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Workplace Guidelines for Disability Duration The Most Widely-Used Duration Guidelines in the Industry Adopted in the US and in 38 other Countries The Comprehensive Evidence-Based Return-to-Work Reference Available in Four Formats (Internet, Book, CD-ROM, Data Integration) The foundation for a non-adversarial, standards-based approach to case management for occupational and non-occupational claim professionals To obtain a copy of the MDA, or for a free trial, please visit us at www.rgl.net www.rgl.net | 866.889.4449 | 303.247.1860 celebrated geniuses in music, literature, theater, science, and politics were probably so “affl icted.” Others may experience Bipolar Affective Disorder
long and intense depressions with only fl eeting episodes of a near-normal mood in between.
DSM-IV-TR divides bipolar disorder into four categories de-pending on the particular presentation. Bipolar I disorder is characterized by the occurrence of one or more manic or mixed Related Terms
episodes, and depressive episodes may have occurred. Bipolar II disorder is characterized by the occurrence of major depressive episodes and hypomanic episodes. Cyclothymic disorder features symptoms of hypomania and depression. Bipolar disorder, NOS (not otherwise specifi ed) is applied when symptoms do not Medical Codes
clearly fall into any of the above categories.
• ICD-9-CM: 296, 296.4, 296.7
There is no single proven cause but it is thought to be a bio- • ICD-10: F31.6, F31.7, F31.8
chemical problem related to lack of stability in transmission of Defi nition
nerve impulses in the brain. This biochemical imbalance makes individuals with bipolar affective disorder more vulnerable to Although bipolar affective disorder is classifi ed as a mood disorder, the condition also affects cognition and behavior and frequently is complicated by psychotic symptoms (e.g., Risk: Bipolar affective disorder can present at virtually any
delusions, hallucinations, disorganized thinking). As many as point across the life span. Data from the National Institute of two-thirds of bipolar patients have a lifetime history of psycho- Mental Health Epidemiologic Catchment Area (ECA) study sis (Rivas-Vasquez). Bipolar affective disorder is a disturbance discovered a median age of onset of 18. Bipolar affective disorder of the brain characterized by major mood swings. When the is a heritable biologic illness with occurrence higher in relatives condition is severe, an individual may experience episodes of of individuals with the condition. The presentation and course extreme highs (mania) and extreme lows (depression) several of bipolar disorder differs between women and men, depending times a year. These episodes may last between a few days to on the subtype of the condition. The onset of bipolar disorder a few months. The DSM-IV-TR (Diagnostic and Statistical tends to occur later in women than men, and women more Manual of Mental Disorders, 4th Edition, Text Revision) adds often have a seasonal pattern of the mood disturbance. Women the suffi x “rapid cycling” to the diagnosis of bipolar disorder if experience depressive episodes, mixed mania, and rapid cycling the individual experiences four or more mood episodes (depres- sion, manic, or mixed) during a twelve month period. The suffi x Incidence and Prevalence: Estimates of the lifetime prevalence
“with seasonal pattern” applies to bipolar affective disorder when of bipolar affective disorder from two major community surveys the depressive component is related to the season of the year of the general population of the US vary from 1.0% to 1.6% In mania, the essential feature is brain overactivity. Thought Diagnosis
processes are accelerated, mood is generally elevated, the need History: The diagnosis can be made based on history or by
for sleep is greatly reduced or absent, and energy seems limitless. psychiatric evaluation during a manic phase. During a depres- Unfortunately, thinking becomes less critical and often illogi- sive phase, observation must be augmented by history to dif- cal. Insight into the condition may be missing entirely as is the ferentiate between bipolar and major depressive disorders. Even ability to discriminate between rational and faulty thinking. with a careful history, the diagnosis may prove to be incorrect Consequently, through impaired judgment, individuals tend in two-thirds of individuals and must be considered a working to greatly overestimate their abilities, act impulsively, and may completely ignore social conventions and often behave in a grossly inappropriate or outlandish manner. Psychosis may be A good medical history is initially necessary to exclude the use present with delusions of grandeur such as being the President of steroids, thyroid supplements, other prescription medica- or Jesus Christ. The periods of depression are also dangerous tions, or nonprescription “street” drugs such as amphetamines particularly when they occur in the wake of a manic episode. The frantic energy, racing thoughts, exuberance, and optimism The DSM-IV-TR spells out specifi c criteria for the diagnosis of characteristic of mania is suddenly replaced by morbid preoc- a manic episode. In general, the mood disturbance must cause “marked impairment” in social or occupational functioning and Bipolar illness presents in many variations both in terms of the must not be due to a medical condition, effect of a medication, severity of mood swings and the rate at which they change. Some or drug intoxication. Three of the following symptoms must be individuals with sustained periods of a milder form of mania present for a minimum of 1 week: infl ated self-esteem, decreased known as hypomania may productively harness the abundance need for sleep, more talkative than usual, racing thoughts, easily of energy and ideas in very creative ways. Many of our most distracted, increased purposeful activity, and excessive involve- w w w . r g l . n e t | C o p y r i g h t 2 0 0 5 R e e d G r o u p | 8 6 6 . 8 8 9 . 4 4 4 9 | 3 0 3 . 2 4 7 . 1 8 6 0 ment in risky endeavors with potential adverse consequences.
Unfortunately, many individuals choose not to take the medica- There may be a history of confl icts at work; legal, fi nancial and tions as directed and as a result relapse into mania. Noncompli- family problems; spending sprees or extravagant purchases; ance with medications is sometimes due to unpleasant side ef- business misadventures; extramarital affairs; impulsive travel; fects. In other cases, however, it is clearly a matter of preference. or turbulent social relations. Psychosis may be present with Many bipolar individuals so enjoy the “high” feelings associated delusions of grandeur such as the individual thinking that he with the mania that they do not want to give it up. Because or she is the President or Jesus Christ.
these medications are potentially damaging and prescribed for During depressive episodes, the individual has feelings of life, periodic laboratory testing is necessary.
sadness, hopelessness, and loss of interest in life activities or Occasionally, the medications prove to be ineffective in bringing relationships. These symptoms are present for at least 2 weeks a manic episode under control. In this instance, electroconvul- and make it diffi cult for the individual to function. They are sive therapy (ECT) may control the acute episode, and may also associated with at least four of the following: thoughts of death be continued on a regular basis as a preventive measure against or suicide, trouble sleeping or sleeping too much, poor appetite or overeating, diffi culty concentrating and making decisions, During manic episodes, there is a high-risk of accidental death. feeling slowed down or too agitated to sit still, feeling worthless Psychiatric hospitalization is frequently necessary to ensure the or guilty with very low self esteem, and loss of energy or feeling individual’s safety. The periods of depression are also dangerous, tired all the time. Hearing voices or seeing things that aren’t particularly when they occur in the wake of a manic episode, there (auditory or visual hallucinations) or believing things and may also require hospitalization. When antidepressants that aren’t true (delusions) may accompany severe depressive must be used, they should be given with a mood stabilizer to prevent the individual from rebounding into hypomania. As Physical exam: When the illness is fi rst noticed, a thorough
with most serious psychiatric illnesses, there is no cure. Medica- exam should be performed to exclude physical causes such as tion-assisted remissions are common, however, and may result hyperthyroidism or neurological disease. Observation of the individual’s orientation, dress, mannerisms, behavior, and con- Pharmacotherapy is the primary treatment for bipolar affective tent of speech provide essential signs to diagnose the illness. A disorder, but many authorities recommend augmentation with psychiatric evaluation should be done as soon as possible if a various psychotherapeutic techniques. A primary goal of psycho- therapy is reducing the high rate of medication discontinuation Tests: Psychological testing such as the Minnesota Multiphasic
and overall noncompliance with the pharmacological regime. Personality Inventory (MMPI-2) may aid in diagnosis if the Other risk factors associated with mood instability also serve as evaluation is made while the individual is in a near-normal mood psychotherapy objectives. Psycho-educational classes, support and the history is merely suggestive of bipolar illness. Laboratory groups, and cognitive behavioral therapy groups lend themselves tests should be done to rule out endocrine or metabolic distur- well to adjunctive treatment of bipolar disorder, and spouse and bances, or to monitor compliance if medications are already family involvement can also be helpful. If an individual has a being prescribed. As low blood levels of thyroid hormone are dual diagnosis of mental illness and addiction, integrated dual more common in individuals with rapid cycling than in other diagnosis treatment may be helpful. This type of treatment individuals, thyroid function tests should be done before, during focuses on treating both diagnoses simultaneously by the same and after treatment as medically indicated. Urine screens for clinician or team of clinicians on a personalized basis.
licit and illicit drugs should be done to rule out drugs as factors contributing to the symptom picture.
Prognosis
Individual outcomes vary greatly. During manic episodes, there Treatment
is a high-risk of accidental death. Manic episodes can last any- Medications are the mainstay of treatment, with psychotherapy where from a few days to several months. With medications, the a useful supportive tool. Medications consist primarily of mood duration of manic episodes can be shortened signifi cantly but stabilizers, such as lithium and valproic acid, that moderate may still involve a month or more of intensive therapy, often on the intensity of mood swings. The most extensively studied an inpatient basis. Suicide attempts may complicate a depressive mood-stabilizing agent is lithium and often the fi rst choice of episode. Individuals with bipolar affective disorder have at least treatment for bipolar affective disorder. Anticonvulsant medi- a 15-fold greater risk of suicide than the general population. Left cations, such as valproic acid, lamotrigine, and carbamazepine, untreated, the illness becomes worse with time and may end have increasingly been employed as important pharmacothera- up being very resistant to treatment, rendering the individual peutic alternatives, either as a primary pharmacotherapy or as incapable of working or having normal relationships.
augmentation to lithium. Antipsychotic medications such as Bipolar disorder was the sixth leading cause of disability world- olanzapine and clozapine may be used. Recently the FDA has wide in 1990 (Keck). Morbidity resulting from the illness is not approved risperidone and quetiapine as primary and as adjunct limited to acute episodes of mania or depression. Full recovery therapies for the treatment of bipolar affective disorder. In Au- of functioning often lags behind remission of symptoms.
gust, 2004 the FDA approved ziprasidone for manic and mixed (high and low) episodes.
w w w . r g l . n e t | C o p y r i g h t 2 0 0 5 R e e d G r o u p | 8 6 6 . 8 8 9 . 4 4 4 9 | 3 0 3 . 2 4 7 . 1 8 6 0 In general, bipolar disorder cannot be cured but the symptoms Return to Work
can usually be controlled. Individuals can frequently lead normal Accommodations depend on the type of work required. Stressful and productive lives. In less fortunate cases, the illness may be events and/or lack of sleep may increase risk of igniting a manic nearly impossible to arrest or control and results in permanent episode. Rotating shifts should be avoided. Regular daytime total or near-total disability. Early in the course of the disease, hours may be necessary for signifi cant periods of time. High- spontaneous remissions of up to several years duration are some- pressure jobs or jobs with deadlines requiring the individual times seen. This “honeymoon period” may delay diagnosis or to work extremely long hours over extended time periods are convince the individual that the diagnosis was incorrect.
also not recommended. Leaves of absence may be necessary Up to 60% of individuals with bipolar disorder obtain some relief from lithium and other mood stabilizers, but the response rate is lower in those with rapid cycling (Hillard).
Failure to Recover
Differential Diagnoses
Regarding diagnosis:
• Was diagnosis confi rmed? Based on what criteria?
• Even if a clear history of bipolar illness is present, have the history, physical exam, and testing excluded other possible • Does medication and drug history reveal use of steroids, thyroid supplements, other prescription medications, or Specialists
street drugs that could cause similar symptoms? • Is there evidence of rapid cycling (defi ned as four or more episodes of mania, excitement with moderate behavior Comorbid Conditions
change, or depression in any 12-month period)? Because it responds poorly to treatment, could failure to improve be • Because low blood levels of thyroid hormone are more common in individuals with rapid cycling than in other bipolar individuals, were thyroid function tests performed Complications
Complications depend on the severity of the illness and the • Is there a history or evidence of current substance abuse presence of impaired reality testing (psychosis). The most that makes an individual more prone to cycling with serious complication is accidental death or suicide. Other consequences of impaired judgment may include confl icts at Regarding treatment:
work; legal, fi nancial and family problems; spending sprees or • Does individual fi t criteria for rapid cycling? extravagant purchases; business misadventures; extramarital • Is thyroid replacement therapy warranted based on thyroid affairs; impulsive travel; and turbulent social relations. Lifelong substance abuse affects up to 50% of bipolar individuals and may • Has use of antidepressants precipitated hypomania, warranting discontinuation or change in medications? Factors Infl uencing Duration
• Is there current evidence of substance abuse? How A history of episodes of relatively short duration, good response successfully is the substance abuse being addressed? to medications, and long periods of normal mood predict the • What plan is in place to ensure compliance with shortest period of disability. Substance abuse, noncompliance with medications, psychosis, and a history of lengthy hospital- • If combinations of medications and psychotherapy have izations tend to delay recovery. Serious episodes of mania may not provided adequate relief, is electroconvulsive therapy take 1 to 2 months and occasionally longer to be controlled suffi ciently to allow return to work. Some individuals may be • If self-harm or personal neglect put individual at risk, is unable to maintain stable employment largely because of sub- stance abuse or problems getting along with others.
Regarding prognosis:
• Does individual display any tendency toward self-harm or
Length of Disability
suicide? What preventive safeguards are in place? Psychotherapy and pharmacotherapy, bipolar affective
• Is illness interfering with self-esteem, friendships, social disorder.
• Would individual benefi t from one-on-one psychotherapy DURATION IN DAYS
based on interpersonal, cognitive, or behavioral • Is individual involved in a support group? w w w . r g l . n e t | C o p y r i g h t 2 0 0 5 R e e d G r o u p | 8 6 6 . 8 8 9 . 4 4 4 9 | 3 0 3 . 2 4 7 . 1 8 6 0 • If no improvement occurs after 6 to 8 weeks or if symptoms Keck, P. E., et al. “Advances in the Pathophysiology and Treatment have worsened, is it time to try another treatment approach of Psychiatric Disorders: Implications for Internal Medicine.” Medical or another medication? Get a second opinion from another Clinics of North America 85 3 (2001): 645-661.
Rivas-Vasquez, R. A., et al. “Current Treatments for Bipolar Disorder: A Review and Update for Psychologists.” Professional Psychology: Research Cited References
and Practice 33 2 (2002): 212-223.
Frances, Allen, ed. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Tennen, Melissa. “Bipolar By-Product: Substance Abuse.” Health A to Z. Apr. 2004. 8 Dec. 2004 <http://www.healthatoz.com>.
Hillard, Erika Bukkfalvi. Manic-Depressive Illness. New Westminster, Thase, M. E., M. Bhargava, and G. S. Sachs. “Treatment of Bipolar B.C.: Royal Columbian Hospital, 1992. Internet Mental Health. Phillip Depression: Current Status: Continued Challenges, and the STEP-BD W. Long. 8 Dec. 2004 <http://www.mentalhealth.com/book/p40-ma01.
Approach.” Psychiatric Clinics of North America 26 2 (2003): 495-518. National Center for Biotechnology Information. National Library of Medicine. 8 Dec. 2004 <PMID: 12778844>.
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Source: http://www.dlt.state.ri.us/tdi/pdf/BipolarAffectiveDisorder.pdf