I continue to be challenged by patients when the diagnosis of bipolar disorder is made. For this reason I have decided to write another blog regarding this subject. This is a bit like standing alongside a carousel and trying to draw a picture of a horse on the rotating carousel. Each time the horse passes you draw a line. After fifteen or twenty passes, you have a picture of a horse. After fifteen or twenty blogs, we will have a complete picture of bi-polar disorder.
The bipolarity index takes into account a number of dimensions that are not included in the DSM. It contributes to the idea of bipolarity not as a "do I have it or don't I have it", a yes or no phenomena; but, rather as a how much of this do I have. I always emphasize that my diagnosis at the first interview should be viewed as a statistical probability and that the proposed treatment should be viewed as an empirical test, i.e., does it produce the result desired. This is a bit like dating. You don't ask someone to get married on the first date and start a family. That can occur over a long period of time and shared experience. Treatment is the same.
The Bipolarity Index, developed about seven years ago by Gary Sachs and his colleagues at the Harvard Department of Psychiatry, includes ratings in five dimensions and each dimension is given point scores from twenty to two points. The five dimensions are 1) episode characteristics, 2) age of onset, 3) illness course and other features, 4) response to medications, and 5) family history.
With regard to episode characteristics, most points are awarded for manic symptoms especially euphoria, grandiosity, and expansiveness. The next most points for symptoms of mania with dysphoria and/or irritability. Following those is hypomania or mania following use of an antidepressant. With regard to age of onset, the most points are awarded for onset between 15 to 19 years of age; the next most for age of onset between 20 to 30 or below 15 years of age. Less points are awarded for onset between 30 to forty and even less for onset over 45 years of age. With regard to the illness course, most points are awarded for manic episodes separated by full recovery, less points are awarded for incomplete recovery between manic episodes or hypomania with full recovery between episodes. Less points are given for incomplete recovery between manic episodes or substance abuse, or psychosis during mood episodes or legal problems associated with mania. The dimension of response to medications awards the most points for full recovery within 4 weeks of treatment with mood stabilizers. The next most points are given for full recovery within 12 weeks of treatment or relapse within 12 weeks of stopping mood stabilizers or switch to mania within 12 weeks of starting an antidepressant. The dimension of family history awards the most points for having a first degree relative (brother, sister, parent, child -50% identical DNA) with clear bipolar disorder, the next most points for second degree relative with bipolar disorder or first degree relative with unipolar disorder.
Please note that the above includes the most important aspects of the bipolarity index. For those interested in examining it in complete detail, please search for it on the web where it is easily found. Using the bipolarity index to score patients with a number is an error as the points meaning has not been worked out, although, most bipolar I patients score above 60.