NYC Psychiatry & Primary Medical:Bipolar Disorder evaluation and treatment in Manhattan NYC.
Updated by NatanSchleider, M.D. on January 12, 2021
DOCTOR IN THE FAMILY: NYC Psychiatry & Primary Medical Care Doctorsspecialize in Bipolar Disorder evaluation and treatment in Manhattan NYC from our Manhattan Office or via Telepsychiatry.
Our NYC Psychiatrists follow DSM V(Diagnostic Statistical Manual) criteria in confirming a diagnosis of Bipolar Disorder.
NOTE THIS IS OFTEN DIFFICULT AND TAKES TIME SINCE BIPOLAR PATIENTS MAY PRESENT ONLY WITH SYMPTOMS OF DEPRESSION FOR WEEKS OR YEARS BEFORE HAVING A MANIC OR HYPOMANIC EPISODE.
What Is Bipolar Disorder?
Bipolar disorder is characterized by shifts in mood, and those who have it can experience high energy, euphoria, and become overactive. This is known as mania, and it can also include irritability, and some people can become easily agitated in a manic state. Manic episodes also associated with risk-taking behaviors and increased impulsivity
On the other end of the spectrum, people with bipolar disorder can have very low moods, and this is the depressive side of the condition. Just like with major depression, bipolar sufferers who are having a depressive episode can feel down on themselves, have low energy and motivation, and think about death and suicide.
Nonetheless, these mood swings are not typically short and temporary. Instead, these episodes must last at least a week for mania and two weeks for depression for the person to have Bipolar I disorder. This is not only important for diagnosing bipolar disorder, in general, but it can also determine what type a person has, which you will learn more about in the next section.
Types Of Bipolar Disorder
There are different types of Bipolar Disorder:
- Bipolar I Disorder: consists of manic episodes that last for a minimum of seven days and occur for most of the day, or when the symptoms require hospital care due to their severity. People with Bipolar I will experience depressive episodes lasting two weeks or longer; then they will have periods of normal mood.
- Bipolar II Disorder: characterized by depressive and hypomanic episodes. The symptoms of mania are not as severe or long-lasting as with Bipolar I.
- Cyclothymic Disorder: hypomanic and depressive symptoms that are persistent but not intense enough or do not last long enough to qualify as hypomanic or depressive episodes. These symptoms can last for at least two years in adults, and for one year in kids and adolescents.
- Other Specified and Unspecified Bipolar and Related Disorders: this category includes bipolar disorder symptoms that do not match any of the types previously mentioned
However, the DSM bipolar section goes into greater detail as to what constitutes a manic, hypomanic, or depressive episode, which will be covered next.
According to the DSM-5 by the American Psychiatric Association, here is, verbatim, the specifications for each type of episode:
For Manic Episodes
- A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least one week and present most of the day, nearly every day (or any duration if hospitalization is necessary)
Note: In the bipolar disorder DSM-5 versus DSM-IV, Criterion A is revised to include increased energy/activity as a core symptom
- During the period of mood disturbance and increased energy or activity, 3 (or more) of the following symptoms (4 if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
(1) Inflated self-esteem or grandiosity
(2) Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
(3) More talkative than usual or pressure to keep talking
(4) Flight of ideas or subjective experience that thoughts are racing
(5) Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed
(6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity)
(7) Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
- The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
- The episode is not attributable to the physiologic effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medication
At least one-lifetime manic episode is required for a diagnosis of bipolar I disorder
For Hypomanic Episodes
- A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least four consecutive days and present most of the day, nearly every day.
- During the period of mood disturbance and increased energy and activity, 3 (or more) of the following symptoms (4 if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree:
(1) Inflated self-esteem or grandiosity
(2) Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
(3) More talkative than usual or pressure to keep talking
(4) Flight of ideas or subjective experience that thoughts are racing
(5) Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed
(6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
(7) Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
- The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.
- The disturbance in mood and the change in functioning are observable by others.
- The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic symptoms, the episode is, by definition, manic.
- The episode is not attributable to the physiologic effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medication.
Hypomanic episodes are common in bipolar I disorder but are not required for a diagnosis of bipolar I disorder. Criteria for a past or current hypomanic episode and a past or current major depressive episode are required for diagnosis of bipolar II disorder.
For Depressive Episodes
Five or more of the following A Criteria (at least one includes A1 or A2)
(A1) Depressed mood-indicated by subjective report or observation by others (in children and adolescents, can be irritable mood).
(A2) Loss of interest or pleasure in almost all activities-indicated by subjective report or observation by others.
(A3) Significant (more than 5 percent in a month) unintentional weight loss/gain or decrease/increase in appetite (in children, failure to make expected weight gains).
(A4) Sleep disturbance (insomnia or hypersomnia).
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(A5) Psychomotor changes (agitation or retardation) severe enough to be observable by others.
(A6) Tiredness, fatigue, or low energy, or decreased efficiency with which routine tasks are completed.
(A7) A sense of worthlessness or excessive, inappropriate, or delusional guilt (not merely self-reproach or guilt about being sick).
(A8) Impaired ability to think, concentrate, or make decisions-indicated by subjective report or observation by others.
(A9) Recurrent thoughts of death (not just fear of dying), suicidal ideation, or suicide attempts.
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The symptoms are not due to the direct physiological effects of a substance (e.g., drug abuse, a prescribed medication’s side effects) or a medical condition (e.g., hypothyroidism).
The symptoms do not meet criteria for a mixed episode. A mixed episode is characterized by the symptoms of both a major depressive episode and a manic episode occurring almost daily for at least 1 week. This exclusion does not include episodes that are substance-induced (e.g., caffeine) or the side effects of medication.
There has never been a manic episode or hypomanic episode.
MDE is not better explained by schizophrenia spectrum or other psychotic disorders.
The symptoms are not better accounted for by bereavement (i.e., after the loss of a loved one, the symptoms persist for longer than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation). This differentiation requires clinical judgment based on cultural norms and the individual’s history.
The DSM V bipolar chapter also states that it is important to note that each symptom must either be new or must have worsened compared with the person’s pre-episode status and must persist most of the day, daily, for at least two weeks in a row. Exclude symptoms that are clearly due to a general medical condition, mood-incongruent delusions, or mood-incongruent hallucinations. Additionally, symptoms must persist most of the day, daily, for at least two weeks in a row, excluding A3 and A9.
Conclusion
By knowing what each episode entails from the DSM 5 bipolar disorder listing, a doctor can determine which variant of the condition a patient has. For example, if he or she sees that someone has exhibited depressive symptoms and hypomania a diagnosis for Bipolar II can be made. If no manic or hypomanic symptoms were present at all, it would more than likely indicate major depression disorder, instead of bipolar.
Treatment for Bipolar Disorder
Most of our patient have tried talk therapy and various over the counter or prescription antidepressants before consulting us. If these work, terrific; however, antidepressants INCREASE the risk of inducing a manic episode and we use these with caution.
Mood stabilizers are our primary medical treatment choice and include medicines form different families.
For example, my favorite is lamotrigine (Lamictal) which is an anti-seizure medicine FDA approved for mood stabilization. I like it since it has few side effects and dosing is once daily. Depakote is another favorite in the anti-seizure family.
Many other medicines for Bipolar Disorder exist. All must be taken daily. Some are in the ‘anti-psychotic’ family and include Abilify, Seroquel, and Geodon. These tend to work fast and be stronger so patients MUST be watched closely to ensure they are not overmedicated and ‘feeling like zombies.’
Lithium is the oldest of the Bipolar medicines. It has advantages like it has been around for 40 plus years and therefore is not known to cause any brain damage although levels must be checked in the blood periodically to make sure they are therapeutic and not toxic.
Please contact DOCTOR IN THE FAMILY psychiatrists and primary care doctos in NYC if you are seeking diagnosis, second opinion, and/or treatment options for Bipolar Disorder by calling or texting 646-957-5444.
