Bipolar Disorder

Topic Highlights

●    Bipolar disorder is a psychiatric disorder characterized by unusual mood swings.

●    The alternating episodes of mania and depression results in disrupted personal and social relationships.

●    This presentation provides information on the types of bipolar disorder, its symptoms, pathophysiology, diagnostic criteria, and treatment (such as drug and electroconvulsive therapy), with a note on self-care.

Transcript

Bipolar disorder can cause a great deal of suffering. Many patients face rejection, humiliation and isolation, often silently. Sometimes patients may be overcome by constant fears and negative thoughts, leading to drug and alcohol abuse or even suicide. Family members are also affected by these actions and the disorder itself.

Bipolar disorder can result in the disruption of personal and social relationships. It has a significant economic impact due to loss of productivity and the increased cost of health and social services.

Previously known as Manic Depression, Bipolar disorder is a serious, persistent mental illness that is characterized by periods of deep depression, which alternate with periods during which the patient experiences intense feelings of euphoria, also termed as mania. In between these distinct mood swings the patient may experience normal moods that allow normal functioning. Bipolar disorder affects a person's thoughts, actions, emotions and perceptions.

The lifelong prevalence rate for Bipolar disorder is 0.3 to 1.5 percent worldwide. 25-50% of individuals with Bipolar disorder attempt suicide, and 11% succeed. The usual age of onset is 15 to 25 years, however, it is not uncommon to find it even in childhood.

According to the Diagnostic and Statistical Manual of Mental Disorders, revised fourth edition, also called DSM-IV-TR, the criteria for correct diagnosis of Bipolar disorder includes three key components: discovering the existence of manic or hypomanic episodes, mixed episodes, and major depressive episodes.

The Classification of Mental and Behavioral Disorders, or ICD-10 by the World Health Organization provides diagnostic guidelines for a manic episode, Hypomania, mania with and without psychotic symptoms, depressive episode, mild and moderate depressive episodes, and severe depressive episodes with and without psychotic symptoms.

The high phase, or mania, of bipolar disorder is characterized by a boost in physical and mental activity. The person experiences a rise in energy levels. Patient may also be aggressive and feel an exaggerated feeling of self-importance. The need for less sleep without feeling tired, an inability to focus, rushing through speech, rapid thoughts and impulsive actions are also characteristic of the manic phase.

Symptoms such as excessive spending or sexual promiscuity may lead to the disruption of jobs or marriage. Patients may indulge in risky activities and in rare cases patients may exhibit psychotic symptoms like hallucinations. The manic phase may last for a few days to a few weeks or even months and may be severe enough to require hospitalization.

The low phase, or clinical depression, is characterized by sadness, loss of interest, weight loss, sleep disturbance, loss of energy, feelings of guilt or worthlessness, poor concentration and suicidal thoughts. The patient may also experience excessive fatigue, sleep problems and a difficulty focusing.

The symptoms of depression experienced in bipolar disorder are identical to those of major depression. Patients may experience a change in appetite: they may have an increased appetite causing weight gain or loss of appetite causing weight loss. Pessimistic thoughts may result in suicidal tendencies and even actual attempts at suicide.

Bipolar disorder is classified based on symptoms.

●    Bipolar I is characterized by episodes of mania and depression, with the manic phase lasting from a week to over  several months. Mania may be accompanied by delusions and may require hospitalization.

●    In bipolar II, the mania is less severe and is referred to as hypomania. The severity and duration of mania is less and  is more manageable. Hypomania can also cause impaired functioning. This phase may feel good, often causing the  patient to stop taking medication. But this may make the disorder difficult to control.

●    Bipolar disorder is characterized by nearly eight to ten manic or depressive episodes during one's lifetime. But some  people may experience four or more episodes of highs or lows in a year. This is called rapid cycling.

●    Mixed episodes of bipolar disorder are characterized by symptoms of depression and mania occurring together. The  patient may experience high energy and aggressiveness along with depression.

●    Cyclothymic disorder is a milder version of bipolar disorder characterized by hypomania and mild depression for a period of at least two years. Cyclothymic disorder can later become full-scale bipolar disorder or may continue as a mild but recurring condition.

Heredity is an important risk factor for bipolar disorder. Many people with bipolar disorder have a family history. If a brother or sister had bipolar disorder there is a 12% to 20% chance of bipolar disorder occurring in their family. In some cases, a stressful event in life may trigger the first episode of mania.

The pathophysiology of bipolar disorder remains poorly understood despite extensive research. Since genetic factors are important in the development of bipolar disorder, research has helped identify certain gene loci for bipolar disorder. These include 18p11, 18q22, 4p16, 21q21 and Xq26.

However, it is difficult to identify a specific gene candidate responsible for bipolar disorder. Since bipolar disorder is a mood disorder, it is believed that the dysfunction of the mood regulatory circuits in the brain could be the cause of bipolar disorder. There are two main mood regulatory circuits in the brain: the limbic-thalamic-cortical circuit and the limbic-striatal-pallidal-cortical circuit.

Damage or dysfunction of certain structures within the brain, like the frontal and temporal lobes, basal ganglia, prefrontal cortex, certain areas of the limbic system, and in some even the hippocampus may be responsible for the development of bipolar disorder.

Negative thoughts associated with depressive periods of bipolar disorder are believed to arise from abnormalities of the cerebral cortex of the brain.

Bipolar patients exhibit abnormalities in brain regions including the amygdala, globus pallidus, caudate, putamen, and thalamus that are involved in the regulation of mood.

Neuroimaging studies have revealed that patients with bipolar disorder tend to have a significantly smaller amygdala than people without the disorder, suggesting that abnormalities in this brain structure may be implicated in pathophysiology of the illness.

Neurotransmitters like noradrenaline, serotonin, dopamine, and acetylcholine are chemicals that help in conduction of nerve impulses across the synapse of two communicating neurons within the brain. The abnormalities in the effects that these neurotransmitters produce within the post-synaptic neuron and changes in the release and reuptake of these neurotransmitters are also a likely cause for bipolar disorder.

Bipolar disorder can also be triggered by an imbalance in the Hypothalamic-Pituitary-Adrenal Axis or the HPA axis. The HPA axis is regulated by the corticotrophin releasing hormone or CRH, Arginine Vasopressin or AVP, Adrenocorticotropic hormone or ACTH and cortisol, which are all involved in stress response.

To diagnose bipolar disorder a psychiatrist would observe the patient and talk to the patient and family members to assess their behavior and mental state. The doctor would study the medical history in detail and ask questions about any medications taken. The doctor would also ask the patient about any recent mood swings and their duration. In addition, a complete physical examination is done to rule out other diseases which may produce similar symptoms. Lab tests are also conducted to rule out certain medical conditions or drug abuse that may cause similar symptoms.

Medication with supportive counseling is the usual approach to the treatment of bipolar disorder. Most psychiatrists use one set of drugs to treat mania and another set to treat depression. Olanzapine, risperidone and other antipsychotics are useful in mania. These drugs act by blocking the receptors for neurotransmitters, thereby reducing the levels of activity.

All drug treatments have side effects, some more than others. Some of the antipsychotic drugs may increase the risk of diabetes, obesity and high blood pressure. Thus it is important that these patients are regularly screened and monitored. Treatment of mania may require hospitalization.

Drugs such as Lithium and anticonvulsants are prescribed as mood stabilizers. The majority of patients start with Lithium. Lithium helps to maintain a normal amount of neurotransmitters in the synaptic gap, thus maintaining mental stability. Lithium can reduce subsequent mania, although it may not affect subsequent depression.

A combination of an antidepressant with a mood stabilizer is usually prescribed for the treatment of the depression phase of bipolar disorder. All antidepressants work by increasing the levels of neurotransmitters in the synaptic gaps, though their exact workings differ for each type of drug.

Selective serotonin reuptake inhibitors or SSRIs such as paroxetine, fluoxetine, citalopram and sertraline act by selectively preventing the reuptake of serotonin in the synaptic space, thus leading to an increase in the levels of serotonin.

Electroconvulsive Therapy or ECT is sometimes recommended in severe resistant depression and extreme resistant mania but is rarely used. In this treatment the patient will be given a general anesthetic and the doctor will send short bursts of electric shock into his/her brain, which alters the levels of neurotransmitters.

Patients with bipolar disorder need support from family and friends to keep a control over their moods. Steps should be taken to keep to a routine and prevent stress:

●    Keep a regular routine of sleeping and waking.

●    Take medications regularly.

●    Avoid drug abuse and use of alcohol.

●    Before taking medications for other conditions, check with the consulting psychiatrist about drug interactions.

●    Meet with a therapist regularly.

●    Pay attention to observations made by friends and relatives, as the patient may not be capable of judgment.

●    Eat a balanced and healthy diet.

●    Exercise regularly.