Psychiatry

Last updated on: August 24th, 2021

Bipolar disorder

Clinicals - History

Definition

Bipolar affective disorder (BPAD) is a mood disorder; its symptoms overlap with a range of related diagnoses in the DSM-5. Within this group, Bipolar I disorder (BP I) and Bipolar II disorder (BP II) are the main diagnoses seen in clinical practice.

Epidemiology

BP affects 1-2% of the general population. There is similar prevalence across all races and genders. BP I is slightly more common than BP II.

Etiology

BPAD appears to have a genetic component. However, a lack of complete concordance with monozygotic twins and development of unipolar depression rather than BPAD in relatives, suggests that environmental factors may influence disease development.

Mania

Mania is characterized by a pathologically elevated mood, exaggerated self-confidence, easy distractability, disinhibited behavior (e.g., reckless spending or an indiscriminate increase in sexual drive), grandiose thinking, and a history of sleeplessness; episodes last for at least 7 days and generally require hospitalization. Hypomanic episodes present with similar features, but are less severe; they generally do not warrant hospitalization.

Depression

Depressive episodes are characterized by a low mood, anhedonia, thoughts of hopelessness or helplessness, guilt, low self-worth and suicidal thoughts. This occurs in both BP I and BP II and is of variable duration.

Mixed states

Mixed states are those in which the patient displays features of both mania and depression. These typically present as irritability and agitation.

Psychotic features

BPAD can be, but is not always, associated with psychotic features. These include hallucinations, delusions, disorganized speech or behavior.

Suicidality

BPAD is associated with increased suicidal ideation. The rate of suicide has been found to be nearly 10-30 times higher, as compared to the general population.

Course of the illness

BPAD is usually a relapsing-remitting episodic illness.

Chronic illness

BPAD is associated with chronic ill health. Patients experience a higher reduction in life expectancy due to medical comorbidities, as compared to the general population.

Psychiatric co-morbidities

BPAD is associated with multiple psychiatric conditions. These include drug, alcohol and substance abuse, anxiety disorders, attention deficit disorder (ADHD), post-traumatic stress disorder (PTSD) and borderline personality disorder (BPD).

Substance abuse

When patients already diagnosed with BPAD present with symptoms of psychiatric decompensation, such as mania or psychosis, the most common culprits are non-compliance with medications or concurrent drug use.

Prodrome

There is often a period of milder mood disturbance consisting of episodic mood changes including mood lability, anxiety, depression and subthreshold manic symptoms. These precede the first presentation of BPAD and are strong indicators of future BPAD development. A prodromal period may also precede a relapse.

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