Task Force Proposes New Bipolar Guidelines

An international team of experts recently proposed expanding the diagnostic criteria for several subtypes of bipolar disorder, adding a pediatric bipolar disorder category and eliminating the schizoaffective disorder category.

The Diagnostic Guidelines Task Force of the International Society for Bipolar Disorder (ISBD) has been examining diagnostic issues since 2004 and recently presented its recommendations at ISBD's third biennial meeting in India and in the society's journal, Bipolar Disorders (February, part 2).

Task force chairman S. Nassir Ghaemi, MD, MPH, told Psychiatric Times that the task force brought together some of the world's clinical experts on bipolar disorder and key researchers with the goal of having them develop a more systematic and coherent set of diagnostic guidelines.

The task force's charge, originally developed by then ISBD president Samuel Gershon, MD, was to evaluate current diagnostic systems, identify key similarities and differences among them, reconcile the data, provide an organizational schema for diagnosis of bipolar disorder across cultures, and highlight continuing differences for further research.

In a summary article on the guidelines, Ghaemi and his coauthors¹ noted that too often "diagnostic guidelines are almost an afterthought" to treat- ment guidelines.

"Creating treatment guidelines without diagnostic guidelines is like trying to wash your hair with shampoo but not water—the 2 things go together," said Ghaemi, who is director of the Bipolar Disorder Research Program and associate professor of psychiatry and public health at Emory University in Atlanta. Good nosology begets good psychopharmacology and treatment, he explained.

Task force members were divided into subgroups based on diagnostic subtypes: acute mania, bipolar depression, bipolar disorder type II, rapid cycling, spectrum concepts, pediatric bipolar disorder, schizoaffective disorder, and mixed states. They proposed possible revisions to current DSM-IV and International Classification of Diseases, 10th Revision (ICD-10) nosology and provided diagnostic guidance for clinicians. They not only broadened the definitions of acute mania, bipolar depression, and bipolar II but also proposed definitions of bipolar spectrum and pediatric bipolar disorders.

Broadening criteria
The acute mania subgroup, for example, recommended broadening of the definition to include irritable/dysphoric states and added a diagnostic seasonal specifier for mania. Also expanded was the definition of bipolar depression, according to Ghaemi. "It is not just depression in someone who happens to have had manic episodes but rather specific kinds of depression with specific features," he said.

Drawing on various studies, the depression subgroup proposed a probabilistic approach to diagnosing bipolar I depression in a person experiencing a major depressive episode with no clear previous episode of mania. Clinical features include early onset of first depression (before age 25 years), multiple (5 or more) previous episodes of depression, family history of bipolar disorder, atypical depressive symptoms (such as leaden paralysis), psychomotor retardation, psychotic features, and/or pathological guilt.

Looking at bipolar II, the subgroup concluded "bipolar II disorder is supported as a distinct category within mood disorders, but the definition and boundaries deserve greater clarification in DSM-V and ICD-11."

The subgroup recommended that dysphoric hypomania be specifically described in DSM-V and that the minimum duration criteria for a hypomanic episode be shortened from 4 days to 2 days, Ghaemi said.

Bipolar II is often underdiagnosed or misdiagnosed, the subgroup said, and it is frequently accompanied by high morbidity and mortality. "Bipolar II disorder, sometimes wrongly called 'soft bipolar disorder,' is actually a severe pathology," the subgroup said. "[It] often implies a higher episode frequency, comorbidity, suicidal behavior, and rapid cycling."

The rapid cycling subgroup decided to retain the DSM-IV definition of rapid cycling. While episode cycling can be conceptualized as a dimensional phenomenon between the extremes of no cycling and continuous ultradian cycling, it said, "there is insufficient new evidence to modify the existing DSM-IV definition of rapid cycling in a manner that would be less arbitrary."

The subgroup went on to recommend adding a specifier "with ultra-rapid cycling" to the bipolar disorder not otherwise specified (NOS) category in order to include patients who may be similar to those with bipolar I and II rapid cycling.

Additions
The bipolar spectrum illness subgroup determined that both the phenomenological and the epidemiological literature somewhat support the concept of a spectrum model of bipolar disorder—one that views the presentations of this condition in terms of more or fewer manic symptoms rather than simply presence or absence of the full manic or hypomanic syndrome.

"We have specific definitions and criteria that are proposed that can be used for clinical practice as well as for research. We think they should be added to DSM-V and DSM-VI, and only eliminated if they prove to not be helpful," Ghaemi said.

For example, the subgroup recommended that the bipolar spectrum concept be added under bipolar NOS with 2 descriptors: subthreshold hypomanic episodes in the context of multiple other signs of bipolar disorder as well as multiple signs of bipolarity without hypomanic or manic episodes.