What is bipolar disorder?

Definition

Bipolar disorder is one of the most common mood disorders.

It is also known as “bipolar disorder” because it is characterised by episodes of mania, in which the person’s mood is elevated, and episodes of depression, in which the person’s mood is depressed.

There are two types of bipolar disorder: Bipolar I disorder, which is characterised by manic episodes with various symptoms caused by abnormally elevated mood, and Bipolar II disorder, which is characterised by hypomanic episodes with milder symptoms and relatively short duration.

Typically, major depressive episodes may occur in isolation or in combination over the course of the illness.

Findings in depressive episodes that are more suggestive of bipolar disorder than unipolar depressive disorder include Onset at a young age, acute onset, excessive sleep, failure to respond to antidepressant medication, depressive episodes with psychotic symptoms, and a history of postpartum depression should be considered for bipolar disorder rather than depressive disorder.

Causes

There is no clear cause of bipolar disorder. Research is currently being conducted in the areas of genetics, neurobiology, psychopharmacology, endocrine function, and brain imaging.

Symptoms

Mania is a mood state characterised by an elevated, exaggerated, or irritable mood.

Elevated moods can be euphoric and affect those around them, so inexperienced doctors may miss the diagnosis.

People who don’t know the patient may not notice the patient’s unusual mood, but people who know the patient well, such as family members, may notice that the patient’s mood is abnormal.

People in manic episodes may be over-planners, overconfident, and easily irritable when their ambitious plans are thwarted. Their mood is generally elevated, but they may become angry at small things and act out.

Most patients are initially euphoric and then become irritable as the disease progresses. They may engage in pathological gambling and deviant behaviour such as wearing inappropriately bright clothing or jewellery in public.

They may have impulse control problems that cause them to harm themselves or others, and they may become overly preoccupied with religious, political, economic, sexual, and harmful ideas, which may develop into complex delusions.

Symptoms of manic episodes may include behaviours that undermine the person’s credibility, such as lying, and a lack of good judgement, which can lead to a variety of professional and social problems, including financial problems.

When speaking, the person’s voice is loud and they interrupt others to the point where normal communication is difficult. An abnormal flow of thought that makes it difficult to understand what is being said.

Hallucinations may occur. The person is usually excited, talkative and hyperactive, and if the behavioural problems become severe enough, they may require compulsory hospitalisation as there is little pathology to their illness.

In the depressive episode, the person may complain of depressed mood, anxiety, agitation, helplessness, and hopelessness. The person feels pessimistic about the future and worries a lot.

You feel unconfident in yourself and feel as if you can’t do anything because the things you’ve done before seem difficult. You feel like you are worthless and have thoughts of suicide. You may also experience paranoid thoughts that people around you are laughing at you or making fun of you, which can become paranoid if it becomes severe.

Thinking slows down, and comprehension and judgement decrease. Difficulty concentrating when reading, not remembering what they’ve read before and having to reread and reread again, not understanding what they’ve read, and not being able to concentrate on conversations.

Decreased interest in the outside world and lack of interest in anything. Depersonalisation (feeling that you are not yourself) and derealisation (feeling that your surroundings are not the same as before) are also common.

They have no energy, feel tired all the time, and have a feeling of being overwhelmed. Many patients do not feel or report depressed mood, but only autonomic nervous system symptoms or physical symptoms such as headaches, indigestion, and muscle pain. Sleep and appetite may decrease or increase.

Mania in adolescence is often misdiagnosed as conduct disorder or schizophrenia. Symptoms include psychosis, abuse of alcohol or other substances, suicide attempts, academic problems, preoccupation with philosophical topics, obsessive-compulsive symptoms, various physical symptoms, marked irritability, fighting, and other antisocial behaviours.

Many of these symptoms may be present in normal adolescents, but if they are severe or persistent, bipolar disorder should be considered in the differential diagnosis.

Diagnosis/Testing

A diagnosis of bipolar disorder is made through an examination by a psychiatrist, a medical history, and a question and answer process.

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the diagnostic criteria for a manic episode are as follows

A. There are distinct periods of unusually excited, euphoric, or irritable mood and increased activity and energy that last for at least 4 consecutive days, almost every day, and for most of the day.

B. During the period of mood disturbance and increased energy and activity, you have three (or more) of the following symptoms (four if your mood is only irritable), and the change from your usual self is marked and severe.

1) Increased or exaggerated self-esteem

2) A decreased need for sleep (e.g., feeling like just three hours of sleep is enough)

3) Talking more than usual or talking so much that it’s hard to stop

4) Subjective experience of leaps in thinking or a feeling that thoughts are racing and biting their tails at a high rate of speed

5) Subjectively reported or objectively observed distractibility (e.g., being too easily distracted by unimportant or irrelevant external stimuli)

6) Increased goal-directed activity (social or sexual activity at work or school) or psychomotor agitation (e.g., fidgeting without purpose or goal)

7) Over-indulgence in activities that are likely to have distressing consequences (e.g., overspending, such as excessive shopping, reckless sexual behaviour, foolish business investments).

C. The illustration is accompanied by changes in functioning that are distinctly different from those characteristic of individuals without symptoms.

D. Mood disturbances and changes in functioning can be objectively observed.

E. The illustration is not severe enough to cause significant impairment of social or occupational functioning or to require hospitalisation. If there is a psychotic aspect, it is by definition a manic episode.

F. The symptoms are not due to the physiological effects of a substance (e.g., a drug of abuse, therapeutic medication, or other treatment).

Note: A hypomanic episode that occurs during treatment for depression (e.g., medication, electroconvulsive therapy) may be diagnostic of a hypomanic episode if the hypomanic symptoms persist beyond the period when the direct physiological effects of the treatment can be seen. However, caution must be exercised in diagnosis, and one or two symptoms (increased irritability, anxiety, or agitation following the use of antidepressants) are not sufficient to diagnose a hypomanic episode, and the same is true for bipolar tendencies.

Note: Diagnostic criteria A through F constitute an illustration of hypomania. Although hypomanic episodes are common in bipolar disorder, they are not required for a diagnosis of bipolar disorder.

The diagnostic criteria for major depressive episode are the same as for major depressive disorder.

There are two types of bipolar disorder: Bipolar I disorder, which is characterised by manic episodes of abnormally elevated mood and a range of symptoms, and Bipolar II disorder, which is characterised by hypomanic episodes, which are milder and shorter in duration than manic episodes.

Bipolar disorder, rather than depressive disorder, should be considered in the following cases: onset at a young age, acute onset, excessive sleep, failure to respond to antidepressant medication, depressive episodes with psychotic symptoms, and a history of postpartum depression.

Treatment

The primary and most important treatment for bipolar disorder is medication. It is important to develop a comprehensive treatment plan that incorporates a psychotherapeutic approach around medication.

Since the traditional treatment, lithium, a variety of medications have been developed and used in clinical practice with good overall results. Mood stabilisers as well as antipsychotics are used, and depending on the individual, combination therapy with antidepressants may be required.

Inpatient treatment may be required if the symptoms are dangerous to self or others, if rapid medication adjustment is required, if there are serious internal medical problems such as adverse drug reactions, and if an accurate differential diagnosis is desired.

Progression/Complications

Bipolar disorder tends to have a recurrent course of improvement and relapse, and the prognosis for bipolar disorder is thought to be poorer than for depressive disorder. However, recent advances in treatment have led to significant improvements with accurate diagnosis and treatment. In the case of recurrent episodes, it is important to continue medication to prevent relapse.

In 70% of cases, bipolar disorder begins with depression. Most people experience both depressive and manic episodes, but 10-20% experience only manic episodes. The average manic episode lasts 5-10 weeks, depressive episodes last 19 weeks, and mixed episodes last 36 weeks, but there is a lot of individual variation.

Prevention

There is no known way to prevent bipolar disorder.

Diet and lifestyle

Alcohol and illicit drugs should be avoided as they can make moods more unstable. Lifestyle habits such as regular sleep, eating, and adequate exercise can help control symptoms.

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