CNS 19: Intro to Bipolar Disorder

In this discussion, we will go over presentations of bipolar disorders, types of bipolar disorder, and how to assess patients for bipolar disorder.

Bipolar Disorder Introduction

Bipolar disorder can be difficult to diagnose. Many patients were misdiagnosed, and some were overdiagnosed. It used to be referred to as Manic Depression. Now, we refer to this disorder as bipolar, whereas depression is sometimes referred to as unipolar.

Bipolar disorders affect about 1-5% of the total population. These patients tend to be chronic and have an elevated risk for suicide. In the DSM-5, bipolar disorder is sandwiched between Schizophrenia and Depression. The reason behind this was to have bipolar disorder acts as a bridge between the two groups. There might also be a genetic link between the three disorders.

There are three disorders under the bipolar disorder umbrella:

• Bipolar I Disorder – Manic and Depressive
• Bipolar II Disorder – Hypomania and Depressive
• Cyclothymic Disorder

Among these, there are four different types of episodes/phrases that patients go through:

• Manic Episode – Abnormally elevated or highly irritable mood
  • Must last longer than one week
  • Characterize by an increase in energy
  • Increase risk of impulsive behaviors (gambling, substance use, and sex)
  • Decreased need for sleep
  • Increase in goal-directed activity and flight of ideas
• Hypomanic Episode – Similar to a manic episode, but less severe and for a shorter duration
  • Must last longer than four days
  • No psychotic symptoms
• Major Depressive Episode – Abnormally depressed mood or loss of interest
  • SIG-E-CAPS
• Mixed Episode – Both manic and major depressive at the same time

DSM-5 of Manic Episode

There are four elements:

1. Abnormally persistently elevated and irritable mood for at least 1 week
2. A noticeable change from usual behavior (must have at least 3):
   • Inflated self-esteem
   • Decreased need for sleep
   • More talkative
   • Flight of ideas
   • Distractibility
   • Increase in goal-directed activity
   • Excessive involvement in activity with a high potential for painful consequences
3. Marked impairment in a social or occupational setting
4. Not attributed to other illnesses or medications

There are multiple bipolar specifiers, such as anxious distress, with mixed features during a depressive episode, with rapid cycling (4+ mood episodes in 12 months), with atypical features, or with seasonal patterns.

There is bipolar III and a half, which is a bipolar disorder with substance abuse. These patients experience all two types of presentations, with substance abuse presenting similarly to a depressive episode but with less severity.

DSM-5 criteria for Hypomanic Episode is the same as manic except for the 4 days duration and less in severity. No psychosis and the individual may be able to see a slight increase in job performance.

DSM-5 of Cyclothymic Disorder

There are six elements:

1. Episodes of hypomanic and depression that do not meet hypomania or MDD DSM-5 for at least 2 years
2. The symptoms must be presented for at least half the time of the 2 years without lapsing for longer than 2 months.
3. No history of manic, hypomanic, or depressive episodes
4. Not due to other illness
5. Not due to medications
6. Cause significant impairment in social or occupational functioning

The onset of cyclothymic disorder is usually during adolescence or early adulthood, with a prevalence of around 0.04% to 1%. The primary risk factor is having a first-degree relative with bipolar I.

Prevalence of Bipolar Disorder

There is an estimated 2.8% of adults in the United States with bipolar disorder. There is equal gender representation. The most prevalent age is between 18-29 years.

About 82.9% of patients with bipolar have a serious impairment. This is the highest percentage of serious impairment amount mental disorders.

Patients with bipolar disorder have the highest rate of suicide attempts as well, with an estimated between 25-60% attempted suicide and 4-19% complete suicide.

The rating scales that are commonly utilized are the Young Mania Rating Scale and Sheehan Disability Scale.

Common treatments include lithium (increases the risk of Ebstein’s anomaly,) valproic acid and lamotrigine.

Patients with bipolar disorder require ongoing therapy, mood stabilizers, and family support.