Bipolar Disorders: Information, Causes, Sign and Symptoms

Bipolar Disorders

Thorough evaluation of many persons with depression reveals bipolar traits, and as many as one in five patients with a depressive disorder also develops frank hypomania or mania. Most switches from unipolar to bipolar disorder occur within 5 yr of the onset of depressive manifestations. Predictors of a switch include early onset of depression ( 25 yr old), postpartum depression, frequent episodes of depression, quick brightening of mood with somatic treatments (eg, antidepressants, phototherapy, sleep deprivation, electroconvulsive therapy), and a family history of mood disorders for three consecutive generations.

Between episodes, patients with bipolar disorder exhibit depressive moodiness and sometimes high-energy activity; disruption in developmental and social functioning is more common than in unipolar disorder. In bipolar disorder, episodes are shorter (3 to 6 mo), age of onset is younger, onset of episodes is more abrupt, and cycles (time from onset of one episode to that of the next) are shorter than in unipolar disorder. Cyclicity is particularly accentuated in rapid-cycling forms of bipolar disorder (usually defined as 4 episodes/yr).

In bipolar I disorder, full-fledged manic and major depressive episodes alternate. Bipolar I disorder commonly begins with depression and is characterized by at least one manic or excited period during its course. The depressive phase can be an immediate prelude or aftermath of mania, or depression and mania can be separated by months or years.

In bipolar II disorder, depressive episodes alternate with hypomanias (relatively mild, nonpsychotic periods of usually 1 wk). During the hypomanic period, mood brightens, the need for sleep decreases, and psychomotor activity accelerates beyond the patient's usual level. Often, the switch is induced by circadian factors (eg, going to bed depressed and waking early in the morning in a hypomanic state). Hypersomnia and overeating are characteristic and may recur seasonally (eg, in autumn or winter); insomnia and poor appetite occur during the depressive phase. For some persons, hypomanic periods are adaptive because they are associated with high energy, confidence, and supernormal social functioning. Many patients who experience pleasant elevation of mood, usually at the end of a depression, do not report it unless specifically questioned. Skillful questioning may reveal morbid signs, such as excesses in spending, impulsive sexual escapades, and stimulant drug abuse. Such information is more likely to be provided by relatives.

Patients with major depressive episodes and a family history of bipolar disorders (unofficially called bipolar III) often exhibit subtle hypomanic tendencies; their temperament is termed hyperthymic (ie, driven, ambitious, and achievement-oriented).

Symptoms of Bipolar Disorder

Symptoms of the depressive phase are similar to those of unipolar depression (see above), except that psychomotor retardation, hypersomnia, and, in extreme cases, stupor are more characteristic.

In full-blown manic psychosis, the mood is usually elation, but irritability and frank hostility with cantankerousness are not uncommon. Typically, manic patients are exuberant and flamboyantly or colorfully dressed; they have an authoritative manner with a rapid, unstoppable flow of speech. They tend to believe they are in their best mental state. Their lack of insight and their inordinate capacity for activity can lead to a dangerously explosive psychotic state. Interpersonal friction results and may lead to paranoid delusions that they are being unjustly treated or persecuted.

Accelerated mental activity is experienced as racing thoughts by the patient, is observed as flights of ideas by the physician, and, in its extreme form, is difficult to distinguish from the loose associations of the schizophrenic. Easily distracted, patients may constantly shift from one theme or endeavor to another. Thoughts and activities are expansive and may progress into frank delusional grandiosity (ie, false conviction of personal wealth, power, inventiveness, and genius or temporary assumption of a grandiose identity). Some patients believe they are being assisted by external agents. Auditory and visual hallucinations sometimes occur. The need for sleep is decreased. Manic patients are inexhaustibly, excessively, and impulsively involved in various activities without recognizing the inherent social dangers. In the extreme, psychomotor activity is so frenzied that any understandable link between mood and behavior is lost; this senseless agitation is known as delirious mania, which is the counterpart of depressive stupor. Rarely seen in psychiatric practice today, delirious mania constitutes a medical emergency, because patients may die from sheer physical exhaustion.

Mixed states are blends of depressive and manic (or hypomanic) manifestations and distinguish bipolar disorders from their unipolar counterparts. The most typical examples include momentary switches to tearfulness during the height of mania or racing thoughts during a depressive period. In at least 1/3 of persons with bipolar disorders, the entire attack--or a succession of attacks--occurs as a mixed episode. A common presentation consists of a dysphorically excited mood, crying, curtailed sleep, racing thoughts, grandiosity, psychomotor restlessness, suicidal ideation, persecutory delusions, auditory hallucinations, indecisiveness, and confusion. This presentation is referred to as dysphoric mania, ie, prominent depressive symptoms superimposed on manic psychosis. Dysphoric mania often develops in women and in persons with a depressive temperament. Alcohol and sedative-hypnotic abuse contributes to the development or aggravation of mixed states.

Depressive mixed states, which are not specifically characterized in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, are best regarded as intrusions of hypomanic symptoms or hyperthymic traits into a retarded major depressive episode. Antidepressant drugs may aggravate these states by producing a subacute irritable depressive state that lasts many months. The clinical picture consists of irritability, pressure of speech against a background of retardation, extreme fatigue, guilty ruminations, free-floating anxiety, panic attacks, intractable insomnia, increased libido, histrionic appearance yet genuine expressions of depressive suffering, and, in the extreme, suicidal obsessions and impulses. Patients with a depressive mixed state and those with dysphoric mania are at high risk of suicide and require expert clinical management.

Mortality from cardiovascular causes is modestly increased in patients with bipolar disorder; the increase is not explained by cardiotoxicity from lithium or tricyclic antidepressants and tends to also occur in first-degree biologic relatives who do not have frank affective episodes. The increase is probably related to comorbid hypertension, diabetes, and coronary artery disease, all of which are aggravated by nicotine and alcohol dependence, which are prevalent in patients with bipolar disorder.

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