1 DSM 5 diagnostic criteria for bipolar and related disorders in persons with IDRobert J. Pary NADD 2016
2 Acknowledgement Co-authors Lauren Charlot Sherman Fox Jessica HellingsAnne D. Hurley
3 Disclosures None
4 Aim To update evidence-based literature pertaining to the diagnosis of bipolar and related disorders in persons with ID
5 Historical context It is only in the past three plus decades that clinicians generally accepted the notion that a person with ID might be able to experience a mood disorder such as a bipolar disorder
6 Current Goal Ensure reliable assessments at the symptom level rather than developing new sets of criteria Use clear behaviorally based descriptions of possible manifestations of each DSM-5 symptom criterion
7 Work Group In the DSM-IV-TR (and in DM-ID), Bipolar Disorders were included in the Mood Disorders chapter In DSM5 and DM-ID2, Bipolar and Related Disorders comprise a separate chapter
8 Potential Bias To varying degrees, members of the work group believed that during the past several years the diagnosis (and subsequent pharmacologic treatment) of bipolar disorders spiked in persons with IDD
9 DSM5 CRITERIA Manic Episode Criterion AA distinct period of abnormally and persistently elevated, expansive, or irritable mood AND
10 DSM5 CRITERIA Manic Episode Criterion Aabnormally and persistently increased goal- directed activity or energy
11 DSM5 CRITERIA Manic Episode Criterion Alasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary)
12 DSM5 CRITERIA Manic Episode Criterion BDuring the period of mood disturbance and increased energy or activity
13 DSM5 CRITERIA Manic Episode Criterion Bthree (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree AND
14 DSM5 CRITERIA Manic Episode Criterion Brepresent a noticeable change from usual behavior:
15 DSM5 CRITERIA Manic Episode Criterion B1. Inflated self-esteem or grandiosity
16 DSM5 CRITERIA Manic Episode Criterion B2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
17 DSM5 CRITERIA Manic Episode Criterion B3. More talkative than usual or pressure to keep talking
18 DSM5 CRITERIA Manic Episode Criterion B4. Flight of ideas or subjective experience that thoughts are racing
19 DSM5 CRITERIA Manic Episode Criterion B5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
20 DSM5 CRITERIA Manic Episode Criterion B6. Increase in goal- directed activity (either socially, at work or school, or sexually) or psychomotor agitation
21 DSM5 CRITERIA Manic Episode Criterion B7. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions etc.)
22 DSM5 CRITERIA Manic Episode Criterion CThe mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning OR
23 DSM5 CRITERIA Manic Episode Criterion Cto necessitate hospitalization to prevent harm to self or others OR
24 DSM5 CRITERIA Manic Episode Criterion Cthere are psychotic features
25 DSM5 CRITERIA Manic Episode Criterion DThe episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) OR
26 DSM5 CRITERIA Manic Episode Criterion Da general medical condition (e.g., hyperthyroidism)
27 DSM5 CRITERIA Manic Episode CriterionNote: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment
28 DSM5 CRITERIA Manic Episode Criterionis sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis
29 DSM5 Categories Bipolar I Disorder Bipolar II DisorderCyclothymic Disorder Substance/Medication-Induced Bipolar and Related Disorder Induced Bipolar and Related Disorder Due to Another Medical Condition Other Specified Bipolar and Related Disorder Unspecified Bipolar and Related Disorder
30 Diagnostic Issues between General Population and Persons with IDRapid cycling, 4 or more episodes in a year, is more common in persons with ID than in general population Cerebral dysfunction is presumed to be a factor in the increased risk of rapid cycling
31 Diagnostic Issues between General Population and Persons with IDDevelopmental stage can affect cognitive symptoms of mania (i.e. "inflated self-esteem or grandiosity")
32 Diagnostic Issues between General Population and Persons with IDWhen cognitive symptoms are described in people with ID, content may be simplified May believe they possess more normal abilities they actually have Arrange for wedding but no girlfriend Try to buy a car but no driver’s license
33 Diagnostic Issues between General Population and Persons with IDPressured speech can appear as increased vocalization (rate or volume) or gesturing in individuals who have limited expressive language
34 Diagnostic Issues between General Population and Persons with IDMight be completely silent during depressive episodes but vocalizes or babbles almost continuously during manic periods
35 Diagnostic Issues between General Population and Persons with IDDistractibility may manifest as changes in ability level No longer completing daily living activities Skipping from one activity to another
36 Diagnostic Issues between General Population and Persons with IDIncreased energy Walking for miles Repeatedly changing clothes More frenzied baseline behaviors Rapidly piling up books or aligning objects
37 Diagnostic Issues between General Population and Persons with IDOccasionally, one behavior can capture several manic criteria Vigorous masturbation LASTING throughout the night Knocked mattress off bed
38 Diagnostic Issues between General Population and Persons with IDRecording of challenging behaviors can fluctutate so that the pattern suggests bipolar disorder
39 Diagnostic Issues between General Population and Persons with IDChallenging behaviors may be consistently under or over-reported Relief staff during weekends Prolonged substitute coverage High staff turnover Staff perceived medication change
40 Diagnostic Issues between General Population and Persons with IDChallenging behaviors are accurately reported, but variations are due to indirect effects of: On-site visits/inspections Sporadic family or close friend contact Serious illness: housemate, family or close friend
41 2nd Mania Not ALL bipolar-like symptoms MEAN Bipolar Dx AutoimmuneEndocrine Neurologic Cerebrovascular Metabolic Substance withdrawal
42 2nd Mania The authors of DSM-5 opted not to include a concrete list of medical causes because such a list is never complete Clinical judgment is critical to diagnosing bipolar disorder due to a medical condition
43 2nd Mania Any medical condition that can result in bipolar symptoms in the general population can cause manic symptoms in persons with ID
44 Method NADD expert work group examined changes in the Diagnostic Statistical Manual 5 (DSM 5) Reviewed pertinent evidenced-based literature for persons with IDD Submitted draft for peer review Revised draft
45 Method – Levels of EvidenceType I: good systematic review and meta-analyses with at least one randomized control trial (RCT) Type II: a RCT Type III: well-designed interventional study without randomization Type IV: well-designed observational Type V: expert opinion, influential reports and studies
46 Results No type I or type II levels of evidence were foundVast majority of studies were type IV or V
47 Results – DSM5 Modifications for Bipolar DisorderCriterion A is revised to include increased energy or activity as a core symptom
48 Results – DSM5 Modifications for Bipolar DisorderA person, who meets both the full criteria for mania and depression, is diagnosed with bipolar disorder I The new is “with mixed features” instead of bipolar disorder I, mixed episode as in DSM-IV
49 Results – DSM5 Modifications for Bipolar DisorderThe third pertinent change is the introduction of the diagnostic category of disruptive mood dysregulation disorder within the depressive disorders chapter
50 Disruptive mood dysregulation disorder - new DSM5 categoryChronic irritability - no distinct periods of mania Onset before 10 years. Temper outbursts inconsistent with developmental level Present for at least 12 months; without a three- month symptom-free period Little is known about treatment or outcome Often previously diagnosed with pediatric mania (early onset bipolar disorder)
51 Results In general population, 40-fold increase in diagnosis of bipolar disorders in young people over a decade (Blader & Carlson, Biol Psychiatry 62: ) Level V evidence of over-diagnosis of bipolar disorders in persons with IDD
52 For a reliable bipolar diagnosis in a youth with IDClear change from previous functioning Not merely a worsening of, or fluctuation in, a condition present since early childhood
53 Over-diagnosis of Bipolar DisorderIndividuals at risk for over- diagnosis of bipolar disorder include those with persistent irritability
54 Over-diagnosis of Bipolar DisorderOver-diagnosis of bipolar disorder can result in unnecessary exposure and the subsequent potential adverse effects of psychotropic medications
55 IASSIDD Meeting Colleagues from Europe and Australian/New Zealand did not agree that bipolar disorder was too frequently diagnosed Is over-diagnosis of Bipolar Disorder more typical of United States? North America?
56 DSM5 Bipolar Disorders Systematic, prospective, well- controlled studies have not been conducted Using reliable means of assessing the presence of full DSM5 criteria In representative samples of people with ID
57 DSM5 Bipolar Disorders Bipolar Related Disorders have RARELY been studied Cyclothymia Bipolar II
58 Caution Case reports of bipolarChromosome 22.q11.2 deletion (velocardiofacial or diGeorge syndrome) Chromsome 22q13.3 deletion (Phelan- McDermid syndrome) Premature to associate any chromosomal syndromes with an increased risk for bipolar disorder
59 Limitation Data were not kept as to number of studies reviewed and those that were excluded from review involving persons with IDD
60 Conclusion Mood dysregulation disorder may provide greater diagnostic clarity for pediatric bipolar disorder The review highlights the potential over-diagnosis of bipolar and related for persons with IDD