Bipolar disorder history and symptoms
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
History and symptoms
Bipolar disorder is a cyclic illness where people periodically exhibit elevated (Manic) and depressive episodes. Most people will experience a number of episodes, averaging 0.4 to 0.7 a year with each lasting 3-6 months.[1] Late adolescence and early adulthood are peak years for the onset of the illness.[2][3] These are critical periods in a young adult's social and vocational development, and they can be severely disrupted by disease onset.
- The manic phase may last from days to months. It can include the following symptoms:
- Easily distracted
- Little need for sleep
- Poor judgment
- Poor temper control
- Reckless behavior and lack of self control
- Binge eating, drinking, and/or drug use
- Poor judgment
- Sex with many partners (promiscuity)
- Spending sprees
- Very elevated mood
- Excess activity (hyperactivity)
- Increased energy
- Racing thoughts
- Talking a lot
- Very high self-esteem (false beliefs about self or abilities)
- Very involved in activities
- Very upset (agitated or irritated)
- These symptoms of mania occur with bipolar disorder I. In people with bipolar disorder II, the symptoms of mania are similar but less intense.
- The depressed phase of both types of bipolar disorder includes the following symptoms:
- Daily low mood or sadness
- Difficulty concentrating, remembering, or making decisions
- Eating problems
- Loss of appetite and weight loss
- Overeating and weight gain
- Fatigue or lack of energy
- Feeling worthless, hopeless, or guilty
- Loss of pleasure in activities once enjoyed
- Loss of self-esteem
- Thoughts of death and suicide
- Trouble getting to sleep or sleeping too much
- Pulling away from friends or activities that were once enjoyed
- There is a high risk of suicide with bipolar disorder. Patients may abuse alcohol or other substances, which can make the symptoms and suicide risk worse.
- Sometimes the two phases overlap. Manic and depressive symptoms may occur together or quickly one after the other in what is called a mixed state.
Diagnosis
Diagnosis is based on the self-reported experiences of the patient as well as abnormalities in behavior reported by family members, friends or co-workers, followed by secondary signs observed by a psychiatrist, social worker, clinical psychologist or other clinician in a clinical assessment. There is a list of criteria that must be met for someone to be so diagnosed. These depend on both the presence and duration of certain signs and symptoms.
An initial assessment includes a comprehensive history and physical examination by a physician. Although there are no biological tests which confirm bipolar disorder, tests are carried out to exclude medical illnesses which may rarely present with psychiatric symptoms. These include blood tests measuring TSH to exclude hypo- or hyperthyroidism, basic electrolytes and serum calcium to rule out a metabolic disturbance, full blood count including ESR to rule out a systemic infection or chronic disease, and serology to exclude syphilis or HIV infection; two commonly ordered investigations are EEG to exclude epilepsy, and a CT scan of the head to exclude brain lesions. There are several psychiatric illnesses which may present with similar symptoms; these include schizophrenia,[4] drug intoxication, brief drug-induced psychosis, schizophreniform disorder and borderline personality disorder.
The last is important as both diagnoses involve symptoms commonly known as "mood swings". In bipolar disorder, the term refers to the cyclic episodes of elevated and depressed mood which generally last weeks or months (notwithstanding Rapid Cycling variant of greater than four episodes a year). The term in borderline personality refers to the marked lability and reactivity of mood, known as emotional dysregulation, due to response to external psychosocial and intrapsychic stressors; these may arise or subside suddenly and dramatically and last for seconds, minutes, hours or days. A bipolar depression is generally more pervasive with sleep, appetite disturbance and nonreactive mood, whereas the mood in dysthymia of borderline personality remains markedly reactive and sleep disturbance not acute.[5]
The relationship between bipolar disorder and borderline personality disorder has been debated; some hold that the latter represents a subthreshold form of affective disorder,[6][7] while others maintain the distinctness, though noting they often coexist.[8][9]
Investigations are not generally repeated for relapse unless there is a specific medical indication. These may include serum BSL if olanzapine has previously been prescribed, lithium or valproate level to check compliance or toxicity with those medications, renal or thyroid function if lithium has been previously prescribed and taken regularly. Assessment and treatment are usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to self or others.
The most widely used criteria for diagnosing bipolar disorder are from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, the current version being DSM-IV-TR, and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems, currently the ICD-10. The latter criteria are typically used in European countries while the DSM criteria are used in the USA or the rest of the world, as well as prevailing in research studies.
Diagnostic criteria
Flux is the fundamental nature of bipolar disorder. Both within and between individuals with the illness, energy, mood, thought, sleep, and activity are among the continually changing biological markers of the disorder. The diagnostic subtypes of bipolar disorder are thus static descriptions—snapshots, perhaps—of an illness in continual change, with a great diversity of symptoms and varying degrees of severity. Individuals may stay in one subtype, or change into another, over the course of their illness. The DSM V, to be published in 2011 , will likely include further and more accurate sub-typing (Akiskal and Ghaemi, 2006).
There are four types of bipolar illness. The Diagnostic and Statistical Manual of Mental Disorders-IV-TR (DSM-IV-TR) details four categories of bipolar disorder, Bipolar I, Bipolar II, Cyclothymia, and Bipolar Disorder NOS (Not Otherwise Specified).
For a diagnosis of Bipolar I disorder according to the DSM-IV-TR, there requires one or more manic or mixed episodes. A depressive episode is not required for the diagnosis of Bipolar I disorder but it frequently occurs.
Bipolar II, which occurs more frequently is usually characterized by at least one episode of hypomania and at least one depression.
A diagnosis of Cyclothymic Disorder requires the presence of numerous hypomanic episodes, intermingled with depressive episodes that do not meet full criteria for major depressive episodes. The main idea here is that there is a low-grade cycling of mood which appears to the observer as a personality trait, but interferes with functioning.
If an individual clearly seems to be suffering from some type of bipolar disorder but does not meet the criteria for one of the subtypes above, he or she receives a diagnosis of Bipolar Disorder NOS (Not Otherwise Specified).
Although a patient will most likely be depressed when they first seek help, it is very important to find out from the patient or the patient's family or friends if a manic or hypomanic episode has ever been present, using careful questioning. This will prevent misdiagnosis of Depressive Disorder and avoids the use of an antidepressant which may trigger a "switch" to hypomania or mania or induce rapid cycling. Recent screening tools such as the Hypomanic Check List Questionnaire (HCL-32) have been developed to assist the quite often difficult detection of Bipolar II disorders.
Delay in diagnosis
The behavioral manifestations of bipolar disorder are often not understood by patients nor recognized by mental health professionals, so people may suffer unnecessarily for over 10 years in some cases before receiving proper treatment.[10]
That treatment lag is apparently not decreasing, even though there is now increased public awareness of this mental health condition in popular magazines and health websites. Recent TV specials, for example the BBC's The Secret Life of the Manic Depressive,[11] MTV's True Life: I'm Bipolar, talk shows, and public radio shows, and the greater willingness of public figures to discuss their own bipolar disorder, have focused on psychiatric conditions thereby further raising public awareness.
Despite this increased focus, individuals are still commonly misdiagnosed.[12]
Children
Children with bipolar disorder do not often meet the strict DSM-IV definition. In pediatric cases, the cycling can occur very quickly (see section above on rapid cycling). Children with bipolar disorder tend to have rapid-cycling or mixed-cycling. Rapid cycling occurs when the cycles between depression and mania occur quickly, sometimes within the same day or the same hour. When the symptoms of both mania and depression occur simultaneously, mixed cycling occurs.
Often other psychiatric conditions are diagnosed in bipolar children. These other diagnoses may be concurrent problems, or they may be misdiagnosed as bipolar disorder. Depression, ADHD, ODD, schizophrenia, and Tourette syndrome are common comorbid conditions. Furthermore some children with histories of abuse or neglect may have Bipolar I Disorder. There is a high comorbidity between Reactive attachment disorder and Bipolar I Disorder with about 50% of children in the Child Welfare System who have Reactive Attachment Disorder also have Bipolar I Disorder[13]
Misdiagnosis can lead to incorrect medication.
On September, 2007, experts (from New York, Maryland and Madrid) found that the number of American children and adolescents treated for bipolar disorder increased 40-fold from 1994 to 2003, and it was increasing ever since. However, the increase was due to the fact that doctors more aggressively applied the diagnosis to children, and not that the incidence of the disorder had increased. The study calculated the number of visits which increased, from 20,000 in 1994 to 800,000 in 2003, or 1% of the population under age 20. [14]
References
- ↑ Kessler, RC; McGonagle, KA; Zhao, S; Nelson, CB; Hughes, M; Eshleman, S; Wittchen, HU; Kendler, KS (1994), "Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States", Archives of General Psychiatry, 51 (1): 8–19
- ↑ Christie KA, Burke JD Jr, Regier DA, Rae DS, Boyd JH, Locke BZ (1988). (abstract) "Epidemiologic evidence for early onset of mental disorders and higher risk of drug abuse in young adults" Check
|url=value (help). Am J Psychiatry. 145: 971–975. Retrieved 2007-07-01. - ↑ Goodwin & Jamison. p121
- ↑ Pope HG (1983). Distinguishing bipolar disorder from schizophrenia in clinical practice: guidelines and case reports. Hospital and Community Psychiatry, 34: 322–328.
- ↑ Goodwin & Jamison. p108-110
- ↑ Akiskal HS, Yerevanian BI, Davis GC, King D, Lemmi H (1985). "The nosologic status of borderline personality: Clinical and polysomnographic study". Am J Psychiatry. 142: 192–198.
- ↑ Gunderson JG, Elliott GR (1985). "The interface between borderline personality disorder and affective disorder". Am J Psychiatry. 142: 277–288.
- ↑ McGlashan, TH (1983). "The borderline syndrome:Is it a variant of schizophrenia or affective disorder?". Arch Gen Psychiatry. 40: 1319–1323.
- ↑ Pope HG Jr, Jonas JM, Hudson JI, Cohen BM, Gunderson JG (1983). "The validity of DSM-III borderline personality disorder: A phenomenologic, family history, treatment response, and long term follow up study". Arch Gen Psychiatry. 40: 23–30.
- ↑ S. Nassir Ghaemi (2001). "Bipolar Disorder: How long does it usually take for someone to be diagnosed for bipolar disorder?". Retrieved 2007-02-20.
- ↑ "The Secret Life of the Manic Depressive". BBC. 2006. Retrieved 2007-02-20.
- ↑ Roy H. Perlis (2005). "Misdiagnosis of Bipolar Disorder". Retrieved 2007-02-20. Unknown parameter
|publication=ignored (help) - ↑ Alston, J., (2000), Correlation between Childhood Biploar I Disorder and Reactive Attachment Disorder, Disinhibited Type. In Attachment Interventions, Edited ty T. Levy, 2000, Academic Press.
- ↑ New York Times, Bipolar Illness Soars as a Diagnosis for the Young