ICD-10 Criteria for Bipolar Disorder
The definitions given below are from ICD-10 Classification
of Mental and Behavioral Disorders, by the World Health Organization,
CH-1211, Geneva 27, Switzerland, 1992. (http://www.who.ch) The materials excerpted below are for
educational (non-commercial) purposes only, and there is no intent to violate
copyright regulations.
This disorder is characterized by repeated (i.e. at least two) episodes in
which the patient's mood and activity levels are significantly disturbed, this
disturbance consisting on some occasions of an elevation of mood and increased
energy and activity (mania or hypomania), and on others of a lowering of mood
and decreased energy and activity (depression). Characteristically, recovery is
usually complete between episodes, and the incidence in the two sexes is more
nearly equal than in other mood disorders. As patients who suffer only from
repeated episodes of mania are comparatively rare, and resemble (in their
family history, premorbid personality, age of onset, and long-term prognosis)
those who also have at least occasional episodes of depression, such patients
are classified as bipolar.
Manic episodes usually begin abruptly and last for between 2 weeks and 4-5
months (median duration about 4 months). Depressions tend to last longer
(median length about 6 months), though rarely for more than a year, except in
the elderly. Episodes of both kinds often follow stressful life events or other
mental trauma, but the presence of such stress is not essential for the
diagnosis. The first episode may occur at any age from childhood to old age.
The frequency of episodes and the pattern of remissions and relapses are both
very variable, though remissions tend to get shorter as time goes on and
depressions to become commoner and longer lasting after middle age.
Although the original concept of "manic-depressive psychosis" also
included patients who suffered only from depression, the term
"manic-depressive disorder or psychosis" is now used mainly as a
synonym for bipolar disorder.
Includes:
manic-depressive illness, psychosis or reaction
Excludes:
bipolar disorder, single manic episode, cyclothymia
The patient has had at least one manic, hypomanic, or mixed affective
episode in the past and currently exhibits either a mixture of a rapid
alternation of manic, hypomanic, and depressive symptoms.
Diagnostic Guidelines
Although the most typical form of bipolar disorder consists of alternating
manic and depressive episodes separated by periods of normal mood, it is not
uncommon for depressive mood to be accompanied for days or weeks on end by over
activity and pressure of speech, or for a manic mood and grandiosity to be
accompanied by agitation and loss of energy and libido. Depressive symptoms and
symptoms of hypomania or mania may also alternate rapidly, from day to day or
even from hour to hour. A diagnosis of mixed bipolar affective disorder should
be made only if the two sets of symptoms are both prominent for the greater
part of the current episode of illness, and if that episode has lasted for a
least 2 weeks.
Excludes:
single mixed affective episode
Three degrees of severity are specified here, sharing the common underlying
characteristics of elevated mood, and an increase in the quantity and speed of
physical and mental activity. All the subdivisions of this category should be
used only for a single manic episode. If previous or subsequent affective
episodes (depressive, manic, or hypomanic), the disorder should be coded under
bipolar affective disorder.
Includes:
bipolar disorder, single manic episode
Hypomania is a lesser degree of mania, in which abnormalities of mood and
behavior are too persistent and marked to be included under cyclothymia but are
not accompanied by hallucinations or delusions. There is a persistent mild
elevation of mood (for at least several days on end), increased energy and
activity, and usually marked feelings of well-being and both physical and
mental efficiency. Increased sociability, talkativeness, overfamiliarity,
increased sexual energy, and a decreased need for sleep are often present but
not to the extent that they lead to severe disruption of work or result in
social rejection. Irritability, conceit, and boorish behavior may take the
place of the more usual euphoric sociability.
Concentration and attention may be impaired, thus diminishing the ability to
settle down to work or to relaxation and leisure, but this may not prevent the
appearance of interests in quite new ventures and activities, or mild
over-spending.
Diagnostic Guidelines
Several of the features mentioned above, consistent with elevated or changed
mood and increased activity, should be present for at least several days on
end, to a degree and with a persistence greater than described for cyclothymia.
Considerable interference with work or social activity is consistent with a
diagnosis of hypomania, but if disruption of these is severe or complete, mania
should be diagnosed.
Differential Diagnosis
Hypomania covers the range of disorders of mood and level of activities
between cyclothymia and mania. The increased activity and restlessness (and
often weight loss) must be distinguished from the same symptoms occurring in
hyperthyroidism and anorexia nervosa; early states of "agitated
depression", particularly in late middle-age, may bear a superficial
resemblance to hypomania of the irritable variety. Patients with severe
obsessional symptoms may be active part of the night completing their domestic
cleaning rituals, but their affect will usually be the opposite of that
described here.
When a short period of hypomania occurs as a prelude to or aftermath of
mania, it is usually not worth specifying the hypomania separately.
Mood is elevated out of keeping with the individual's circumstances and may
vary from carefree joviality to almost uncontrollable excitement. Elation is
accompanied by increased energy, resulting in overactivity, pressure of speech,
and a decreased need for sleep. Normal social inhibitions are lost, attention
cannot be sustained, and there is often marked distractibility. Self-esteem is
inflated, and grandiose or over-optimistic ideas are freely expressed.
Perceptual disorders may occur, such as the appreciation of colors as
especially vivid (and usually beautiful), a preoccupation with fine details of
surfaces or textures, and subjective hyperacusis. The individual may embark on
extravagant and impractical schemes, spend money recklessly, or become
aggressive, amorous, or facetious in inappropriate circumstances. In some manic
episodes the mood is irritable and suspicious rather than elated. The first
attack occurs most commonly between the ages of 15 and 30 years, but may occur
at any age from late childhood to the seventh or eighth decade.
Diagnostic Guidelines
The episode should last for at least 1 week and should be severe enough to
disrupt ordinary work and social activities more or less completely. The mood
change should be accompanied by increased energy and several of the symptoms
referred to above (particularly pressure of speech, decreased need for sleep,
grandiosity, and excessive optimism).
The clinical picture is that of a more severe form of mania as described
above. Inflated self-esteem and grandiose ideas may develop into delusions, and
irritability and suspiciousness into delusions of persecution. In severe cases,
grandiose or religious delusions of identity or role may be prominent, and
flight of ideas and pressure of speech may result in the individual becoming
incomprehensible. Severe and sustained physical activity and excitement may
result in aggression or violence, and neglect of eating, drinking, and personal
hygiene may result in dangerous states of dehydration and self-neglect. If
required, delusions or hallucinations can be specified as congruent or
incongruent with the mood. "Incongruent" should be taken as including
affectively neutral delusions and hallucinations; for example, delusions of
reference with no guilty or accusatory content, or voices speaking to the
individual about events that have no special emotional significance.
Differential Diagnosis
One of the commonest problems is differentiation of this disorder from
schizophrenia, particularly if the stages of development through hypomania have
been missed and the patient is seen only at the height of the illness when
widespread delusions, incomprehensible speech, and violent excitement may
obscure the basic disturbance of affect. Patients with mania that is responding
to neuroleptic medication may present a similar diagnostic problem at the stage
when they have returned to normal levels of physical and mental activity but
still have delusions or hallucinations. Occasional hallucinations or delusions
as specified for schizophrenia may also be classed as mood-incongruent, but if
these symptoms are prominent and persistent, the diagnosis of schizoaffective
disorder is more likely to be appropriate.
Includes: manic stupor
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