Die Diagnostik in der ICD-10 unterscheidet zwischen einer manischen Störung (Manie) , bei der nur manische Phasen auftreten und einer manisch-depressiven bzw. bipolaren Störung, bei der im Krankheitsverlauf manische und depressive Phasen auftreten.
Die „Manie“ oder „manische Störung“
In der ICD-10 werden drei Schweregrade der Manie unterschieden:
- Hypomanie (F30.0)
- Manie ohne psychotische Symptome (F30.1)
- Manie mit psychotischen Symptomen (F30.2)
- mit synthymen psychotischen Symptomen (F30.20)
- mit parathymen psychotischen Symptomen (F30.21)
Folgende Symptome sind besonders charakteristisch für die manische Störung:
- gehobene Stimmung
- Steigerung in Ausmass und Geschwindigkeit der körperlichen und psychischen Aktivität
Die diagnostischen Kennzeichen für Hypomanie und Manie in der ICD-10 lauten wie folgt:
- Für die Hypomanie (F30.0)
- anhaltende leicht gehobene Stimmung
- gesteigerter Antrieb und gesteigerte Aktivität
- gewöhnlich ein auffallendes Gefühl von Wohlbefinden und körperlicher und seelischer Leistungsfähigkeit
- gesteigerte Geselligkeit
- gesteigerte Gesprächigkeit
- übermässige Vertraulichkeit
- gesteigerte Libido
- vermindertes Schlafbedürfnis
- Beeinträchtigung der Konzentration und Aufmerksamkeit
- übertriebene Geldausgaben
Anstatt der positiven, euphorischen Veränderungen können auch Reizbarkeit, Selbstüberschätzung und flegelhaftes Verhalten vorhanden sein das Ausmass der Veränderungen ist auffällig, aber nicht so ausgeprägt, dass vollständige Arbeitsunfähigkeit oder ausgeprägte soziale Ablehnung resultiert oder grössere Verschuldungen auftreten. Eine deutliche Beeinträchtigung der Berufstätigkeit und der sozialen Aktivität sowie vermehrte Geldausgaben sind dagegen mit dieser Diagnose vereinbar. Die Dauer beträgt mindestens mehrere Tage
„Wenn eine kurze hypomanische Phase nur als Einleitung oder Nachwirkung einer Manie (F30.1 und F30.2) auftritt, soll sie nicht getrennt diagnostiziert werden.“ (ICD-10, S. 133)
- Für die Manie ohne psychotische Symptome (F30.1)
- Stimmung „situationsinadäquat“ gehoben, „kann zwischen sorgloser Heiterkeit und fast unkontrollierbarer Erregung schwanken“
- Antriebssteigerung
- Überaktivität
- Rededrang
- vermindertes Schlafbedürfnis
- Verlust üblicher sozialer Hemmungen
- erhebliche Defizite in der Aufmerksamkeit mit starker Ablenkbarkeit
- starke Selbstüberschätzung, Grössenideen und massloser Optimismus
- leichtsinniges Geldausgeben
- Aggressivität, Verliebtheit oder Scherzhaftigkeit in falschen Situationen
- Durchführung überspannter Projekte, Fehleinschätzungen
- besondere Beeindruckbarkeit durch Geräusche, Farben oder Oberflächenstrukturen, alles wird intensiver erlebt
Anstatt einer euphorischen und gehobenen Stimmung kann auch Gereiztheit und Misstrauen vorherrschen. Das Ausmass geht deutlich über das bei der Hypomanie hinaus, die berufliche und soziale Funktionstüchtigkeit wird durch die Störung mehr oder weniger vollständig unterbrochen! Die Dauer beträgt wenigstens 1 Woche
Stimmungsveränderung in Kombination mit Antriebssteigerung sind obligatorische Symptome, begleitet von mehreren der anderen genannten Symptome, meist handelt es sich um die oben fett gedruckten Symptome.
- Für die Manie mit psychotischen Symptomen (F30.2)
- Symptome wie bei der einfachen Manie plus psychotische Symptome wie (meistens) Wahnvorstellungen (Verfolgungswahn, Grössenwahn, Beziehungswahn, auch religiöser Beziehungswahn mit Sendungsbewusstsein) oder Halluzinationen Die Antriebssteigerung in Verbindung mit den psychotischen Realitätsverkennungen können zu starken Erregungszuständen führen und in Aggressivität und Gewalttätigkeit mündenOft ist eine Verständigung in der akuten manisch-psychotischen Phase sehr erschwert, was zu einer gefährlichen Steigerung der Symptomatik führen kann.
- Wenn psychotische Symptome vom Patienten kongruent zur Stimmung wahrgenommen werden (z. B. Liebeswahn bei gehobener Stimmung oder Verfogungswahn bei gereizt, misstrauischer Stimmung), dann spricht man von synthymen psychotischen Symptomen. Passen die Wahnvorstellungen dagegen nicht zum eigenen Stimmungsbild, werden sie als „fremd“ empfunden, spricht man von parathymen psychotischen Symptomen.
Differenzialdiagnose der Manie mit psychotischen Symptomen
Die schwierigste differentialdiagnostische Abgrenzung der Manie mit psychotischen Symptomen ist die gegenüber der Schizophrenie.
Die „bipolare Psychose“ (manisch-depressive Erkrankung)
Wenn bei einem Patient zeitversetzt sowohl mindestens eine depressive als auch mindestens eine manische Phase aufgetreten sind, spricht man von einer „bipolaren Störung“. Die Manie ist symptomatisch dabei das „Gegenstück“ zur Depression. Manische und depressive Symptome können sowohl als voneinander getrennte Phasen auftreten, was der typische Verlauf ist, als auch in gemischter Form vorliegen. In der ICD-10 heisst es dazu:
„Bei dieser Störung treten einmal eine gehobene Stimmung, vermehrter Antrieb und Affektivität (Manie oder Hypomanie) auf, dann wieder eine Stimmungssenkung, verminderter Antrieb und ‚Aktivität (Depression). Charakteristischerweise ist die Besserung zwischen den Episoden vollständig.“ (ICD-10, S. 135)Für die „gemischte“ Form gilt:
„Der Betreffende hatte wenigstens eine manische, hypomanische oder gemischte affektive Episode in der Anamnese und zeigt gegenwärtig entweder eine Mischung oder einen raschen Wechsel von manischen, hypomanischen und depressiven Symptomen“ (ICD-10, S. 138)
Allgemeine Kennzeichen der bipolaren Störung:
- die manischen Phasen beginnen meist abrupt
- depressive Phasen dauern im Schnitt länger (6 Monate) als die manischen Phasen (4 Monate)
- beide Geschlechter sind gleich häufig betroffen
- Episoden werden oft nach belastenden Lebensereignissen oder anderem Stress ausgelöst
- die Erkrankung kann in jedem Alter beginnen
- das Verlaufsmuster ist sehr variabel und wenig vorhersehbar
- im Alter gibt es eine Tendenz zur Verkürzung der Phasenintervalle und zur Verlängerung depressiver Phasen
In den modernen Klassifikationssystemen (ICD-10 und DSM-IV) versucht man bewusst auf theoretische Vorannahmen über die Entstehungsursachen der Manie, der bipolaren Störung oder anderer Störungsbilder zu verzichten und macht die Definition möglichst ausschliesslich an objektivierbaren, beschreibbaren und „operationalisierbaren Kriterien“ fest. Dieses Vorgehen hat grob gesagt den Vorteil, dass bei entsprechender Schulung auf die vorher festgelegten „Kriterien“ Psychiater und Therapeuten unterschiedlichster Schulen diese Kriterien wiedererkennen und dann bei der Diagnosestellung zum gleichen Ergebnis kommen. Es hat, wenn man der diagnostischen Erfahrung eines Arztes einen Wert beimessen möchte, den Nachteil, dass die diagnostizierenden Ärzte eben nicht mehr ihrer Erfahrung und ihrer Intuition vertrauen können, sondern an das Manual mit den Diagnosekriterien gebunden sind, ferner dass davon abweichende Symptommuster oder Beschwerden nicht in einer Diagnose formuliert werden können und dass die „Validierung“ des Diagnosemanuals, also die Feststellung, ob mit dem Kriteriensatz wirklich das abgebildet wird, was vorgegeben wird (z.B. eine Depression oder eine Manie) nur noch den mit der Weiterentwicklung des Manuals befassten Wissenschaftlern und Hochschullehrern vorbehalten bleibt. Pointiert und etwas provokativ formuliert: Der Arzt vor Ort wird gezielt zum „Spezialisten für die Anwendung eines vorgegebenen Diagnosemanuals“ geschult, und die Forschung läuft Gefahr, sich im Kreise zu drehen und nur noch Belege für die selbst aufgestellten Prämissen (Vorannahmen) zu produzieren! Da auf theoretische Vorannahmen über die Entstehung der Störungen verzichtet werden soll, ist man in der Bezeichnung vorsichtiger geworden. Man spricht nicht mehr von der Manie als „Krankheit„, sondern man spricht von einem „manischen Syndrom“ und von einer „manischen oder bipolaren Störung“. Die Bezeichnung „manisches Syndrom“ kennzeichnet nur noch eine Gruppe von Kern-Symptomen, die vorhanden sein muss, um die Diagnose stellen zu können. Der Begriff „Störung“ wirkt weniger wuchtig als „Krankheit“ und öffnet die Türe zu einer „störungsorientierten“ (d.h. Symptom-bezogenen) Forschung und Therapie. Philosophisch-hermeneutische Verstehens- und Forschungsansätze und psychodynamische Therapiemethoden verlieren aktuell eher an Bedeutung zugunsten einer pragmatisch ausgerichteten und am Symptom orientierten Forschung und Therapie. Dazu korrespondiert der Trend, der Behandlung mit und der weiteren Erforschung von spezifischen Medikamenten sowie den eher symptomorientierten Psychotherapieverfahren (kognitive Therapie, Verhaltenstherapie) mehr Bedeutung für die Heilung zuzuerkennen. Diese Behandlungs- und Forschungsschwerpunkte finden deshalb auch am ehesten eine begriffliche Entsprechung in den modernen Klassifikationssystemen ICD-10 und DSM-IV.
Entsprechend den ICD-10-Kriterien für die einzelne depressive bzw. manische Phase wird unterschieden:
- Bipolare affektive Störung, gegenwärtig hypomanische Episode (F31.0)
Bipolare affektive Störung, gegenwärtig manische Episode ohne psychotische Symptome (F31.1)
Bipolare affektive Störung, gegenwärtig manische Phase mit psychotischen Symptomen (F31.2)- synthyme (F31.20) oder parathyme (F31.21) psychotische Symptome
Bipolare affektive Störung, gegenwärtig leichte oder mittelgradige depressive Episode (F31.3)
- mit (F31.30) oder ohne (F31.31) somatisches Syndrom
Bipolare affektive Störung, gegenwärtig schwere depressive Episode ohne psychotische Symptome (F31.4)
Bipolare affektive Störung, gegenwärtig schwere depressive Episode mit psychotischen Symptomen (F31.5)
- synthyme (F31.20) oder parathyme (F31.21) psychotische Symptome
- Bipolare affektive Störung, gegenwärtig gemischte Episode (F31.6)
Zusätzlich gibt es (analog zu den rezidivierenden depressiven Störungen, siehe oben) auch hier die
Variante:
- Bipolare affektive Störung, gegenwärtig remittiert (F31.7)
Und für die spezielle Verlaufsform eines sehr raschen Phasenwechsels gibt es noch die Rubrik:
- Sonstige bipolare affektive Störungen (F31.8)
Dazu gehören die Begriffe
- bipolare-II-Störung
- kurzphasische bipolare Störungen (Kurzzykler)
- rapid cycler
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