Bipolar Disorder

last authored: Aug 2013, David LaPierre

 

Introduction

Bipolar disorder is a psychiatric condition in which patients experience disruptions in mood extremes. People with bipolar disorder can live healthy, productive lives if their condition is under control, though when moods are very elevated or depressed, function can be significantly impaired and result in profound negative consequences, including death.

 

Bipolar I disorder is a condition characterized by at least one manic or mixed episode (see definitions below); at least one major depressive episode is common but not required.

 

Bipolar II disorder is a condition characterized by at least one hypomanic and at least one major depressive episode.

 

Cyclothymia is characterized by hypomanic and depressive symptoms that do not meet criteria for bipolar II disorder; no major depressive episodes

 

Bipolar disorder may also be diagnosed

BD is now occurring more often and earlier globally, with potiential causes including increased rates of assessment and diagnosis, to the destabilizing world we live in, or possibly due to the evolving human mind.

 

The World Health Organization has identified bipolar disorder as the 12th most common moderately to severely disabling condition globally (WHO, 2004), and in the United States, bipolar has a lifetime prevalence of 4% (Merikangas et al, 2007).

 

The most common age of onset is 15-25 years. Over 90% of those with manic episodes have future episodes.

 

Common comorbidities include anxiety disorders, substance use disorders, and attention deficit/hyperactivity disorders; the presence of these can significantly worsen function. Even alone, bipolar disorder can be a devestating condition, and suicide rates are 20 times the healthy population. One-third of patients with bipolar disorder attempt suicide (Cassidy, 2011).

 

 

 

 

 

The Case of Fred R

Fred R is a 26 year-old man who is brought to the emergency department by his wife, who is very concerned by his behaviour.

Fraternal Twins by Robert King

Over the past 10 days he has largely stopped sleeping and has staying awake studying books on 'beating the system'. He spends at least 5 hours daily at the casino and has lost thousands of dollars.

 

Questions:

What questions do you ask Fred?

What tests do you order in assessing him?

 

 

 

 

 

 

 

 

Causes and Risk Factors

In children at highest risk (those with bipolar parents), initial manifestations appear to begin even before puberty. These include anxiety, sleep disturbance, leanring disorders, ADHD, and cluster A traits.

**It would be good to have a diagram here outlining progression from childhood to mania.**

**Three subtypes of BD include typical BD (manic depression), psychosis spectrum, and character disorder**

 

 

Triggers

At first, stressors usually precede episodes, acting as triggers. It is thought that kindling occurs over time, with no triggers required as the illness progresses. Triggers include:

 

Genetic Influence

Family history is the strongest risk factor, with a 4-15% risk in children with bipolar parents (Barnett and Smoller, 2009). This appears to be linked to both genetics and environmental influences, including a stressful upbringing, suicide in a family member, disruptions in sleep, and high expressed emotion in family members or caregivers (Proudfoot et al, 2011).

 

Manifestations in children are affected by the nature of the condition in adults, including variables such as:

No specific genes identified conclusively; likely oligogenic trait, with additive effects. Synaptic proteins may be important.

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Signs, Symptoms and Diagnosis

 

 

 

 

Primary care providers, especially family physicians and emergency room physicians, are often the first point of contact for patients with mania or hypomania. Once suspicion is raised and referral to psychiatry is made, adequate time should be given to sufficiently understanding the details of signs and symptoms, past and present.

 

 

  • history
  • screening
  • defining episodes
  • psychological testing
  • lab testing

History

While not diagnostic, the following symptoms should raise heightened concern regarding bipolar:

 

Symptoms

Racing thoughts interfering with sleep

Irritability, impulsivity, irrationality

Extreme mood swings (changes from low to high)

Times of signficiant goal setting

Reduced need for sleep for a few days without feeling tired

Sleep disruptions (e.g., shift work; childcare; travel; time change; change in season, especially spring and fall) that trigger a manic or hypomanic event

Atypical depression: labile mood, increased sleep, hypersomnia, increased appetite, psychotic features

Age of onset

 

Medical history

Prior episodes of depression, especially with early onset (age 13 years or younger) or seasonal variability

Prior episodes of mania or hypomania

No response to three or more antidepressant trials

Intolerance of an antidepressant, steroid, or other medication, especially if it caused agitation or mania

Cardiovascular and other co-morbidities

 

Family history

Drug and/or substance abuse

Bipolar disorder

Depression, anxiety, or attention-deficit/hyperactivity disorder, or psychotic disorders

Hospitalizations

Suicide

Jail

 

Social History

Multiple divorces

Legal or financial problems

Attempted suicide

Drug or alcohol abuse

Recurrent job loss

 

 

As the interview unfolds, consider:

  • patient's expectations
  • collateral, including family and past medical records
  • collective plan of assessment
  • daily ratings of mood, anxiety, energy, and sleep

Screening

 

 

The Patient Health Questionnaire (PHQ) can be used as a screening tool for depression.

The Mood Disorder Questionnaire can be used to screen for bipolar, though is not sufficient for diagnosis.

 

A manic episode is a period of abnormally elevated, expansive, or irritable mood lasting at least one week or requiring hospitalization. It is severe enough to cause marked impairment in occupational functioning or in relationships with others, or includes psychotic features.

 

A hypomanic episode is a period of abnormally elevated, expansive, or irritable mood lasting at least four days. Change in function is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization.

 

Both manic and hypomanic episodes require the presence, to a significant degree, of at least three of the following symptoms:

memory aide: DIGFAST

  • Distractibility
  • Indiscretion: pleasurable activities with painful consequences
  • Grandiosity or inflated self-esteem
  • Flight of ideas
  • Activity increased, with goal-directed impulsivity or psychomotor agitation
  • Sleep
  • Talkativeness

Rapid Cycling occurs when four or more episodes per year are present. It occurs in up to 15-20% patients, and is associated with females, antidepressants, middle age, mental retardation, hypothyroidism. Treat with thyroid medication, regardless of lab tests.

Psychological Testing

 

MMPI?

Lab Testing

 

Rule out medical conditions through the following tests:

  • TSH hyperthyroidism
  • CBC anemia
  • estrogen, progesterone, and prolactin in women
  • vitamins: B12, vitamin D, folic acid

Blood levels of any current mood stabilizing medications.

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Differential Diagnosis

Between 40-70% of patients with bipolar disorders are initially misdiagnosed (ref).

 

 

Drug abuse and withdrawal

Diseases

Vitamin deficiency

Medications

 

 

 

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Treatments

 

Immediate Stabilization

Assess safety/functioning and establish treatment settings.

Discontinue antidepressants, caffeine, alcohol,and illicit substances.

Rule out medical causes, including delerium, etc.

 

 

Medical management

First-line mood stabilizers include lithium, valproic acid, lamotrigine, olanzepine, or quetiapine.

Some clinicians beleieve multiple drugs should be added together until therapeutic benefit is reached; others believe rational selection and optimization are the best way to proceed. The fact that some patients respond excellently to one drug but not others suggests patient profiles can be helpful in determining initial medication.

Lithium

  • clear episodic episodes, with absence of symptoms between
  • more dysphoria than MDD (CHECK THIS)
  • normal childhood recollection

Atypical antipsychotics

  • onset of continuing symptoms before age 12
  • frequent or exclusive activated/manic episodes
  • psychotic episodes
  • negative symptoms
  • raid cycling

Lamotrigine

  • anxiety
  • substance abuse
  • poor childhood recollection

 

First: mood stabilizer (for life)

Benzodiazepines

 

If this treatment fails, check adherence, optimize, then try another first line agent.

Treatment of depression (ie with antidepressants) must be done very cautiously to avoid switching to mania.

ECT can also be used.

 

Lithium is safest during pregnancy, though carries a slight risk of Epstein's cardiac malformation.

 

Psychosocial support

It is important to discuss triggers with people who have suffered manic or hypomanic episodes. Responsible use of alcohol and drugs, including caffeine needs to be discussed, as does sleep hygience

Psychotherapy can include cognitive behavioural therapy. Behavioural strategies/rhythms and psychoeducation are very useful.

Quitting drugs and alcohol, which can be powerful triggers, is important to consider.

Occupational training/leave from school/work; , substitute decision maker for finances,

Sleep hygeine, social skills training.

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Course and Prognosis

It can be very difficult to predict course of illness, and the untreated course is extremely variable.

The duration of an episode is usually 1-6 months, and the median number of episodes is 9.

 

Good prognosis: short episodes, good quality of remission, advanced age of onset, good premorbid functioning

Over time, cycles may shorten

variability of intervals between epidodes is small in people but can be large among individuals. Some people have their own rhythm and follow distinct patterns

Patients with BD have increased mortality primarily due to suicide. Other increased risks of death include accidents and respiratory disease.

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Additional Resources

Touched with Fire

 

 

Barnett JH, Smoller JW. 2009. The genetics of bipolar disorder. Neuroscience. 164(1):331–343.

 

Cassidy F. 2011. Risk factors of attempted suicide in bipolar disorder. Suicide Life Threat Behav. 41(1):6–11.

 

Merikangas KR et al. 2007. Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication. Arch Gen Psychiatry. 64(5):543–552.

 

Proudfoot J, Doran J, Manicavasagar V, Parker G. 2010. The precipitants of manic/hypomanic episodes in the context of bipolar disorder: a review. J Affect Disord. 133(3): 381-387.

 

World Health Organization. The global burden of disease: 2004 update. Part 3: disease incidence, prevalence and disability.

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