related disorders
 
 
 
Bipolar Affective Disorder
 
 
Introduction
 
Bipolar Affective Disorder, also known as Manic-depressive Disorder, is distinguished from unipolar mood disorder (depression).  It affects 1% of the general population in any given year.
 
The risk is higher for those who have a positive family history.  The risk for people with a sibling who has the disorder is increased by 10-20%.  Socioeconomic status has no bearing on our risk of developing the disease.
 
 
Subtypes
 
Bipolar Affective Disorder is also divided into Bipolar Disorder I (at least one episode of mania and one episode of major depression) and Bipolar Disorder II, where sufferers only experience what is referred to as hypomania and major depression.
 
 
Relationship to Schizophrenia
 
Bipolar Disorder is included in the list of related disorders because people who suffer from this disorder may experience all of the same symptom as people with Schizophrenia at some time during the course of their illness.  
 
The difference is that they experience predominant symptoms of disturbed mood.  The disturbance in mood may be related to the quality of mood (in the case of mania, depression or mixed episodes), or be related to the stability of mood (in the case of rapid cycling mood states).  Rapid cycling Bipolar Disorder requires more than four significant mood changes in one year.
 
 
Onset
 
This disease typically emerges in adolescence or early adulthood (age 15 to 24), but may begin in childhood.  The vast majority of cases are diagnosed by age 30.
 
 
Course
 
The course is quite variable.
 
 
Causes
 
The exact cause for Bipolar Affective Disorder is unknown, but a variety of biologic, genetic and environmental factors appear to be involved in the development of this disease.  It appears that there are several genes that influence whether or not we may develop this disease.  Environmental factors include trauma and stress, particularly in childhood.  Antidepressants, substance abuse, including caffeine, and sleep deprivation may trigger manic episodes.
 
 
Symptoms
 
Symptoms can be considered based upon three categories:
 
  1. depressive symptoms  
  2. manic symptoms  
  3. the cyclic nature of these mood states
 
Symptoms of depression include:
 
  1. sad or unhappy mood  
  2. sleep disturbance, including problems with the onset of sleep, or getting to sleep (initial insomnia), staying asleep (interval insomnia), or waking up early (terminal insomnia)
  3. appetite increase, or more commonly, decreased appetite
  4. a negative perspective (pessimism) or hopelessness  
  5. reduced libido (sex drive)  
  6. lack of interest or ability to experience pleasure (anhedonia)  
  7. poor concentration or memory
  8. morbid thoughts or thoughts of death or suicide (active or passive suicidal ideation)
 
Manic symptoms include:
 
  1. elevated or expansive mood states, including euphoria or irritability  
  2. increased energy and activity levels  
  3. pressured or pushed, fast paced, speech  
  4. inflated self esteem which may involve grandiose delusions  
  5. hallucinations
  6. a diminished need for sleep
  7. an increased appetite for food or sex
  8. excesses that include spending money, starting a variety of projects or substance use  
  9. acting impulsively
  10. exhibitionism
 
These groups of symptoms alternate with one another in cycles or may overlap (in the case of mixed states, where people with this disorder experience symptoms of both depression and mania).  Mood cycles may occur during intervals of days, weeks or months.  
 
Some people experience predominantly one type of symptom that recurs over long periods.  If these exclusively involve depressive symptoms, patients may eroneously receive the diagnosis of Recurrent Major Depression.  Treatment efforts may be less than satisfactory, as the patient my require mood stabilizing agents in addition to antidepressants to achieve optimal recovery.
 
Some people experience long periods of normal mood between episodes, while other are plagued with some degree of disturbed mood continuously.
 
 
Diagnosis
 
Diagnosis is made by a clinician with knowledge of psychiatric disorders and is based upon a complete medical and psychiatric history and Mental Status Examination.  A comprehensive evaluation should include a physical examination to rule out medical illnesses that may be responsible for the symptoms.  Substance abuse, particularly stimulant (cocaine or amphetamine) intoxication, should be ruled out.
 
 
DSM-IV1 Diagnostic Criteria
 
The essential feature of Bipolar I Disorder is a clinical course that is characterized by the occurrence of one or more Manic Episodes or Mixed Episodes.  Often individuals have also had one or more Major Depressive Episodes.
 
Episodes of Substance-Induced Mood Disorder (due to the direct effects of a medication, other somatic treatments for depression, a drug of abuse, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Bipolar I Disorder. In addition, the episodes are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
 
Bipolar I Disorder is subclassified in the fourth digit of the code according to whether the individual is experiencing a first episode (i.e., Single Manic Episode) or whether the disorder is recurrent. Recurrence is indicated by either a shift in the polarity of the episode or an interval between episodes of at least 2 months without manic symptoms. A shift in polarity is defined as a clinical course in which a Major Depressive Episode evolves into a Manic Episode or a Mixed Episode or in which a Manic Episode or a Mixed Episode evolves into a Major Depressive Episode.
 
In contrast, a Hypomanic Episode that evolves into a Manic Episode or a Mixed Episode, or a Manic Episode that evolves into a Mixed Episode (or vice Versa), is considered to be only a single episode.
 
For recurrent Bipolar I Disorders, the nature of the current (or most recent) episode can be specified (Most Recent Episode Hypomanic, Most Recent Episode Manic, Most Recent Episode Mixed, Most Recent Episode Depressed, Most Recent Episode Unspecified).
 
 
Manic Episode
 
A.  A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
 
B.  During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
 
  1. inflated self-esteem or grandiosity
  2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
  3. more talkative than usual or pressure to keep talking
  4. flight of ideas or subjective experience that thoughts are racing
  5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
  6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
  7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
 
C.  The symptoms do not meet the criteria for a Mixed Episode.
 
D.  The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
 
E.  The symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication or other treatment) or a general medical condition (e.g., hyperthyroidism).
Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.
 
 
Mixed Episode
 
A.  The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.
 
B.  The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
 
C.  The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

NOTE: Mixed-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.
 
 
Hypomanic Episode
 
A.  A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.
 
B.  During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
 
  1. inflated self-esteem or grandiosity
  2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
  3. more talkative than usual or pressure to keep talking
  4. flight of ideas or subjective experience that thoughts are racing
  5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
  6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
  7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
 
C.  The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
 
D.  The disturbance in mood and the change in functioning are observable by others.
 
E.  The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
 
F.  The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

NOTE: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II Disorder.
 
 
Major Depressive Episode
 
A.  Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.
 
  1. depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
  2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation mad by others)
  3. significant weight loss when not dieting or weight gain (e.g. a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
  4. insomnia or hypersomnia nearly every day
  5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
  6. fatigue or loss of energy nearly every day
  7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
  8. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
  9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
  10. The symptoms do not meet criteria for a Mixed Episode.
 
B.  The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
 
C.  The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g. hypothyroidism)
 
D.  The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for long than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
 
 
Specifiers
 
The following specifiers for Bipolar I Disorder can be used to describe the current Manic, Mixed, or Major Depressive Episode (or, if criteria are not currently met for a Manic, Mixed, or Major Depressive Episode, the recent Manic, Mixed, or Major Depressive Episode):
        
  1. Mild
  2. Moderate
  3. Severe Without Psychotic Features
  4. Severe With Psychotic Features
  5. In Partial Remission
  6. In Full Remission
  7. With Catatonic Features
  8. With Postpartum Onset
 
The following specifiers apply only to the current (or most recent) Major Depressive Episode only if it is the most recent type of mood episode:
          
  1. Chronic
  2. With Melancholic Features
  3. With Atypical Features
         
The following specifiers can be used to indicate the pattern of episodes:
           
  1. Longitudinal Course Specifiers (With or Without Full Interepisode Recovery
  2. With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes
  3. With Rapid Cycling
 
 
Treatments
 
There is no cure for this disorder.  Treatment may consist of outpatient follow-up or inpatient care.  Treatment is aimed at identifying and avoiding whatever may trigger episodes and at controlling symptoms.  Psychotherapy can be helpful, but the mainstay of treatment involves the use of medications.
 
They include mood stabilizing agents, such as lithium and a variety of anticonvulsants:
 
  1. carbamazapine (Tegretal)
  2. oxcarbazapine (Trileptal)
  3. valproate (Depakote)
  4. lamotrigine (Lamictal)
 
Lithium is the only agent known to decrease the rate of suicide.
 
Antidepressants and antipsychotic agents are often employed.
 
Many people with this disorder lead essentially normal lives with appropriate treatment.
 
 
Suicide
 
Approximately 15% of people with this disorder commit suicide.
 
1The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition APA (American Psychiatric Association)
 
 
(Sources: The author’s knowledge base, unless otherwise noted.)
______________________________________________________________________
 
Related Articles:
 
Related Disorders
 
Personality Disorders
 
Paranoid Personality Disorder
 
Schizoid Personality Disorder
 
Schizotypal Personality Disorder
 
Delusional Disorder
 
Schizophreniform Disorder
 
Schizoaffective Disorder
______________________________________________________________________