Bipolar Disorder
Bipolar Disorders
Presentation
The patients with bipolar disorder present with manic episodes characterized by diminished need for sleep, irritability, excessive talking, pressured speech, racing thoughts, excessive pleasurable activities and evidence of distractibility.
Major depressive episodes are characterized by depressed mood, hypersomnia or insomnia, psychomotor retardation, loss of energy, decreased ability to concentrate and even suicidal attempts.
In mixed episodes, the patient experiences both manic disorders and major depression. Depressive events last for at least 1 week. Mood disturbances are unrelated to substance abuse or medical conditions and result in marked depression and disruption of social activities.
Entire Body System
Weight Gain
- Mean weight gain with placebo was 0.4 kg, and for both quetiapine groups was 1.7 kg. The rates of clinically significant ( 7%) weight gain were 12.2% with quetiapine and 0% with placebo, resulting in an NNH for 7% weight gain of 8.2.[ncbi.nlm.nih.gov]
- […] or greater than 7% weight gain, and 3.3% developed hypomania.[ncbi.nlm.nih.gov]
- Valproate may be less effective than olanzapine but may cause less sedation and weight gain.[ncbi.nlm.nih.gov]
- Although VPA is mostly well-tolerated, common adverse effects include gastrointestinal symptoms (nausea, vomiting, diarrhea), neurological symptoms (sedation, ataxia, tremor), weight gain, and alopecia.[ncbi.nlm.nih.gov]
- EPS, sedation Among the least likely second-generation antipsychotics to cause weight gain Asenapine 10 mg bid EPS, sedation … Olanzapine c 15–20 mg/d Sedation, weight gain, less commonly EPS Weight gain; lipid and glucose derangements may be particularly[ncbi.nlm.nih.gov]
Fatigue
- Possible benzodiazepine side effects include: Drowsiness or dizziness Lightheadedness Fatigue Blurred vision Slurred speech Memory loss Muscle weakness Benzodiazepines can be habit-forming and addictive.[webmd.com]
- Individuals with bipolar disorder can quickly swing from extremes of happiness, energy and clarity to sadness, fatigue and confusion. These shifts can be so devastating that individuals may choose suicide.[apa.org]
- During periods of depression, patients may: Lose interest in regular activities Feel tormented Become bored easily Feel fatigued Be pessimistic Some may even develop suicidal thoughts, which may lead to attempted suicide.[bumrungrad.com]
- […] episodes are characterized by: Persistent sad or negative mood Loss of interest in usually pleasurable activities Feelings of guilt, worthlessness, helplessness, hopelessness Sleeping too much or too little, or early morning awakening Decreased energy, fatigue[amenclinics.com]
Weight Loss
- Although the data on weight loss were not analysed formally, weight loss was marked in the topiramate treated group. Several unpublished trials have been identified and data from these trials may be included in future reviews.[ncbi.nlm.nih.gov]
- Weight loss was reported in each of the treatment groups. The mean weight loss was 5.8 kilograms (kg) in the topiramate treated group and 1.2 kg in the bupropion SR treated group.[doi.org]
- The aforementioned research started out by identifying the factors that make weight loss difficult in bipolar patients.[bpkids.org]
- loss, or overeating and weight gain Fatigue or lack of energy Feelings of worthlessness, hopelessness, or guilt Loss of pleasure in activities once enjoyed Loss of self-esteem Thoughts of death or suicide Trouble getting to sleep or sleeping too much[nlm.nih.gov]
Hypersomnia
- Hypersomnia presents as excessive daytime sleepiness with a prevalence of 7.1% in general population. Hypersomnia has serious negative effects on persons functioning.[ncbi.nlm.nih.gov]
- Episodes are characterized by hypersomnia, cognitive impairment, feelings of derealization, and, less frequently, hyperphagia (66%), hypersexuality [53% (principally men)], and depressed mood [53% (predominantly women)].[ncbi.nlm.nih.gov]
- Major depressive episodes are characterized by depressed mood, hypersomnia or insomnia, psychomotor retardation, loss of energy, decreased ability to concentrate and even suicidal attempts.[symptoma.com]
- Note: in children, consider failure to make expected weight gains. insomnia or hypersomnia nearly every day psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down[bipolar.stanford.edu]
Family History of Depression
- Depressive symptoms are common in schizophrenia [ 51 ] and appear more frequent when there is family history of depression [ 53 ]. In our models “late” age at onset seemed protective towards depressive dimension in schizophrenia.[doi.org]
- If some of these associated features, such as early onset of illness and a family history of depression, are present but no hypomanic episode can be documented, the clinician has a dilemma.[ps.psychiatryonline.org]
Gastrointestinal
Overeating
- A patient presenting with bipolar I disorder and comorbid anxiety, ADHD, and dyslexia was taught deep touch pressure strategies to alleviate severe symptoms of sensory over-responsivity and anxiety.[ncbi.nlm.nih.gov]
- In this case patient had all manic episodes without any depressive or schizophrenia-like episodes, suggesting a diagnostic stability over a long period of over fifteen years.[ncbi.nlm.nih.gov]
- A 53 year old woman developed symptoms of mania in her 50s leading to a personality change involving a continuously labile mood and irritability over a number of years.[ncbi.nlm.nih.gov]
- Differences in methodology contribute to the perception that rates of BD have increased over time. Rates varied markedly by geographic region, even after controlling for all other predictors.[doi.org]
Constipation
- (M‐H, Fixed, 95% CI) 1.91 [0.66, 5.51] 3.3 Withdawal because patient no longer needed hospital admission 2 185 Risk Ratio (M‐H, Fixed, 95% CI) 3.24 [0.80, 13.17] 4 Adverse events Show forest plot 3 Risk Ratio (M‐H, Fixed, 95% CI) Subtotals only 4.1 Constipation[doi.org]
- Other common olanzapine adverse events are somnolence, agitation, dizziness and asthenia; less frequent effects are constipation, dry mouth, rhinitis and hepatic enzyme elevations ( McEvoy 1999 ).In schizophrenia olanzapine is normally associated with[doi.org]
- More frequently reported common adverse effects in younger populations include sialorrhoea, constipation, orthostatic hypotension, weight gain and sedation.[ncbi.nlm.nih.gov]
- In consequence, a number of adverse events were reported sporadically (like constipation, or nausea), making sensible analysis of them impossible.[ncbi.nlm.nih.gov]
- Total number of participants experiencing the following specific side effects: agitation/anxiety constipation delusions diarrhoea dissociative symptoms dizziness dry mouth hallucinations headache hypo/hypertension insomnia mania/hypomania nausea seizure[doi.org]
Abdominal Pain
- However, the patient complained of severe abdominal pain. Blood amylase was found to be markedly high, and computed tomography revealed pancreatomegaly and an increased amount of peripancreatic fat.[ncbi.nlm.nih.gov]
- His life was also made miserable by chronic diarrhea, abdominal pain, chronic respiratory illness, depression, and alcohol abuse.[nejm.org]
- The most common adverse events resulting in discontinuations included somnolence (5%), nausea (3%), abdominal pain (2%) and vomiting (2%).[ncbi.nlm.nih.gov]
Musculoskeletal
Motor Restlessness
- ., subjective sense of motor restlessness); parkinsonism (i.e., cogwheel rigidity of tendons, masked facies, or muscle stiffness or rigidity); and other movement disorders, such as dystonias and dyskinesias.[aafp.org]
Psychiatrical
Anxiety Disorder
- disorder reached 51.2% while rates for a current anxiety disorder reached 30.5%; comorbid anxiety tended to be more common in patients with bipolar I disorder compared with bipolar II. 11 Anxiety may be interwoven into the fabric of syndromic bipolarity[web.archive.org]
- These people may be suffering from an anxiety disorder, bipolar disorder, or both. It is not uncommon for someone with an anxiety disorder to also suffer from bipolar disorder.[adaa.org]
- These people may be suffering from an anxiety disorder , bipolar disorder, or both. It is not uncommon for someone with an anxiety disorder to also suffer from bipolar disorder.[adaa.org]
- Furthermore, it is well-known that comorbid anxiety disorders can lead to a worse prognosis in bipolar patients but it is not exactly clear to what extent.[ncbi.nlm.nih.gov]
- Bipolar disorder frequently occurs together with other psychiatric disorders, especially anxiety disorders and substance abuse.[ncbi.nlm.nih.gov]
Distractibility
- Mania is a mood disturbance that is characterized by abnormally intense excitement, elation, expansiveness, boisterousness, talkativeness, distractibility, and irritability.[britannica.com]
- Rapidly changing interests; rapidly changing the topic of conversation or what they are doing or being easily distracted.[bumrungrad.com]
- Symptoms of Mania: Excessively “high,” euphoric mood Extreme irritability Unrealistic beliefs in one’s abilities and powers, such as feeling able to control world events Decreased need for sleep without feeling tired Racing thoughts or fast speech Distractibility[halfofus.com]
- However, in some patients, hypomania manifests as distractibility, irritability, and labile mood, which the patient and others find less attractive.[merckmanuals.com]
- The patients with bipolar disorder present with manic episodes characterized by diminished need for sleep, irritability, excessive talking, pressured speech, racing thoughts, excessive pleasurable activities and evidence of distractibility.[symptoma.com]
Suicidal Ideation
- It is currently unclear if these same factors or others predict suicide ideation among older adults with BD.[ncbi.nlm.nih.gov]
- Patients and their support systems should be educated about mood relapse, suicidal ideation, and the effectiveness of early intervention to reduce complications.[ncbi.nlm.nih.gov]
- RESULTS: After adjusting for demographic characteristics and mood and substance use disorders, BD-relatives were at increased risk for suicidal ideation and attempts but not for NSSI.[ncbi.nlm.nih.gov]
- Many patients experience severe hopelessness and suicidal ideation and the disorder is associated with one of the highest mortality rates of all psychiatric disorders.[ncbi.nlm.nih.gov]
- Seite 247 - 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[books.google.com]
Indecisiveness
- Seite 247 - 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[books.google.com]
- […] sadness or unexplained crying spells Significant changes in appetite and sleep patterns Irritability, anger, worry, agitation, anxiety Pessimism, indifference Loss of energy, persistent lethargy Feelings of guilt, worthlessness Inability to concentrate, indecisiveness[dbsalliance.org]
- […] as expected can be a sign of depression) Either insomnia or sleeping too much Either restlessness or slowed behavior Fatigue or loss of energy Feelings of worthlessness or excessive or inappropriate guilt Decreased ability to think or concentrate, or indecisiveness[mayoclinic.com]
- […] elated, enthusiastic, excited, angry, irritable or depressed E nergy - increased energy, over-talkative or over-active S leeping - reduced need for sleep and marked difficulty in getting off to sleep T hinking - racing thoughts, ‘pressure in the head’, indecision[aware.ie]
Feeling of Worthlessness
- During an episode of depression, you may have overwhelming feelings of worthlessness, which can potentially lead to thoughts of suicide .[healthdirect.gov.au]
- […] of worthlessness, hopelessness, or guilt Loss of pleasure in activities once enjoyed Loss of self-esteem Thoughts of death or suicide Trouble getting to sleep or sleeping too much Pulling away from friends or activities that were once enjoyed People[nlm.nih.gov]
- When experiencing a depressed episode, it’s common to feel or experience: loss of interest in activities changes in appetite weight loss or gain changes in sleeping patterns a loss of energy difficulties with concentration feelings of worthlessness or[au.reachout.com]
Urogenital
Sexual Dysfunction
- Monitoring recommendations Comments Antipsychotics, atypical Varies Somnolence, dry mouth, orthostatic hypotension, extrapyramidal effects, akathisia, tardive dyskinesia, weight gain, hyperglycemia, neuroleptic malignant syndrome, hyperprolactinemia, sexual[aafp.org]
Neurologic
Irritability
- This condition is marked by irritability and sudden mood swings, and has no specific diagnostic criteria. Disagreement is even greater for bipolar disorder in preschool age.[ncbi.nlm.nih.gov]
- We examine current research on the diagnostic boundaries of BD in youths, in particular the issues of episodicity and irritability, and provide assessment guidelines.[ncbi.nlm.nih.gov]
- A 53 year old woman developed symptoms of mania in her 50s leading to a personality change involving a continuously labile mood and irritability over a number of years.[ncbi.nlm.nih.gov]
- One third of manic episodes are euphoric and two-thirds are irritable or a depressed mood.[web.archive.org]
Hyperactivity
- Keywords Attention Deficit Hyperactivity Disorder Bipolar Disorder Attention Deficit Hyperactivity Disorder Conduct Disorder Oppositional Defiant Disorder These keywords were added by machine and not by the authors.[doi.org]
- Converseley, an understanding of the common mechanisms of sensitisation (such as regionally selective alterations in brain derived neurotrophic factor (BDNF) and hyperactivity of striatally based habit memories), could also result in single therapies[ncbi.nlm.nih.gov]
- We present a patient whose symptoms of depression, anxiety, attention-deficit/hyperactivity disorder, oppositional behavior, and mania are rated by a parent and plotted on a weekly basis in the Child Network under a Johns Hopkins Institutional Review[ncbi.nlm.nih.gov]
- Previous studies have shown that individuals with autism spectrum disorders and attention- deficit/hyperactivity disorder (ADHD) experience sensory over-responsivity (SOR) in which a heightened response is evoked by stimuli in the environment.[ncbi.nlm.nih.gov]
- While the Greeks did indeed speak of mania and melancholia, these terms covered all sorts of hyperactive deliriums and lethargic stupors, the majority of which were probably caused by infectious or post-infectious states, or perhaps by Parkinson’s disease[web.archive.org]
Agitation
- He was psychiatrically hospitalized for agitation, aggression, and manic symptoms including insomnia, rapid and pressured speech, and hyperactivity. After multiple medication trials, ECT was recommended.[ncbi.nlm.nih.gov]
- Agitation. Agitation, prominent in depressive, manic, and mixed states, includes two basic disturbances ( 35 ).[doi.org]
- Benzodiazepines are generally not a "core" treatment for mania, but they can rapidly help control certain manic symptoms -- such as restlessness, agitation, or insomnia -- in bipolar disorder until mood-stabilizing drugs can take effect.[webmd.com]
- Seite 95 - ... 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 (eg, engaging in unrestrained[books.google.com]
- It is typical for dementia or delirium to be associated with nighttime agitation and confusion in patients ("sundowning").[web.archive.org]
Excitement
- Depressive, positive, negative, excitement and disorganised domains were detected in SCH sample, whereas depressive, excitement and psychotic appeared for BD [ 14, 15, 16, 17, 18 ].[doi.org]
- To combine the CACNA1C perturbations in the presence of BD in this patient and in patients with the common CACNA1C SNP risk allele, we would propose that either increase or decrease in calcium influx in excitable cells can be associated with BD.[ncbi.nlm.nih.gov]
- 296.0 Delirium, delirious 780.09 manic, maniacal (acute) (see also Psychosis, affective) 296.0 Disease, diseased - see also Syndrome Bell's (see also Psychosis, affective) 296.0 Disorder - see also Disease manic (see also Psychosis, affective) 296.0 Excitement[icd9data.com]
- Bipolar used to be known as 'manic depression', because people tend to experience extreme moods – both low (depressed), and high or excited (manic).[beyondblue.org.au]
- An anxious mood may shift into an excited mood with a simple change of perspective, and a depressed mood may shift into a happier one upon hearing pleasing news.[mentalhelp.net]
Behavior Problem
- Behavioral and psychosocial therapies are also generally indicated for juvenile mania to address disruptive behavior problems and the impact of the illness on family and community functioning.[ncbi.nlm.nih.gov]
- The chloroquine was subsequently replaced with hydroxychloroquine for the next six months without any behavioral problems, following which, the SLE and mood disorder were in remission.[ncbi.nlm.nih.gov]
- Most people can get help for mood changes and behavior problems. Steady, dependable treatment works better than treatment that starts and stops. Treatment options include: 1. Medication. There are several types of medication that can help.[nimh.nih.gov]
- problems (minor problems alone aren’t consistent with bipolar illness) is always episodic, meaning that a child experiences cycles of major changes in her level of functioning always includes mania, which involves a marked increase in energy, activity[childrenshospital.org]
- Childhood behavior problems and bipolar disorder—Relationship or coincidence? Journal of Affective Disorders, 28, 143 – 153. Caspi, A., Moffitt, T. E., Morgan, J., Rutter, M., Taylor, A., Arseneault, L., et al. ( 2004 ).[doi.org]
Workup
The diagnosis of bipolar disorder is mainly clinical. The following investigations may be helpful in the diagnosis.
Laboratory investigations:
- The level of thyroid hormones should be evaluated to rule out hypothyroidism (which causes depression) and hyperthyroidism (which causes mania).
- Erythrocyte sedimentation rate should also be measured to rule out any infection.
- Drug and alcohol screening should also be done.
- Liver function tests and tests for rapid plasma reagent (RPR) are also important.
Imaging studies:
Brain imaging via CT scan (computerized tomography) or MRI (magnetic resonance imaging) should also be done to rule out infections, stroke or tumor.
Procedures:
Electroencephalography should be done if temporal lobe epilepsy is suspected.
Rhythm
Torsades De Pointes
- Antipsychotic-related QTc prolongation, torsade de pointes and sudden death. Drugs. 2002; 62 (11):1649–71. [ PubMed ] [ Google Scholar ] 31. Harrigan EP, Miceli JJ, Anziano R, et al.[ncbi.nlm.nih.gov]
- de pointes possible, particularly with higher than recommended dosages Benzodiazepines Lorazepam (Ativan) 0.5 to 2 mg orally or intramuscularly, up to 4 mg per day Reduce dose by 50 percent in patients who are older and debilitated, patients taking valproate[aafp.org]
Treatment
The treatment of bipolar disorder directly depends upon severity of disease. In severe disease, the patient should be hospitalized. Less severe cases can be treated on an outpatient basis.
A number of drugs are used to reduce anxiety and depression in these patients. These including antipsychotics, valproate and benzodiazepines.
Manic episodes are usually treated with lithium, which may also have a neuro-protective role [10].
Certain lifestyle changes are also associated with a better prognosis. Patients with bipolar depressive illness are advised to have adequate levels of omega-3 in their diet [11]. Salt intake should be reduced. They should also be encouraged to plan a proper exercise schedule.
Prognosis
Bipolar disorder is a severely impairing illness and has a deep impact on many aspects of the life of the patient [7]. A typical patient with bipolar disorder has an average of 8 to 10 manic episodes over a lifetime. It is not yet clear how frequently childhood disorder persists into adulthood or as future illness.
Patients suffering from bipolar disorder also have an increased risk for the development of respiratory and circulatory disorders [8]. Owing to these co-morbidities, the patients suffering from bipolar disorder die an average of 9 years earlier as compared to the normal population [9].
Etiology
Genetic predisposition plays a key role in the development of this disease. Major life stressors and external factors can trigger the initial and subsequent episodes.
Genetic factors
Bipolar disorder has a well-documented genetic predisposition. The concordance of this disease in monozygotic twins is around 40 to 70% whereas in dizygotic twins, it is 5 to 25%. 50% of the patients have atleast one parent with a mood disorder.
The major genes involved in the development of bipolar disorder are the ANK3, CACNA1C and CLOCK genes [1] [2].
Biochemical factors
Drugs that increase the levels of monoamine neurotransmitters (such as serotonin, norepinephrine and dopamine) can cause bipolar disorder. High glutamate level are also known to have an association. Calcium channel blockers and hormonal imbalances may also contribute to bipolar disorder.
Environmental factors
External pressure and work load may also be a cause of increased stress in these patients. Pregnancy, for example, is a particular stress for women with a manic-depressive illness history.
Epidemiology
Bipolar disorder is one of the most common mental illnesses. The age of onset is usually 15 to 30 years. The incidence is greater in the higher socioeconomic classes.
In the United States, the prevalence of bipolar disease varies from 1 to 1.6%. Studies indicate differences in prevalence of bipolar disease to be 1.0% for bipolar I disease and 1.1% for bipolar II disease [3].
Worldwide, the prevalence rate is 0.3-1.5%. The lifetime prevalence for bipolar disorder (BP-I) is 0.6%. For bipolar II disorder (BP-II), the prevalence is 0.4% whereas for sub-threshold bipolar disorder, it is 1.4% [4].
Patients suffering from bipolar disorder also commonly suffer from other disorders such as cardiovascular disease, diabetes mellitus, obesity and mental disorders [5]. These disorders are the major source of mortality and morbidity in these patients.
Pathophysiology
The pathophysiology of bipolar disorder is not fully understood.
The role of genetic factors in predisposing the patient to this disease is well-documented. The underlying dysregulation of biogenic amines or neurotransmitters (especially serotonin, norepinephrine and dopamine) is also well known.
Magnetic resonance imaging (MRI) findings suggest abnormalities in the prefrontal cortical areas, striatum and amygdala.
Functional neuroimaging studies also reveal the presence of hyperactivity and hypoactivity in certain regions of the brain in this illness [6].
Prevention
Bipolar disorder cannot be prevented; however, the mood swings can be controlled by medication.
Summary
Bipolar disorder is a group of mood disorders that are characterized by episodes of mania and depression. Bipolar disorder has two common types; bipolar I (BP-I) and bipolar II (BP-II).
Bipolar I disorder is the more severe of the two and is characterized by at least one manic or mixed episode alternating with episodes of major depression. It causes marked impairment and requires hospitalization.
In contrast, bipolar II disorder is characterized by at least one episode of major depression and at least one episode of a mild form of mania (hypomania).
Patient Information
Bipolar disorder is a common severe and persistent mental illness which is characterized by episodes of depression and irritability. The disease is commonly diagnosed around the age of 21 years. The severity of the disease varies from patient to patient. Medications can be used to control depression and mood swings in these patients.
References
Article
- Sklar P, Smoller JW, Fan J, et al. Whole-genome association study of bipolar disorder. Molecular psychiatry. Jun 2008;13(6):558-569.
- Baum AE, Akula N, Cabanero M, et al. A genome-wide association study implicates diacylglycerol kinase eta (DGKH) and several other genes in the etiology of bipolar disorder. Molecular psychiatry. Feb 2008;13(2):197-207.
- Calabrese JR. Overview of patient care issues and treatment in bipolar spectrum and bipolar II disorder. The Journal of clinical psychiatry. Jun 2008;69(6):e18.
- Merikangas KR, Jin R, He JP, et al. Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Archives of general psychiatry. Mar 2011;68(3):241-251.
- Price AL, Marzani-Nissen GR. Bipolar disorders: a review. American family physician. Mar 1 2012;85(5):483-493.
- Houenou J, Frommberger J, Carde S, et al. Neuroimaging-based markers of bipolar disorder: evidence from two meta-analyses. Journal of affective disorders. Aug 2011;132(3):344-355.
- Ketter TA. Diagnostic features, prevalence, and impact of bipolar disorder. The Journal of clinical psychiatry. Jun 2010;71(6):e14.
- Hoang U, Stewart R, Goldacre MJ. Mortality after hospital discharge for people with schizophrenia or bipolar disorder: retrospective study of linked English hospital episode statistics, 1999-2006. Bmj. 2011;343:d5422.
- Crump C, Sundquist K, Winkleby MA, Sundquist J. Comorbidities and mortality in bipolar disorder: a Swedish national cohort study. JAMA psychiatry. Sep 2013;70(9):931-939.
- Bauer M, Alda M, Priller J, Young LT, International Group For The Study Of Lithium Treated P. Implications of the neuroprotective effects of lithium for the treatment of bipolar and neurodegenerative disorders. Pharmacopsychiatry. Nov 2003;36 Suppl 3:S250-254.
- Sarris J, Mischoulon D, Schweitzer I. Omega-3 for bipolar disorder: meta-analyses of use in mania and bipolar depression. The Journal of clinical psychiatry. Jan 2012;73(1):81-86.