Task Force Proposes New Bipolar Guidelines

Psychiatric TimesPsychiatric Times Vol 25 No 4
Volume 25
Issue 4

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.

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.

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.

Childhood bipolar disorder should be formally described in both the DSM and ICD, the pediatric bipolar subgroup said. The group members also agreed that some presentations in children are similar to manic symptoms in adulthood; that bipolar disorder in children is not reducible to attention-deficit/hyperactivity disorder (ADHD), although these conditions are often present together; and that there is more risk of bipolar disorder in children whose families include persons with bipolar disorder.

"The task force wanted to state that children do have straightforward mania according to the DSM-IV current adult definition and that this definition, at the very least, should be used," Ghaemi said.

In its recommended revision to DSM-IV, the subgroup described pediatric bipolar disorder as follows: (A) presence of acute manic, mixed, or hypomanic plus depressed episodes before age 18; and (B) the definition of the acute manic or hypomanic or mixed episode meets adult criteria. If only irritable mood is present, and not euphoria, then documented spontaneously episodic fluctuations in the presence or absence of symptoms of mania are required for the diagnosis of an acute manic, hypomanic, or mixed episode.

"Some researchers claim that schizoaffective disorder is consistent with the idea that there is no distinction to be made between schizophrenia and mood disorders, but the committee didn't agree with that," Ghaemi said.

Most of the evidence, he explained, suggests that schizoaffective disorder does not represent a separate categorical disease entity; rather, it is "a variation on schizophrenia or a variation on mood disorder or co-occurrence of the two."

The subgroup recommended dropping the schizoaffective disorder diagnostic category altogether from DSM-V and replacing it with additional specifiers for chronic psychosis in mood disorders and new specifiers for mood episodes in schizophrenia.

Mixed states According to Ghaemi, the mixed states subgroup turned out to have the most difficult job overall.

There was agreement in the subgroup that the current system of definition of mixed states is inadequate, but there was not sufficient agreement to recommend an adequate replacement, Ghaemi said. The subgroup's attempts to broaden the narrow DSM-IV definition of mixed manic-depressive states to include depressive mixed state and dysphoric mania were met with rejection by the peer reviewers.

The peer reviewers' lack of approval of the subgroup's article is indicative of the existence of differences in concepts concerning the nature of mixed states, said Ghaemi.

Diagnostic tools
While the subgroups' reports discussed possible revisions to current DSM-IV and ICD-10 definitions, they also described diagnostic tools that might aid clinicians. Among the self-report scales described were the Mood Disorder Questionnaire, which has 13 yes-or-no items derived from the DSM-IV criteria and from clinical experience; the Hypomania Checklist, a 32-item questionnaire to help identify hypomania in depressive epi-sodes and increase detection of bipolar II disorder and minor bipolar disorders; and the Bipolar Spectrum Diagnostic Scale (BSDS), designed to determine whether a bipolar disorder is present or absent.

The BSDS has a descriptive paragraph that presents multiple aspects of mood course in bipolar disorder. Patients are asked to endorse any of 19 aspects of mania and depression on the scale.

"Regarding clinician interview scales, the gold standard is the SCID-I [Structured Clinical Interview for DSM-IV Axis I Disorders], which is not difficult to use," Ghaemi said. "I use it in my own clinical practice. The mood module is about 2 pages long."

Ghaemi noted that Akiskal and Benazzi have adapted the mood module of the SCID in order to more accurately identify hypomania.

Another assessment instrument under development is the Bipolarity Index, currently being tested at Massachusetts General Hospital's bipolar clinic, Ghaemi said. Although not yet validated or standardized, the index allows for the illness to exist as a matter of degree and places patients on a presumed continuum of bipolarity rather than categorizing their illness as bipolar or unipolar.

Studies needed
One of the goals of the task force, according to Ghaemi, was to highlight areas requiring additional research. "Most of the research we drew on [for the task force reports was from] studies that clinicians and researchers did on their own, often with very little or no funding."

Ghaemi called for large, government-funded studies, including one focused on the bipolar spectrum concept, using diagnostic validators such as symptoms, family history, treatment response and course, and one study focused on childhood bipolar disorder. The goal is to compare the broad definition, which would include irritability and aggression, with more classic definitions of mania.

"Long-term studies into adulthood of children with bipolar disorder also are very important," he said, as are studies teasing out the differences between bipolar disorder and ADHD in children.

As a final question, Ghaemi was asked if he believed bipolar disorder is being overdiagnosed. "While unipolar depression, personality disorders, and schizophrenia have each had periods of overdiagnosis, there has never been an era in which bipolar disorder has been overdiagnosed," he said, "no matter what skeptics claim."

He said that concerns about bipolar overdiagnosis are largely anecdotal, have not been empirically well-established, and ignore solid evidence of continued underdiagnosis.

The lack of focus on bipolar disorder has led to neglect and controversy, Ghaemi noted. "Our task force," he said, "is a step toward more consensus and less controversy."





Ghaemi SN, Bauer M, Cassidy F, et al; ISBD Diagnostic Guidelines Task Force. Diagnostic guidelines for bipolar disorder: a summary of the

International Society for Bipolar Disorders

Diagnostic Guidelines Task Force Report.

Bipolar Disord.

2008;10(1, pt 2): 117-128.

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