Bipolar affective disorder

In the past, bipolar disorder was considered to be manic depressive disorder or manic depression. Today, it is defined as a severe mental illness that causes the sufferer to engage in life-threatening behavior, destroy personal relationships and careers, and provoke suicidal thoughts - especially if the illness is not treated.

What is bipolar disorder?

Bipolar affective disorder is characterized by sudden mood swings - for example, an overly elevated mood, mania, suddenly changes to a deeply depressed mood, depression. At the same time, between these attacks of mood swings, the person feels quite normal and experiences a mood appropriate to the situation.

The order in which the depressive and manic phases appear is not clear. If the cyclical nature of the disease is not recognized, the diagnosis is incorrect and treatment is seriously hampered. The correct choice of treatment also depends on whether the cyclical mood changes occur quickly or slowly, and whether episodes of mixed and dysphoric mania are present.

"Mania" can be described as a state in which the patient is extremely excited, full of energy, excessively talkative, carefree, feels omnipotent, and is in a state of euphoria. In this state, the patient is prone to excessive spending of money or casual sexual relations. And at one point this elevated mood disappears, irritability, embarrassment, anger and a feeling of hopelessness appear.

And this other mood is called a state of depression, when the patient becomes sad, tearful, feels worthless, experiences a decline in strength, loses interest in entertainment and has problems with sleep.

But since mood swings are strictly individual in each case, bipolar affective disorder is very difficult to diagnose as a disease. In some cases, the state of mania or depression can last for weeks, months, or even years. In other cases, bipolar disorder takes the form of frequent and sudden mood swings.

"There's a spectrum of symptoms and mood states that define bipolar disorder," says Michael Aronson, an allopathic physician. "It's not just about mood swings. In fact, some patients feel great. Mania can be quite productive. People feel like they're doing great."

The trouble comes when this state develops into something more than just a good mood. "Such a change can have disastrous consequences. People behave recklessly, spend a lot of money, lead a promiscuous sex life, which can lead to serious diseases."

As for the depressive phase, it is also life-threatening for the patient: It can cause frequent thoughts of suicide.

It's a difficult disease for families to come to terms with. It's the most complex mental illness that families can't understand, says Aronson. "Families are much more accepting of schizophrenia because they understand it better. With bipolar disorder, they can't understand how someone can be productive and then suddenly become reckless and feeble-minded. It brings chaos to the family. They think it's just bad behavior and not wanting to pull themselves together."

If you feel like something similar is happening in your family or with a loved one, the first thing you should do is see a psychiatrist. Regardless of what diagnosis the doctor makes, bipolar disorder or another mood disorder, there are a number of effective treatments at your disposal. But the most important thing in treatment is your attention and desire to get better.

Bipolar disorders typically begin in young adults, in their 20s and 30s. Lifetime prevalence is about 1%. The prevalence is about equal among men and women.

Bipolar disorder is classified as bipolar I disorder, bipolar II disorder, or bipolar disorder not elsewhere classified, depending on the severity of symptoms and characteristics of episodes. Forms associated with another medical condition or medication use are classified as bipolar disorder due to a general medical condition or drug-induced bipolar disorder.

Cause of Bipolar Disorder

To this day, doctors still don't fully understand what causes bipolar disorder. But over the past 10 years, they've gotten a much better understanding of the wide range of mood swings that characterize it, including the cycle from extreme highs to deep depressions, and all the things that happen in between.

Experts believe that bipolar affective disorder is hereditary and that genetic predisposition plays a major role in its development. There is also undeniable evidence that the patient’s environment and lifestyle affect the severity of his or her illness. Stressful life situations, alcohol or drug abuse make bipolar affective disorder more resistant to treatment.

There is evidence of dysregulation of serotonin and norepinephrine. Stressful life events are often a trigger, although a clear link has not been established.

Bipolar disorder or symptoms of bipolar disorder may occur with a number of medical conditions, as a side effect of many medications, or as part of other mental disorders.

Symptoms of Bipolar Disorder

Symptoms of bipolar disorder can be divided into two types:

• Bipolar depression, which involves feelings of sadness, hopelessness, helplessness, and worthlessness.
• Bipolar mania, in which a person experiences a state of euphoria and increased enthusiasm.

What are the symptoms of bipolar depression?

Symptoms of the depressive phase of bipolar disorder include:

• Depressive mood and low self-esteem
• Frequent bouts of crying
• Loss of strength and an indifferent outlook on life
• Sadness, loneliness, helplessness and guilt
• Slow speech, fatigue, poor coordination and inability to concentrate
• Insomnia or excessive sleepiness
• Thoughts of suicide or death
• Change in appetite (overeating or no appetite at all)
• Drug use: self-medication with drugs
• Constant pain, the origin of which cannot be explained
• Loss of interest and indifference to once favorite activities

What are the symptoms of bipolar mania?

• A state of euphoria or irritability
• Excessive talkativeness, wandering thoughts
• Inflated self-esteem
• Unusual energy; decreased need for sleep
• Use of alcohol or illegal drugs - cocaine or methamphetamines
• Impulsiveness, restless pursuit of pleasure - making senseless purchases, impulsive travel, frequent and promiscuous sexual relations, investing money in risky projects, driving fast in a car
• Hallucinations or illusions (in acute forms of the disease with psychotic tendencies)

Bipolar Disorder - Symptoms

Diagnosis of bipolar disorder

Some patients with hypomania or mania do not report their condition unless specifically questioned. Detailed questioning may reveal morbid signs (e.g., excessive spending, impulsive sexual behavior, abuse of stimulant drugs). This information is often provided by relatives. The diagnosis is based on the symptoms and signs described above. All patients should be asked gently but directly about suicidal thoughts, plans, or actions.

To exclude drug-induced or medically ill patients, the patient's medication history (especially amphetamines, particularly methamphetamine), medications, and medical status should be assessed. Although there are no laboratory tests that are pathagnomonic for bipolar disorder, routine blood tests should be performed to rule out medical disorders; thyroid-stimulating hormone (TSH) should be performed to rule out hyperthyroidism. Other medical disorders (eg, pheochromocytoma) can sometimes complicate the diagnosis. Anxiety disorders (eg, social phobia, panic attacks, obsessive-compulsive disorder) should also be considered in the differential diagnosis.

It took doctors many years to accurately diagnose and recognize the different moods of bipolar disorder. Until recently, doctors lumped bipolar disorder together with schizophrenia, a mental illness that causes incoherent speech, delusions, or hallucinations. Now that doctors know more about mental illness, they can easily distinguish between the symptoms of bipolar depression, hypomania, or mania, and thus prescribe highly effective medication for bipolar disorder.

Many of us are used to the fact that in order to make an accurate diagnosis, it is necessary to undergo numerous examinations and take many tests, sometimes expensive ones. However, when diagnosing bipolar affective disorder, laboratory tests become unnecessary, since their results will not be able to help the doctor in any way. The only diagnostic method that gives an excellent picture of the disease is a frank conversation with the doctor about the patient's mood, behavior and life habits.

While various tests will give your doctor a picture of your overall health, talking openly and describing your bipolar disorder symptoms will give your doctor the opportunity to make a diagnosis and prescribe an effective course of treatment.

• What does a doctor need to know to diagnose bipolar disorder?

Bipolar disorder can be diagnosed only when the doctor listens carefully to all of the patient's symptoms, including their severity, duration, and frequency. The most common symptom of bipolar disorder is sudden mood swings that do not fit into any framework. The patient can also be diagnosed by following the advice given in the Diagnostic and Management Manual of Mental Disorders, Volume 4, which was published by the American Psychiatric Association.

When making a diagnosis, the first question the doctor should ask is whether there is a history of mental illness or bipolar disorder in the patient's family. Since bipolar disorder is a genetic disorder, it is important to be honest with the doctor about any mental illnesses that have occurred in your family.

The doctor will also ask you to describe your symptoms in detail. He may also ask questions that will help him determine your ability to concentrate and think clearly, remember, express your thoughts clearly, and maintain a relationship with your loved one.

• Can other mental illnesses have the same symptoms as bipolar disorder?

Some serious illnesses, such as lupus, AIDS, and syphilis, can have signs and symptoms that at first glance resemble bipolar disorder. This results in misdiagnosis and incorrect treatment.

In addition, scientists claim that bipolar disorder exacerbates symptoms of disorders such as anxiety disorder, obsessive-compulsive disorder, panic disorder, social anxiety disorder, and post-traumatic stress disorder. If left untreated, these disorders will soon cause unnecessary suffering and deterioration.

Another problem that can coexist with bipolar disorder is the use of steroids, which are used to treat rheumatoid arthritis, asthma and allergies, ulcerative colitis, eczema, and psoriasis. These drugs can cause episodes of mania or depression that can be mistaken for symptoms of bipolar disorder.

• What to do before visiting a doctor regarding bipolar disorder.

Before your appointment, write down any symptoms of depression, mania, or hypomania. Often, a friend or close relative will know more about the patient's unusual behavior and will be able to describe them in more detail. Before your appointment, consider the following questions and write down the answers:

1. Are you concerned about your mental and physical health?
2. Symptoms you have noticed
3. Unusual behavior
4. Past illnesses
5. Your family history of mental illness (bipolar disorder, mania, depression, seasonal affective disorder, or others)
6. Medicines you are currently taking or have taken in the past
7. Natural nutritional supplements (if you take them, bring them with you to your doctor's appointment)
8. Lifestyle (exercise, diet, smoking, alcohol or drug abuse)
9. Dream
10. Causes of stress in life (marriage, work, relationships)
11. Any questions about bipolar disorder

• What tests will a doctor perform when diagnosing bipolar disorder?

Your doctor may ask you to fill out a questionnaire that will help you recognize the symptoms and behaviors of bipolar depression, mania, or hypomania. In addition, your doctor may order blood and urine tests to rule out other medical conditions. Your doctor may also order a drug test. Blood tests can help rule out thyroid dysfunction, as this condition is often associated with depression in patients.

• Can a brain ultrasound or x-ray reveal the presence of bipolar disorder?

Although doctors do not rely on such tests to diagnose bipolar disorder, some high-tech scanning devices can help doctors make specific psychiatric diagnoses and see how a patient's body is responding to a prescribed drug. Many of these high-tech devices are widely used to study the effects of medications and their response in the body, including lithium and anticonvulsants, and to better understand the neurotransmission processes that accompany recurrent episodes of the disease.

According to the National Institute of Mental Health, recent research shows that electroencephalograms and magnetic resonance imaging (MRI) scans of the brain can differentiate between bipolar disorder and simple behavioral changes that cause similar symptoms to bipolar disorder in children.

• If I think my loved one has bipolar disorder, how can I help them?

If you suspect that someone you love is developing bipolar disorder, talk to them about your concerns. Ask if you can make an appointment with the doctor and accompany them to the appointment. Here are some tips on how to do this:

• Be sure to tell your doctor that this is the first time you have come to him with such a problem and that he may need more time to conduct the examination.
• Try to write down all your experiences on paper, this will help you tell the doctor everything without forgetting anything.
• Try to clearly describe the essence of the problem, what exactly worries you - bipolar depression, mania or hypomania.
• Describe the patient's mood swings and behavior clearly and in detail to the doctor.
• Describe any severe mood swings, especially anger, depression, or aggression.
• Describe changes in personality characteristics, especially if agitation, paranoia, delusions, or hallucinations occur.

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Prognosis and treatment of bipolar affective disorder

Most patients with hypomania can be treated on an outpatient basis. Acute mania usually requires inpatient treatment. Mood stabilizers are commonly used to induce remission in patients with acute mania or hypomania. Lithium and certain anticonvulsants, especially valproate, carbamazepine, oxcarbazepine, and lamotrigine, act as mood stabilizers and are about equally effective. The choice of mood stabilizer depends on the patient's medical history and the side effects of the particular drug.

Two-thirds of patients with uncomplicated bipolar disorder respond to lithium. A number of mechanisms of therapeutic action have been proposed but are unproven. Predictors of a good therapeutic response to lithium include euphoric mania as part of the primary mood disorder, fewer than two episodes per year, and a personal or family history of a positive response to lithium therapy. Lithium is less effective in patients with mixed states, rapid-cycling forms of bipolar disorder, comorbid anxiety disorders, substance abuse, or neurological disease.

Lithium carbonate is given initially at a dose of 300 mg orally 2 or 3 times daily and titrated up over 7 to 10 days until a blood level of 0.8 to 1.2 mEq/L is achieved. Lithium levels should be maintained between 0.8 and 1.0 mEq/L, usually achieved with 450 to 900 mg of the extended-release form orally 2 times daily. Adolescents with good glomerular function require higher doses of lithium; older patients require lower doses. During a manic episode, the patient retains lithium and excretes sodium; oral doses and blood lithium levels should be higher during acute treatment than during maintenance prophylaxis.

Because lithium has a 4-10 day latency period for its onset of action, antipsychotics may be needed initially; they are given as needed until the mania is controlled. Acute manic psychoses are increasingly being treated with second-generation antipsychotics such as risperidone (usually 4-6 mg orally once daily), olanzapine (usually 10-20 mg once daily), quetiapine (200-400 mg orally twice daily), ziprasidone (40-80 mg twice daily), and aripiprazole (10-30 mg once daily) because they have the least risk of extrapyramidal side effects. For hyperactive psychotic patients with inadequate food and water intake, intramuscular antipsychotics and supportive care for 1 week before initiating lithium treatment are preferred. In uncooperative, quarrelsome manic patients, a depot phenothiazine (eg, fluphenazine 12.5-25 mg intramuscularly every 3-4 weeks) may be used instead of an oral antipsychotic. Many patients with bipolar disorder and mood-incongruent psychotic symptoms beyond the limits of pure mood disorder require intermittent courses of depot antipsychotics. Lorazepam or clonazepam 2-4 mg intramuscularly or orally 3 times daily, given early in acute therapy, may help reduce the antipsychotic dosage required.

Although lithium reduces bipolar mood swings, it does not affect normal mood. Lithium is also thought to have an anti-aggressive effect, although it is unclear whether this effect occurs in people without bipolar disorder. Lithium may cause sedation and cognitive impairment directly or indirectly by causing hypothyroidism. The most common acute, mild side effects are fine tremor, fasciculations, nausea, diarrhea, polyuria, thirst, polydipsia, and weight gain (partially due to drinking high-calorie beverages). These effects are usually transient and often resolve with small dose reductions, divided doses (eg, 3 times daily), or use of slow-release formulations. Once the dosage has been stabilized, the entire dose should be taken after the evening meal. This regimen may improve compliance, and the lower blood levels are thought to protect the kidneys. Beta blockers (eg, atenolol 25-50 mg orally once a day) help with severe tremor. Some beta blockers may worsen depression.

Lithium toxicity primarily manifests as coarse tremors, increased deep tendon reflexes, persistent headache, vomiting, confusion, and may progress to stupor, seizures, and arrhythmias. Toxicity is more common in the elderly and in patients with decreased creatinine clearance or with sodium loss, which may occur with fever, vomiting, diarrhea, or diuretic use. Nonsteroidal anti-inflammatory drugs other than aspirin may contribute to hyperlithemia. Serum lithium levels should be measured, including during periods of dose changes and at least every 6 months. Lithium may precipitate hypothyroidism, especially in patients with a family history of hypothyroidism. Therefore, it is necessary to measure the level of thyroid-stimulating hormone at the beginning of lithium administration and at least annually if there is a family history or symptoms suggestive of thyroid dysfunction, or twice a year for all other patients.

Lithium therapy often leads to exacerbation and chronicity of acne and psoriasis, and may cause nephrogenic diabetes insipidus; these phenomena may decrease with dose reduction or temporary interruption of lithium treatment. Patients with parenchymatous renal disease are at risk of structural damage to the distal tubules. Renal function should be assessed at the beginning of therapy, and serum creatinine levels should be checked periodically thereafter.

Anticonvulsants acting as mood stabilizers, especially valproate, carbamazepine, oxcarbazepine, are often used in the treatment of acute mania and mixed states (mania and depression). Their exact therapeutic action in bipolar disorder is unknown, but may involve a mechanism of action via gamma-aminobutyric acid and ultimately via the G-protein signaling system. Their main advantages over lithium are a wide therapeutic margin and the absence of renal toxicity. The loading dose for valproate is 20 mg/kg, then 250-500 mg orally 3 times a day. Carbamazepine is not prescribed in a loading dose, its dosage should be gradually increased to reduce the risk of toxic effects. Oxcarbazepine has fewer side effects and is moderately effective.

For optimal results, a combination of mood stabilizers is often necessary, especially in severe manic or mixed states. Electroconvulsive therapy is sometimes used when mood stabilizers are ineffective.

Treatment of a primary manic or hypomanic episode with mood stabilizers should be continued for at least 6 months and then gradually tapered. Mood stabilizers are resumed if episodes recur and are converted to maintenance therapy if isolated episodes occur for less than 3 years. Maintenance therapy with lithium should be initiated after 2 classic manic episodes occurring in isolation for less than 3 years.

Patients with recurrent depressive episodes should be treated with antidepressants and mood stabilizers (the anticonvulsant lamotrigine may be particularly effective), as monotherapy with antidepressants (especially heterocyclics) may provoke hypomania.

Rapid Cycling Warning

Antidepressants, even when given with mood stabilizers, may induce rapid cycling in some patients (eg, patients with bipolar II disorder). Antidepressants should not be used prophylactically unless the preceding episode of depression was severe and, if given, for no more than 4-12 weeks. If significant psychomotor agitation or mixed states occur, additional second-generation antipsychotics (eg, risperidone, olanzapine, quetiapine) may stabilize the patient.

To determine the cause of rapid cycling, antidepressants, stimulants, caffeine, benzodiazepines, and alcohol should be gradually discontinued. Hospitalization may be required. Lithium (or divalproex) with bupropion may be considered. Carbamazepine may also be helpful. Some experts combine anticonvulsants with lithium, trying to maintain the dosages of both drugs at 1/2 to 1/3 of their average dose and blood levels within appropriate and safe limits. Since latent hypothyroidism also predisposes to rapid cycling (especially in women), thyroid-stimulating hormone levels should be checked. Thyroid hormone replacement therapy should be performed if thyroid-stimulating hormone levels are high.

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Phototherapy

Phototherapy is a relatively new approach to treating seasonal bipolar disorder or bipolar II disorder (with fall/winter depression and spring/summer hypomania). It is probably most effective as an adjunct.

Can bipolar disorder be cured?

It is impossible to completely cure this disease, but with the help of psychotherapy sessions, mood stabilizers and other medications, you can learn to live a normal and full life. It is also important to note that bipolar disorder is a lifelong mental illness that carries the risk of recurrence of its attacks. In order to be able to control your condition and prevent serious attacks, the patient must constantly take medications and regularly visit the attending physician.

In addition, these people can attend support groups themselves or with their family members, where the former can speak openly about their condition, and the latter can learn to support their loved ones. A patient who has just started a course of treatment simply needs constant support. In addition, studies claim that among patients who receive outside support, there are more working people than among those who do not.

Bipolar Disorder - Treatment

Precautions during pregnancy

Most medications used to treat bipolar disorder should be tapered before or early in pregnancy. Women who wish to have a child should have at least 2 years of effective maintenance therapy in the absence of illness before stopping lithium. Lithium is stopped during the first trimester to avoid the risk of Epstein anomaly, a heart defect. Carbamazepine and divalproex should be stopped during the first trimester of pregnancy because they can cause neural tube defects. Other mood stabilizers (such as lamotrigine, oxycarbazepine) can be prescribed during the second and third trimesters if absolutely indicated, but they should be stopped 1-2 weeks before delivery and resumed a few days after delivery. Electroconvulsive therapy is safer for severe exacerbations during the first trimester of pregnancy. Powerful antipsychotics are relatively safe for early exacerbations of mania. Women taking mood stabilizers should not breastfeed because these medications pass into breast milk.

Education and psychotherapy

Support from loved ones is crucial in preventing major episodes. Group therapy is often recommended for patients and their spouses; they receive information about bipolar disorder, its social consequences, and the essential role of mood stabilizers in treatment. Individual psychotherapy can help the patient better cope with the challenges of everyday life and adjust to the illness.

Patients, especially those with bipolar II disorder, may not adhere to mood stabilizers because they feel that these medications make them less alert and creative. The physician should explain that decreased creativity is unusual because mood stabilizers generally allow for more balanced behavior in interpersonal, academic, occupational, and artistic activities.

Patients should be counseled about the need to avoid stimulants and alcohol, the importance of adequate sleep, and recognizing early signs of exacerbation. If the patient has a tendency to spend money, the funds should be given to a trusted family member. Patients with a tendency to sexual excesses should be informed about the consequences for the family (divorce) and the infectious risks of promiscuity, especially AIDS.

To help patients with bipolar disorder, different types of psychotherapy are used, for example:

• Individual psychotherapy: This is therapy that involves only the patient and a doctor who specializes in bipolar disorder, and focuses on the patient's problems alone. During sessions, the doctor will help the patient come to terms with the diagnosis, learn more about the disease, and teach them how to recognize its symptoms and how to cope with stress.
• Family therapy: Bipolar affective disorder affects one member of the family and thus affects the lives of all its members. During family therapy sessions, family members learn more about the disease and learn to recognize the first signs of mania or depression.
• Group therapy: This type of therapy allows people with similar problems to share their problems and learn stress management techniques together. The peer support method used during group therapy may be the best method to help you change your mind about bipolar disorder and improve your stress management techniques.

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How to avoid bipolar disorder?

Bipolar affective disorder, also known as manic depression, is a mental illness that is characterized by sudden changes from extremely elevated mood to depressed depression. Bipolar affective disorder affects people of all ages, genders, and ethnicities. It is also known that genetics plays an important role in the development of this disease, as scientists have found that this disease is most often inherited within one family.

Since bipolar disorder cannot be prevented, it is important to know its early signs. Recognizing the early symptoms of the disease and visiting your doctor regularly will help you control your mood, ensure effective and safe medication use, and help prevent your condition from getting worse.

Despite the fact that it is absolutely necessary to treat mood swings, scientific research suggests that the initial and primary goal of a doctor should be to prevent the first attacks of mood swings.