Bipolar Disorders

INTRODUCTION

Bipolar Mood Disorders (BPDs), once referred to as a manic depressive illness, are common psychiatric disorders affecting 1.5 to 3% of the population. They are now recognised as being life long with 90% experiencing recurring manic episodes, the majority of which precedes or follows a major depressive episode. The symptoms and course of BPDs leads to significant morbidity. For some they are lethal. The BPDs are the sixth leading cause of disability in developed nations worldwide. Morbidity is minimised with an early diagnosis and functional recovery is enhanced with continuous management, a recovery that often lags behind symptom remission.

Recent neuroimaging studies have identified specific anatomical abnormalities in the brains of those with BPDs, abnormalities that progressively change during the course of the illnesses. Although the cause of the BPDs are unknown, that genetic factors are clearly implicated is highlighted by the familial nature of the BPDs with other family members often suffering a BPD. Using modern tools of genetic analysis, a gene contributing to the genetic risk for the BPDs was recently identified.

THE ILLNESS

Mood swings are part of every day life, they rarely impact upon the sufferer's ability to function. In contrast the mood and energy changes in BPDs are severe and disabling unrelated to the events of the moment and compromise social and occupational functioning.

THE SYMPTOMS OF BPDS

Four kinds of mood states occur in BPDs with the specific diagnosis being dependent upon the mixture of states.

Manic Episodes

A manic episode is a distinct period of an abnormal persistently elevated, expansive or irritable mood, symptoms that often go unrecognised as signs of an illness. Mania may begin with a pleasurable sense of heightened energy, creativity and a social ease that escalates to a full - blown episode, at which time, the individual feels high and energised. Mental activity is accelerated with the mind racing. Ideas and thoughts change rapidly, the tempo of verbal expression increases, attention and concentration deteriorate, reason and judgment become impaired, behaviour becomes disorganised and confusion emerges. A denial of their illness and the inappropriateness of their actions may occur, as does the blaming of others for their predicament. A loss of control is also felt.

Some feel that they are about to burst, self - confidence is elevated and a feeling of invincibility is stated. Perceptions alter; colours are brighter, noises louder and 50% experience psychotic symptoms. Antisocial behaviour occurs, ethical standards become ignored, physical appearance may change and flamboyancy displayed. Multiple tasks may be attempted simultaneously and sociability is increased. Catatonic behaviours may also be observed manifesting in such psychomotor disturbances as extreme immobility. When a manic episode concludes, regret is often experienced and an apology made. For the diagnosis of a manic episode, there must be a change in mood, impairment in daily functioning and four of the symptoms listed in Table 1.

Hypomania

Hypomania is a milder form of mania with similar symptoms to those in Table 1 but less severe and impairing. During hypomanic episodes, the individual feels good, is energised, has increased confidence and becomes impulsive, however, there is an absence of psychotic symptoms. An episode is often recognised by its abrupt onset with rapid escalation of symptoms and a mood state considered unusual and out of character for the individual. Between 5 to 15% will later develop a manic episode, for most, a depressive episode precedes or follows a hypomanic episode. Warning signs for the onset of a hypomanic episode include changes in sleep patterns i.e., sleep loss of a few hours and an acceleration of speech and thoughts.

Depression

Depression in bipolar disorders may occur alone or as part of a mixed state with the symptoms varying between individuals. Depression is more than sadness as shown in Table 2.

Mixed Episode

A mixed episode involves the symptoms of mania and depression that occurs simultaneously or alternates frequently throughout a day. Mixed states often indicate a severe BPD with relapse more common, resistance to medication higher, recovery time longer and suicide more likely. Studies suggest that up to 40% experience mixed episodes.

TYPES OF BIPOLAR DISORDERS

Types of BPDs are referred to as clusters of symptoms that describe a common pattern of the disorder. Four types of BPDs commonly described are:

Bipolar1 Disorder (BP1)
BP1 is the most severe form of BPD with 50% experiencing psychotic symptoms. The illness is characterised by recurring manic and depressive episodes as well as mixed states with features of both extremes combined. Ninety percent of individuals who have a single manic episode go on to develop future episodes. Between episodes, subsyndromal, depressive and hypomanic symptoms occur. The depressive symptoms are the more common. As the number of episodes increases, morbidity and mortality increases. The sex ratio for BP1 is similar, however, the onset is different. Males often commence with a manic episode, females a depressive episode. The average age of onset of BP1 is in the mid twenties, however, earlier and later onset occurs.

Bipolar11 Disorder (BP11)
In this condition, hypomanic and depressive episodes occur, there is an absence of manic states, mixed states or psychosis. The hypomanic episodes alternate with longer periods of major depression. Sixty to seventy percent of the hypomanic episodes in BP11 occur imediately before or after a major depressive episode.

Bipolar Disorder Not Otherwise Specified (BPNOS)
The diagnosis of Bipolar Disorder Not Otherwise Specified is made when the presenting symptoms do not meet the criteria for a specific bipolar disorder diagnosis.

Cyclothymic disorder
Cyclothymic disorder is best described as a milder form of BPD, characterised by an alternating mood disturbance involving hypomanic and depressive symptoms. This condition is equally common in women and men. It is often chronic with an insidious onset in adolescence or in early adulthood. Most with cyclothymic disorder function well except during periods of lowered mood.

Rapid cycling
Rapid cycling, which can occur in BP1 or BP11 is defined when four episodes of any combination of mania, hypomania and mixed episodes occur within one year. Between 5 to 15% of sufferers with BPDs experience rapid cycling.

BIPOLAR DISORDERS AND THEIR IMPACT

Morbidity of the BPDs is manifested in all facets of life; family, social and occupational function is impaired. The severity of impairment is linked to the frequency of episodes, i.e., the greater the frequency of episodes, the greater the impairment.

Family and occupational function
Family life is disrupted and life becomes an undeniable challenge in adjusting to the changing nature of the illness. While remission brings relief, apprehension and fear emerges about the next episode and what that may entail. Relationships become dysfunctional, at times they may dissolve. Employment is often terminated and career opportunities compromised.

Suicide
Twenty - five percent of those with BPDs attempt suicide, 10% will succeed. For some, the suicide attempts are carefully planned, for others an impulsive act. Specific risk factors for suicide include familial history of suicide, substance abuse, severe depression, social isolation, risk taking personality, recent loss and poor response to medication.

Substance abuse
Up to 60 to 70% of those with BPDS have a lifetime history of substance abuse. Alcohol is one of the more commonly abused drugs. For many, abuse follows the onset of a BPD that leads to an accelerated relapse, greater severity of depressive symptoms, an increased risk for suicide and greater socio-economic impairment.

Violent behaviour
Those with BPDs are no more dangerous then the rest of the general population, however, a small percentage may become abusive. Facts associated with violent behaviours include irritability, mania and being in the mixed state.

RISK FACTORS FOR RELAPSE

Maintaining wellness is a challenge for those with BPDs. To meet this challenge, modifying the risk factors for mania listed in Table 3 is beneficial.

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