1. Diagnostic Accuracies
In
Bipolar Disorder
FAREED A. MINHAS
Prof. & Head
Institute of Psychiatry
Rawalpindi Medical College

2. Differential diagnosis of Bipolar disorder
Implications for treatment
Differentiating Bipolar disorder from other
mood disorders and checking underlying
etiology is crucial for optimal patient
management
Misdiagnosis may have adverse
consequences for the patient:
−Prescription of treatment which adversely
affects condition
−Lack of appropriate pharmacologic treatment
−Lack of appropriate psychotherapy

3. Under-recognition and
misdiagnosis
 Very common in Bipolar disorder
− diagnostic criteria limitations
− lack of patient awareness, reluctance to
receive treatment (especially if hypomanic)
 Currently, 40–60% of patients with Bipolar I
disorder are thought not to be receiving
treatment
 Time between first symptoms and first treatment
is about 10 years
 Conversion rate of unipolar depression to Bipolar
disorder is around 5–10%
1,2
3
4
Kessler RC et al. Psychol Med 1997;27(5):1079–89;
Reiger DA et al. Arch Gen Psychiatry 1993;50:85–94;
Goodale LC, Lewis L. Bipolar Disord 2001;3(Suppl. 1):19
American Psychiatric Association, 1994
1
2
3
4

4. Areas of confusion in Bipolar
disorder
Substance
abuse
Anxiety
Hyperactivity
ADHD
Unipolar
depression
Social
phobia
Depressive
symptoms
Delusional
disorder
Psychotic
symptoms
Personality
disorders
Schizophrenia
Schizoaffective
disorder

5. DSM-IV and ICD-10 criteria
 Two major sets of criteria for Bipolar disorder diagnosis
− DSM-IV: Diagnostic and Statistical Manual of the
American Psychiatric Association, 4th edition
− ICD-10: International Classification of Diseases,
10th edition
 Broad diagnosis: at least one episode of mania,
hypomania or a mixed episode
− Type I: manic episode results in hospitalization or seriously
affects normal daily functioning
− Type II: milder episodes of mania
 Additional subtypes of Bipolar disorder proposed
− Type III
− soft Bipolar spectrum

6. Awareness For Better
Diagnosis
 Education of physicians for correct diagnosis
 Accurate history-taking will lead to identification of the types
− assess long-term symptoms
− obtain information from family and friends
 Increase patient’s awareness of Bipolar disorder symptoms,
particularly mild mood elevations

7. What is the best treatment strategy
for Bipolar disorder?
 The strategy that results in the fewest, mildest or
briefest episodes
 Primary therapeutic objectives
− treat acute mania
− treat acute depression
− prevent recurrence of manic/depressive
episodes (prophylaxis)
 Efficacy across a broad range of clinical
presentations (e.g. rapid cycling, mixed mania)

8. Standard treatments for
Bipolar disorder
Mood stabilisers
Antipsychotics
Benzodiazepines
Antidepressants

9. YOUNG MANIA RATING SCALE
A Rating Scale For Mania
1
Elevated Mood
0
1
2
3
4
2
Increased Motor Activity - Energy
0
1
2
3
4
3
Sexual Interest
0
1
2
3
4
4
Sleep
0
1
2
3
4
5
Irritability
0
2
4
6
8
6
Speech (Rate and Amount)
0
2
4
6
8
7
Language - Thought Disorder
0
1
2
3
4
8
Content
0
2
4
6
8
9
Disruptive - Aggressive Behaviour
0
2
4
6
8
10
Appearance
0
1
2
3
4
11
Insight
0
1
2
3
4
0
15
30
45
60
Total Rating
Patient's Score

10. THE HAMILTON RATING SCALE
1
Depressed Mood
0
1
2
3
4
2
Feeling of Guilt
0
1
2
3
4
3
Suicide
0
1
2
3
4
4
Insomnia Early
0
1
2
5
Insomnia Middle
0
1
2
6
Insomnia Late
0
1
2
7
Work And Activities
0
1
2
3
4
8
Retardation : Psychomotor
0
1
2
3
4
9
Agitation
0
1
2
3
4
10
Anxiety (Psychological)
0
1
2
3
4
11
Anxiety Somatic
0
1
2
3
4
12
Somatic Symptoms (Gastrointestinal)
0
1
2
13
Somatic Symptoms General
0
1
2

11. THE HAMILTON RATING SCALE
14
Genital Symptoms
0
1
2
15
Hypochondriasis
0
1
2
3
16
Loss of Weight
0
1
2
3
17
Insight
0
1
2
18 - A
Diurnal Variation
0
1
2
18 - B
Diurnal Variation
0
1
2
19
Depersonalization and Derealization
0
1
2
3
20
Paranoid Symptoms
0
1
2
3
21
Obsessional and Compulsive Symptoms
0
1
2
Total Rating
0
22
44
Patient's Score
36
4
4
40