Bipolar disorders and manic depressive syndrome: causes, symptoms, diagnosis, medication, psychotherapy
Bipolar disorders (formerly called manic-depressive syndrome) are a group of psychiatric disorders characterised by comprising the two extremes of alternating mood disorders: depression and mania (or a less severe form called hypomania)
They affect, with varying intensity, around 4% of the population.
Bipolar disorders affect men and women equally, especially adults, while they are rare in children.
The main bipolar disorders are:
- Bipolar I disorder: the subject has had at least one complete manic episode (such as to inhibit functional normality or including hallucinations) and usually depressive episodes.
- Bipolar II disorder: the subject has had at least one major depressive episode, at least one severe manic episode (hypomania), but no complete manic episode.
However, some subjects have episodes reminiscent of bipolar disorder but do not meet the specific criteria for bipolar I or II disorder.
Such episodes are classified as unspecified bipolar disorder or cyclothymic disorder.
Causes of bipolar disorders
The exact cause of bipolar disorder is not known.
Heredity is believed to be involved in the development of bipolar disorder.
In addition, certain substances produced by the body, such as the neurotransmitters noradrenaline or serotonin, may not be regulated normally (neurotransmitters are substances that nerve cells use to communicate).
Bipolar disorders sometimes arises after a stressful event, or such an event may trigger another episode
However, no causal relationship has been proven. The symptoms of bipolar disorder, depression and mania, can occur in certain diseases, such as in the presence of high levels of thyroid hormones (hyperthyroidism).
In addition, episodes can be triggered by various substances, such as cocaine and amphetamines.
Bipolar disorders, the symptoms
In bipolar disorder, symptomatic episodes alternate with virtually symptom-free periods (remissions).
Episodes may last from a few weeks to 3-6 months.
Cycles (from the date of onset of one episode to the date of the next) vary in duration.
Some individuals present infrequent episodes, perhaps only two in a lifetime, while others experience more than four episodes a year (rapid-cycling bipolar disorder).
Despite this great variability, the duration of the cycle for each person is relatively regular.
Episodes consist of depression, mania or less severe mania (hypomania).
Only a minority of subjects alternate episodes of mania and depression in each cycle.
In most cases, one of the two episodes is partially predominant.
Depression
Depression in bipolar disorder resembles unipolar depression.
The person feels excessively sad and loses interest in his or her activities, thinks and acts slowly, may sleep more than usual, appetite and weight may increase or decrease, and he or she may be overwhelmed by feelings of worthlessness and guilt.
He may not be able to concentrate or make decisions.
Psychotic symptoms (such as hallucinations and fixations) are more common in the depression accompanying bipolar disorder than in unipolar depression.
Mania
Manic episodes end more abruptly than those of depression and are usually shorter, lasting a week or so.
The subject feels exuberant, energetic, exalted or irritable, and may also feel overconfident, act or dress extravagantly, sleep little and talk more than usual.
His thoughts overlap rapidly.
The subject is easily distracted and constantly moves from one topic to another or from one occupation to another; he or she engages in one activity after another (work commitments, betting or dangerous sexual behaviour), without thinking about the consequences (such as loss of money or injury).
However, the subject often tends to believe he or she is in the best possible state of mind and lacks the ability to understand his or her own condition.
This lack, together with the great capacity to act, can make him impatient, intrusive, brash and aggressively irritable when annoyed.
This leads to problems in social relationships and a feeling of injustice or persecution.
Some individuals experience hallucinations, i.e. they see or hear things that are not there.
Bipolar disorders, manic psychosis
Manic psychosis is an extreme form of mania.
The subject presents psychotic symptoms that resemble schizophrenia.
He may have extreme delusions of grandeur, such as believing he is Jesus.
Others may feel persecuted, such as being wanted by the FBI.
The activity level increases dramatically; the subject may run everywhere shouting, swearing or singing.
Psycho-physical activity can be so altered that there is a complete loss of coherent ideation and appropriate behaviour (delusional mania), resulting in extreme exhaustion.
A person so affected requires immediate treatment.
Hypomania
Hypomania is not as severe as mania.
The subject feels cheerful, needs little sleep and is mentally and physically active.
For some subjects, hypomania is a productive state.
One feels energetic, creative and confident, often has positive feedback in social situations and does not necessarily want to leave this fulfilling condition.
Other hypomania sufferers, however, are easily distracted and irritated, sometimes with fits of rage.
The subject often makes commitments that he cannot keep or starts projects that he then does not complete and quickly changes mood; he may recognise these reactions and be upset by them, just like the people around him.
Mixed episodes
When depression and mania or hypomania occur in a single episode, the subject may suddenly start to cry during a moment of exaltation or his thoughts may start to gallop during depression.
Often, the subject goes to bed depressed and wakes up in the early morning feeling exalted and energised.
The risk of suicide in mixed episodes is particularly high.
Diagnosis for bipolar disorders
Diagnosis is based on the characteristic picture of the symptomatology.
However, the subject with mania may not report his symptoms correctly because he believes he has no problems.
For this reason, the doctor often has to obtain information from family members.
The subject and his or her family can use a short questionnaire to help them assess the risk of bipolar disorder.
In addition, the doctor asks the subject if he or she has suicidal thoughts, examines the medication taken to check whether any of it may be contributing to the symptoms, and checks for signs of other illnesses that may be supporting the symptoms.
For example, he or she may request blood tests to check for hyperthyroidism and urine tests to check for drug abuse.
The doctor determines whether the person has manic or depressive episodes so that the correct treatment can be administered.
Treatment of bipolar disorders
For severe mania or depression, hospitalisation is often necessary.
In less severe manic forms, hospitalisation may be necessary during periods of hyperactivity to protect the subject and his or her family from dangerous financial activities and sexual behaviour.
Most subjects with hypomania can be treated without hospitalisation.
Subjects with rapid cycles are more difficult to treat. Without treatment, bipolar disorder recurs in almost all subjects.
Treatment may include:
- phototherapy, which may be useful in treating seasonal bipolar disorder;
- stabilising drugs (mood stabilisers), such as lithium and some anticonvulsants (drugs usually used to treat epileptic seizures);
- antipsychotic drugs;
- antidepressant drugs;
- psychotherapy;
- electroconvulsive therapy, sometimes used when other systems have failed.
Lithium
Lithium can reduce manic and depressive symptoms and in many individuals it helps avoid mood swings.
Since lithium takes 4 to 10 days to take effect, a drug that acts more quickly, such as an anticonvulsant or a newer (second-generation) anti-psychotic drug, is often given to control the manic ideation and activity.
Lithium can have side effects, can cause drowsiness, involuntary spasms (tremors), muscle spasms, nausea, vomiting, diarrhoea, thirst, excessive diuresis and weight gain.
The subject’s acne or psoriasis often worsens.
However, these side effects are usually temporary and the doctor can reduce or mitigate them by adjusting the dosage.
Sometimes, lithium intake must be discontinued due to side effects, which disappear after discontinuation.
The doctor checks the lithium level in the blood with regular blood tests, because if the levels are too high, side effects are more likely to occur.
Long-term use of lithium can lower thyroid hormone levels (hypothyroidism) and, rarely, impair kidney function.
For this reason, regular blood tests should be carried out to monitor thyroid and kidney function.
Lithium toxicity occurs when the level of lithium in the blood is extremely high.
It can cause persistent headache, mental confusion, drowsiness, convulsions and heart rhythm abnormalities.
Side effects are more frequent in the elderly and in persons with renal dysfunction.
Women who wish to become pregnant should discontinue lithium because, in rare cases, it can cause cardiac malformations in the foetus.
Anticonvulsants
The anticonvulsants valproate and carbamazepine can be used to treat mania when it first occurs or to treat both mania and depression when they occur simultaneously (mixed episode).
Unlike lithium, these drugs do not damage the kidneys, however carbamazepine may cause a significant reduction in erythrocyte and leucocyte counts.
Although rare, valproate can damage the liver (mainly in children) or severely damage the pancreas.
With careful medical monitoring, these problems can be detected in time.
Valproate is not recommended in women with bipolar disorder who are pregnant or breastfeeding, as it appears to increase the risks of genetic defects in the brain or spinal cord (neural tube defects) and autism in the foetus.
Valproate and carbamazepine may be useful, especially if the subject has not responded to other treatments.
Lamotrigine is sometimes used to control mood swings, especially during episodes of depression.
Lamotrigine may cause a severe rash. Rarely, the rash evolves into Stevens-Johnson syndrome, which is potentially fatal.
When taking lamotrigine, the subject should watch for the onset of new rashes (particularly around the anus and genitals), fever, glandular enlargement, mouth or eye sores, and swelling of the lips or tongue, and report everything to the doctor.
To reduce the risk of developing these symptoms, the doctor must strictly follow the recommended schedule for increasing the dose.
Taking the drug starts with a relatively low dosage, which is slowly increased (over a few weeks) to the recommended maintenance dose.
If the dose is discontinued for at least 3 days, the gradually increasing schedule must be restarted.
Antipsychotics
Manic episodes are increasingly treated with second-generation antipsychotics, because they act quickly and the risk of serious side effects is lower than with other drugs used to treat bipolar disorder.
Among these drugs are aripiprazole, lurasidone, olanzapine, quetiapine, risperidone and ziprasidone.
For bipolar depression, certain antipsychotics may be the best choice.
Some of them are administered with an antidepressant.
Long-term effects of antipsychotics include weight gain and metabolic syndrome.
Metabolic syndrome is excess fat in the abdomen with reduced sensitivity to the effects of insulin (insulin resistance), hyperglycaemia, abnormal cholesterol levels and high blood pressure.
The risk of such syndrome may be lower with aripiprazole and ziprasidone.
Antidepressants
Some antidepressants are sometimes used to treat severe depression in people with bipolar disorder, but the issue is controversial.
Therefore, these drugs are only used for short periods and are generally administered in combination with a mood-stabilising drug such as an antipsychotic.
Psychotherapy
Psychotherapy is often recommended to individuals undergoing treatment with mood-stabilising drugs, especially to help them follow the treatment as directed.
Group therapy often helps individuals and their partners or family members to understand bipolar disorder and its effects.
Individual psychotherapy can help the subject understand how best to live with the problems in everyday life.
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