Bipolar and Related Disorders

Definition

Bipolar and Related Disorders is a category of conditions in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5).

The Bipolar and Related Disorders included in this Entitlement Eligibility Guideline (EEG) are:

• Bipolar I Disorder
• Bipolar II Disorder
• Cyclothymic Disorder

The common features of Bipolar and Related Disorders are the presence of significant shifts in mood, energy, thinking and behaviours.

NOTE: Substance/ Medication-Induced Bipolar and Related Disorder and Bipolar and Related Disorder due to Another Medical Condition are also mental disorders included in this category.

If a substance(s), medication(s) or another medical condition(s) is claimed to be related to the clinical onset or clinical aggravation of a Bipolar or Related Disorder, consultation with Medical Advisory is strongly recommended.

Criteria Sets for Bipolar and Related Disorders

Knowledge of the criteria sets for a Manic Episode, a Hypomanic Episode and a Major Depressive Episode is required to apply the criteria sets for Bipolar and Related Disorders.

Manic Episode, Hypomanic Episode, Major Depressive Episode and Bipolar and Related Disorder criteria sets are derived from the DSM-5.

Manic Episode:

Criterion A

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 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).

Criterion B

During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four 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).

Criterion C

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.

Criterion D

The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition.

Hypomanic Episode:

Criterion A

A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy lasting at least 4 consecutive days and present most of the day, nearly every day.

Criterion B

During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four 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).

Criterion C

The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.

Criterion D

The disturbance in mood and the change in functioning are observable by others.

Criterion E

The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization. If there are psychotic features, the episode is, by definition manic.

Criterion F

The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment).

Major Depressive Episode:

Criterion A

Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful).
2. Markedly diminished interest or pleasure in all, or most all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g., change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Criterion B

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion C

The episode is not attributable to the physiological effects of a substance or another medical condition.

Bipolar I Disorder:

Criterion A

Criteria have been met for at least one Manic Episode (Criteria A-D under “Manic Episode” above).

Criterion B

The occurrence of the Manic and Major Depressive Episode(s) is not better explained by Schizoaffective Disorder, Schizophrenia, Schizophreniform Disorder, Delusional Disorder or Other Specified or Unspecified Schizophrenia Spectrum and Other Psychotic Disorder.

Bipolar II Disorder:

Criterion A

Criteria have been met for least one Hypomanic Episode (Criteria A-F under “Hypomanic Episode” above) and at least one Major Depressive Episode (Criteria A-C under “Major Depressive Episode” above).

Criterion B

There has never been a Manic Episode.

Criterion C

The occurrence of the Hypomanic Episode(s) and Major Depressive Episode(s) is not better explained by Schizoaffective Disorder, Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Other Specified or Unspecified Schizophrenia Spectrum and Other Psychotic Disorder.

Criterion D

The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Cyclothymic Disorder:

Criterion A

For at least 2 years, there have been numerous periods with hypomanic symptoms that do not meet criteria for a Hypomanic Episode and numerous periods with depressive symptoms that do not meet criteria for a Major Depressive Episode.

Criterion B

During the above 2-year period, the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time.

Criterion C

Criteria for a Major Depressive, Manic, or Hypomanic Episode have never been met.

Criterion D

The symptoms in Criterion A are not better accounted for by Schizoaffective Disorder, Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Other Specified or Unspecified Schizophrenia Spectrum and Other Psychotic Disorder.

Criterion E

The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hypothyroidism).

Criterion F

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Diagnostic Standard

A diagnosis from a qualified medical practitioner (family physician or psychiatrist) or a registered/licensed psychologist is required.

The diagnosis is made clinically. Supporting documentation should be as comprehensive as possible.

NOTE: Entitlement should be granted for a chronic condition only. For VAC purposes, "chronic" means the signs and symptoms of the condition have existed for at least six months. Signs and symptoms are generally expected to persist despite medical attention, although they may wax and wane over the six month period and thereafter.

Entitlement Considerations

A. Causes And/Or Aggravation

Causal or Aggravating Factors versus Predisposing Factors

Causal or aggravating factors directly result in the onset or aggravation of the claimed psychiatric condition.

Predisposing factors do not cause a claimed condition. Predisposing factors are experiences or exposures which affect the individual's ability to cope with stress. Predisposing factors makes an individual more susceptible to developing the claimed condition. For example, the presence of a remote history of severe childhood abuse may be a predisposing factor in the onset of a significant psychiatric condition later in life.

Partial entitlement should only be considered for non-service related causal or aggravating factors.

Partial entitlement should not be considered for predisposing factors.

If it is unclear if a factor is a causal or aggravating factor versus a predisposing factor consultation with Medical Advisory is strongly recommended.

NOTE: The factors listed in Section A of the Entitlement Considerations include specific timelines for the clinical onset or aggravation of Bipolar and Related Disorders. The timelines are not binding. Each case should be adjudicated on the evidence provided and its own merits. If the medical evidence indicates an alternate timeline, consultation with Medical Advisory is strongly recommended.

NOTE: The following list of factors is not all inclusive. Factors, other than those listed in Section A, may be claimed to cause or aggravate a Bipolar or Related Disorder. Other factors may be considered based on the individual merits and medical evidence provided for each case. Consultation with Medical Advisory is strongly recommended.

1. Directly experiencing a traumatic event(s) within one year before the clinical onset or aggravation of a Bipolar or Related Disorder
   
   Traumatic events include, but are not limited to:
   1. exposure to military combat
   2. threatened physical assault or being physically assaulted
   3. threatened sexual assault or being sexually assaulted
   4. being kidnapped
   5. being taken hostage
   6. being in a terrorist attack
   7. being tortured
   8. incarceration as a prisoner of war
   9. being in a natural or human-made disaster
   10. being in a severe motor vehicle accident
   11. killing or injuring a person in a non-criminal act
   12. experiencing a sudden, catastrophic medical incident
2. Witnessing, in person, a traumatic event(s) as it occurred to another person(s) within one year before the clinical onset or aggravation of a Bipolar or Related Disorder
   
   Witnessed traumatic events include, but are not limited to:
   1. threatened or serious injury to another person
   2. an unnatural death
   3. physical or sexual abuse of another person
   4. a medical catastrophe in a close family member or close friend.
3. Experiencing repeated or extreme exposure to aversive details of a traumatic event(s) within one year before the clinical onset or aggravation of a Bipolar or Related Disorder
   
   Exposures include, but are not limited to:
   1. viewing and/or collecting human remains
   2. viewing and/or participating in the clearance of critically injured casualties
   3. repeated exposure to the details of abuse and/or atrocities inflicted on another person(s)
   4. dispatch operators exposed to violent or accidental traumatic event(s)
   Note: Factor 3 applies to exposure through electronic media, television, movies and pictures only if the exposure is work related.
4. Living or working in a hostile or life-threatening environment for a period of at least four weeks before the clinical onset or aggravation of Bipolar or Related Disorder
   
   Situations or settings which have a pervasive threat to life or bodily integrity including but not limited to:
   1. being under threat of artillery, missile, rocket, mine or bomb attack
   2. being under threat of nuclear, biologic or chemical agent attack
   3. being involved in combat or going on combat patrols
5. Experiencing the death of a close family member or close friend within one year before the clinical onset or aggravation of a Bipolar or Related Disorder
6. Experiencing a stressful life event within one year before the clinical onset or aggravation of a Bipolar or Related Disorder
   
   Events which qualify as stressful life events include, but are not limited to:
   1. being socially isolated and unable to maintain friendships or family relationships, due to physical location, language barriers, disability, or medical or psychiatric illness
   2. experiencing a problem with a long-term relationship including: the break-up of a close personal relationship, the need for marital or relationship counselling, marital separation or divorce
   3. having concerns in the work or school environment including: on-going disharmony with fellow work or school colleagues, perceived lack of social support within the work or school environment, perceived lack of control over tasks performed and stressful workloads, or experiencing bullying in the workplace or school environment
   4. experiencing serious legal issues including: being detained or held in custody, on-going involvement with law enforcement concerning violations of the law or court appearances associated with personal legal problems
   5. having severe financial hardship including, but not limited to: loss of employment, long periods of unemployment, foreclosure on a property, or bankruptcy
   6. having a close family member or close friend experience a major deterioration in their health
   7. being a full-time caregiver to a family member or close friend with a severe physical, mental or developmental disability
7. Being within the one year period following childbirth at the time of the clinical onset or aggravation of a Bipolar or Related Disorder
8. Having Substance Use Disorder at the time of the clinical onset or aggravation of a Bipolar or Related Disorder
9. Having Alcohol Use Disorder at the time of the clinical onset or aggravation of a Bipolar or Related Disorder
10. Having experienced severe childhood abuse before the clinical onset of a Bipolar or Related Disorder
    
    Severe childhood abuse is:
    1. serious physical, emotional, psychological or sexual harm to a child under the age of 16 years; or
    2. neglect involving a serious failure to provide the necessities for health, physical and emotional development, or wellbeing of a child under the age of 16 years;
    where such serious harm or neglect has been perpetrated by a parent, a care provider, an adult who works with or around the child, or any other adult in contact with the child.
11. Inability to obtain appropriate clinical management of a Bipolar or Related Disorder

NOTE: Substance/Medication-Induced Bipolar and Related Disorder and Bipolar and Related Disorder due to Another Medical Condition are also mental disorders included in this category.

If a substance(s), medication(s) or another medical condition(s) is claimed to be related to the clinical onset or clinical aggravation of a Bipolar or Related Disorder, consultation with Medical Advisory is strongly recommended.

B. Medical Conditions Which Are To Be Included In Entitlement/Assessment

NOTE: If specific conditions are listed for a category, only these conditions are included in the entitlement and assessment of a Bipolar or Related Disorder.

If no conditions are listed for a category, all conditions within the category are included in the entitlement and assessment of a Bipolar or Related Disorder.

• Other Bipolar and Related Disorders
• Trauma- and Stressor-Related Disorders
• Anxiety Disorders
• Obsessive-Compulsive and Related Disorders
• Depressive Disorders
• Schizophrenia Spectrum and other Psychotic Disorders
• Personality Disorders
• Feeding and Eating Disorders
• Substance-Related and Addictive Disorders
• Dissociative Disorders
• Somatic Symptom and Related Disorders
  • Somatic Symptom Disorder
  • Illness Anxiety Disorder
  • Conversion Disorder
• Pain Disorders/Chronic Pain Syndrome (DSM-IV-TR Axis I Diagnosis)
• Sleep-Wake Disorders
  • Insomnia Disorder
  • Hypersomnolence Disorder
• Neurodevelopmental Disorders
  • Attention-Deficit/Hyperactivity Disorder
• Decreased Libido - if the medical information indicates decreased libido is a symptom of a psychiatric condition.

Separate entitlement is required for a DSM-5 condition not included in Section B of the Bipolar and Related Disorders Entitlement Eligibility Guideline.

C. Common Medical Conditions Which May Result In Whole Or In Part From Bipolar Disorder And/Or Its Treatment

Section C medical conditions may result in whole or in part as a direct result of a Bipolar or Related Disorder, from the treatment of a Bipolar or Related Disorder or the combined effects of a Bipolar or Related Disorder and its treatment.

Conditions listed in Section C of the Entitlement Considerations are only granted entitlement if the individual merits and medical evidence of the case determines a consequential relationship exists. Consultation with Medical Advisory is strongly recommended.

If it is claimed a medication required to treat a Bipolar or Related Disorder resulted in whole, or in part, in the clinical onset or aggravation of a medical condition the following must be established:

1. The individual was receiving the medication at the time of the clinical onset or aggravation of the medical condition.
2. The medication was used for the treatment of a Bipolar or Related Disorder.
3. The medication is unlikely to be discontinued or the medication is known to have enduring effects after discontinuation.
4. The individual's medical information and the current medical literature support the medication can result in the clinical onset or aggravation of the medical condition.
5. Note: Individual medications may belong to a class, or grouping, of medications. The effects of a specific medication may vary from the grouping. The effects of the specific medication should be considered and not the effects of the group.

The list of Section C conditions is not all inclusive. Conditions, other than those listed in Section C, may be claimed to have a consequential relationship to a Bipolar or Related Disorder and/or its treatment. Other conditions may be considered for entitlement based on the individual merits and medical evidence provided for each case. Consultation with Medical Advisory is strongly recommended.

• Sexual Dysfunction (e.g., Erectile Dysfunction)
• Irritable Bowel Syndrome
• Bruxism
• Xerostomia
• Periodic Limb Movement Disorder
• Restless Leg Syndrome
• Obstructive Sleep Apnea

References For Bipolar And Related Disorders

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4^th ed. Text Revision (DSM-IV-TR) Washington: American Psychiatric Association, 2000.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5^th ed. (DSM-5) Washington: American Psychiatric Association, 2013.
3. Australia. (2009). Statement of principles concerning bipolar disorder. No. 27 of 2009.
4. Australia. (2009). Statement of principles concerning bipolar disorder. No. 28 of 2009.
5. Sadock B.J.Sadock V.A. Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 8^th ed. Philadelphia: Lippincott Williams & Wilkins, 2005.