Bipolar and related disorders

CHAPTER 7 Bipolar and related disorders



Bipolar mood disorders (BD) are characterised by the occurrence of elevated mood and (usually) depressed mood, either at different times or simultaneously (see Table 7.1 and Box 7.1). The precise delineation between ‘normal’ mood swings, mood instability as part of a personality disorder, and mood swings which are an indicator of bipolar disorder, is complex. As in all mood disorders, the disruption of normal mood is not the only or even necessarily the most prominent element of the disorder.


TABLE 7.1 Features of bipolar affective disorder according to DSM–IVTR and ICD–10









DSM–IVTR (synopsis) ICD–10 (synopsis)










Clinical features



Mania


Mania is a mental state in which motivation, energy, mood and/or thinking are elevated. The need for sleep is reduced, thought content is more grandiose, speed of thinking is increased, but thoughts remain connected (‘flight of ideas’), distractibility is high, libido is increased, behaviour is more socially disinhibited (including excessive spending of money), judgment is impaired and often the person is more physically active than usual. The person is often intolerant of challenge and may become aggressive if frustrated. This can pose a major problem for ‘significant others’ when faced with very inappropriate behaviour.


The separation of mania and hypomania is the subject of some variation. Some authorities maintain that manic symptoms which do not significantly impair function or require hospitalisation constitute hypomania. Others insist that mania is defined by the presence of psychosis and that absence of psychotic symptoms and signs in a patient with manic symptoms constitutes hypomania. The latter definition is more objective and more coherent than relying upon decisions regarding admission to hospital and the severity of disruption in life function, but the former is more commonly used in the literature.


Upon mental state examination, the person may appear obviously euphoric, but if the thought content is more anxiety provoking or hostile, the facial expression may change accordingly. They may present with dramatic choice of clothing or none at all. Physical and intellectual capacity during a state of mania can be exceptionally high for that individual, sometimes with remarkable feats of ability. Assessment is usually facilitated by the person’s lack of inhibition, but insight may be poor and the diagnosis of mania may evoke rage and denial. The decision to seek help usually comes from a relative or other interested person rather than the patient.



Depressed phase of bipolar disorder


The clinical presentation is essentially the same as in depressive disorders (see Ch 6), but is more likely to be severe, and associated somatic (melancholic) features are more likely. Abrupt onset of a severe melancholic depression in a young person (particularly an adolescent) may be a harbinger of bipolar disorder, and careful monitoring of antidepressant response (to check for manic switch) is required. ‘Atypical’ depressive clinical features are more common in bipolar disorders than other mood disorders. The different phases of illness are shown in Figure 7.1.




Course of bipolar disorders


In bipolar I disorder, episodes of both mania and severe depression occur. Bipolar II disorder is characterised by episodes of hypomania, interspersed by separate and often severe episodes of depression. Rapid cycling bipolar disorder refers to a subset of patients with either bipolar I or bipolar II disorder whose illness includes more than four episodes of both mania/hypomania and depression per year. This form of the illness is particularly disruptive and may be provoked by substances such as antidepressant medications and stimulants.


Mania and hypomania often arise quickly, over a period of days, but may also show early signs for several weeks with reduced need for sleep and increased resilience to life stresses. Monitoring changes in sleep patterns can be helpful in identifying a manic or depressive change in a euthymic individual with known bipolar disorder.


Depressive episodes are the most common state in bipolar disorders, but a very small group of people will suffer only manic symptoms. The most common sequence is for mania and/or hypomania to be followed by depression, but the reverse also occurs. Depression followed by mania or hypomania is often more resistant to mood stabilisers than the opposite sequence. Manic symptoms become less common with age in bipolar individuals and mixed manic and depressive symptoms more common. Figure 7.2 is a pictorial representation of a patient with bipolar I.





Schizoaffective disorder


When an individual has presented with clear features of schizophrenia (see Ch 5) and at other times clear features of mania, a diagnosis of schizoaffective disorder can be considered. This is a controversial concept and illustrates the limitations of our current diagnostic system.


Jun 8, 2016 | Posted by in PSYCHIATRY | Comments Off on Bipolar and related disorders

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