Armando Hasudungan
Biology and Medicine videos

Bipolar Disorder

DSM V categorise these as seperate disorders

  • Depressive disorders
  • Bipolar disorders
  • Anxiety disorders

Overview

Overview Bipolar disorder, previously termed manic depression, is a psychiatric diagnosis characterised by abnormally elevated or irritable mood episode(s) accompanied by disruptive symptoms of distractibility, indiscretions, grandiosity, flight of ideas, hyperactivity, decreased need for sleep, and talkativeness. It is well known that bipolar disorder carries with it high mortality and morbidity rates. The lifetime risk for suicide for people with bipolar disorder is 15%. Early recognition and treatment of bipolar disorders improve outcomes

Definition
Bipolar disorder type I: A syndrome with complete manic symptoms occurring during the course of the disorder.
Bipolar disorder type II: Hypomania, characterized by depression and episodes of mania that do not meet the full criteria for manic syndrome.
Hypomonia: Symptoms are similar to those of mania, although they do not reach the same level of severity or cause the same degree of social impairment.
Rapid-cycling bipolar disorder: Occurrence of at least four episodes— both retarded depression and hypomania/mania—in a year.
Labile: A mood and/or affect that switches rapidly from one extreme to another. For example, a patient can be laughing and euphoric one minute, followed by a display of intense anger and then extreme sadness in the following minutes of an interview.

Psychiatric History

Interview

History

  • History of presenting Illness
  • Medical history – Psychiatric as well
    • Admissions
  • Medication history
  • Drug and Alcohol
  • Forensic History
  • Social History
    • Relationship
    • Work
  • Developmental history
  • MSE

Mini State Examination (MSE) Findings in Bipolar (Mania episode)
Appearence and Behaviour Brightly coloured clothes, overactive, restless, overfriedly, increased appetitie, increased sexual desire, may be dishevelled
Speech Pressure of speech, rapid and copious
Mood and affect Elated mood, cheerful and optimistic, euhphoria, may be iritable/hostile
Thought form and though content Flight of ideas, imparied judgement, expansive ideas, extravaganat, grandiose delusions, persecutory delusions
Cognition ↓concentration and attention, easily distractable
Insight Invariably impaired, sees no reason why their grandiosity should be restrained
Perception Hallucinations (auditory), consistent with mood (eg. people talking about his special power)

 

Mini State Examination (MSE) Findings in Bipolar (Depressive episode)
Appearence and Behaviour Desheveled, furrowing of brows, ↓rate of blinking, shoulder bent, head down, ↓gesture, ↓eye contant
Speech Slow, long pauses, little spontaneous speech, low volume
Mood and affect Low mood/misery (worse in morning), pessimistic about the present, hopelessness about future, guilt about the past, suicidal, dysphoric, blunt affect
Thought form and though content Delusions common (especially persecutory)
Cognition ↓attention, concentration and memory
Insight variable
Perception reduced intensity of normal perceptions. Occasionally auditory hallucinations

Mental State Examination (ABCDEFGHIJ)

  • Appearence and Behaviours
  • Cognition
  • Delusion (Thought content) 
  • Emotion (mood and affect) 
  • Thought Form
  • Gab (speech)
  • Hallucinations and illusions (perception)
  • Insight and Judgement

Types

Type I Bipolar

  • Manic episode
  • Between manic episodes depression

Type II Bipolar

  • Less severe
  • Hypomania
  • Between manic episodes depression
Remember Bipolar disorder is characterised by recurrent episodes of elevated mood and depression, together with changes in activity levels. Elevated mood is severe and sustained (mania) in bipolar I disorder and less severe (hypomania) in bipolar II disorder

Risk Factors

  • Family history
  • Stressful life events
  • Previous history of depression
  • Substance abuse
  • Age <25yo
  • Presence of an anxiety disorder
  • Obesity
  • Cardiovascular disease
Side note Children of parents with bipolar disorders have a 4 to 15 percent risk of also being affected, compared with a 0 to 2 percent risk in children of parents without bipolar disorders

Signs and Symptoms

Bipolar disorders often are first diagnosed in adolescence or early adulthood after several years of symptoms. Patients with bipolar disorders often present for treatment with depression or in a mixed state. The clinical course of bipolar disorders varies. Patients rarely experience a single episode, with relapse rates reported at more than 70 percent over five years.

Signs of Mania

Mood

  • Irritability
  • Euopharia
  • Liability

Cognition

  • Grandiosity
  • Flight of ideas/racing thoughts
  • Distractibility/ poor concentration
  • Confusion

Behaviour

  • Rapid Speech
  • Hyperactivity
  • Decrease sleep
  • Hypersexuality

Psychotic symptoms (Not common)

  • Delusions
  • Hallucinations
DIGFAST

  • Distractibility
  • Insomnia, Irritability, Impulsivitiy
  • Grandiosity
  • Flight of ideas
  • Activity increased
  • Agitation
  • Speech, Sleep and Apetite
  • Thoughtlessness
Think Patients in the midst of an episode of mania are often quite irritable and have very little insight into their own disease, making compliance with treatment difficult.

Signs of Depression

Depressed mood

  • Feeling unhappy
  • Sad
  • Depressed

Anhedonia

  • Inability to enjoy things
  • Loss of interest inactivities or pastimes

Other minor symptoms

  • Significant weight or appetite change
  • Insomnia or hypersomnia
  • Psychomotor agitation or retardation
  • Fatigue or loss of energy
  • Feelings of worthlessness or guilt
  • Diminished ability to think or concentrate or indecisiveness
  • Recurrent thoughts of death or suicide
Think Patients in the midst of an episode of mania are often quite irritable and have very little insight into their own disease, making compliance with treatment difficult.
Remember Depression is usually more common and longer lasting than elevated mood, and—together with inter-episode milder symptoms—contributes most to overall morbidity

Differential Diagnosis

  • Substance induced mood disorder
  • Major depressive disorder
  • Dysthmic disorder
  • Psychotic disorder
  • Personality disorder
  • Obsessive compulsive disorder
  • ADHD

Investigations

  • Serum drug screening
    • Opiates
    • Amephatines
    • Cocaine
  • FBC – anaemia
  • Thyroid function test – to rule out hyperthyroidism
  • Serum Vitamin D – as a cause of mood symptoms
  • Lipid studies – usually abnormal in patients with bipolar disorder
  • Serum Glucose – rules out diabetes
  • Urinalysis – to rule out infection in elderly

Diagnosis

DSM V criteria for a manic episodes (DIGFAST)

  • Distractibility
  • Insomnia, Irritability, Impulsivitiy
  • Grandiosity
  • Flight of ideas
  • Activity increased
  • Agitation
  • Speech, Sleep and Apetitite
  • Thoughtlessness

Factors that support Diagnosis

  • Family History
  • Personal history
  • Substance abuse

Management

Early diagnosis and treatment of acute mood episodes improve prognosis by reducing the risk of relapse and doubling the rate of response to medications. Treatment should continue indefinitely because of the risk of relapse. In the maintenance phase, patients with bipolar disorders should receive regular clinical examinations that focus on depressive, manic, and sleep symptoms; suicide risk; comorbid conditions and general medical health; and substance abuse

Maintenance Non- pharmacological methods

  • Cognitive behavioral therapy
  • Caregiver support
  • Psychoeducation regading the early warning signs of mood replase

Maintenance Pharmacological (Prophylaxis) – Mood stabilizers

  • Lithium carbonate
  • Valproic acid
  • Second line – Carbamazepine or oxcarbazepine
Pharmacology Lithium is a mood stabilizer. Side effects (LITHIUM CV): Leukocytes Increased Tremors Increased Urine Mother-teratogenic Coma Vision problems.
Remember During the course of an episode of acute mania, patients almost always require an antipsychotic in addition to a mood stabilizer, at least for the short term.

Emergency Acute Mania Patients with acute mania need to be hospitalized because they could harm themselves or others.

  • Lithium OR
  • Olazapine OR
  • Sodium Valproate
  • +/- antipsyhotics

Emergency Acute Depresion Patients with acute depression should be assessed for suicidal or homicidal ideation and the need for inpatient treatment

  • Lithium OR
  • Lamotrigine OR
  • Antipsychotic
Scheduling (must assess patient within 24hrs of admission)
Mentally ill or disorder
Facility and treatment available
Risk to themselves or others
Least restrictive method
They wont admit voluntarily

Complications and Prognosis

Complication

Mental disorder

  • Cognitive dysfunction
  • Suicide
  • Disability

Medication

  • Weight gain
  • lithium nephrotoxicity
  • lithium hypothyroidism
  • lithium intoxication
  • lithium neurotoxicitiy
  • lamotrigine induced rash
  • valproate induced hyperammonaemic encephalopathy
Remember Other psychiatric disorders, such as anxiety disorder and alcohol and drug misuse, are common

Prognosis

  • Likelihood of recurrence is almost certain, as the vast majority of patients have more than 1 lifetime episode.
  • Manic episodes typically have an abrupt onset, developing over a few days, while depressive episodes usually develop more gradually. With treatment, episodes of mania, depression, or mixed states last for approximately 3 months.
  • Mortality is higher among patients with bipolar disorder when compared with the general population.

Suicide

References

Anderson., IA, (2012). Clinical Review: Bipolar disorder. British Medical Journal. 345.
Price., AL & Marzani-Nissen., GR, Bipolar Disorders: A Review. American Family Physician. 85(5). 483-493.