bipolar affective disorder terminology

[bluecolourskies]

Can someone please help? This is driving me nuts.

Ocassionally on charts I will see "bipolar affective disorder" or "manic depression."

Is this an old term from DSM 3 or something? Or a current one from ICD-10? Does it more closely resemble schizoaffective disorder or is it just bipolar? Does this term just mean "bipolar" with a few extra words thrown in before and after? Or is like here is "bipolar" and "bipolar affective disorder" like how we use bipolar 1 and bipolar 2?

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[erg923]

Can someone please help? This is driving me nuts.

Ocassionally on charts I will see "bipolar affective disorder" or "manic depression."

Is this an old term from DSM 3 or something? Or a current one from ICD-10? Does it more closely resemble schizoaffective disorder or is it just bipolar? Does this term just mean "bipolar" with a few extra words thrown in before and after? Or is like here is "bipolar" and "bipolar affective disorder" like how we use bipolar 1 and bipolar 2?

"Bipolar Affective Disorder" means "Bipolar Disorder." It is technically correct. More a term from the late 70s and 80s...but still.

The diagnosis and ultimate definition is probably built more on provider interview, history gathering, provider bias, and clinical judgment more than anything else. Many would say "Schizoaffective Disorder" is not really a thing and is just misdiagnosed.

 

[bluecolourskies]

"Bipolar Affective Disorder" means "Bipolar Disorder." It is technically correct. More a term from the late 70s and 80s...but still.

The diagnosis and ultimate definition is probably built more on provider interview, history gathering, provider bias, and clinical judgment more than anything else. Many would say "Schizoaffective Disorder" is not really a thing and is just misdiagnosed.

I see medication ads for “manic depression” during Hulu breaks (not sure what they are hinting at) but this also bugged me because I was like “but what is that??”

I then assumed it is a depression medication that has minimal risk of spiraling someone into a manic state (unlike Wellbutrin)

 

[erg923]

Yes, Bipolar Disorder was once titled "Manic-Depression." It's not wrong/inaccurate actually....the term has just fallen out of favor.

The switching thing is not really solid clinical science. That said, I would certainly suggest that a lengthy history and, preferably a semi-structured interview (and maybe a lifetime rating scale?) be done to help support and differentiate Bipolar Disorder vs MDD prior to treatment initiation...especially if considering Wellbutrin and/or Valproate.

 

[MAClinician]

Manic depression is from DSM 3 or earlier. In DSM 4 it became bipolar disorder. I think(?) the “affective” part gets included to distinguish it as a mood disorder. People often referred to borderline personality disorder as BPD which could be confused with bipolar (BP) disorder (D). I have read medical charts that refer to BPAD for the mood disorder.

 

[allantois]

I still see charts using the DSM 4 system so.

I would find bipolar affective dx annoying as well as I would any diagnosis that does not match with the current DSM system

 

[allantois]

The diagnosis and ultimate definition is probably built more on provider interview, history gathering, provider bias, and clinical judgment more than anything else. Many would say "Schizoaffective Disorder" is not really a thing and is just misdiagnosed.

I’m surprised you’d say that. I don’t find schizoaffective to be a controversial diagnosis, but is often over-diagnosed where it’s just schizophrenia with negative symptoms rather than a depressive episode in someone with schizophrenia. I find it more accurate for the manic type, however

 

[pediatric_psydoc]

When I worked inpatient with psychiatrists, the older ones would use the term “bipolar affective disorder” and psychological testing orders written by them would often state “r/o BAD.” They meant it synonymously with “bipolar disorder” and did not typically specify whether they were referring to type 1 or 2.

 

[erg923]

I’m surprised you’d say that. I don’t find schizoaffective to be a controversial diagnosis, but is often over-diagnosed where it’s just schizophrenia with negative symptoms rather than a depressive episode in someone with schizophrenia. I find it more accurate for the manic type, however

Yes. Very controversial diagnosis. "Two weeks" for this and that and the other thing....forgetabut it, son.

My Uncle Louis...a nutjob that guy. Ya know.....backwards mechanic and all that.

 

[erg923]

When I worked inpatient with psychiatrists, the older ones would use the term “bipolar affective disorder” and psychological testing orders written by them would often state “r/o BAD.” They meant it synonymously with “bipolar disorder” and did not typically specify whether they were referring to type 1 or 2.

PGY-1 Day 1 and 2 is Bipolar Disorder. Day 3 has to be the Schizophrenia?

 

[smalltownpsych]

Yes. Very controversial diagnosis. "Two weeks" for this and that and the other thing....forgetabut it, son.

My Uncle Louis...a nutjob that guy. Ya know.....backwards mechanic and all that.

I tend to think when clinicians are throwing in the term affective disorder they are distinguishing it from a more clearly psychotic presentation. Seems to be a few different disorders that look a lot alike depending on how severe the stressors are and where the progression of the disease is. Bipolar with psychotic features vs Schizoaffective vs Schizophrenia. i don’t know if there really is such a thing as schizoaffective, but sometimes I see a clear manic presentation that never seems to progress to a more severe or psychotic state. Other times, manic presentation and the more manic they get the more psychotic they get and some of these can prrogess into a chronic psychotic state consistent with schizophrenia. Some patients seem to go right to the schizophrenia type of state with little or no mood symptoms. Throw a little cannabis use in the mix and it clouds the picture more because it can flip any of these patients into psychosis except maybe for the manic folk who don’t ever seem to get psychotic no matter how fast they are going.
Hope this makes some sense, didn’t really feel like editing and organizing my thoughts. Just kind of stream of consciousness based on the last few years of experience working with these clients in a long term program.

 

[romanticscience]

Can someone please help? This is driving me nuts.

Ocassionally on charts I will see "bipolar affective disorder" or "manic depression."

Is this an old term from DSM 3 or something? Or a current one from ICD-10? Does it more closely resemble schizoaffective disorder or is it just bipolar? Does this term just mean "bipolar" with a few extra words thrown in before and after? Or is like here is "bipolar" and "bipolar affective disorder" like how we use bipolar 1 and bipolar 2?

I use "bipolar affective disorder" because its acronym (BPAD) is differentiated from borderline personality disorder (BPD). I know people (e.g., Ghaemi and Phelps) use or prefer "manic depression" because it captures a broader spectrum of clinical pictures than the DSM allows. It's a bit dated now, but the bipolar bible was titled this.

Ghaemi has written a lot about the "bipolar spectrum," and Akiskal has even conceptualized bipolar 2.5, 3, 4, 5 (these are mentioned in the Stahl Pharmacology books).

This is a pretty cool paper that provides for assessing a "bipolarity index," which is pretty practical:

The Bipolarity Index: a clinician-rated measure of diagnostic confidence - PubMed

The Bipolarity Index can enhance the clinical assessment of mood disorders and, at a score ≥50 has good sensitivity and specificity for identifying bipolar disorders.

pubmed.ncbi.nlm.nih.gov

 

[clausewitz2]

"Manic Depressive Insanity and Paranoia" was the book in which Kraeplin laid out the distinction he observed between essentially what we would today consider severe affective disorders and psychotic disorders. Notably he said himself that cases that were a mixture of both were probably the mode rather than pure cases of either. MDI is not synonymous with bipolar disorder; many cases that today would be diagnosed as severe MDD without a hint of mania/hypomania would fall under MDI as Kraeplin envisioned it.

Bipolar disorder as we conceptualize it today is really more the work of Karl Leonhardt, an East German psychiatrist who was not translated into English until the 60s and had a very, very detailed classification of various endogenous psychoses. Incidentally he was also an actual no-fooling hero; working in a psychiatric hospital in Germany under the Nazis he deliberately mis-diagnosed dozens of patients to make sure they were not considered suitable for euthanasia. It is from Leonhardt that we get the idea of polarity being important.

 

[smalltownpsych]

"Manic Depressive Insanity and Paranoia" was the book in which Kraeplin laid out the distinction he observed between essentially what we would today consider severe affective disorders and psychotic disorders. Notably he said himself that cases that were a mixture of both were probably the mode rather than pure cases of either. MDI is not synonymous with bipolar disorder; many cases that today would be diagnosed as severe MDD without a hint of mania/hypomania would fall under MDI as Kraeplin envisioned it.

Bipolar disorder as we conceptualize it today is really more the work of Karl Leonhardt, an East German psychiatrist who was not translated into English until the 60s and had a very, very detailed classification of various endogenous psychoses. Incidentally he was also an actual no-fooling hero; working in a psychiatric hospital in Germany under the Nazis he deliberately mis-diagnosed dozens of patients to make sure they were not considered suitable for euthanasia. It is from Leonhardt that we get the idea of polarity being important.

I find it interesting how little exposure I had to Kraeplin throughout my education and the little that was seemed aimed at minimizing or discrediting him. Yet, since participating on this forum it seems that many of the psychiatrists mention him frequently and although the terms were changed, his descriptors seem to fit clinical work better than some of our other concepts or constructs around the more severe disorders.

 

[neurotic_cow]

I see medication ads for “manic depression” during Hulu breaks (not sure what they are hinting at) but this also bugged me because I was like “but what is that??”

I then assumed it is a depression medication that has minimal risk of spiraling someone into a manic state (unlike Wellbutrin)

I've also seen ads for meds for "bipolar depression" and had questions about that. Are they referring to the depression that occurs in Bipolar disorder? Or what? Weird terminology to me.

 

[allantois]

I've also seen ads for meds for "bipolar depression" and had questions about that. Are they referring to the depression that occurs in Bipolar disorder? Or what? Weird terminology to me.

yes as not all meds are effective in both phases of bipolar disorder

 

[bluecolourskies]

thank you guys, i didn't know about any of this, learned a lot!

 

[smalltownpsych]

yes as not all meds are effective in both phases of bipolar disorder

Are you sure about that? Most of what I have seen, albeit mainly the info provided during free drug rep
lunches, makes me think it is more marketing hype based on FDA approval as opposed to being demonstrated to be more effective head to head than another medication. Seroquel was the first big one to be pushed that way after they had to make up for the cash they had to pay out after marketing it off label for sleep. I also haven’t seen it really prescribed in that way either. Also, I just don’t see that many people needing medication for depressed mood for patients with Bipolar Disorder. Usually seems that they are more “depressed” because they are contrasting with the elevated mood of mania as opposed to a moderate to severe depressive episode. Not saying it doesn’t happen, I just haven’t seen it much.

 

[allantois]

Are you sure about that? Most of what I have seen, albeit mainly the info provided during free drug rep
lunches, makes me think it is more marketing hype based on FDA approval as opposed to being demonstrated to be more effective head to head than another medication. Seroquel was the first big one to be pushed that way after they had to make up for the cash they had to pay out after marketing it off label for sleep. I also haven’t seen it really prescribed in that way either. Also, I just don’t see that many people needing medication for depressed mood for patients with Bipolar Disorder. Usually seems that they are more “depressed” because they are contrasting with the elevated mood of mania as opposed to a moderate to severe depressive episode. Not saying it doesn’t happen, I just haven’t seen it much.

If you believe in studies, some medications we use don’t have evidence in (or have negative evidence) for use in manic vs depressive phases. For instance Abilify has negative evidence for using it in depressive phase. Lamictal isn’t as great for mania as it is for depression. The opinions on these among psychiatrists will vary, however, medications may be added or subtracted during various phases and some medications are more effective in various phases than others.

I’m not sure what your exposure to bipolar patients is; if it’s in an inpatient setting you probably mostly see the manic phases. In an outpatient setting it’s more common we see the depressive phases as patients often feel great when they are manic but will seek help once they crash. It’s interesting to me that in psychodynamic literature manic-depressive (bipolar and MDD) is viewed on the same spectrum and I don’t see a considerable difference between bipolar depression and MDD, however, some bipolar patients don’t really get that profoundly depressed but many do, especially those with true bipolar 1).

 

[EnPsychlopedia]

Just wanted to jump in and say that I do not agree in the slightest that schizoaffective disorder is just misdiagnosed bipolar disorder. I work in specialty research for psychosis and there’s a clear difference in manifestation between the two. Primarily, people with bipolar 1 (which is much rarer than the number of diagnoses makes it seem…many diagnosticians mistake hypomania for full-blown mania due to never having seen the latter) will only experience psychosis while in a clear manic or depressive episode. Psychosis tends to be secondary to other symptoms. For schizoaffective disorder, psychosis is primary and often present in the absence of any clear affective (not counting negative symptoms) episode. Thought disorder is much more pervasive in schizoaffective than in bipolar, with it often not existing at all in the latter case except during mood episodes. For schizoaffective, the thought disorder tends to attenuate, but not fully dissipate, between mood cycles (and absent meds). Anyway, just my $0.02. For people who don’t interact with psychosis or bipolar 1 disorder much, or who don’t see it literally every day, differential diagnosis can be tricky, but it becomes more clear with time. I’m certainly not the most experienced person in the world in this regard, but three years of full-time research on just psychosis sort of gives one an “eye” for when the psychosis is primary or secondary.

 

[bluecolourskies]

Just wanted to jump in and say that I do not agree in the slightest that schizoaffective disorder is just misdiagnosed bipolar disorder. I work in specialty research for psychosis and there’s a clear difference in manifestation between the two. Primarily, people with bipolar 1 (which is much rarer than the number of diagnoses makes it seem…many diagnosticians mistake hypomania for full-blown mania) will only experience psychosis while in a clear manic or depressive episode. Psychosis tends to be secondary to other sx. For schizoaffective dx, psychosis is primary and often present in the absence of any clear affective (not counting negative sx) episode. Thought disorder is much more pervasive in ScZA than in bipolar, with it often not existing at all in the latter case except during mood episodes. For ScZA the thought disorder tends to attenuate, but not fully dissipate, between mood cycles (and absent meds). Anyway, just my $0.02. For people who don’t interact with psychosis or bipolar 1 dx much, or who don’t see it literally every day, it can be tricky, but it becomes more clear with time. I’m certainly not the most experienced person in the world in this regard, but three years of full-time research on just psychosis sort of gives one an “eye” for it.

Can I make sure I understood that right?
You are saying that delusions continue between episodes for schizoaffective disorder. But delusions will typically go away between episodes for bipolar disorder.

Just making sure I read that correctly!

 

[EnPsychlopedia]

Can I make sure I understood that right?
You are saying that delusions continue between episodes for schizoaffective disorder. But delusions will typically go away between episodes for bipolar disorder.

Just making sure I read that correctly!

I'm saying thought disorder, broadly (delusions as well as general disorganized thought processes or cognitive dysregulation), will attenuate but often not dissipate between mood episodes with schizoaffective disorder, sans treatment, and that full psychosis can occur independently of any mood episodes for people with schizoaffective. But any thought disorder and/or psychosis experienced during bipolar 1 disorder usually happens almost exclusively during manic episodes, and more rarely during depression. When mood symptoms dissipate, the psychosis tends to dissipate. In other words, the psychosis is secondary to the mood pathology. In fact, psychosis or psychotomimetic symptoms being present exclusively during mood episodes is a discriminant criterion for bipolar 1 differential to schizoaffective.

Edit: Also, full negative symptoms profiles are extremely rare in bipolar disorder but not in schizoaffective disorder. During depressive states, those with bipolar 1 will obviously demonstrate some anhedonia and avolition, but profound negative symptoms in the absence of mood disturbance is not common in the former, though it is (or can be) in the latter. Also, general "schizotypy" (magical thinking, ideas of reference, ideation of special status, "odd" beliefs, etc.) sticks around sans mood symptoms in schizoaffective disorder but rarely in bipolar 1. Schizoaffective disorder is much more similar to "schizophrenia plus recurrent mood disorder" than it is to "bipolar disorder plus psychosis," if that makes any sense.

 

[bluecolourskies]

I'm saying thought disorder, broadly (delusions as well as general disorganized thought processes or cognitive dysregulation), will attenuate but often not dissipate between mood episodes with schizoaffective disorder, sans treatment, and that full psychosis can occur independently of any mood episodes for people with schizoaffective. But any thought disorder and/or psychosis experienced during bipolar 1 disorder usually happens almost exclusively during manic episodes, and more rarely during depression. When mood symptoms dissipate, the psychosis tends to dissipate. In other words, the psychosis is secondary to the mood pathology. In fact, psychosis or psychotomimetic symptoms being present exclusively during mood episodes is a discriminant criterion for bipolar 1 differential to schizoaffective.

Edit: Also, full negative symptoms profiles are extremely rare in bipolar disorder but not in schizoaffective disorder. During depressive states, those with bipolar 1 will obviously demonstrate some anhedonia and avolition, but profound negative symptoms in the absence of mood disturbance is not common in the former, though it is (or can be) in the latter. Also, general "schizotypy" (magical thinking, ideas of reference, ideation of special status, "odd" beliefs, etc.) sticks around sans mood symptoms in schizoaffective disorder but rarely in bipolar 1. Schizoaffective disorder is much more similar to "schizophrenia plus recurrent mood disorder" than it is to "bipolar disorder plus psychosis," if that makes any sense.

Thank you for taking the time to type all that out )

 

[clausewitz2]

If you believe in studies, some medications we use don’t have evidence in (or have negative evidence) for use in manic vs depressive phases. For instance Abilify has negative evidence for using it in depressive phase. Lamictal isn’t as great for mania as it is for depression. The opinions on these among psychiatrists will vary, however, medications may be added or subtracted during various phases and some medications are more effective in various phases than others.

I’m not sure what your exposure to bipolar patients is; if it’s in an inpatient setting you probably mostly see the manic phases. In an outpatient setting it’s more common we see the depressive phases as patients often feel great when they are manic but will seek help once they crash. It’s interesting to me that in psychodynamic literature manic-depressive (bipolar and MDD) is viewed on the same spectrum and I don’t see a considerable difference between bipolar depression and MDD, however, some bipolar patients don’t really get that profoundly depressed but many do, especially those with true bipolar 1).

One of the problems with the current conception of bipolar disorders is that there are absolutely people who experience fairly intense manias that are very classic but have never been identifiably depressed for any real length of time. This has been recognized since, well, literally Leonhardt 's original description of bipolar disorder, and yet somehow this remains an obscure fact.

 

[bluecolourskies]

I'm saying thought disorder, broadly (delusions as well as general disorganized thought processes or cognitive dysregulation), will attenuate but often not dissipate between mood episodes with schizoaffective disorder, sans treatment, and that full psychosis can occur independently of any mood episodes for people with schizoaffective. But any thought disorder and/or psychosis experienced during bipolar 1 disorder usually happens almost exclusively during manic episodes, and more rarely during depression. When mood symptoms dissipate, the psychosis tends to dissipate. In other words, the psychosis is secondary to the mood pathology. In fact, psychosis or psychotomimetic symptoms being present exclusively during mood episodes is a discriminant criterion for bipolar 1 differential to schizoaffective.

Edit: Also, full negative symptoms profiles are extremely rare in bipolar disorder but not in schizoaffective disorder. During depressive states, those with bipolar 1 will obviously demonstrate some anhedonia and avolition, but profound negative symptoms in the absence of mood disturbance is not common in the former, though it is (or can be) in the latter. Also, general "schizotypy" (magical thinking, ideas of reference, ideation of special status, "odd" beliefs, etc.) sticks around sans mood symptoms in schizoaffective disorder but rarely in bipolar 1. Schizoaffective disorder is much more similar to "schizophrenia plus recurrent mood disorder" than it is to "bipolar disorder plus psychosis," if that makes any sense.

Since this is your research area, any thoughts on atypical bipolar and classic bipolar disorder? (or anyone feel free to comment)

I came across this in my EPPP study materials, the difference being clear manic/depressive episodes vs more mixed episodes and whether lithium or anticonvulsants work better

 

[EnPsychlopedia]

Since this is your research area, any thoughts on atypical bipolar and classic bipolar disorder? (or anyone feel free to comment)

I came across this in my EPPP study materials, the difference being clear manic/depressive episodes vs more mixed episodes and whether lithium or anticonvulsants work better

Bipolar isn’t my research area—psychosis, particularly the schizophrenia spectrum—is. Occasionally I interact with bipolar in the course of my work but I’m not the one to have strong opinions on it, except insofar as pertains to how it differs from primary psychosis. That said, lithium tends to be the gold standard (from what I remember of my psychopharmacology class), it just isn’t used as much due to having such a narrow therapeutic index.

 

[allantois]

Since this is your research area, any thoughts on atypical bipolar and classic bipolar disorder? (or anyone feel free to comment)

I came across this in my EPPP study materials, the difference being clear manic/depressive episodes vs more mixed episodes and whether lithium or anticonvulsants work better

I think we should refrain from utilizing outdated non-DSM terminology such as atypical bipolar, as I’m not sure what you are communicating with that term. Lithium is usually bundled up with mood stabilizers and is considered gold standard for bipolar disorder, however, I see it used more for refractory cases

 

[clausewitz2]

I think we should refrain from utilizing outdated non-DSM terminology such as atypical bipolar, as I’m not sure what you are communicating with that term. Lithium is usually bundled up with mood stabilizers and is considered gold standard for bipolar disorder, however, I see it used more for refractory cases

Lithium is absolutely the gold standard and if you don't at least have a discussion about it if you think someone has legitimate bipolar disorder you are doing folks a disservice.

Pragmatically, if you want to assess the efficacy, consider this: it is literally a mineral, a rock you dig out of the ground. You cannot patent it. It has never had an ad campaign. It is in no one's financial interests to promote it. It is a tremendous PITA to prescribe and can have scary long-term medical consequences.

And somehow 80 years later we are still using it.

 

[bluecolourskies]

I think we should refrain from utilizing outdated non-DSM terminology such as atypical bipolar, as I’m not sure what you are communicating with that term. Lithium is usually bundled up with mood stabilizers and is considered gold standard for bipolar disorder, however, I see it used more for refractory cases

I agree, and it would confuse me when it would come up on the EPPP materials so I wasn’t sure if that was perhaps another term that I didn’t know clinicians used.

Before anyone asks, it was current 2022 materials!