The ICD-10 Classification of Mental and Behavioural
Disorders
World Health Organization, Geneva, 1992
Bipolar Affective Disorder
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 overactivity 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 behaviour 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 behaviour 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
distractability. Self-esteem is inflated, and grandiose or
over-optimistic ideas are freely expressed.
Perceptual disorders may occur, such as the appreciation of
colours 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
In typical depressive episodes of all three varieties described
below (mild, moderate, and severe), the individual usually suffers
from depressed mood, loss of interest and enjoyment, and reduced
energy leading to increased fatiguability and diminished activity.
Marked tiredness after only slight effort is common. Other common
symptoms are:
(a) reduced concentration and attention;
(b) reduced self-esteem and self-confidence;
(c) ideas of guilt and unworthiness (even in a mild type of
episode);
(d) bleak and pessimistic views of the future;
(e) ideas or acts of self-harm or suicide;
(f) disturbed sleep;
(g) diminished appetite.
The lowered mood varies little from day to day, and is often
unresponsive to circumstances, yet may show a characteristic
diurnal variation as the day goes on. As with manic episodes, the
clinical presentation shows marked individual variations, and
atypical presentations are particularly common in adolescence. In
some cases, anxiety, distress, and motor agitation may be more
prominent at times than the depression, and the mood change may
also be masked by added features such as irritability, excessive
consumption of alcohol, histrionic behaviour, and exacerbation of
pre-existing phobic or obsessional symptoms, or by hypochondriacal
preoccupations. For depressive episodes of all three grades of
severity, a duration of at least 2 weeks is usually required for
diagnosis, but shorter periods may be reasonable if symptoms are
unusually severe and of rapid onset.
Some of the above symptoms may be marked and develop
characteristic features that are widely regarded as having special
clinical significance. The most typical examples of these
"somatic" symptoms are: loss of interest or pleasure in
activities that are normally enjoyable; lack of emotional
reactivity to normally pleasurable surroundings and events; waking
in the morning 2 hours or more before the usual time; depression
worse in the morning; objective evidence of definite psychomotor
retardation or agitation (remarked on or reported by other
people); marked loss of appetite; weight loss (often defined as 5%
or more of body weight in the past month); marked loss of libido.
Usually, this somatic syndrome is not regarded as present unless
about four of these symptoms are definitely present.
The categories of mild, moderate and severe depressive episodes
described in more detail below should be used only for a single
(first) depressive episode. Further depressive episodes should be
classified under one of the subdivisions of recurrent depressive
disorder.
These grades of severity are specified to cover a wide range of
clinical states that are encountered in different types of
psychiatric practice. Individuals with mild depressive episodes
are common in primary care and general medical settings, whereas
psychiatric inpatient units deal largely with patients suffering
from the severe grades.
Acts of self-harm associated with mood (affective) disorders,
most commonly self-poisoning by prescribed medication, should be
recorded by means of an additional code from Chapter XX of ICD-10
(X60-X84). These codes do not involve differentiation between
attempted suicide and "parasuicide", since both are
included in the general category of self-harm.
Differentiation between mild, moderate, and severe depressive
episodes rests upon a complicated clinical judgement that involves
the number, type, and severity of symptoms present. The extent of
ordinary social and work activities is often a useful general
guide to the likely degree of severity of the episode, but
individual, social, and cultural influences that disrupt a smooth
relationship between severity of symptoms and social performance
are sufficiently common and powerful to make it unwise to include
social performance amongst the essential criteria of severity.
The presence of dementia or mental retardation does not rule
out the diagnosis of a treatable depressive episode, but
communication difficulties are likely to make it necessary to rely
more than usual for the diagnosis upon objectively observed
somatic symptoms, such as psychomotor retardation, loss of
appetite and weight, and sleep disturbance.
Includes:
* single episodes of depression (without psychotic symptoms),
psychogenic depression or reactive depression)
Diagnostic Guidelines
Depressed mood, loss of interest and enjoyment, and increased
fatiguability are usually regarded as the most typical symptoms of
depression, and at least two of these, plus at least two of the
other symptoms described above should usually be present for a
definite diagnosis. None of the symptoms should be present to an
intense degree. Minimum duration of the whole episode is about 2
weeks.
An individual with a mild depressive episode is usually
distressed by the symptoms and has some difficulty in continuing
with ordinary work and social activities, but will probably not
cease to function completely.
A fifth character may be used to specify the presence of the
somatic syndrome:
F32.00 Without somatic symptoms
The criteria for mild depressive episode are fulfilled, and there
are few or none of the somatic symptoms present.
F32.01 With somatic symptoms
The criteria for mild depressive episode are fulfilled, and four
or more of the somatic symptoms are also present. (If only two or
three somatic symptoms are present but they are unusually severe,
use of this category may be justified.)
Diagnostic Guidelines
At least two of the three most typical symptoms noted for mild
depressive episode should be present, plus at least three (and
preferably four) of the other symptoms. Several symptoms are
likely to be present to a marked degree, but this is not essential
if a particularly wide variety of symptoms is present overall.
Minimum duration of the whole episode is about 2 weeks.
An individual with a moderately severe depressive episode will
usually have considerable difficulty in continuing with social,
work or domestic activities.
A fifth character may be used to specify the occurrence of
somatic symptoms:
F32.10 Without somatic symptoms
The criteria for moderate depressive episode are fulfilled, and
few if any of the somatic symptoms are present.
F32.11 With somatic symptoms
The criteria for moderate depressive episode are fulfilled, and
four or more or the somatic symptoms are present. (If only two or
three somatic symptoms are present but they are unusually severe,
use of this category may be justified.)
In a severe depressive episode, the sufferer usually shows
considerable distress or agitation, unless retardation is a marked
feature. Loss of self-esteem or feelings of uselessness or guilt
are likely to be prominent, and suicide is a distinct danger in
particularly severe cases. It is presumed here that the somatic
syndrome will almost always be present in a severe depressive
episode.
Diagnostic Guidelines
All three of the typical symptoms noted for mild and moderate
depressive episodes should be present, plus at least four other
symptoms, some of which should be of severe intensity. However, if
important symptoms such as agitation or retardation are marked,
the patient may be unwilling or unable to describe many symptoms
in detail. An overall grading of severe episode may still be
justified in such instances. The depressive episode should usually
last at least 2 weeks, but if the symptoms are particularly severe
and of very rapid onset, it may be justified to make this
diagnosis after less than 2 weeks.
During a severe depressive episode it is very unlikely that the
sufferer will be able to continue with social, work, or domestic
activities, except to a very limited extent.
This category should be used only for single episodes of severe
depression without psychotic symptoms; for further episodes, a
subcategory of recurrent depressive disorder should be used.
Includes:
* single episodes of agitated depression
* melancholia or vital depression without psychotic symptoms
Diagnostic Guidelines
A severe depressive episode which meets the criteria given for
severe depressive episode without psychotic symptoms and in which
delusions, hallucinations, or depressive stupor are present. The
delusions usually involve ideas of sin, poverty, or imminent
disasters, responsibility for which may be assumed by the patient.
Auditory or olfactory hallucinations are usually of defamatory or
accusatory voices or of rotting filth or decomposing flesh. Severe
psychomotor retardation may progress to stupor. If required,
delusions or hallucinations may be specified as mood-congruent or
mood-incongruent.
Differential Diagnosis
Depressive stupor must be differentiated from catatonic
schizophrenia, from dissociative stupor, and from organic forms of
stupor. This category should be used only for single episodes of
severe depression with psychotic symptoms; for further episodes a
subcategory of recurrent depressive disorder should be used.
Includes:
* single episodes of major depression with psychotic symptoms,
psychotic depression, psychogenic depressive psychosis, reactive
depressive psychosis
ICD-10 copyright © 1992 by World
Health Organization.
AZ Psychiatry copyright
© (www.azpsychiatry.info)
by Dr. Manaan Kar Ray
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