Site icon almostadoctor

Biploar Disorder

Psychiatry

Psychiatry

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:

It is important to distinguish bipolar disorder from unipolar depression, as the treatments are different. In 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

In my personal experience, many cases of bipolar which present with a depressive episode are typically diagnosed and treated as depression, and it may not be truly diagnosed as bipolar disorder for many years – Dr Tom Leach

Aetiology

Factors than can precipitate an event include:

  • 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.
Patients with any of these factors in their life are likely to have improvement in symptoms if the factors are addressed

Clinical Features

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

The diagnosis is typically based on the manic episodes. DSM-V critter for mania include:
 

Differential diagnosis

Risk Management

Factors that increase risk:
Some patients may need to be sectioned for inpatient care – particularly as during manic episodes, patients feel ‘very healthy’!

Investigations

There are no diagnostic tests for bipolar disorder – the diagnosis is clinical. However investigations are typically used to rule out an organic cause at the first presentation. These might include:

Blood tests

Neurochemistry, Neuroimaging and Neuropathology

Management

Acute Manic Episode
Depressive Episode
General Maintenance

Try to avoid acute 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.
  • First line – Lithium (mood stabiliser)
  • In cases of manic or depressive episodes, first add an atypical antipsychotic, and if response is poor, consider anticonvulsants.
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.
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.

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

References

Read more about our sources

Related Articles

Exit mobile version