Bipolar Spectrum Diagnostic Scale

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The Bipolar Spectrum Diagnostic Scale (BSDS) is a psychiatric self-rating scale created by Ronald Pies in screening for bipolar disorder (BD). [1] Its initial version consists of a descriptive narrative aimed to capture the nuances and milder variants of BD. [2] Upon revision by Nassir Ghaemi and colleagues, the scale was developed into two sections for a total of 20 questions. [2] The BSDS is widely accepted as an important measure of bipolar disorder alongside other diagnostic tools such as the Mood Disorder Questionnaire and the Bipolar Depression Rating Scale. [3]

Contents

Background

Bipolar Disorder (BD) is a psychiatric disorder defined by intermittent episodes of depression and (hypo) mania during the individual's lifetime. The DSM-5 and ICD-11 recognise bipolar disorder as a spectrum with three specific subtypes: bipolar I disorder, Bipolar II disorder and cyclothymic disorder. The lifetime prevalence of BD is approximately 1% in the general population, [4] but rises to 4% when given the broader definition of bipolar spectrum disorder. As a result of the broad and complex nature of bipolar disorder, misdiagnosis is fairly common: 69% of confirmed cases are found to be initially misdiagnosed and more than a third of individuals are misdiagnosed for ten years onwards. [5] For individuals with milder symptoms of BD, this seems to be even more prevalent.

The BSDS was devised to estimate not only severe cases of bipolar disorder, but also milder variants in a more sensitive manner. The scale is ideal for screening, but not for diagnosing BD as the 19 questions do not accurately reflect the main criterion of the DSM-5. [6] The scale has however been found to accurately rule out a diagnosis of BD altogether for an individual. [6]

Development

The original English Version of the BSDS consists of a descriptive passage with nineteen statements ending with a blank space. Patients are first advised to read through the entire passage before starting the assessment. Once completed, they are asked to place a check next to each of the nineteen items they feel relates to their personal experience of BD. [7] Each check is worth one point. The passage is written entirely in a third person narrative.

When assessed by Nassir Ghaemi and colleagues, the original scale demonstrated a high diagnostic sensitivity at 0.76, meaning that most people with clinicians' DSM-5-based cases were accurately diagnosed. [7] The BSDS also correctly identified 85% of unipolar-depressed patients as not having bipolar disorder despite similarities in symptoms, indicating a high specificity score. [7] To improve the original version, Ghaemi created an additional section for the BSDS. This section involved a 4-item Likert scale assessing the extent to which individuals felt that the passage related to their own experience of BD. The 4 item scale includes statements of "This story fits me very well." (worth 6 points), "This story fits me fairly well." (worth 4 points), "This story fits me to some degree but not in most respects." (worth 2 points), to "This story does not really describe me at all." (worth 0 points). [7] [6] The abridged version of BSDS scores range from 0-25 points with the positive threshold for diagnosis at 13 points and above.

The likelihood of BD according to the BSDS is given based on the overall score of both sections. [1] [7] Scores of 0-6 indicates a "highly unlikely" chance of having BD, 7-12 indicates a "low probability", 13-19 indicates a "moderate probability", and a score of 20-25 indicates a "high probability".

Ghaemi's BSDS version increased specificity from the original version from 0.85 to 0.93. The BSDS has since been adjusted and adapted for several other global populations, including Persia, Turkey, and Mexico. [8] [9] [10]

Reliability and validity

The BSDS is a well validated diagnostic tool with a high sensitivity (0.76) and specificity (0.93) score. [2] It was also found to have a high Negative Predictive Value (NPV) of 0.87, suggesting that 87% of the patients who scored below 13 points on the BSDS were correctly identified as not having BD. However, the BSDS was found to have a low Positive Predictive Value (PPV) of 0.36. [11] Zimmermann et al. found a NPV as high as 0.98 and a low PPV of 0.16 when using a representative sample size of 1100 outpatients. [12] This PPV score demonstrates a vulnerability to overdiagnosing BD.

In a systematic review and meta-analysis investigating the accuracy of self-report scales for detecting Bipolar Disorder, the BSDS was found to be one of the best performing options along with the Mood Disorder Questionnaire. [13] The BSDS may do better than other scales at detecting different subtypes of bipolar disorder which do not involve a full manic episode, such as bipolar II or cyclothymic disorder.

Limitations

When interpreting results from the BSDS, it is important to note that the BSDS has several limitations. The BSDS is an example of a self-report scale which relies on the individual's subjective interpretation of their own symptoms and behaviours. An individual may consciously or subconsciously misrepresent the data due to a range of factors from social desirability bias to faulty recall, which can compromise the accuracy of their BSDS score. An additional limitation is that the scale cannot confirm if an individual has bipolar disorder as it does not include all the signs of bipolar spectrum disorder listed by the DSM-5. A further limitation research studies are often conducted on small samples of outpatients, leading to varying scores of the accuracy and reliability of the BSDS. [2]

All these limitations may play some role in why the BSDS has been found to have such a low PPV, leading to the overestimation of BD in individuals completing the scale. As such, it is important that the BSDS be used in conjunction with other clinical information to make a fully accurate diagnosis, but when used alone, the BSDS can have dangerous ramifications in overdiagnosing a serious psychiatric condition such as bipolar disorder to the general population.

See also

Related Research Articles

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Bipolar disorder, previously known as manic depression, is a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks. If the elevated mood is severe or associated with psychosis, it is called mania; if it is less severe and does not significantly affect functioning, it is called hypomania. During mania, an individual behaves or feels abnormally energetic, happy or irritable, and they often make impulsive decisions with little regard for the consequences. There is usually also a reduced need for sleep during manic phases. During periods of depression, the individual may experience crying and have a negative outlook on life and poor eye contact with others. The risk of suicide is high; over a period of 20 years, 6% of those with bipolar disorder died by suicide, while 30–40% engaged in self-harm. Other mental health issues, such as anxiety disorders and substance use disorders, are commonly associated with bipolar disorder.

Bipolar I disorder is a type of bipolar spectrum disorder characterized by the occurrence of at least one manic episode, with or without mixed or psychotic features. Most people also, at other times, have one or more depressive episodes. Typically, these manic episodes can last at least 7 days for most of each day to the extent that the individual may need medical attention. Also, the depressive episodes will be approximately 2 weeks long.

<span class="mw-page-title-main">Mood disorder</span> Mental disorder affecting the mood of an individual, over a long period of time

A mood disorder, also known as an affective disorder, is any of a group of conditions of mental and behavioral disorder where a disturbance in the person's mood is the main underlying feature. The classification is in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD).

Schizoaffective disorder is a mental disorder characterized by abnormal thought processes and an unstable mood. This diagnosis requires symptoms of both schizophrenia and a mood disorder: either bipolar disorder or depression. The main criterion is the presence of psychotic symptoms for at least two weeks without any mood symptoms. Schizoaffective disorder can often be misdiagnosed when the correct diagnosis may be psychotic depression, bipolar I disorder, schizophreniform disorder, or schizophrenia. This is a problem as treatment and prognosis differ greatly for most of these diagnoses. many people with schizoaffective disorder have other mental disorder including anxiety disorders

A spectrum disorder is a disorder that includes a range of linked conditions, sometimes also extending to include singular symptoms and traits. The different elements of a spectrum either have a similar appearance or are thought to be caused by the same underlying mechanism. In either case, a spectrum approach is taken because there appears to be "not a unitary disorder but rather a syndrome composed of subgroups". The spectrum may represent a range of severity, comprising relatively "severe" mental disorders through to relatively "mild and nonclinical deficits".

<span class="mw-page-title-main">Bipolar disorder in children</span>

Bipolar disorder in children, or pediatric bipolar disorder (PBD), is a rare mental disorder in children and adolescents. The diagnosis of bipolar disorder in children has been heavily debated for many reasons including the potential harmful effects of adult bipolar medication use for children. PBD is similar to bipolar disorder (BD) in adults, and has been proposed as an explanation for periods of extreme shifts in mood called mood episodes. These shifts alternate between periods of depressed or irritable moods and periods of abnormally elevated moods called manic or hypomanic episodes. Mixed mood episodes can occur when a child or adolescent with PBD experiences depressive and manic symptoms simultaneously. Mood episodes of children and adolescents with PBD are different from general shifts in mood experienced by children and adolescents because mood episodes last for long periods of time and cause severe disruptions to an individual's life. There are three known forms of PBD: Bipolar I, Bipolar II, and Bipolar Not Otherwise Specified (NOS). The average age of onset of PBD remains unclear, but reported age of onset ranges from 5 years of age to 19 years of age. PBD is typically more severe and has a poorer prognosis than bipolar disorder with onset in late-adolescence or adulthood.

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Bipolar II disorder (BP-II) is a mood disorder on the bipolar spectrum, characterized by at least one episode of hypomania and at least one episode of major depression. Diagnosis for BP-II requires that the individual must never have experienced a full manic episode. Otherwise, one manic episode meets the criteria for bipolar I disorder (BP-I).

Bipolar disorder not otherwise specified (BD-NOS) is a diagnosis for bipolar disorder (BD) when it does not fall within the other established sub-types. Bipolar disorder NOS is sometimes referred to as subthreshold bipolar disorder.

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The Mood Disorder Questionnaire (MDQ) is a self-report questionnaire designed to help detect bipolar disorder. It focuses on symptoms of hypomania and mania, which are the mood states that separate bipolar disorders from other types of depression and mood disorder. It has 5 main questions, and the first question has 13 parts, for a total of 17 questions. The MDQ was originally tested with adults, but it also has been studied in adolescents ages 11 years and above. It takes approximately 5–10 minutes to complete. In 2006, a parent-report version was created to allow for assessment of bipolar symptoms in children or adolescents from a caregiver perspective, with the research looking at youths as young as 5 years old. The MDQ has become one of the most widely studied and used questionnaires for bipolar disorder, and it has been translated into more than a dozen languages.

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References

  1. 1 2 Youngstrom, Eric A.; Egerton, Gregory A.; Genzlinger, Jacquelynne; Freeman, Lindsey K.; Rizvi, Sabeen H.; Van Meter, Anna (2018). "Improving the global identification of bipolar spectrum disorders: Meta-analysis of the diagnostic accuracy of checklists". Psychological Bulletin. 144 (3): 315–342. doi:10.1037/bul0000137. ISSN   1939-1455.
  2. 1 2 3 4 Nassir Ghaemi, S.; Miller, Christopher J.; Berv, Douglas A.; Klugman, Jeffry; Rosenquist, Klara J.; Pies, Ronald W. (2005). "Sensitivity and specificity of a new bipolar spectrum diagnostic scale". Journal of Affective Disorders. 84 (2–3): 273–277. doi:10.1016/S0165-0327(03)00196-4.
  3. ↑ Lee, Dongyun; Cha, Boseok; Park, Chul-Soo; Kim, Bong-Jo; Lee, Cheol-Soon; Lee, Sojin (2013). "Usefulness of the combined application of the Mood Disorder Questionnaire and Bipolar Spectrum Diagnostic Scale in screening for bipolar disorder". Comprehensive Psychiatry. 54 (4): 334–340. doi:10.1016/j.comppsych.2012.10.002.
  4. ↑ Rowland, Tobias A.; Marwaha, Steven (2018). "Epidemiology and risk factors for bipolar disorder". Therapeutic Advances in Psychopharmacology. 8 (9): 251–269. doi:10.1177/2045125318769235. ISSN   2045-1253. PMC   6116765 . PMID   30181867.
  5. ↑ Mooney, Brenda (2022-05-29). "Bipolar Disorder Often Misdiagnosed as Major Depression, Leading to Improper Treatment". U.S. Medicine. Retrieved 2023-04-12.
  6. 1 2 3 Harrison, Paul J.; Geddes, John R.; Tunbridge, Elizabeth M. (2018). "The Emerging Neurobiology of Bipolar Disorder". Trends in Neurosciences. 41 (1): 18–30. doi:10.1016/j.tins.2017.10.006. PMC   5755726 . PMID   29169634.
  7. 1 2 3 4 5 Zaratiegui, Rodolfo M.; Vázquez, Gustavo H.; Lorenzo, Laura S.; Marinelli, Marcia; Aguayo, Silvia; Strejilevich, Sergio A.; Padilla, Eduardo; Goldchluk, Aníbal; Herbst, Luis; Vilapriño, Juan J.; Bonetto, Gerardo García; Cetkovich-Bakmas, Marcelo G.; Abraham, Estela; Kahn, Clara; Whitham, Elizabeth A. (2011). "Sensitivity and specificity of the mood disorder questionnaire and the bipolar spectrum diagnostic scale in Argentinean patients with mood disorders". Journal of Affective Disorders. 132 (3): 445–449. doi:10.1016/j.jad.2011.03.014.
  8. ↑ Zimmerman, Mark; Galione, Janine N; Chelminski, Iwona; Young, Diane; Ruggero, Camilo J (2010-08-16). "Performance of the Bipolar Spectrum Diagnostic Scale in psychiatric outpatients: Performance of the Bipolar Spectrum Diagnostic Scale". Bipolar Disorders. 12 (5): 528–538. doi:10.1111/j.1399-5618.2010.00840.x.
  9. ↑ İnce, Bahri; Cansız, Alparslan; Ulusoy, Sevinç; Yavuz, Kasım Fatih; Kurt, Erhan; Altınbaş, Kürşat (2019). "Reliability and Validity Study of the Turkish Version of Bipolar Spectrum Diagnostic Scale". Turk Psikiyatri Dergisi = Turkish Journal of Psychiatry. 30 (4): 272–278. ISSN   2651-3463. PMID   32594489.
  10. ↑ Sánchez de la Cruz, Juan Pablo; Fresán, Ana; González Moralez, Diana Laura; López-Narváez, María Lilia; Tovilla-Zarate, Carlos Alfonso; Pool-García, Sherezada; Juárez-Rojop, Isela; Hernández-Díaz, Yazmín; González-Castro, Thelma Beatriz; Vera-Campos, María de Lourdes; Velázquez-Sánchez, Patricia (2018-11-27). "Validation of the Bipolar Spectrum Diagnostic Scale in Mexican Psychiatric Patients". The Spanish Journal of Psychology. 21: E60. doi:10.1017/sjp.2018.59. ISSN   1988-2904. PMID   30477597.
  11. ↑ Shabani, Amir; Mirzaei Khoshalani, Mosleh; Mahdavi, Seyedreza; Ahmadzad-Asl, Masoud (2019). "Screening bipolar disorders in a general hospital: Psychometric findings for the Persian version of mood disorder questionnaire and bipolar spectrum diagnostic scale". Medical Journal of the Islamic Republic of Iran. 33: 48. doi:10.34171/mjiri.33.48. ISSN   1016-1430. PMC   6708087 . PMID   31456972.
  12. ↑ Zimmerman, Mark; Galione, Janine N. (2011-09-20). "Screening for Bipolar Disorder with the Mood Disorders Questionnaire: A Review". Harvard Review of Psychiatry. 19 (5): 219–228. doi:10.3109/10673229.2011.614101. ISSN   1067-3229.
  13. ↑ Sayyah, Mehdi; Delirrooyfard, Ali; Rahim, Fakher (2022). "Assessment of the diagnostic performance of two new tools versus routine screening instruments for bipolar disorder: a meta-analysis". Brazilian Journal of Psychiatry. 44 (3): 349–361. doi:10.1590/1516-4446-2021-2334. ISSN   1809-452X. PMC   9169473 . PMID   35588536.
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