, the recent Manic, Mixed, or Major Depressive
Episode):
Mild, Moderate, Severe Without Psychotic Features, Severe With
Psychotic Features, In Partial Remission, In Full Remission...
With Catatonic Features...
With Postpartum Onset...
The following specifiers apply only to the current (or most recent)
Major Depressive Episode only if it is the most recent type of mood
episode:
- Chronic...
- With Melancholic Features...
- With Atypical Features...
The following specifiers can be used to indicate the pattern of
episodes:
- Longitudinal Course Specifiers (With or Without Full Interepisode Recovery)...
- With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)...
- With Rapid Cycling...
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Recording Procedures
The diagnostic codes for Bipolar I Disorder are selected as follows:
- The first three digits are 296.
- The fourth digit is 0 if there is a single Manic Episode. For
recurrent episodes, the fourth digit is 4 if the current or most
recent episode is a Hypomanic Episode or a Manic Episode, 6 if it is
a Mixed Episode, 5 if it is a Major Depressive Episode, and 7 if the
current or most recent episode is Unspecified.
- The fifth digit (except for Bipolar I Disorder, Most Recent
Episode Hypomanic, and Bipolar I Disorder, Most Recent Episode
Unspecified) indicates the following: 1 for Mild severity, 2 for
Moderate severity, 3 for Severe Without Psychotic Features, 4 for
Severe With Psychotic Features, 5 for in Partial Remission, 6 for in
Full Remission, and 0 if Unspecified. Other specifiers for Bipolar I
Disorder cannot be coded. For Bipolar I Disorder, Most Recent Episode
Hypomanic, the fifth digit is always 0. For Bipolar Disorder, Most
Recent Episode Unspecified, there is no fifth digit.
In recording the name of a diagnosis, terms should be listed in the
following order: Bipolar I Disorder, specifiers coded in the fourth
digit (e.g., Most Recent Episode Manic), specifiers coded in the
fifth digit (e.g., Mild, Severe With Psychotic Features, In Partial
Remission), as many specifiers (without codes) as apply to the course
of episodes (e.g., With Rapid Cycling); for example, 296.54 Bipolar I
Disorder, Most Recent Episode Depressed, Severe With Psychotic
Features, With Melancholic Features, With Rapid Cycling.
Note that if the single episode of Bipolar I Disorder is a Mixed
Episode, the diagnosis would be indicated as 296.0x Bipolar I
Disorder, Single Manic Episode, Mixed.
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Associated Features and Disorders
Associated descriptive features and mental disorders. Completed
suicide occurs in 10% - 15% of individuals with Bipolar I Disorder.
Child abuse, spouse abuse, or other violent behavior may occur during
severe Manic Episodes or during those with psychotic features. Other
associated problems include school truancy, school failure,
occupational failure, divorce, or episodic antisocial behavior. Other
associated mental disorders include Anorexia Nervosa, Bulimia,
Nervosa, Attention-Deficit/Hyperactivity Disorder, Panic Disorder,
Social Phobia, Substance - Related Disorders.
Associated laboratory findings. There appears to be no laboratory
features that distinguish Major Depressive Episodes found in Major
Depressive Disorder from those in Bipolar I Disorder.
Associated physical examination finding and general medication
conditions. An age at onset for a first Manic Episode after age 40
year should alert the clinician to the possibility that the symptoms
may be due to a general medical condition or substance use. There is
some evidence that untreated thyroid disease worsens the prognosis of
bipolar I Disorder.
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Specific Culture, Age, and Gender Features
There are no reports of differential incidence of Bipolar I Disorder
based on race or ethnicity. There is some evidence that clinicians
may have a tendency to overdiagnose Schizophrenia (instead of Bipolar
Disorder) in some ethnic groups and in younger individuals.
Approximately 10% - 15% of adolescents with recurrent Major
Depressive Episodes will go on to develop Bipolar I Disorder. Mixed
Episodes Appear to be more likely in adolescents and young adults
than in older adults.
Recent epidemiological studies in the United States indicate that
Bipolar I Disorder is approximately equally common in men and women
(unlike Major Depressive Disorder, which is more common in women).
Gender appears to be related to the order of appearance of Manic and
Major Depressive Episodes. The first episode in males is more likely
to be a Manic Episode. The first episode in females is more likely to
be a Major Depressive Episode. Women with Bipolar I Disorder have an
increased risk of developing subsequent episodes (often psychotic) in
the immediate postpartum period. Some women have their first episode
during the postpartum period. The specifier With Postpartum Onset may
be used to indicate that the onset of the episode is within 4 weeks
of delivery...The Premenstrual period may be associated with
worsening of an ongoing Major Depressive, Manic, Mixed, or Hypomanic
Episode.
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Prevalence
The lifetime prevalence of Bipolar I Disorder in community samples
has varied from 0.4% to 1.6%.
Course
Bipolar I Disorder is a recurrent disorder - more than 90% of
individuals who have a single Manic Episode go on to have future
episodes. Roughly 60% - 70% of Manic Episodes occur immediately
before or after a Major Depressive Episode. Manic Episodes often
precede or follow the Major Depressive Episodes in a characteristic
pattern for a particular person. The number of lifetime episodes
(both Manic and Major Depressive) tends to be higher for Bipolar I
Disorder compared with Major Depressive Disorder, Recurrent, Studies
of course of Bipolar I Disorder compared with Major Depressive
Disorder, Recurrent. Studies of the course of Bipolar I Disorder
prior to lithium maintenance treatment suggest that, on average, four
episodes occur in 10 years. The interval between episodes tends to
decrease as the individual ages. There is some evidenced that changes
in sleep-wake schedule such as occur during time zone changes or
sleep deprivation may precipitate or exacerbate a Manic, Mixed, or
Hypomanic Episode. Approximately 5% - 15% of individuals with Bipolar
I Disorder have multiple (four or more) mood episodes (Major
Depressive, Manic, Mixed, or Hypomanic) that occur within a given
year. if this pattern is present, it is noted by the specifier With
Rapid Cycling...A rapid-cycling pattern is associated with a poorer
prognosis.
Although the majority of individuals with Bipolar I Disorder return
to a fully functional level between episodes, some (20% - 30%)
continue to display mood lability and interpersonal or occupational
difficulties. Psychotic symptoms may develop after days or weeks in
what was previously a nonpsychotic Manic or Mixed Episode. When an
individual has Manic Episodes with psychotic features, subsequent
Manic Episodes are more likely to have psychotic features. Incomplete
interepisode recovery is more common when the current episode is
accompanied by mood-incongruent psychotic features.
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Familial Pattern
First-degree biological relatives of individuals with Bipolar I
Disorder have elevated rates of Bipolar I Disorder (4%-24%), Bipolar
II Disorder (1%-5%), and Major Depressive Disorder (4%-24%). Twin and
adoption studies provide strong evidence of a genetic influence for
Bipolar I Disorder.
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Differential Diagnosis
Major Depressive, Manic, Mixed, and Hypomanic Episodes in Bipolar I
Disorder must be distinguished from episodes of a Mood Disorder Due
to a General Medical Condition. The diagnosis is Mood Disorder Due to
a General Medical Condition for episodes that are judged to be the
direct physiological consequence of a specific general medical
condition (e.g., multiple sclerosis, stroke, hypothyroidism). This
determination is based on the history, laboratory findings, or
physical examination.
A Substance-Induced Mood Disorder is distinguished from Major
Depressive, Manic, or Mixed Episodes that occur in Bipolar I Disorder
by the fact that a substance (e.g., a drug of abuse, a medication, or
exposure to a toxin) is judged to be etiologically related to the
mood disturbance. Symptoms like those seen in a Manic, Mixed, or
Hypomanic Episode may be part of an intoxication with or withdrawal
from a drug of abuse and should be diagnosed as a Substance-Induced
Mood Disorder (e.g., euphoric mood that occurs only in the context of
intoxication with cocaine would be diagnosed as Cocaine-Induced Mood
Disorder, With Manic Features, With Onset During Intoxication).
Symptoms like those seen in a Manic or Mixed Episode may also be
precipitated by antidepressant treatment such as medication,
electroconvulsive therapy, or light therapy. such episodes may be
diagnosed as a Substance-Induced Mood Disorder (e.g., Amitriptyline-
Induced Mood Disorder, With Manic Features; Electroconvulsive Therapy
- Induced Mood Disorder, With Manic Features) and would not count
toward a diagnosis of Bipolar I Disorder. however, when the substance
use or medication is judged not to fully account for the episode
(e.g., the episode continues for a considerable period autonomously
after the substance is discontinued), the episode would count toward
a diagnosis of Bipolar I Disorder.
Bipolar I Disorder is distinguished from Major Depressive Disorder
and Dysthymic Disorder by the lifetime history of at least one Manic
or Mixed Episode. Bipolar I Disorder is distinguished from Bipolar II
Disorder by the presence of one or more Manic or Mixed Episodes. When
an individual previously diagnosed with Bipolar II Disorder develops
a Manic or Mixed Episode, the diagnosis is changed to Bipolar I
Disorder.
In Cyclothymic Disorder, there are numerous periods of hypomanic
symptoms that do not meet criteria for a Manic Episode and periods of
depressive symptoms that do not meet symptom or duration criteria for
a Major Depressive Episode. Bipolar I Disorder is distinguished from
Cyclothymic Disorder by the presence of one or more Manic or Mixed
Episodes. If a Manic or Mixed Episode occurs after the first 2 years
of Cyclothymic Disorder, then Cyclothymic Disorder and Bipolar I
Disorder may both be diagnosed.
The differential diagnosis between Psychotic Disorders (e.g.,
Schizoaffective Disorder, Schizophrenia, and Delusional Disorder) and
Bipolar I Disorder may be difficult (especially in adolescents)
because these disorders may share a number of presenting symptoms
(e.g., grandiose and persecutory delusions, irritability, agitation,
and catatonic symptoms), particularly cross-sectionally and early in
their course. In contrast to Bipolar I Disorder, Schizophrenia,
Schizoaffective Disorder, and Delusional Disorder are all
characterized by periods of psychotic symptoms that occur in the
absence of prominent mood symptoms. Other helpful considerations
include the accompanying symptoms, previous course, and family
history, Manic and depressive symptoms may be present during
Schizophrenia, Delusional Disorder, and Psychotic Disorder Not
Otherwise Specified but rarely with sufficient number, duration and
pervasiveness to meet criteria for a Manic Episode or a Major
Depressive Episode. However, when full criteria are met (or the
symptoms are of particular clinical significance), a diagnosis of
Bipolar Disorder Not Otherwise Specified may be made in addition to
the diagnosis of Schizophrenia, Delusional Disorder, or Psychotic
Disorder Not Otherwise Specified.
If there is a very rapid alternation (over days) between manic
symptoms and depressive symptoms (e.g., several days of purely manic
symptoms followed by several days of purely depressive symptoms) that
do not meet minimal duration criteria for a Manic Episode or Major
Depressive Episode, the diagnosis is Bipolar Disorder Not Otherwise
Specified.
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Diagnostic criteria for 296.0x Bipolar I Disorder, Single Manic Episode
A. Presence of only one Manic Episode...and no past major Depressive
Episodes.
Note: Recurrence is defined as either a change in polarity from
depression or an interval of at least 2 months without manic symptoms.
B. The Manic Episode is not better accounted for by Schizoaffective
Disorder and is not superimposed on Schizophrenia, Schizophreniform
Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise
Specified.
Specify if:
Mixed: if symptoms meet criteria for a Mixed Episode...
Specify (for current or most recent episode).
Severity/Psychotic/Remission Specifiers...
With Catatonic Features...
With Postpartum Onset...
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Diagnostic criteria for 296.40 Bipolar I Disorder, Most Recent
Episode Hypomanic
A. Currently (or most recently) in a Hypomanic Episode...
B. There has previously been at least one Manic Episode...or Mixed
Episode...
C. The mood symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
D. The mood episodes in Criteria a and B are not better accounted for
by Schizoaffective Disorder and are not superimposed on
Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or
Psychotic Disorder Not Otherwise Specified.
Specify:
Longitudinal Course Specifiers (With and Without Interepisode
Recovery)...
With Seasonal Pattern (applies only to the pattern of Major
Depressive Episodes)...
With Rapid Cycling...
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Diagnostic criteria for 296.4x Bipolar I Disorder, Most Recent
Episode Manic
A. Currently (or most recently) in a Manic Episode...
B. There has previously been at least one Major Depressive
Episode...,Manic Episode...,or Mixed Episode...
C. The mood episodes in Criteria A and B are not better accounted for
by Schizoaffective Disorder and are not superimposed on
Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or
Psychotic Disorder Not Otherwise Specified.
Specify (for current or most recent episode):
Severity/Psychotic/Remission Specifiers...
With Catatonic Features...
With Postpartum Onset...
Specify
Longitudinal Course Specifiers (With and Without Interepisode
Recovery)...
With Seasonal Pattern (applies only to the pattern of Major
Depressive Episodes)...
With Rapid Cycling...
Diagnostic criteria for 196.6x Bipolar I Disorder, Most Recent
Episode Mixed
A. Currently (or most recently) in a Mixed Episode...
B. There has previously been at least one Major Depressive
episode...,Manic Episode...,or Mixed Episode...
C. The mood episodes in Criteria A and B are not better accounted for
by Schizoaffective Disorder and are not superimposed on
Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or
Psychotic Disorder Not Otherwise Specified.
Specify (for current or most recent episode):
Severity/Psychotic/Remission Specifiers...
With Catatonic Features...
With Postpartum Onset...
Specify:
Longitudinal Course Specifiers (With and Without Interepisode
Recovery)...
With Seasonal Pattern (applies only to the pattern of Major
Depressive Episodes)...
With Rapid Cycling...
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Diagnostic criteria for 296.5x Bipolar I Disorder, most Recent
Episode Depressed
A. Currently (or most recently) in a Major Depressive Episode...
B. There has previously been at least one Manic Episode...or Mixed
Episode...
C. The mood episodes in Criteria A and B are not better accounted for
by Schizoaffective Disorder and are not superimposed on
Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or
Psychotic Disorder Not Otherwise Specified.
Specify (for current or most recent episode)
Severity/Psychotic/Remission Specifiers...
Chronic...
With Catatonic Features...
With Melancholic Features...
With Atypical Features...
With Postpartum Onset...
Specify:
Longitudinal Course Specifiers (With and Without Interepisode
Recovery)...
With Seasonal Pattern (applies only to the pattern of major
Depressive Episodes)...
With Rapid Cycling...
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Diagnostic criteria for 296.7 Bipolar I Disorder, most Recent Episode
Unspecified
A. Criteria, except for duration, are currently (or most recently)
met for a Manic..., a hypomanic..., or a Major Depressive Episode...
B. There has previously been at least one Manic Episode
The above is for educational purposes.
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