BJPsych Advances (2020), vol. 26, 50–57 doi: 10.1192/bja.2019.54 ARTICLE Bordering on the bipolar: a review of criteria for ICD-11 and DSM-5 persistent mood disorders Jason Luty Jason Luty, MB, ChB, PhD, SUMMARY MRCPsych, is a consultant in addic- Persistent low mood with lack of enjoyment (‘anhe- tions, liaison and general psychiatry The principal manuals for psychiatric diagnosis donia’) is common and often hard to treat in psychi- in south-east England. He trained at have recently been updated (ICD-11 was released atric practice. Recent changes in the two major the Maudsley Hospital, London, and in June 2018 and DSM-5 was published in 2013). spent 8 years as a consultant in diagnostic classification systems – ICD-11 released A common diagnostic quandary is the classification addictions with the South Essex in June 2018 (World Health Organization 2018) Partnership NHS Trust. He has a PhD of people with chronic low mood, especially those in pharmacology, following a study of with repeated self-harm (‘emotionally unstable’ or and DSM-5 (American Psychiatric Association the molecular mechanisms of recep- ‘borderline’ personality disorder). There has been 2013) – make the time apposite to review the diag- tor desensitisation and tolerance, and a great interest in use of type II bipolar affective dis- nostic categories relevant to persistent mood has published in the addictions field. order (‘bipolar II disorder’) as a less pejorative diag- disorders. Correspondence Dr Jason Luty, nostic alternative to ‘personality disorder’,despite fi Consultant Psychiatrist, Athona There is signi cant diagnostic overlap with emo- Recruitment Ltd, 1st Floor, Juniper the radically different treatment options for these tionally unstable/borderline personality disorder, House, Warley Hill Business Park, disorders. DSM-5 (but not ICD-11) clearly distin- with several common features, such as impulsivity, The Drive, Brentwood CM13 3BE, UK. guishes between borderline personality disorder mood instability, inappropriate anger, suicidal Email: [email protected] and bipolar II disorder, indicating that intense emo- behaviour and unstable relationships. The recent tional experiences (such as anger, panic or despair; history of psychiatric classification has oscillated First received 20 Jul 2018 irritability; anxiety) should persist for only a few Final revision 9 Aug 2019 between the placement of dysthymia and cyclothy- Accepted 19 Aug 2019 hours in people with a personality disorder. Both manuals now use the term ‘borderline personality mia as mood disorders (state disorders) or as person- Copyright and usage disorder’ rather than ‘emotionally unstable person- ality disorders (trait disorders). Similarly, of the © The Royal College of Psychiatrists ality disorder’. The diagnostic criteria for cyclothy- bipolar affective disorders, bipolar II disorder has 2019 mic disorder remain confusing. many features suggestive of a chronic trait disorder (such as dysthymic mood) rather than an episodic LEARNING OBJECTIVES state disorder (typified by bipolar I disorder). The After reading this article you will be able to: problems with classification reflect practical difficul- • appreciate the key differences in diagnostic ties in clinical diagnosis. The reliability of these classification between persistent mood disor- manualised diagnostic categories is also imperfect. ders: bipolar II disorder, borderline personality The reliability of the diagnostic categories for disorder and dysthymia fi • be aware of the modest differences between DSM-5 from eld trials are reported from eleven aca- ICD-10, ICD-11 and DSM-5 in diagnostic cri- demic centres involving 264 patients (Regier 2013). teria for these disorders The correlation between clinicians varied from 0.28 • appreciate that intense emotional experiences (questionable reliability) for major depressive dis- need persist for only a few hours to meet cri- order to 0.54 (good reliability) for borderline person- teria for DSM-5 borderline personality disorder ality disorder. By contrast, field trials for ICD-11 and that persistent emotional dysregulation (e.g. involved 28 centres in 13 countries with over 1800 irritability, impulsiveness, disinhibition) for a few patients and 339 clinicians (Reed 2018). Intraclass days meets criteria for DSM-5 bipolar II kappa correlation coefficients for selected disorders disorder. ranged from 0.45 for dysthymic disorder to 0.64 DECLARATION OF INTEREST for a depressive episode (good reliability for both). ‘ None. The category of emotionally unstable personality disorder’ has been dropped from ICD-11 and was KEYWORDS never used in the recent DSM manuals – both Bipolar affective disorders; borderline personality manuals now use the term ‘borderline personality disorder; depressive disorders. disorder’. 50 BJPsych Advances (2020), vol. 26, 50–57 doi: 10.1192/bja.2019.54 Downloaded from https://www.cambridge.org/core. 29 Sep 2021 at 04:16:35, subject to the Cambridge Core terms of use. Bordering on the bipolar The treatment of bipolar affective disorder typic- an interactive website with coding tools (World ally relies on medication (National Institute for Health Organization 2018). ICD-11 will formally Health and Care Excellence 2009), including mood replace ICD-10 in 2022. stabilisers such as lithium, whereas treatment of per- sonality disorder is largely based psychotherapy Major depressive disorder (National Institute for Health and Care Excellence See the section on major depressive disorder 2014). There tends to be an assumption that type I ‘Clinical descriptions: DSM-5’ below. and type II bipolar disorder are related, although there are actually significant differences in clinical Dysthymic disorder presentation and they may be quite separate diagnos- In ICD-11 ‘dysthymia’ or ‘dysthymic disorder’ tic entities (American Psychiatric Association 2013). includes patients with low mood for most of the ‘ DSM-5 uses the term persistent depressive dis- time for 2 years or longer, although the severity ’ order to include chronic depression and dysthymic must not meet criteria for a depressive episode. In disorder entities (American Psychiatric Association other words, dysthymia is a description for subsyn- 2013). Symptoms overlap with those of other disor- dromal depression associated with anhedonia, ders characterised by persistent low mood and lack impaired concentration, low self-esteem or inappro- of enjoyment, including bipolar II disorder and bor- priate guilt, pessimism, disturbed sleep and appe- derline personality disorder. These disorders have tite, and fatigue. In contrast to dysthymic disorder, several common characteristics and the distinction depressive episodes require that there is ‘significant’ fi is often dif cult. Moreover, persistent mood disorders impairment of functioning, suicidality and objective are widespread. For example, dysthymic disorder has symptoms such as psychomotor agitation or retard- been estimated to have a life-time prevalence of up to ation that are observed by others and persist for at – 2 4% in the general population, and borderline per- least 2 weeks. The presence of a 2-week depressive – sonality disorder is estimated to affect around 1 2% episode within a 2-year period excludes a diagnosis of the population. The prevalence of bipolar II dis- order varies from 0.4 to 0.8%, although the preva- lence is also affected by the duration of hypomanic BOX 1 A simplified algorithm for differential diagnosis in persistent symptoms (Angst 2010). All persistent mood disor- depression ders are associated with greatly increased risk of suicide (Zanarini 1998; Kessler 2005; Merikangas Any manic episode (with ‘marked’ impairment avoid abandonment; unstable intense rela- 2007;Grant2008; Korzekwa 2008;Hasin2018). of functioning for 7 days or psychosis)? tionships; identity disturbance; impulsivity; In this article I examine the distinction between diag- – suicidality; unstable mood; chronic empti- fi Yes Bipolar I disorder nostic categories in the classi cation of persistent, mild- ness; anger-management problems; transient No: Any hypomanic episode (at least 4 days)? to-moderate mood disorders in adults. The term ‘per- stress-induced paranoid or dissociative sistent’ refers to symptoms occurring most of the time Yes – Bipolar II disorder symptoms. DSM-5 requires that symptoms for 2 years or more. Note that, conventionally, a No: Any intense emotional dysregulation begin in early adult life. primary diagnosis of mood disorder is not made if the persisting for a few hours (such as anger, In ICD-11 personality disorder, there must be patient has symptoms that are more typical of schizo- panic or despair; irritability; anxiety) ‘substantial’ distress or ‘significant’ impair- phrenia, substance use disorders or organic syndromes Yes – Consider borderline personality ment of functioning for 2 years, with a such as dementia, head injury or medical conditions. disorder negative view of the self or impaired inter- Depressed mood means feeling sad, empty and No: Low mood with ‘significant’ impairment personal functioning (dissatisfaction with hopeless. Anhedonia means lack of enjoyment. of functioning, suicidality and objective relationships or interpersonal conflict). In ICD- Distractibility means that the person’s attention is symptoms such as psychomotor agitation or 11, personality disorder is classified as mild, moderate or severe. Any suicidality auto- too easily drawn to unimportant or irrelevant exter- retardation for 2 weeks? matically leads to a diagnosis of severe