### Date : 2024-06-23 11:46 ### Topic : Bipolar Disease #medicine #psychiatry ---- ### Bipolar Disorder Overview **Bipolar disorder**, also known as **manic-depressive illness**, is a mental health condition characterized by extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). These mood swings can affect sleep, energy, activity, judgment, behavior, and the ability to think clearly. ### Types of Bipolar Disorder  <Photo from: https://www.osmosis.org/learn/Bipolar_disorder> 1. **Bipolar I Disorder:** - **Definition:** Characterized by manic episodes lasting at least seven days or by manic symptoms that are so severe they require immediate hospital care. Depressive episodes occur as well, typically lasting at least two weeks. - **Manic Episode:** A period of abnormally elevated mood, energy, and activity levels. 2. **Bipolar II Disorder:** - **Definition:** Defined by a pattern of depressive episodes and hypomanic episodes, but not the full-blown manic episodes that are typical of Bipolar I Disorder. - **Hypomanic Episode:** A less severe form of mania, not severe enough to cause significant impairment or require hospitalization. 3. **Cyclothymic Disorder (Cyclothymia):** - **Definition:** Periods of hypomanic symptoms and periods of depressive symptoms lasting for at least two years (one year in children and adolescents), but the symptoms do not meet the diagnostic criteria for hypomanic episodes and depressive episodes. 4. **Other Specified and Unspecified Bipolar and Related Disorders:** - **Definition:** Bipolar disorder symptoms that do not match the three categories listed above. ### Symptoms **Manic/Hypomanic Episode Symptoms:** - **Euphoria:** Abnormally upbeat or jumpy. - **Increased Energy:** Hyperactivity, reduced need for sleep. - **Grandiosity:** Inflated self-esteem or grandiosity. - **Racing Thoughts:** Flight of ideas or racing thoughts. - **Talkativeness:** Increased talkativeness. - **Risky Behavior:** Engaging in risky behaviors, such as spending sprees, sexual indiscretions, or foolish business investments. **Depressive Episode Symptoms:** - **Sadness:** Persistent sadness, hopelessness. - **Anhedonia:** Loss of interest in activities once enjoyed. - **Fatigue:** Decreased energy or fatigue. - **Sleep Disturbances:** Insomnia or sleeping too much. - **Appetite Changes:** Weight loss or gain unrelated to dieting. - **Concentration Issues:** Difficulty concentrating, remembering, or making decisions. - **Suicidal Thoughts:** Thoughts of death or suicide. ### Diagnosis **Clinical Evaluation:** - **Medical History:** Detailed patient history, including mood swings, behavior changes, and family history of bipolar disorder or other mental health conditions. - **Psychiatric Assessment:** Structured interviews and questionnaires to assess mood, behavior, and thought patterns. **Diagnostic Criteria:** - **DSM-5 Criteria:** Diagnosis is based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria, which outlines specific symptoms and duration for manic, hypomanic, and depressive episodes. **Laboratory Tests:** - **Rule Out Other Conditions:** Blood tests and imaging studies to rule out other medical conditions that might mimic bipolar disorder symptoms, such as thyroid disorders. ### Diagnostic Criteria for Bipolar Disorder (DSM-5) The **Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)**, provides specific criteria for diagnosing different types of bipolar disorder. These criteria include the presence of manic, hypomanic, and depressive episodes, along with the duration and severity of symptoms. ### Bipolar I Disorder **Manic Episode:** - **Duration:** At least one week (or any duration if hospitalization is necessary). - **Symptoms:** At least three (four if the mood is only irritable) of the following: 1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep (e.g., feels rested after only three hours of sleep). 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli). 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity). 7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). **Additional Criteria:** - The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. - The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. ### Bipolar II Disorder **Hypomanic Episode:** - **Duration:** At least four consecutive days. - **Symptoms:** At least three (four if the mood is only irritable) of the same symptoms listed for a manic episode. - **Additional Criteria:** - The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. - The disturbance in mood and the change in functioning are observable by others. - The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. - The episode is not attributable to the physiological effects of a substance or another medical condition. **Major Depressive Episode:** - **Duration:** At least two weeks. - **Symptoms:** Five or more of the following, present during the same two-week period and representing a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day. 3. Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day. 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day. 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day. 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. **Additional Criteria:** - The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. - The episode is not attributable to the physiological effects of a substance or another medical condition. ### Cyclothymic Disorder **Criteria:** - For at least two years (one year in children and adolescents), there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode. - During the above two-year period (one year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than two months at a time. - Criteria for a major depressive, manic, or hypomanic episode have never been met. - The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. - The symptoms are not better explained by another mental disorder, are not attributable to the physiological effects of a substance or another medical condition. ### Other Specified and Unspecified Bipolar and Related Disorders **Criteria:** - Symptoms characteristic of a bipolar and related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the bipolar and related disorders diagnostic class. **Examples include:** - Short-duration hypomanic episodes (2-3 days) and major depressive episodes. - Hypomanic episodes with insufficient symptoms and major depressive episodes. - Hypomanic episode without prior major depressive episode. - Short-duration cyclothymia (less than 24 months). ### Example Case Study **Patient Profile:** - **Name:** Jee Hoon Ju - **Age:** 30 - **Occupation:** Software Developer **Medical History:** - **Symptoms:** Periods of extreme euphoria and energy followed by deep depression, difficulty sleeping, racing thoughts, risky spending during manic episodes, and suicidal thoughts during depressive episodes. **Clinical Evaluation:** - **Psychiatric Assessment:** Confirms the presence of multiple manic and depressive episodes. **Diagnosis:** Based on the clinical presentation and DSM-5 criteria, Jee Hoon Ju is diagnosed with Bipolar I Disorder. ### Management 1. **Medications:** - **Mood Stabilizers:** Lithium, valproate, and carbamazepine to control mood swings. - **Antipsychotics:** Atypical antipsychotics like olanzapine, quetiapine, or risperidone, especially for manic episodes. - **Antidepressants:** Sometimes used cautiously, often in combination with mood stabilizers, to treat depressive episodes. 2. **Psychotherapy:** - **Cognitive Behavioral Therapy (CBT):** Helps patients identify and change negative thought patterns and behaviors. - **Psychoeducation:** Educates patients and their families about the disorder, treatment options, and how to recognize early warning signs of mood swings. - **Interpersonal and Social Rhythm Therapy (IPSRT):** Focuses on stabilizing daily rhythms, such as sleep, wake, and meal times, to help manage mood swings. 3. **Lifestyle Modifications:** - **Regular Exercise:** Helps improve mood and overall well-being. - **Healthy Diet:** Balanced diet to support overall health. - **Sleep Hygiene:** Maintaining a regular sleep schedule to prevent mood swings. - **Avoiding Alcohol and Drugs:** Reduces the risk of triggering mood episodes. 4. **Support Systems:** - **Support Groups:** Joining support groups for individuals with bipolar disorder to share experiences and coping strategies. - **Family Support:** Involving family members in treatment to provide support and understanding. 5. **Monitoring and Follow-Up:** - **Regular Psychiatric Visits:** Ongoing monitoring by a psychiatrist to assess medication effectiveness and adjust treatment as necessary. - **Mood Charting:** Keeping a diary of mood changes, sleep patterns, and life events to help identify triggers and manage the disorder. ### Prognosis - **Long-Term Management:** Bipolar disorder is a chronic condition that requires long-term treatment and management. - **Quality of Life:** With effective treatment and support, individuals with bipolar disorder can lead fulfilling and productive lives. - **Risk of Recurrence:** Regular treatment and monitoring can help reduce the frequency and severity of mood episodes. ### Conclusion Bipolar disorder is a complex and challenging mental health condition characterized by significant mood swings. Early diagnosis, appropriate treatment, and ongoing management are crucial for improving outcomes and helping individuals with bipolar disorder maintain stability and lead fulfilling lives. Comprehensive care involving medications, psychotherapy, lifestyle changes, and support systems is essential for effective management of the disorder.