BIPOLAR DISORDER

Also known as Manic Depressive Disorder, and related emotional difficulties

It is truly unfortunate that mental illness is still a great source of shame in our society, in our families and even in those around us. Medicine is able to treat symptoms and greatly improve the situation of patients. However, it is a shame that medicine in its current state of development cannot cure these diseases. The care is palliative for the most part.

Although I could talk about mental health in general, I have chosen to devote my next articles to the main types of emotional illnesses, which are bipolar disorders, schizophrenia, anxiety-related difficulties (such as panic attacks and agoraphobia), addiction-related disorders (including substance abuse) and, finally, personality disorders. These emotional states affect the greatest number of people and have the highest morbidity and cost to our society.

If you, my readers, want me to address a specific mental health topic, please send me your suggestions by filling out the form following this article. I wish to help you as best I can. In addition, if you have specific questions about this or any other topic related to psychological illnesses, write them to me, and I will answer as many questions as possible, either in a possible article, or in private in an email if it suits you better.

First of all, when I talk about bipolar disorders, or mental health problems, I use words like emotional problems, mental difficulties, psychological or psychiatric illnesses, and bipolar disorders, and various disorders interchangeably. All of these terms have a fairly close meaning. They all refer to diseases that affect the emotional state of the patient. In addition, all these difficulties are part of the field of psychiatry.

Most of these difficulties are also treated by psychologists, however in most countries of the world psychologists are not allowed to prescribe drugs, which are often used to treat the most severe psychotic conditions and other difficulties.

What is particularly important is that here in the United States there is an increasingly influential movement to allow, in some states, psychologists who treat psychiatric illnesses, who are not doctors, admit their patients to hospital and treat them with medication. This has created a very polarizing situation here in the professional medical community that treats psychiatric patients and for professionals in other areas related to mental health treatment. Psychiatrists, in particular, are opposed to this movement because psychologists do not have the scientific, pharmacological and medical training to prescribe these drugs safely. Of particular concern is that psychotropic drugs interact with many other drugs and can aggravate health problems (physical or mental).

However, treatment teams are often composed of specialists from a variety of areas related to mental health. These teams work together to treat these patients, especially those with the most severe symptoms. In addition, treatment teams may include occupational therapists, music therapists, yoga specialists, specialized nurses (in psychiatry), addiction and alcohol counsellors, psychologists, psychiatrists and possibly other specialists who target specific diseases, problems or conditions.

3-D representation of a molecule of lithium bicarbonate, first used as a mood stabilizer in the late 19th century.
Molecular formula of lithium

PART 2

Diagnosis of mania (symptoms A-D)

If you think that a person could be showing signs of a manic episode, what criteria are used to help you decide ? Most clinicians utilized a system of diagnosis based on four categories of symptoms. The following criteria A to D define a manic episode.

Criterion A – Duration

* To diagnose a manic episode, it is necessary to have a clearly defined period, during which the mood is elevated, expansive, or abnormally and persistently irritable.

* During this period, the person’s activity is either oriented towards a specific objective goal or characterized by disorganized and non-directional energy without a specific goal.

* Symptoms are present most of the time, and this period lasts at least a week, but usually about a month, if not longer.

* If the symptoms are so severe that they warrant hospitalization, the duration criterion is not necessary.

B. At least three symptoms are required at the same time

During this period of mood disturbance and increased energy, at least three of the following symptoms should be present with significant intensity. In addition, these symptoms must represent a significant change from the usual behaviour of this individual. However, if the person’s mood is only irritable, four of the following symptoms should be present.

1. An increase in self-esteem or ideas of grandiosity.

2. Reduced need for sleep, for example, the person feels rested after only three hours of sleep.

3. A greater tendency to communicate than usual or a constant desire to speak.

4. A flight of ideas caused by unnecessary or irrelevant stimuli.

5. An increase in goal-oriented activity (social, occupational, academic or sexual) or psychomotor agitation (i.e., activity without an objective and not goal-oriented).

6. Excessive engagement in activities that may be dangerous (for example, engaging in reckless purchases, risky, inconsistent sexual conduct, or unreasonable financial business investments).

C. Mood disturbance is severe enough to have a negative impact on work or social relationships. or the symptoms are severe enough to make hospitalization necessary, because there are fears of suicide attempts or homicide attempts.

In addition, we see psychotic symptoms, such as visual or auditory hallucinations, or unfounded fixed ideas, which are called delusions.

D. The episode is not due to the psychological effects of a drug, medication or other treatment (except psychotropic medications), or a physical condition.

To conclude this part of the discussion on the symptoms of a diagnosis of a manic episode, it must be understood that criteria A to D occur simultaneously to define a manic episode. At least one episode during life is required for a diagnosis of bipolar disorder, type 1.

If the patient has only hypomanic episodes and depressive episodes, this is not sufficient to make a diagnosis of bipolar disorder, type 1.

We will now continue our discussion with hypomaniac and depressive episodes to better understand the complexities of bipolar disorders.

Graphic representation of mood disorders with mania/depression on the x axis and time along the y axis.

PART 3

THE DIAGNOSIS OF A MAJOR DEPRESSIVE EPISODE in the context of Bipolar Disorder, type 1

A. To diagnose a major depressive episode, all three conditions A, B and C must be met. At least five of the following symptoms occur over a period of at least 2 weeks and represent a change from the patient’s usual behavior. In addition, at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. It is important not to include symptoms from another medical condition.

1. Persistent depressive mood described by the patient (for example, the person feels sad, empty or hopeless), OR the person is observed by others (for example, to cry, self-isolate, become mute or express specific suicidal ideation.

In a child or adolescent, a depressed mood my manifest in the form of irritability.

2. Significant loss of interest or pleasure, in any given situation (as described by the person or as observed by others.

3. Significant loss or gain of weight in the absence of a diet (for example, a modification in total body weight of more than 5% in one month). Acquaintances of the patient might also notice a decrease or increase in appetite almost every day (often without a change in weight). In a child or infant, one must take into account the absence of normal expected weight gain for age and size. *

4. Insomnia or hypersomniaque almost every day.

5. Constant psychomotor retardation or agitation, either described by the patient or his friends or family. Sometimes, these symptoms can include excitation, a feeling of agitation or mental/physical slowness, and a decrease in the speed of movement, in energy and in activities, whether this is voluntary or involuntary.

6. Fatigue or loss of energy almost every day.

7. A feeling of self-deprecation or excessive or inappropriate guilt that can be delusional, almost every day. These feelings are not limited to self-reproach for being ill.

8. A loss in the ability to concentrate or severe indecision almost every day (described by the subject or by others around him).

9. A recurrent desire to be dead (not only a fear of dying), recurrent suicidal ideation without specific plans, suicide attempt(s) or a precise plan for suicide.

B. These symptoms provoke acute distress or a change in the usual social, occupational or personal behavior of the person in everyday life.

C. The episode is not the result of the psychological effects of a substance/drug or of another physical medical illness.

The criteria A through C define a Major Depressive Disorder. Such episodes are very frequent in people who suffer from Bipolar Disorder, type 1, but these depressive symptoms are not required to make its diagnosis. Often the first Major Depressive Episode diagnosed in a patient with Bipolar Disorder, type 1, is first seen several years after the patient’s first manic episode, however this depressive episode may not appear for 5 years, for a decade, or even longer.

In addition, the response to a significant loss (for example, mourning, bankruptcy, financial failure, losses due to a natural catastrophe, a severe medical illness or a severe handicap) can often include a sense of intense sadness, ruminations about the loss, insomnia, a loss of appetite and a significant loss of weight.

These symptoms are included in criterion A and resemble a Major Depressive Episode. They can all be judged understandable and reasonable given the degree of the losses. In such a case, where the cause of the depressive symptoms is unclear, the possibility of a Major Depressive Episode, in combination with a reactive depressive response to the losses, must be seriously considered. This decision calls on the experience and judgement of the physician in the context of his prior relationship with the patient, his level of functioning and the cultural normes of the patient.

A good familiarity of transcultural psychiatry plays an important role in the precise diagnosis of persons from diverse cultures from around the world, especially since massive international migrations are acutely increasing.

In order to be certain of a diagnosis of Bipolar Disorder, type1, is correct, these two important factors must be kept in mind :

1. The patient’s symptoms must meet the criteria of at least one manic episode. (Criteria A through D for “Manic Episode”.

2. The onset of the concerned manic and depressive episodes cannot be better explained by another illness such a schizotypal disorder, schizophrenia, a schizophreniform disorder, a delusional disorder, or another disorder in the spectrum of schizophrenia or other psychotic disorders, specified or non-specified.

PART 4

Other symptoms in favor of a diagnosis of Bipolar Disorder

Often, persons presenting with a manic episode do not perceive themselves as being ill and they vehemently refuse all efforts of treatment. They might change their style of dressing/fashion, their makeup 💄 or their physical appearance to appear more sexually attractive or develop an extravagant style of dress and behavior.

Some people report an acute change in their perception of odors/smells, sounds or visual stimuli. Risky bets and gambling or antisocial behavior can accompany a manic episode. Certain persons can become hostile or physically agressive towards others, and under the influence of delusional thoughts they become physically aggressive or suicidal.

The consequences of a manic episode, often caused by poor judgement, induce a feeling of guilt related to being emotionally ill and/or inappropriately hyperactive. The patient often requires involuntary hospitalization, has conflicts with legal authorities, and serious financial difficulties.

Mood can change very rapidly from extreme euphoria or to a depressive state. Depressive symptoms can develop within a short period of time (several minutes), several hours or more rarely over several days. Please refer to the section of this article where I explain Bipolar Disorder with characteristics of mixed states (having manic and depressive symptoms at the same time or switching back and forth very quickly, as much as several times per day.

Prevalence :

The prevalence over 12 months of Bipolar Disorder, type 1, is estimated at 0.6% of the population of the United States, Canada, Australia, New Zealand and in the 11 countries that make up Western Europe that have equivalent levels of healthcare for emotional illness. The prevalence of Bipolar Disorder, type 1, has not yet been sufficiently studied in developing countries in Asia, Africa, Central America, Mexico, South America or in the Middle East.

Development and Evolution :

The average age of a first manic episode or the first major depressive episode is usually around 18 years of age for Bipolar Disorder, type 1. Particular attention is required to establish this diagnosis in children. Given that children of the same chronological age can be at quite different stages of emotional development, it is often difficult to determine what behaviors are considered “normal” or “expected” for a particular young child.

As a result, each child must be carefully evaluated in terms of what is normal behavior for him or her. The pathology of Bipolar Disorder can have its first onset at any age, including ages as advanced as 60 or 70 years old. Manic symptoms (such as social and sexual disinhibition) that have their onset at mid-life or later should suggest to the clinician that the cause of such behavior might be some sort of underlying medical pathology, especially if the changes include cognitive decline (dementia) or “fronto-temporal” behavioral changes that include personality alteration or acute withdrawal from an illicit substance.

More than 90% of persons who present a manic episode will have additional manic episodes later in life. Around 60% of hypomanic episodes immediately preceded a major depressive episode. Patients presenting with Bipolar Disorder, type 1, with 4 episodes per year (including a Major depressive episode, a Manic episode or a hypomanic episode all within one year) meet the criteria for Rapid-cycling Bipolar Disorder.

Patients who have only cycling between hypomanic episodes and major depressive episodes throughout their life are considered to have Bipolar Disorder, type 2. In general, the psychiatric symptoms are somewhat less intense, however the treatment methods are largely the same.

RISK FACTORS & PROGNOSIS :

ENVIRONMENTAL : The diagnosis of Bipolar Disorder is more frequent in countries where annual income is higher than in countries where many people live in poverty (1.4% vs 0.7%). Persons who are separated, divorced or widowed have a higher risk of presenting with Bipolar Disorder, type 1, compared to people who are married or single. However, these results are difficult to interpret with absolute accuracy. It is generally believed that in countries where the quality of life is higher, the healthcare systems are more highly developed. As a result, more citizens are routinely screened for mental disorders and Bipolar Disorder, so these are found at a higher frequency in wealthier countries. The disparity would seem to indicate a lack of mental health resources and screening in developing countries, which would reflect a lower incidence of Bipolar Disorder in poorer countries.

GENETICS AND PHYSIOLOGY :

A positive family history of Bipolar is one of the major risk factors and is the most clearly established risk factor. The risk of developing Bipolar Disorder is, on average, 10 times higher in a person/patient who has at least one parent affected with Bipolar Disorder, type 1 or 2. The risk increases with the degree of kinship within the family.
Schizophrenia and Bipolar Disorder share common hereditary risk factors, which accounts for a familial cooccurrence for both of these psychiatric disorders.

FACTORS INFLUENCING EVOLUTION :

A subject who has had a manic episode with psychotic features will be more likely to have manic relapses with psychotic features. Better remission between episodes is more common when the manic episode is accompanied by euphoric psychotic disorders, rather than psychotic disorders such as persecution delirium.

DIAGNOSTIC QUESTIONS RELATED TO CULTURE :

There is little evidence of differences in clinical expression of bipolar type I disorder as a function of culture. This can be partly explained by the fact that diagnostic instruments are often translated and used without cross-cultural validation. In an American study, the 12-month prevalence of bipolar type I disorder was significantly lower among Afro-West Indians in the Antillais than among African Americans or Caucasians.

DIAGNOSTIC QUESTIONS RELATED TO GENDER :

Women are at greater risk of developing rapid cycles and mixed states (see below). They are also likely to have different comorbidities than men, such as eating disorders (anorexia and bulimia, for example). Women, regardless of the type of disorder* I or II, are more likely to have depressive symptoms than men. They are also at a greater risk of developing an alcohol use disorder in their lifetime than men and women in the general population.

SUICIDAL RISK :

The risk of suicide in a person with bipolar disorder is estimated to be at least 15 times higher than in the general population. Bipolar disorder could account for a quarter of all suicides. A history of suicide attempts and more days spent in depression in the past year are associated with a higher risk of suicide attempts or suicide.

Graphic representation of variation in mood in Bipolar Disorder and in Cyclothymic Disorder

PART 5

A DESCRIPTION OF HYPOMANIA, OFTEN PART OF A CYCLOTHYMIC DISORDER

Compared to acute episodes of mania, hypomania episodes are characterized by an accumulation of several less severe symptoms. During hypomania episodes, the severity of symptoms, the duration of symptoms and the negative consequences of these symptoms on a person’s life tend to be much less. Moreover, hypomaniac states do not cause psychosis, that is to say that the connection with reality is not broken during these episodes.

The prognosis of a patient with intermittent and recurrent hypomanic episodes over the long term is much more favorable for the future of this person. These people have a high probability of having a very pleasant life, both at work and interpersonal relationships. This is due to the fact that their psychopharmacological treatment is much less restrictive or cumbersome than that of bipolar type I patients. The weekly schedule of verbal psychotherapy is also easier to follow for most people affected.

Having symptoms described in criteria A through E defines a hypomanic episode :

A. At least 4 days of symptoms : A clearly defined period during which the mood is continuously elevated, expansive or abnormally irritable, with an unusual increase in activity or energy level, persistent most of the time, for at least 4 consecutive days.

B. 3 or 4 symptoms are required to diagnose this syndrome. During this period of mood disturbance and increased energy or activity, at least 3 of the following symptoms (4 if the mood is only irritable) must be present with significant intensity and represent a significant change from usual behaviour:

1. Increased self-esteem or ideas of grandiosity.

2. A reduction in the need for sleep 🛌 (for example, the patient feels rested after only 3 hours of sleep).

3. Greater than usual communicability or a constant desire to speak.

4. A flight of ideas ideas or sensations that seem to race through the mind of the person concerned..

5. Distractibility (i.e., attention is too easily distracted by unimportant or irrelevant external stimuli) reported or observed by others.

6. An increase in goal-oriented activity (social, occupational, academic or sexual) or psychomotor agitation.

7. Excessive engagement in activities that can be dangerous (for example, engaging in reckless purchases, risky sexual behaviour or unreasonable financial investments).

C. The episode is not due to the psychological effects of a drug of abuse, medication or other treatment (e.g., psychotropic drugs), or a physical condition.

D. Mood disturbances and changes in functioning are evident to others.

E. The severity of the episode is not sufficient to cause a marked impairment of professional or social functioning, or to require hospitalization. If there are psychotic characteristics, the episode is, by definition, manic.

A graphic representation of the variations in mood in Bipolar Disorder, Major Depressive Disorder or Cyclothymic Disorder.

PART 6

CYCLOTHYMIC DISORDER

Diagnostic criteria for Cyclothymic Disorder(s)

Symptoms required to establish the diagnosis :

1. For at least 2 years, (and at least 1 year in children and adolescents), there are many periods exhibiting hypomanic symptoms without the criteria of a full manic episode being met and many periods during which depressive symptoms are present without the criteria of a full Major depressive episode. Both types of symptomatic periods occur either separately, overlapping partially or at the same time with rapid daily fluctuations or mood cycles.

2. During the two-year period described above (one year in children and adolescents), hypomanic and depressive periods were present for at least half the time and the person did not experience a period of more than two consecutive months without symptoms.

3. The criteria for a manic episode, a hypomanic episode or a major depressive episode have never been met.

4. The symptoms during episodes of mania, hypomania or depression are not better explained by schizoaffective disorder, schizophrenia, a schizophrenic-related disorder, delusional disorder, or specified or unspecified schizophrenia spectrum disorder or other psychotic disorder. (I will explain the symptoms and definitions of diseases that belong to the schizophrenic family in a future article on psychiatric disorders.)

5. The symptoms are not due to the psychological effects of a substance (e.g., illicit drug or medication) or other medical condition (e.g., hyperthyroidism).

6. Symptoms result in clinically significant distress or impairment in all important areas of life the person’s life, including social and occupational functioning, as well, as well as in most very interpersonal relationship.

PART 7

The Differential Diagnosis of Bipolar Disorders with or without the abuse of illicit drugs,or substances :

When a person is affected by bipolar disorder, it is often difficult to diagnose the main or major problem and the problems associated with these morbidities. It is unknown what percentage of these conditions or mixed diseases are inherited, environmental or partially both.

1. Major depressive disorder. It seems obvious that the most difficult differential diagnosis to be made is the one with a major depressive disorder which can be associated with hypomaniac or manic symptoms not meeting the full criteria of an episode (that is, there is either a presence of fewer symptoms or a shorter duration of symptoms than that required to diagnose a hypomanic episode). This is particularly true for subjects with irritability, which may be associated with either a major depressive disorder or bipolar disorder II, where the symptoms of depression and/or mania are somewhat less severe or of shorter duration.

2. Cyclothymic disorder. During cyclothymic disorder, there are many periods with hypomanic symptoms and many periods with depressive symptoms that do not meet the criteria of a major depressive episode. Bipolar disorder II is distinguished from cyclothymic disorder by the presence of at least one major depressive episode. If a major depressive episode occurs after the first two years of a cyclothymic disorder, an additional diagnosis of bipolar disorder II is made.

3. The schizophrenia spectrum of disorders and other related psychotic disorders. Bipolar disorder II must be distinguished from psychotic disorders (for example schizoaffective disorder, schizophrenia and delirious disorders). Schizophrenia, schizoaffective disorders and delirious disorders are characterized by periods of psychotic symptoms that occur in the absence of primary mood symptoms in the foreground, such as depression. Other factors to consider are concomitant psychiatric symptoms, concomitant medical illness with psychological symptoms, past history and family history.

4. Panic disorders and other anxiety disorders. Anxiety disorders should be considered in the differential diagnosis but are often present as associated disorders with many mood disorders.

5. Disorders of substance use/abuse. Disorders of substance use and abuse are included in the differential diagnosis, mainly because of the high incidence of a dual diagnosis of these two disorders.

6. Attention deficit/hyperactivity. Attention deficit/hyperactivity disorder (ADHD) may be confused with bipolar II disorder, especially in children and adolescents. Many symptoms of ADHD, such as rapid speech, thoughts, distractibility and reduced need for sleep, overlap with hypomania symptoms. In order to avoid double-counting of symptoms for both ADHD and bipolar disorder II, it is necessary to identify the existence of distinct episodes and to see if these correspond to a change from the usual behavior in the patient. Additionally, the clinician must be hyper-vigilant in the accuracy of his criteria required for the diagnosis of bipolar disorder II.

7. Personality disorder. The same principle as that used for ADHD applies when evaluating a subject for a personality disorder such as a borderline personality, since emotional lability and impulsivity are dimensions common to both pathologies. For bipolar disorders, the symptoms must be part of an episode and be markedly increased compared to the usual state. A diagnosis of personality disorder should not be made during an untreated episode except when the medical history is in favour of the existence of a personality disorder.

8. Other bipolar or mood disorders. The diagnosis of bipolar disorder II should be differentiated from bipolar disorder, type I by carefully looking for previous episodes of mania, and other specified bipolar disorders. A thorough psychiatric history must be obtained from friends and relatives of the patient to understand the existence and presentation of hypomania, depressive episodes and/or any unspecified mood disorders.

COMORBIDITY

Bipolar disorder II is most often associated with one or more comorbid mental disorders, with anxiety disorders being the most common. Approximately 60% of people with bipolar disorder have at least three associated psychiatric disorders, 75% have an anxiety disorder, and 37% have a substance use disorder. Children and adolescents with bipolar II disorder have a higher incidence of associated anxiety disorders than those with bipolar I disorder and most often, the anxiety disorder precedes the onset of the bipolar disorder. Anxiety disorders and substance use disorders are more common than in the general population. The two or three comorbidities must be treated at the same time as an inpatient or outpatient. The monitoring of illicit substance abuse should be monitored regularly by blood tests and controlled sufficiently before bipolar disorders can be effectively treated by the medical team. There are many mental health treatment centres that specialize in managing the recovery of patients such as these, who are affected by a dual diagnosis, that is, a psychiatric or bipolar disorder and a substance abuse disorder.

PART 8

THE TREATMENT OF BIPOLAR DISORDER AND MOOD DISORDERS : what is the role of psychotropic medications ?

As the evolution of psychopharmacology is changing extremely rapidly, I will not spend much time talking about the treatments of these psychiatric disorders.

3-D image of a Lithium bicarbonate molecule
Molecular formula of lithium

During the 1950s and 1960s, lithium bicarbonate was the basis for the treatment of emotional instabilities, but the effectiveness of this molecule was discovered in the late 19th or early 20th century at thermal springs in Europe. Once discovered, the use of lithium was widespread to stabilize the mood of patients with a wide variety of emotional instability. Even today, lithium is often added to the cocktail of medications for schizophrenics or patients diagnosed with schizoaffective disorder. This later condition has symptoms shared by those with schizophrenia and those with bipolar disorders. The efficacy of lithium also supports a genetic or hereditary link between these two emotional conditions.

Over the decades, multiple psychotropic drugs have been discovered and thoroughly evaluated. Today, there is a huge “armamentarium” of psychotherapeutic possibilities available to regulate mood disorders and mood instability. In fact, this group of emotional disorders is among the most studied and understood. The prognosis for these patients is among the best for almost all psychiatric disorders and most of these patients enjoy the most comprehensive and productive professional and interpersonal relationships with rich lives.

One small disadvantage is that some mood stabilizers require blood tests to determine active blood levels and these patients need to be monitored regularly. However, given the huge improvements in their quality of life, this is considered a rather modest price to pay.

Quality of life has improved significantly among people with bipolar disorders in recent years. When I started working in psychiatry over 40 years ago, the lives of these patients were controlled by their illogical flight of ideas. Today, many people suffering from a form of bipolar disorder are no longer held hostage by their illogical, racing or depressed thoughts. Most can lead a satisfying life at work, in their families, as well as in their social and interpersonal relationships. The prospects for treatment and management of patients with bipolar disorder are expected to improve further in the coming decades.

This is the end of my explanation of Bipolar Disorder. I hope I was able to answer some of your questions to help you understand better this group of related illnesses.

Thank you very much for your interest in this topic. I am open to answering your questions and explaining parts that might have been unclear to you.

Best of health and have a great day ! 🙏👍🤞

Published by Psychiatre, couturier de courtepointes, apprenant perpétuel de français, jardiner

Psychiatre, couturier de courtepointes, apprenant perpétuel de français, jardiner. Ces sont mes passions de la vie et une source de ma propre psychothérapie et mon bonheur.

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