Bipolar disorder

Clinic

• Previously known as manic depression, is a mental disorder characterized by periods of depression and periods of abnormally elevated mood
• If the elevated mood is severe or associated with psychosis, it is called mania; if it is less severe, it is called hypomania.
• During mania, an individual behaves or feels abnormally energetic, happy or irritable, and they often make impulsive decisions with little regard for the consequences. There is usually also a reduced need for sleep during manic phases.
• During periods of depression, the individual may experience crying and have a negative outlook on life and poor eye contact with others.
• High risk of suicide
• Other mental health issues, such as anxiety disorders and substance use disorders, are commonly associated with bipolar disorder.
• Bipolar disorder occurs in approximately 1% of the global population
• Exact mechanism underlying the disorder remains unclear

Signs / Symptoms

• Late adolescence and early adulthood are peak years for the onset of bipolar disorder. The condition is characterized by intermittent episodes of mania and/or depression, with an absence of symptoms in between.
• Constant fidgeting during mania
• Slowed movements during depression
• Euphoria or dysphoria and irritability.
• Psychotic symptoms such as delusions or hallucinations may occur in both manic and depressive episodes

Manic episodes

• Elevated or irritable mood which can range from euphoria to delirium
• Core symptom of mania is an increase in energy of psychomotor activity.
• Increased self-esteem or grandiosity, racing thoughts, pressured speech that is difficult to interrupt, decreased need for sleep,
• Disinhibited social behavior
• Increased goal-oriented activities
• Impaired judgement which can lead to exhibition of behaviors characterized as impulsive or high-risk, such as hypersexuality or excessive spending. To fit the definition of a manic episode, these behaviors must impair the individual's ability to socialize or work. If untreated, a manic episode usually lasts three to six months.
• In severe manic episodes, a person can experience psychotic symptoms, where thought content is affected along with mood. They may feel unstoppable, or as if they have a special relationship with God, a great mission to accomplish, or other grandiose or delusional ideas. This may lead to violent behavior and, sometimes, hospitalization in an inpatient psychiatric hospital. The severity of manic symptoms can be measured by rating scales such as the Young Mania Rating Scale, though questions remain about the reliability of these scales.

The onset of a manic or depressive episode is often foreshadowed by sleep disturbance. Manic individuals often have a history of substance use disorder developed over years as a form of "self-medication".

Hypomanic episodes

An 1858 lithograph captioned 'Melancholy passing into mania' Hypomania is the milder form of mania, defined as at least four days of the same criteria as mania, but which does not cause a significant decrease in the individual's ability to socialize or work, lacks psychotic features such as delusions or hallucinations, and does not require psychiatric hospitalization. Overall functioning may actually increase during episodes of hypomania and is thought to serve as a defense mechanism against depression by some. Hypomanic episodes rarely progress to full-blown manic episodes. Some people who experience hypomania show increased creativity, while others are irritable or demonstrate poor judgment.

Hypomania may feel good to some individuals who experience it, though most people who experience hypomania state that the stress of the experience is very painful. People with bipolar disorder who experience hypomania tend to forget the effects of their actions on those around them. Even when family and friends recognize mood swings, the individual will often deny that anything is wrong. If not accompanied by depressive episodes, hypomanic episodes are often not deemed problematic unless the mood changes are uncontrollable or volatile. Most commonly, symptoms continue for time periods from a few weeks to a few months.

Depressive episodes

Main article: Major depressive disorder 'Melancholy' by William Bagg, after a photograph by Hugh Welch Diamond Symptoms of the depressive phase of bipolar disorder include persistent feelings of sadness, irritability or anger, loss of interest in previously enjoyed activities, excessive or inappropriate guilt, hopelessness, sleeping too much or not enough, changes in appetite and/or weight, fatigue, problems concentrating, self-loathing or feelings of worthlessness, and thoughts of death or suicide. Although the DSM-5 criteria for diagnosing unipolar and bipolar episodes are the same, some clinical features are more common in the latter, including increased sleep, sudden onset and resolution of symptoms, significant weight gain or loss, and severe episodes after childbirth.

The earlier the age of onset, the more likely the first few episodes are to be depressive. For most people with bipolar types 1 and 2, the depressive episodes are much longer than the manic or hypomanic episodes. Since a diagnosis of bipolar disorder requires a manic or hypomanic episode, many affected individuals are initially misdiagnosed as having major depression and incorrectly treated with prescribed antidepressants.

Mixed affective episodes

Main article: Mixed affective state

In bipolar disorder, a mixed state is an episode during which symptoms of both mania and depression occur simultaneously. Individuals experiencing a mixed state may have manic symptoms such as grandiose thoughts while simultaneously experiencing depressive symptoms such as excessive guilt or feeling suicidal. They are considered to have a higher risk for suicidal behavior as depressive emotions such as hopelessness are often paired with mood swings or difficulties with impulse control. Anxiety disorders occur more frequently as a comorbidity in mixed bipolar episodes than in non-mixed bipolar depression or mania. Substance (including alcohol) use also follows this trend, thereby appearing to depict bipolar symptoms as no more than a consequence of substance use.

Comorbid conditions

• Anxiety (71% of people with bipolar disorder)
• Substance abuse (56%)
• Personality disorders (36%)
• Attention deficit hyperactivity disorder (10–20%)

Certain medical conditions such as

• Metabolic syndrome (37%)
• Migraine headaches (35%),
• Obesity (21%)
• Type 2 diabetes (14%)

Entities / Miasms

	GSS	STLE	TBE
Emotional lability	+++	+++	+++
Hallucinations / Delusions		+++	+++
Depression	+++	+++
Psychosis	+++