Bipolar Disorder is a mental health condition characterized by extreme mood swings that include emotional highs (mania or hypomania) and lows (depression).
Causes
- Genetic Factors: A strong hereditary component, as bipolar disorder is more common in individuals with a family history of the condition.
- Neurochemical Imbalances: Dysregulation of neurotransmitters and hormonal imbalances in the brain.
- Environmental Factors: Stressful life events, trauma, and substance abuse can trigger episodes or exacerbate the condition.
- Brain Structure and Function: Brain scans have shown differences in the brain structure and function of people with bipolar disorder.
Diagnosis
- History
- Mood Episodes: History of manic, hypomanic, or major depressive episodes.
- Behavioral Changes: Risk-taking behaviors, decreased need for sleep, unusual talkativeness, racing thoughts, distractibility, or irritability during manic phases; fatigue, withdrawal, low self-esteem, or suicidal thinking during depressive phases.
- Duration and Impact: Symptoms should be severe enough to cause noticeable difficulty at work, at school, in social activities, or in relationships.
- Physical Examination
- General Exam: To rule out physical health problems that could be causing or contributing to mood disturbances.
- Neurological Exam: To assess for any neurologic abnormalities.
- Investigations
- Mental Health Assessment: Including detailed personal and family psychiatric history.
- Screening for Substance Abuse: Substance use can mimic or worsen bipolar disorder.
- Lab Tests: Thyroid function tests, full blood count, and basic metabolic panel to rule out medical causes of mood swings.
Differential Diagnosis (DDx)
- Bipolar I vs Bipolar 2
- In Bipolar I manic episodes +/- depression
- In Bipolar II depression + hypomania (often misdiagnosed as depression)
- Major Depression
- Schizophrenia
- Personality Disorders
- Attention Deficit Hyperactivity Disorder (ADHD)
- Substance-Induced Mood Disorder
- Anxiety Disorders
Management
- Pharmacological
- Mood Stabilizers: Lithium, lamotrigine, valproate
- Antipsychotics: Olanzapine, quetiapine, lurasidone
- Antidepressants: Sometimes used, but cautiously, as they can trigger mania.
- SSRI + a mood stabiliser or antipsychotic
- Psychotherapy
- Cognitive Behavioral Therapy (CBT)
- Family-Focused Therapy
- Psychoeducation
- Interpersonal and Social Rhythm Therapy
- Lifestyle and Home Remedies
- Regular Sleep Patterns
- Healthy Diet and Regular Exercise
- Avoiding Alcohol and Illicit Drugs
Monitoring and Follow-up
- Regular follow-up to monitor medication effects and mood stability.
- Close monitoring for signs of relapse, suicidal thoughts, or side effects of medication (weight gain)
Referral
- Referral to a psychiatrist for diagnosis and management, particularly for complex cases or those with suicidal ideation.
Patient Education
- Educate about the nature of bipolar disorder, importance of medication adherence, and recognition of early signs of mood episodes.
Bipolar disorder is a lifelong condition that can be effectively managed with a combination of medication and psychotherapy. Treatment plans must be individualized, often requiring adjustments over time, and should involve close monitoring for effectiveness and side effects.
Bipolar I vs Bipolar II
Bipolar I and Bipolar II are both subtypes of Bipolar Disorder, but they differ primarily in the severity and duration of the manic episodes.
- Bipolar I Disorder
- Manic Episodes: The defining characteristic of Bipolar I is the occurrence of one or more manic episodes, which are distinct periods of abnormally and persistently elevated, expansive, or irritable mood. Manic episodes in Bipolar I:
- Last at least one week.
- Are severe enough to require hospitalization or cause marked impairment in social or occupational functioning.
- Include symptoms like inflated self-esteem or grandiosity, decreased need for sleep, increased talkativeness, racing thoughts, distractibility, increased goal-directed activity, or excessive involvement in risky behaviors.
- Depressive Episodes: While depressive episodes often occur in Bipolar I, they are not required for the diagnosis.
- Psychotic Symptoms: Can occur during severe episodes (either manic or depressive), such as delusions or hallucinations.
- Severity: Generally, Bipolar I is considered more severe than Bipolar II, with manic episodes that are more intense and disruptive.
- Manic Episodes: The defining characteristic of Bipolar I is the occurrence of one or more manic episodes, which are distinct periods of abnormally and persistently elevated, expansive, or irritable mood. Manic episodes in Bipolar I:
- Bipolar II Disorder
- Hypomanic Episodes: Bipolar II is characterized by the presence of one or more hypomanic episodes. Hypomanic episodes are similar to manic episodes but:
- Last at least four consecutive days.
- Are noticeable to others but not severe enough to cause significant functional impairment or require hospitalization.
- Do not include psychotic features.
- Major Depressive Episodes: Bipolar II requires the occurrence of one or more major depressive episodes that last at least two weeks and are often more frequent and longer-lasting than in Bipolar I.
- No Full Manic Episodes: A key difference is that individuals with Bipolar II have never experienced a full manic episode.
- Severity: While the hypomanic episodes in Bipolar II are less severe than the manic episodes in Bipolar I, the depressive episodes are often as severe as in Bipolar I and can be more debilitating due to their frequency and duration.
- Hypomanic Episodes: Bipolar II is characterized by the presence of one or more hypomanic episodes. Hypomanic episodes are similar to manic episodes but:
- Commonalities and Treatment
- Cyclic Nature: Both disorders involve clear changes in mood, energy, and activity levels, and can significantly impact daily functioning.
- Treatment: Both conditions are typically treated with mood stabilizers, psychotherapy, and sometimes antidepressants (used cautiously).
- Important Considerations
- Diagnosis: Accurate diagnosis can be challenging but is crucial for effective treatment.
- Impact: Both disorders can be equally disabling, although Bipolar I may be more disruptive due to the severity of manic episodes.
- Misdiagnosis Risk: Bipolar II is often misdiagnosed as Major Depressive Disorder due to the prominence of depressive episodes and the less extreme nature of hypomanic episodes.
Understanding the distinction between these subtypes is essential for appropriate treatment and management, as the strategies and medications may vary based on the specific features of the individual’s episodes.