Summary

Formerly known as manic depression, bipolar disorder is now the term used to describe this psychiatric condition that involves both depressive and manic episodes. There are three types:
  • Bipolar 1 disorder – there is underlying depression, interspersed with episodes of main (usually depressive and manic episodes occur in the ratio 1:1
  • Bipolar 2 disorder – the depression is more predominant, and the ratio of depressive to manic episodes is about 5:1. Manic episodes may only be slight, or precipitated by anti-depressant medication
  • Rapid cycling bipolar – a new classification, where there are >4 episodes/year of mania + depression
It is important to distinguish bipolar disorder from unipolar depression, as the treatments are different.

Epidemiology

  • Prevalence of 1-1.5%
  • Bipolar 1 more common
  • More common in women
  • Usual onset in teenage years
  • If first incidence is after 45, suspect organic cause

Aetiology

  • ↑ risk if family member has depression / bipolar
  • ↑ risk in those with a tendenacy to have rapid mood changes (cyclothymia) or unusual periods of elated feelings (hyperthymia)

Clinical Features

  • Elated mood:
    • Mania – this is an elated mood lasting 1-2 weeks (or more), with psychotic symptoms
    • Hypomania – there are no psychotic symptoms, and generally, it does not last as long. Must last >4 days to be classed as hypomania
  • Irritable mood
  • Feelings of ↑ self worth
  • Inappropriate social behaviour – may include sexual behaviour, often includes compulsive actions, such as gambling, spending lots of money
  • General increase in activity – also often includes lack of sleep – patients only feel they need a couple of hours of sleep
  • Delusions and hallucinations – often reflecting the current mood
  • Fast speech
  • Schnieder’s first rank symptoms

Diagnosis

There needs to be elated or irritable mood, with at least 3 other symptoms, in a one week period.
 

Precipitating factors

  • Lack of sleep / early morning waking (e.g. due to shift pattern work)
  • Positive life events (may precipitate mania)
  • Negative life events (may precipitate depressive episode, or depression (not bipolar))

Mental State

  • Appearance – bright coloured clothes, eccentric
  • Behaviour – over friendly, perhaps inappropriate
  • Speech – fast, and difficult to interrupt
  • Mood – elated/irritable
  • Thought – fast, sentences may be logical, but linked by puns and similar sounding words, and not by ideas, patient may be very self important and have grandiose ideas.
  • Perception – Hallucinations – usually occur with elated mood
  • Cognition – distractability – patient will start many tasks, or talk about many subject, and move on without finishing

Differentials

  • Unipolar depression (i.e. ‘normal’ depression)
  • Schizophrenia
  • Organic causes of mania:
    • Endocrine – thyroid, pituitary, adrenal
    • Neurological – MS, CVA, Epilepsy, tumour – particularly those things that affect the frontal and subcortical areas.
    • Drugs – steroids, stimulants, anti-depressives

Risk Management

Factors that increase risk:
  • Reckless behaviour
  • Aggression
  • Promiscuous sexual behaviour
  • Lack of self care
Some patients may need to be sectioned for inpatient care – particularly as during manic episodes, patients feel ‘very healthy’!

Treatment

Acute Manic Episode
  • First line – Atypical antipsychotice.g. Olanzapine, risperidone, quetiapine, Clozapine (Be weary of Agranulocytosis!)
  • Second line –try Valporate, lamotrigine (anticonvulsants), or Lithium
Depressive Episode
  • AVOID ANTIDEPRESSANTS!these can cause rapid cycling mood
  • Clozapine – atypical antipsychotic – this is useful to treat rapid cycling.
  • Consider atypical antipsychotics, anticonvulsant, and possible lithium adjunct.
  • In some cases, SSRI may be suitable, but be very careful
General Maintenance
  • First line – Lithium (mood stabiliser)
  • In cases of manic or depressive episodes, first add an atypical antipsychotic, and if response is poor, consider anticonvulsants.
There are more details about psychiatric medications in the Psychiatric medications article
General principles
Don’t change medications too soon. May take months for drugs to be effect. Psychological treatments (e.g. CBT), are not as effective as unipolar depression.

 

 

More Information

This condition used to be known as manic depression, but is now more correctly called bipolar disorder.
There are two main types of bipolar disorder, and a newly recognised further subtype:

Bipolar 1 disorder – in this there is underlying depression, interspersed with episodes of mania or ‘hypomania’

  • the manic and depressive episodes often occur in a ratio of 1:1

Bipolar 2 disorder exists when the episodes of mania are either very mild, or only occur when on antidepressant medication.

  • the depressive episodes are far more common than the mania/hypomania. They commonly occur in a ratio of about 5:1

Rapid Cycling Bipolar Disorder – this is where there are four or more episodes of mania or depression in the same year. This subtype is important, as its treatment is different from that of other types of the disorder.

It is very important to distinguish bipolar disorder from normal depression. In normal depression, mania does not occur. In all types of bipolar disorder, then it is possible for mania to occur at any time, or when under antidepressant medication.
 

Epidemiology

  • BD has a prevalence of about 1.5%
    • 1% is bipolar 1
    • 0.5% is bipolar 2
  • The condition is more common in females. In type 1, the m:f is slightly in favour of females, but in type 2, the m:f is about 1:4.
  • Peak incidence is between 15-19 years. The first onset of the disease is usually before the age of 30.
  • If the condition presents for the first time after the age of 45, then it is likely there is an organic cause.
  • The first presentation can involve any/all of the following; depression, hypomania, mania

Aetiology

  • ↑ risk (5-10% increase) for people with a first degree relative with bipolar disorder. Therefore – there is an important genetic influence. The exact genes are not really determined – it is thought that there are loads involved. One particular gene that has been identified is the COMT gene associated with rapid cycling bipolar disorder.
  • 60% of patients have a genetic history of either of the following:
    • Cyclothymia – a tendency to experience periods of increased mood/energy/enthusiasm, with intermittent periods of low mood/low energy. Kind of like ‘hypo-bipolar’ in the same way you can get ‘hypomaina’
    • Hyperthymia – like cyclothymia, but without the low mood periods
    • The tendency to experience cyclo/hyperthymia increases the patient’s risk of experiencing bipolar disorder.

Symptoms

  • Elation (even euphoria) (>2 weeks to count as a manic episode)
    • Hypomania is a state where patients have an elated mood that affects their social functioning, but does not have psychotic symptoms.
  • General increased activity – patients will often switch from one activity to another, without finishing any of them. This is sometimes known as distractability – which shows poor attention and concentration.
  • Irritable mood – this can occur between periods of elation, and may be expressed as inappropriate anger. The general mood in mania can be very variable, with periods of elation lasting anywhere between minutes and days. This variable mood is known as a Labile Mood.
  • Inappropriate behaviour / dress
  • Periods of Reckless, unplanned behaviour and inappropriate social behaviour (which may involve spending lots of money, many sexual encounters, and dangerous driving.)
  • Sleep problems – people suffering from mania often only require a few hours sleep. This can be very difficult for carers/family members, and thus the patient may require hospitalisation.
  • Heighten sense of one’s abilities / prestige. They may believe they are a rich, famous, important person.
  • Delusions and Hallucinations may occur during periods of mania, but can occur at any time. They often represent the current mood, e.g. an elated patient will have a pleasant hallucination, whilst a depressed patient may have an unpleasant hallucination.
  • Auditory hallucinations – these are usually second person – i.e. they talk to the patient.
  • Very fast speech – the patient’s thoughts are often excessively fast, and their speech may not be able to ‘keep up’. This makes them difficult to interrupt.
  • Altered perceptions – the patient may perceive colours as brighter, and sounds as louder.
  • Schneider’s First Rank symptoms (of mania) may be present, and can make a diagnosis difficult.

Particular precipitating factors

  • Life factors that lead to early morning waking – can precipitate a manic episode. This can include anything that causes early morning waking, such as working in shift patterns, or even a one off event, such as having to get up early in the morning to e.g. go on a long journey.
  • Positive life events – can also precipitate mania
  • Negative life events – can precipitate both mania depression, although depression is more likely
  • Pregnancy, CVA (or anything that affects frontal lobe or cortical structures) steroids and stimulants can aso precipitate mania
  • Thyroid disease, antidepressants, steroids, alcohol, cannabis – can all cause rapid cycling mood in patients with bipolar disorder.
Most patients with any of these factors in their life are likely to get better if the factors are addressed
Questions to ask when taking a history
  • Have you ever felt especially happy or cheerful? How long does it last? How often does it occur?
  • Do you feel you lose your temper more easily than usual?
  • Do you feel you have more energy than usual?
  • If the patient answers yes to any of these, ask about sleep patterns, restlessness, opinion of the self, libido (↑↑), spending habits.

Mental State

  • Appearance – bright coloured clothes, eccentric
  • Behaviour – over friendly, perhaps inappropriate
  • Speech – fast, and difficult to interrupt
  • Mood – elated/irritable
  • Thought – fast, sentences may be logical, but linked by puns and similar sounding words, and not by ideas, patient may be very self important and have grandiose ideas.
  • Perception – Hallucinations – usually occur with elated mood
  • Cognition – distractability
 

Diagnosis

For a diagnosis to be made, there must be elated or irritable mood, with at least 3 more of the symptoms described above, in a one week period.
Mania lasts at least 1-2 weeks, and is associated with psychotic symptoms
Hypomania lasts at least 4 days, and there are no psychotic symptoms

Psychotic symptoms:

  • Hearing voices
  • Delusions
  • Hallucinations
  • Schizophrenic-like symptoms
If a patient has mania and depression at the same time. If this goes on for longer than a week, we say it is a mixed effective episode.
Differential Diagnosis:
Symptomatic Maniathis is where the mania has an organic cause. Common causes of this are:
  • Drugs
    • Stimulants – cocaine, amphetamines, cannabis, hallucinogens (LSD)
    • Steroids
    • Antidepressants
  • Neurological Disorders
    • MS
    • Epilepsy
    • CVA
    • Brain tumour – particularly one affecting the frontal / subcortical areas.
  • Endocrine Disorders
    • Thyroid
    • Adrenal
    • Pituitary
  • You should particularly consider an organic cause when there is a known organic disorder, and the onset of depression occurs at roughly the same time as the known onset of the organic disorder.

Schizophreniamania can present with psychotic features, making it very difficult to differentiate from schizophrenia. If the symptoms of psychosis persist after the period of ‘excitement’ has passed, then the diagnosis is more likely to be schizophrenia.
Unipolar depressive disorder i.e. ‘normal depression’.

  • This may be mistaken for bipolar 2 disorder in cases where the patient expresses happiness and/or relief when their depression subsides. Other symptoms of hypomania of a decent duration must also be present to diagnose bipolar 2.
  • Depressive episodes in bipolar disorder tend to have fewer obvious precipitating factors.
  • Depression in bipolar disorder is more likely to have symptoms of psychosis and melancholy.
  • This condition is much more common than bipolar disorder!

Borderline Personality Disorder – if patients have a rapidly cycling bipolar depression, it can be very similar to the unstable mood of borderline personality disorder patients.

  • You should be able to differentiate the two by looking at the duration of symptoms. BPD is long-term, but bipolar is episodic.
Neurochemistry, Neuroimaging and Neuropathology
  • PET scan – excessive post synaptic dopamine 2 activity in mania
  • Increased serotonin and noradrenaline levels – during episodes of mania – but the evidence is not conclusive
  • Inositol phosphate – a chemical that increases the metabolism of lithium is increased in mania
  • Cortisol – in mania, there is increase cortisol release/response to stress
  • White-matter hyper-intesities- the presence of these is related to poor prognosis, increased frequency of manic episodes, and cognitive impairment

Managing Risk

Risks in mania:
  • Reckless behaviour
  • Aggression
  • Promiscuous sex (STI’s, pregnancy)
  • Lack of self care (can be a big risk e.g. in diabetes)
Patients who are particularly manic and reckless will probably have to be managed in inpatient care. These patients often feel ‘very healthy’ and so you may have a problem getting them to come into care; thus they often have to be sectioned.

Treatment

There are more details about psychiatric medications in the Psychiatric medications article
Acute Mania
  • Atypical antipsychotic – this is the first line treatment. if there is poor response, try:
  • Valporate (anticonvulsant).
    • Do not give to women of childbearing age, due to high risk of birth abnormality and can cause polycystic ovary disease.
  • Lithium (mood stabiliser, but it increases risk of extrapyramidal side effects)
Bipolar Depression
  • AVOID ANTIDEPRESSANTS! – they can cause mood cycling/episodes of mania – particularly the dual acting antidepressants.
  • Try an atypical antipsychotic – such as quetiapine or olanzapine. If this doesn’t work, try adding the anticonvulsant lamotrigine.
  • If all else fails, you can consider an SSRI – but be very careful!
Maintenance
  • Generally, you need to avoid changes in medication regimens, and assess the effectiveness of current treatments over months
  • Consider a mood diary. As the patient to rate their mood (e.g. out of 10) everyday – it is most effective when part of the bedtime routine. You can then use this to assess the patients mood over a long period – e.g. 12-18 months
  • Consider education/therapy to encourage a proper diurnal pattern.
  • Lithium – this is the first line maintenance treatment. You should add mood stabilisers until the required level of maintenance is attained.
  • Recurrent depressionadd atypical antipsychotic or lamotrigine to maintenance
  • Recurrent mania – add atypical antipsychotic or valproate to maintenance
  • Clozapine can be used in rapid cycling patients.
Psychological treatments
These are less effective than in unipolar depression. There are still some useful techniques, however. For example, patients can be taught to recognise the early warning signs of a manic episode, and then it is possible to avoid the episode completely. Similar techniques can be used for depressive episodes. It is also important to involve family (and perhaps friends), not only for support, but also because they can help recognise some of these signs.

Prognosis

  • It is very unusual for a person to only ever have one manic episode. Therefore if a patient has experienced one, they are very likely to experience others in the future:
    • 50% chance in the next year
    • 80% chance in the next 4 years

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