It is well known that Bipolar Disorder is a condition which is often under diagnosed or misdiagnosed. We propose an inventory
of questions which will help assess the longitutinal history of the patient’s illness, and to evaluate the presence of mixed affective
states, rapid cycling, and comorbidities, all of which have an important bearing on prognosis

Agius, Mark

Verdolini, Norma

English

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  S185Psychiatria Danubina, 2015; Vol. 27, Suppl. 1, pp 185–187 Conference paper © Medicinska naklada - Zagreb, Croatia THE CAMBRIDGE-PERUGIA INVENTORY FOR ASSESSMENT  OF BIPOLAR DISORDER Mark Agius1 & Norma Verdolini2 1Clare College Cambridge, Department of Psychiatry University of Cambridge, Cambridge, UK 2Department of Psychiatry University of Perugia, Perugia, Italy SUMMARY It is well known that Bipolar Disorder is a condition which is often under diagnosed or misdiagnosed. We propose an inventory of questions which will help assess the longitutinal history of the patient’s illness, and to evaluate the presence of mixed affective states, rapid cycling, and comorbidities, all of which have an important bearing on prognosis. Key words: bipolar disorder - mixed affective states - rapid cycling - comorbidities *  *  *  *  *  INTRODUCTION It is well known that Bipolar Disorder is a condition which is often under diagnosed (Bongards 2013) or misdiagnosed. Previous work by ourselves has demon-strated that if systematic assessment of patients is carried out, more patients can be diagnosed with bipolar disorder based on the DSM IV (now V) criteria of the illness (Bongards 2013). Assessment of such criteria requires decision as to whether the alledged high moods and low moods constitute high and low episodes according to DSM criteria and building a picture of how the illness developed over time from the beginning of the process, thus, when the highs and lows began, and whether low moods preceded his (the polarity of the illness). However, often it is difficult for full assess-ments of patients to be carried out, because of pressures of time or other factors, including poor knowledge by clinicians.  Furthermore, bipolar disorder can exhibit many factors, such as rapid cycling and affective mixed states (Akiskal 2005, Akiskal 2005, Dilsaver 2005, Carvalho 2014, Verdolini 2014) which can worsen the prognosis of the illness. Bipolar disorder can also exhibit co-morbidities, such as those of anxiety states, Obsessive Compulsive Disorder, Borderline traits, and substance abuse (Pakpoor 2013, Darby 2011, Shashidhara 2015, Agius 2014) which, because they also worsten the prognosis of the illness, need to be adequately assessed in every patient. Thus, the full assessment of bipolar disorder is a complex issue. We have carried out audits on our own patients, and we have found that even in our practice, some issues, such as whether patients are rapid cycling or not, may not have been fully recorded in the notes (Verdolini 2014, Verdolini 2014). Therefore, to aid doctors in the assessment of bipolar disorder we have developed a series of questions which can be used as an inventory to act as an aid to the full assessment of a patient suspected of having bipolar disorder have been fully assessed and the recording of the assessment in the patient’s notes. We suggest that the inventory can be used in one of two ways; either as a list of formatted questions which can be put in the patient’s notes with the answers written beneath the questions, or as a series of audit points against which the notes can be audited. The choice of method of use is up to the individual psychiatric unit. The questions are as follows: The Cambridge-Perugia Inventory  for assessment of Bipolar Disorder Questions related to Diagnosis  Looking Back, knowing what it feels like when you are depressed, how old were you when you had your first depressive episode (treated or untreated)?  After that, did you continue having recurrent depres-sive episodes?  Looking back, when was your first Hypomanic episode?  How long do the hypomanic episodes last?  When you are high (hypomanic) do you find you do not sleep, spend a lot of money, your thoughts race, you mix a lot with people you do not know, talk quickly, hop from one thought to another, take risks, can be flirtatious?  When you are depressed do you find you comfort eat?  When you are depressed do you find you sleep a lot during the day?  When you are Depressed can you Concentrate?  When you are Depressed, can you enjoy things?  When you are depressed, how long does the de-pression last?  When you are depressed, do you get suicidal thoughts? Mark Agius & Norma Verdolini: THE CAMBRIDGE-PERUGIA INVENTORY FOR ASSESSMENT OF BIPOLAR DISORDER  Psychiatria Danubina, 2015; Vol. 27, Suppl. 1, pp 185–187    S186  When you are depressed, do you ever get severe retardation (being slowed down), paranoid, or have hallucinations?  Do you suffer from irritable bowel syndrome or colitis?  Do you suffer muscular tension?  Do you have a family history of Bipolar Disorder, depression, suicide, or psychosis?  At what time of the year is your illness worse?  Are you a very creative person?  Have anti-depressants ever caused you to go high in mood? Questions related to Mixed States and Rapid Cycling  Do you often get irritable or angry?  Does it sometimes happen that your mood changes rapidly from high to low within a day?   Do you sometimes find that you are happy and crying at the same time?  Do you sometimes find that you are depressed and very irritable at the same time?  When you are in a mixed state as we have just described, do you often find that you have marked suicidal ideation?  In one year, do you get 4 or more changes of mood; at least 2 highs and 2 lows? Questions related to Co-Morbidities  D. Do you suffer from Migraine?  P. Do you suffer with Anxiety, Panic Disorder?  P. Do you suffer from OCD symptoms?  P. Do you have ‘Borderline‘ symptoms but also have episodes of HIGH mood lasting 4 days as described above?  Do you drink alcohol to excess?  Do you use illicit drugs? A Few other Questions related to the Possibility  of Borderline Personality Disorder Co-Morbidity  Do you tend to be Impulsive?  Do you chronically feel ‘Empty’ Inside?  Are your relationships very unstable?  Do you fear being Abandoned by significant Others?  Do you chronically feel bored?  Do you tend to be very emotional?  Do you have concerns about your identity?  INTERPRETATION OF INVENTORY The reason that we prefer to propose an inventory rather than a rating scale is that the answers to the questions relate to each other, and so cannot be rated on a plus or minus or score or non score basis. Thus some answers describe how the illness develops, providing a narrative suce as ‘This person began to have recurrent episodes of depression from the age of 14 years, but then began to develop episodes of clear high mood from the age of 17‘. Other questions explain the quality of the mood changes as well as their rapidity, thus ‘This patient suffers affective mood states and rapid cycles’, others identify co-morbidities, thus ’this patient also suffers anxiety as well as OCD; she drinks important ammounts of alcohol’. Finally, regarding the issue of Bipolar Disorder and borderlne personality disorder (Agius 2014), we suggest the following rule: If there are Highs and lows (rather than ‘normal to high to low’) with the highs fitting the DSM criteria for hypomania, then the patient is Bipolar II, but may be comorbid with Borderline if the other criteria are present. The chief changes from the time that we first proposed many of these questions (Murphy 2013) has been the addition of some questions to identify any ‘borderline’ symptoms which these patients may have.  CONCLUSION We do not wish to give detailed references as to the evidence on which these questions are based. These can be found in our previous papers (Verdolini 2014, Verdolini 2014, Verdolini 2014, Agius 2014). In effect this inventory is simply a number of questions which need to be asked of all patients who are suspected of having bipolar disorder. The interpretation of the answers of these questions must depend on the interviewing clinician. Hence this is not a raiting scale but a method for fully assessing patients with suspected bipolar Disorder.  Acknowledgements: None. Conflict of interest: None to declare.  References 1. Agius M, Verdolini N: Bipolar disorder comorbid with borderline personality disorder and treatment with mood stabilisers. BMJ 2014; 349:g6798. 2. Akiskal HS, Benazzi F, Perugi G, Rihmer Z: Agitated "unipolar" depression re-conceptualized as a depressive mixed state: implications for the antidepressant-suicide controversy. J Affect Disord 2005; 85:245-58. 3. Akiskal HS, Benazzi F: Psychopathologic correlates of suicidal ideation in major depressive outpatients: is it all due to unrecognized (bipolar) depressive mixed states? Psychopathology 2005; 38:273-80. 4. Bongards EN, Zaman R, Agius M: Can we prevent under-diagnosis and misdiagnosis of bipolar affective disorder? Repeat audits to assess the epidemiological change in the caseload of a community mental health team when bipolar disorder is accurately assessed and diagnosed. Psychiatr Danub 2013; 25(Suppl 2):S129-34. 5. Carvalho AF, Dimellis D, Gonda X, Vieta E, Mclntyre RS, Fountoulakis KN: Rapid cycling in bipolar disorder: a systematic review. J Clin Psychiatry 2014; 75:e578-86. Mark Agius & Norma Verdolini: THE CAMBRIDGE-PERUGIA INVENTORY FOR ASSESSMENT OF BIPOLAR DISORDER  Psychiatria Danubina, 2015; Vol. 27, Suppl. 1, pp 185–187    S1876. Darby L, Agius M, Zaman R: Co-morbidity of bipolar affective disorder and obsessive compulsive disorder in a Bedford community psychiatry team. Psychiatr Danub 2011; 23(Suppl 1):S130-3. 7. Dilsaver SC, Benazzi F, Akiskal HS: Mixed states: the most common outpatient presentation of bipolar depressed adolescents? Psychopathology 2005; 38:268-72. 8. Murphy H, Agius M: Proving that a patient has bipolar disorder. CEPiP 2013; 3:174-180. 9. Pakpoor J, Butler S, Agius M, Zaman R: Audit of the prevalence of anxiety in bipolar disorder - a comorbidity that requires attention and action. Psychiatr Danub 2013; 25(Suppl 2):S354-7.  10. Shashidhara M, Sushma BR, Viswanath B, Math SB, Janardhan Reddy YC: Comorbid obsessive compulsive disorder in patients with bipolar-I disorder. J Affect Disord 2015; 174:367-71. 11. Verdolini N, Dean J, Elisei S, Quartesan R, Zaman R, Agius M: Bipolar disorder: The importance of clinical assessment in identifying prognostic factors - An Audit. Part 1: An analysis of potential prognostic factors. Psychiatr Danub 2014; 26(Suppl 1):289-300. 12. Verdolini N, Dean J, Elisei S, Quartesan R, Zaman R, Agius M: Bipolar disorder: The importance of clinical assessment in identifying prognostic factors - An Audit. Part 2: Mixed state features and rapid cycling. Psychiatr Danub 2014; 26(Suppl 1):301-8. 13. Verdolini N, Agius M, Quartesan R, Elisei S: Mixed States: a "new" nosographic entity. Psychiatr Danub 2014; 26(Suppl 1):103-11. Correspondence: Mark Agius, MD Clare College Camridge, Department of Psychiatry, University of Cambridge  Cambridge, UK E-mail: ma393@cam.ac.uk 

THE CAMBRIDGE-PERUGIA INVENTORY FOR ASSESSMENT OF BIPOLAR DISORDER

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