Bipolar Disorder

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Diagnosis and reasoning

This young man has had multiple episodes of abnormal behavior over a 2 month period - a very nonspecific presentation which could be due to a wide range of psychiatric and organic causes. However, a careful review of his history and examination reveals features suggestive of an elevated mood, excessive energy, and most disturbingly, psychotic symptoms. Note that the above is strongly suggestive of an episode of mania; in fact, he does meet the relevant diagnostic criteria defined in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). He has experienced a similar episode in the past, which was then followed by a period of withdrawal and sadness; while the latter is suggestive of an episode of depression, insufficient DSM-5 criteria are present to definitively establish this. Thus, in summary, he appears to have a manic-depressive illness - or in other words, bipolar disorder. The DSM-5 divides bipolar disorder into 7 different categories; this patient best meets the criteria of the bipolar I subtype (i.e. presence of at least one manic episode). That said, it is still essential to rule out other psychiatric and organic conditions which can potentially mimic these signs and symptoms. Key psychiatric diseases which need to be excluded include schizophrenia, borderline personality disorder, panic disorder, and post-traumatic stress disorder (PTSD). Note that the absence of auditory hallucinations and thought disturbances makes schizophrenia unlikely. In addition, while the mental state examination (MSE) reveals grandiose delusions, note that that his appearance, behavior, mood and speech are also disturbed; in delusional disorder, the other aspects of the MSE are usually normal. A personality disorder is also unlikely, given the episodic nature of his symptoms; furthermore, one would not expect to find psychotic symptoms in panic disorder. PTSD is unlikely, given the lack a triggering event. Key organic conditions which need to be excluded include substance abuse, as well as diseases such as hypo- or hyperthyroidism, Cushing's syndrome, head injuries giving rise to frontal lobe damage, multiple sclerosis (MS), neurosyphilis, and rarely systemic lupus erythematosus (SLE). Note that there is no history of abuse of substances such as cocaine, amphetamines, or alcohol; this is corroborated by his family. Nor is there history of brain injury, or clinical findings which would favor Cushing's syndrome, MS or SLE. In addition, a thyroid profile is also normal. Thus, the diagnosis does appear to be bipolar 1 disorder; as he has presented with a fairly severe manic episode, he should be administered a mood stabilizer (such as Lithium), along with an atypical antipsychotic agent such as Olanzepine. In addition, as insomnia may worsen the manic symptoms, a short-term course of benzodiazepines (for example, Lorazepam) should also be considered. Note that atypical antipsychotics have a diabetogenic effect; thus, a baseline fasting plasma glucose is mandatory. Renal functions and serum electrolyte levels should also be estimated, as lithium is excreted by the kidneys, and because hyponatremia can reduce renal excretion of lithium, potentially resulting in life threatening toxicity. Electroconvulsive therapy (ECT) is mainly indicated in patients who prove to be unresponsive to medications, or in whom there is a high risk of suicide, and should not be performed right now.


Discussion

Bipolar disorder is a debilitating psychiatric condition characterized by mood swings that range from depression to mania; it is extremely common worldwide, with an estimated prevalence of 5% to 7%; all genders, races, and ethnicities appear to be equally affected. The underlying pathophysiology is still unclear, although genetic factors are thought to play a significant role; in addition, stressful life events, lack of sleep, and the presence of family members with high expressed emotion are believed to increase susceptibility. The onset of the disease is usually during the mid-teens to mid-twenties, although the time of first presentation is often delayed by several years; affected individuals may present at any phase of the disorder: i.e. with a manic, hypomanic, depressive, or mixed episode. In patients in whom the age of onset is 60 years or more (i.e late-onset bipolar disorder), an underlying organic etiology may be present; possibilities include hypo/hyperthyroidism, Cushing syndrome, head injury causing frontal lobe damage, multiple sclerosis, neurosyphilis, and systemic lupus erythematosus (SLE). The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) describes 7 categories of bipolar disorders; of these, the most common are Bipolar I disorder, Bipolar II disorder, and cyclothymic disorder. Note that the exact diagnostic criteria are easily accessible in the DSM-5, and are thus not further discussed in this monograph. The treatment of bipolar disorder depends on the phase at presentation and the severity of the disease; the optimum management setting (i.e. outpatient vs. in-ward) should be determined following evaluation of the patient's safety and level of functioning. Mild manic or mixed episodes can be treated by monotherapy with a mood stabilizer (such as sodium valproate or lithium) or an antipsychotic; severe symptoms may necessitate use of both these drug classes. Note that atypical antipsychotics are preferred over typical agents, as they have less side effects; olanzapine and risperidone are known to be effective, while clozapine can be used in patients who do not respond to these agents. If the patient is already on antidepressants, these should be tapered off and discontinued. In patients who are significantly disturbed, benzodiazepines such as lorazepam and clonazepam can be used as a short-term adjunctive treatment, so as to prevent insomnia (which is known to worsen the manic symptoms). Individuals who present during a depressive episode are usually treated with either lithium or lamotrigine. In severe cases, an antidepressant may be added, while the presence of co-existent psychotic features may necessitate treatment with an antipsychotic. Monotherapy with antidepressants is not recommended, as this may precipitate a switch from depression into mania. Note also that if the manic or depressive symptoms prove to be uncontrollable with pharmaceutical agents, the use of electroconvulsive therapy (ECT) may be warranted; this may particularly need to be considered in patients with severe or treatment-resistant mania, in individuals experiencing mixed episodes, in pregnant women with severe mania or depression, and in patients with a high suicidal intent or psychosis. Cognitive behavioral approaches may also be beneficial in the long term management, by establishing regular patterns of daily activity, and enhancing self-management of depressive and hypomanic symptoms. Continuous monitoring for resurgence of depression or mania, repeat assessments of the risk of suicide, and treatment of co-existing substance abuse and comorbid medical conditions are other important aspects of the maintenance therapy. In addition, it is essential to educate the patient and their caregivers regarding the risks of relapse and the effectiveness of early intervention. The course and prognosis of bipolar disorder is rather unpredictable; over 90% of patients experience recurrences, while a significant percentage turn into rapid cyclers (i.e. over three episodes per year, with partial or full remissions in-between). These patients are also at increased risk of suicide (10% to 20%), and also have a higher incidence of comorbid psychiatric conditions, as compared to the general population.


Take home messages

  1. Prior to confirmation of the diagnosis of bipolar disorder, treatable organic conditions and substance misuse should be excluded.
  2. Affected patients are at increased risk of suicide, and often may have other psychiatric comorbidities.
  3. The treatment depends on the phase at the time of presentation: hypomanic, manic, depressive, or mixed.
  4. The prognosis and course of the disease is unpredictable, and varies significantly between patients.

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