Bipolar Disorder

Bipolar disorder, also known as manic-depressive illness, is a severe mental illness that is characterized by episodes of depression and mania.

There are four types of bipolar disorder, all of which involve changes in mood, energy and activity levels. The moods in bipolar disorder can vary from “extremely up” to “very down”.

These periods of “extremely up” moods are referred to as manic episodes, which are characterized by excited and energized behaviour. Less severe manic episodes are also known as hypomanic phases.

The “very down” mood is referred to as depressive episodes, which are characterized by feelings of sadness and hopelessness.

Types of bipolar disorder include:

1. Bipolar I disorder: Characterized by a manic or mixed episode with or without psychosis and/ or major depression.
2. Bipolar II disorder: Characterized by a hypomanic episode with major depression, but no history of manic or mixed episodes
3. Cyclothymia: Includes hypomanic and depressive symptoms that do not meet the diagnostic criteria for bipolar II disorder. There are no major depressive episodes.
4. Bipolar disorder not otherwise specified: Does not meet diagnostic criteria for major depression, bipolar I disorder, bipolar II disorder, or cyclothymia.

The World Health Organization (WHO) has placed bipolar disorders collectively as the 12^th most common moderately to severely disabling condition in the world for people of any age group (in 2004).

About 4% of people in the United States experience this disorder in their lifetime. Bipolar disorder can occur at any age, although it is more common in people younger than 25 years. It can affect any race, sex, or ethnic group.

Pathophysiology

Researchers have yet to determine the pathophysiology of bipolar disorder. However, they have found that bipolar disorder may be inherited.

Children of parents who have bipolar disorders have a 4-15% greater risk of developing this disorder compared to children with parents without bipolar disorder, who have a 0-2% risk.

Environmental factors such as stressful life events, disrupted sleep cycle, family members or caregivers with highly expressed emotions have a strong association with inheritance.

New data have shown the involvement of several genes associated with bipolar disorder.

Symptoms

Patients with bipolar disorder often show intense emotions, changes in sleep patterns and activity levels, and unusual behaviours. The symptoms of bipolar disorder can be categorized under the manic episodes or depressive episodes.

Manic Episode Symptoms:

• Very excited, elated, very “up” or “high”
• Very energized
• High activity levels
• Feeling “jumpy or “weird”
• Trouble sleeping
• Becoming more active than normal
• Talking really fast about a number of different things
• Feeling agitated, irritable, or “touchy”
• Racing thoughts
• Thinking they can do a lot of things at once
• Doing risky things, like spending a lot of money or having reckless sex

Depressive Episode Symptoms:

• Sadness, emptiness or hopelessness, feeling very “down”
• Very little energy
• Decreased levels of activity
• Trouble sleeping – they may sleep too much or too little
• Feeling like they can’t enjoy anything
• Feeling worried and empty
• Trouble concentrating
• Forgetting things often
• Eating too much or too little
• Feeling tired or “slowed down”
• Having thoughts about death or suicide

Symptoms may also include:

• A reduced need for sleep for a few days without getting tired
• Sleep disturbances which trigger a hypomanic event
• Depression
• Psychosis
• An excessive feeling of worthlessness or guilt
• Racing thoughts that prevent the patient from falling asleep
• Irritation, impulsivity and irrationality in behaviour
• Mood swings

Mixed Episode Symptoms:

Sometimes a mood episode can include both depressive and manic symptoms. This is known as the mixed episode. Patients who experience a mixed episode may have feelings of sadness, emptiness or hopelessness, while at the same time have feelings of being extremely energized.

Bipolar disorder can also be present in less extreme mood swings. People with hypomanic episode may feel good, productive and well-functioning. The patient may not feel anything wrong but family and friends can recognize the changes in mood or activity levels. Lack of proper treatment of patients with hypomania can lead them to develop severe mania or depression.

Diagnosis

Proper diagnosis is necessary before treating a patient with bipolar disorder. To diagnose bipolar disorder, healthcare providers may conduct a mental exam as well as assess the individual’s appearance, mood, thoughts, and perception. They will also look into suicidal or self-destruction behaviour, violence, aggression, cognition (understanding, intellect, and awareness), judgment and physical health.

Although the diagnosis of bipolar disorder can be done based on the patient’s history and clinical course, some laboratory tests may be necessary to rule out other potential causes behind the patient’s signs and symptoms as well as to have measurements before giving certain medications.

These tests may include:

• Basic metabolism and electrolyte levels: Helps to measure baseline sodium level and renal function in patients taking antipsychotics, antidepressants, anticonvulsants, and lithium.
• Complete blood count: Helps to exclude the possibility of pernicious anemia and establish baseline measurements in patients taking anticonvulsants.
• Complete physical and neurological examination: Helps to exclude any systemic illness, measure body mass index (BMI), blood pressure, waist circumference which are monitored in the treatment of bipolar disorders.
• Electrocardiography: Helps to establish baseline measurements in patients taking antipsychotics, lithium, or other medications like carbamazepine
• Fasting glucose levels and lipid profile: Excludes the presence of diseases such as diabetes mellitus, high lipid levels (hyperlipidemia) and Cushing syndrome and establish baseline measurements in patients taking any medication that can lead to weight gain or high glucose levels.
• Liver function tests: Help exclude hepatitis and establish baseline measurements in patients taking anticonvulsants and antipsychotics.
• Thyroid hormone levels: Helps to exclude the presence of primary or secondary thyroid disorders and establish baseline measurements in patients taking lithium.
• Substance and alcohol screening: Helps to exclude thought and mood disorders due to substance abuse.
• Electroencephalography: Rules out the presence of seizure disorder, or other causes behind psychosis.

Depending on the patient’s condition, other tests such as HIV testing, urine toxicology, test for heavy metals, magnetic resonance imaging (MRI) may be indicated.

Treatments

The treatment for bipolar disorder patients is directly associated with the phase of the episode (depressive or manic), and the severity of that phase. The treatment may involve medications and psychotherapy.

Medications for bipolar disorder include:

• Antipsychotic drugs such as Aripiprazole, Quetiapine, Olanzapine, Clozapine, Haloperidol
• Benzodiazepines such as clonazepam, lorazepam to reduce acute agitation
• Anticonvulsants such as carbamazepine, valproate sodium, lamotrigine
• Anti-manic agents such as lithium

Psychotherapy is usually done in combination with the medications and can be effective to provide support, education, guidance to patients with bipolar disorders and their families. Psychotherapy helps to reduce the relapse rates, improve the quality of life and increase the functioning in bipolar disorder patients.

Some of the psychotherapies for treating patients with bipolar disorder are:

• Cognitive Behavioral Therapy (CBT)
• Family-focused therapy
• Interpersonal and social rhythm therapy
• Psychoeducation

Prevention

Psychological stress is known to be the main trigger behind the depressive and manic symptoms of bipolar disorder. It is believed that patients who get social and family support in recognizing the early warning signs are at a lesser risk of recurrence and hospitalization and have better functioning. Psychotherapy is an important form of treatment to prevent relapse and provide patients with longer periods of relative wellness.

References:

1. National Institute of Mental Health. Bipolar Disorder. https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
2. Stephen Soreff, MD. Bipolar Disorder. https://emedicine.medscape.com/article/286342-overview
3. Price AL, Marzani-Nissen GR. Bipolar disorders: a review. Am Fam Physician. 2012 Mar 1;85(5):483-93.