MYTHS ABOUT BIPOLAR DISORDER (BD) can stand in the way of providing appropriate care for persons who have this condition. One myth—that those with BD should be able to control it by will alone— may prevent sufferers from adhering to therapy or from seeking care in the first place. This article helps you improve patient outcomes by explaining what BD is, how it manifests, and how it’s managed.
The sixth leading cause of disability in the world, BD is an episodic, chronic illness affecting approximately 5.7 million adult Americans. It’s marked by extreme changes in mood, thought, behavior, and energy level. Mood swings can vary in intensity, length, and the degree to which they interfere with functioning. Severe mood swings can last weeks or months and may severely disrupt the person’s life.
BD occurs in all races, ethnic groups, and social classes. Although it affects males and females equally, males tend to have an earlier onset. BD reduces life expectancy by 9.2 years, with up to 33% of sufferers attempting suicide and 15% completing it.
About 69% of persons with BD are misdiagnosed, delaying proper treatment 5 to 10 years. The most common misdiagnosis is major de
pressive disorder—probably because most people with BD seek help when they’re so depressed they can’t function, not when they’re having a manic episode and believe they can accomplish anything.
Causes
Research shows that in persons with BD, neuropathologic changes occur in the amygdala, a structure deep within the brain’s temporal lobes that plays a key role in memory and processing of emotions. Studies also reveal abnormal levels of the neurotransmitters norepinephrine, serotonin, dopamine, glutamate, and gamma-aminobutyric acid (GABA) in this area. Norepinephrine plays a role in mood regulation, arousal, and memory; dopamine acts as the brain’s natural reward system. Serotonin is involved in mood regulation, anxiety, pain perception, appetite, sleep, sexual behavior, and impulsive behavior. Glutamate is the primary excitatory neurotransmitter; GABA, the primary inhibitory transmitter. Evidence suggests that levels of norepinephrine, serotonin, and dopamine are decreased in people with depression. Increasing GABA levels and decreasing glutamate levels can improve or stabilize mood.
Research with twins suggests BD is inheritable: When one twin has BD, the other is at high risk for developing it. Also, more than 66% of people with BD have a first-degree relative who suffers from BD or a major depressive disorder. (See Risk factors for bipolar disorder.)
Signs and symptoms
People with BD frequently report experiencing highs (mania) and lows (depression). Men with BD are more likely to present with a manic episode, whereas women are more likely to present with a depressive episode. (See Two types of bipolar disorder.)
A manic episode is a distinct period of abnormally elevated, expansive, euphoric, or irritable and agitated mood that lasts at least a week and severely impairs the ability to function. During this time, the person may think he or she is functioning exceptionally well. According to criteria from the Diagnostic and Statistical Manual of Mental Disorders (4th edition, text revision; DSM-IV-TR), at least three of the following must be present to qualify as a manic episode:
• inflated self-esteem, extreme optimism and self-confidence, excessive irritability, or aggressive behavior
• decreased need for sleep
• increased talkativeness or pressure to keep talking
• flight of ideas or racing thoughts
• distractibility
• increased goal-directed activity or psychomotor agitation
• excessive involvement in pleasurable activities likely to cause negative consequences, such as spending sprees and sexual indiscretions.
Untreated, a manic episode can last 3 to 6 months. Psychotic signs and symptoms, including hallucinations and delusions, may occur and require hospitalization.
Risk factors for bipolar disorder
When evaluating a patient for bipolar disorder(BD),assess for risk factors and associated factors to help identify BD triggers and comorbid conditions. These factors in clude:
• first-degree relative with BD or major depressive disorder
• anxiety disorder
• eating disorders,thyroid disease,migraines,uremia,epilepsy,brain trauma, or stroke
• substance abuse
• use of such drugsassteroids,antidepressants,bronchodilators,dopamine agonists,or pseudoephedrine
• stressful life events,environmental stressors,andlifestyle factors,such as poor sleep hygiene and nutritional habits.
Hypomanic episodes
A hypomanic episode is an abnormally elevated, expansive, or irritable mood lasting at least 4 days that doesn’t severely impair the ability to function. It’s marked by three or more of the features listed above for manic episodes. During this time, the person may appear extremely happy and believe he or she is functioning well, with high productivity and creativity. No psychotic features are present and hospitalization rarely is required
Diagnosis
Diagnosis rests on a thorough history and exclusion of other conditions. Depending on symptom severity, the patient’s perceptions may be incomplete or inaccurate. You may need to interview family members or significant others to obtain a clearer picture of the patient’s signs and symptoms, medical history (including previous bipolar episodes), and family history.
Many clinicians administer the Mood Disorder Questionnaire, a short self-report instrument, to screen for BD and augment a complete mental status assessment. This tool asks whether the patient has experienced symptoms, if multiple symptoms have occurred during the same time period, and how much of a problem the symptoms have caused. The patient’s responses help guide treatment.
Pharmacologictreatment
Acute treatment focuses on decreasing symptoms and restoring the patient’s coping and functioning ability. After stabilization, the goal is to prevent relapse and limit symptom duration and severity. The odds of a relapse are 85% to 95%, with medication noncompliance a major cause.
Mood-stabilizing drugs are the mainstay of treatment. Algorithms developed from randomized controlled drug trials and expert opinion guide treatment. Severe manic or mixed states typically call for either lithium (an antimanic agent) or valproate (an anticonvulsant), plus an antipsychotic. For less severe manic episodes, lithium, valproate, or an antipsychotic may be used alone.
Twotypesofbipolar disorder Thetwomostcommontypesofbipolardisorder(BD)areBDIandBDII.
• BDI is characterized by at least one manic or mixed episode, with most subsequent episodes either manic or depressive.
• BDII is marked by at least one major depressive episode and one hypomanic episode, but never by manic or mixed episodes.
Anticonvulsants
Anticonvulsants, such as valproate, carbamazepine, and lamotrigine, are first-line drugs used alone or in combination with each other or second-generation antipsychotics, because of their mood-regulating efficacy (especially in mania). Valproate and carbamazepine are recommended for mania; both require regular monitoring of plasma drug levels and liver function. Carbamazepine must be used cautiously because it can cause agranulocytosis and anemia; oxcarbazepine can be substituted if needed.
Benzodiazepines are used to manage BD in patients with severe anxiety or insomnia. Some experts recommend clonazepam for its anticonvulsant and GABA-enhancing effects
Lithium
Lithium is still recommended for BD, although it’s less commonly used today than in the past because of its extensive adverse effects, such as polydipsia, polyuria, weight gain, hypothyroidism, acne, and toxicity risk.
MYTHS ABOUT BIPOLAR DISORDER (BD) can stand in the way of providing appropriate care for persons who have this condition. One myth—that those with BD should be able to control it by will alone— may prevent sufferers from adhering to therapy or from seeking care in the first place. This article helps you improve patient outcomes by explaining what BD is, how it manifests, and how it’s managed.The sixth leading cause of disability in the world, BD is an episodic, chronic illness affecting approximately 5.7 million adult Americans. It’s marked by extreme changes in mood, thought, behavior, and energy level. Mood swings can vary in intensity, length, and the degree to which they interfere with functioning. Severe mood swings can last weeks or months and may severely disrupt the person’s life.BD occurs in all races, ethnic groups, and social classes. Although it affects males and females equally, males tend to have an earlier onset. BD reduces life expectancy by 9.2 years, with up to 33% of sufferers attempting suicide and 15% completing it.About 69% of persons with BD are misdiagnosed, delaying proper treatment 5 to 10 years. The most common misdiagnosis is major depressive disorder—probably because most people with BD seek help when they’re so depressed they can’t function, not when they’re having a manic episode and believe they can accomplish anything.CausesResearch shows that in persons with BD, neuropathologic changes occur in the amygdala, a structure deep within the brain’s temporal lobes that plays a key role in memory and processing of emotions. Studies also reveal abnormal levels of the neurotransmitters norepinephrine, serotonin, dopamine, glutamate, and gamma-aminobutyric acid (GABA) in this area. Norepinephrine plays a role in mood regulation, arousal, and memory; dopamine acts as the brain’s natural reward system. Serotonin is involved in mood regulation, anxiety, pain perception, appetite, sleep, sexual behavior, and impulsive behavior. Glutamate is the primary excitatory neurotransmitter; GABA, the primary inhibitory transmitter. Evidence suggests that levels of norepinephrine, serotonin, and dopamine are decreased in people with depression. Increasing GABA levels and decreasing glutamate levels can improve or stabilize mood.Research with twins suggests BD is inheritable: When one twin has BD, the other is at high risk for developing it. Also, more than 66% of people with BD have a first-degree relative who suffers from BD or a major depressive disorder. (See Risk factors for bipolar disorder.)Signs and symptomsPeople with BD frequently report experiencing highs (mania) and lows (depression). Men with BD are more likely to present with a manic episode, whereas women are more likely to present with a depressive episode. (See Two types of bipolar disorder.)A manic episode is a distinct period of abnormally elevated, expansive, euphoric, or irritable and agitated mood that lasts at least a week and severely impairs the ability to function. During this time, the person may think he or she is functioning exceptionally well. According to criteria from the Diagnostic and Statistical Manual of Mental Disorders (4th edition, text revision; DSM-IV-TR), at least three of the following must be present to qualify as a manic episode:• inflated self-esteem, extreme optimism and self-confidence, excessive irritability, or aggressive behavior • decreased need for sleep • increased talkativeness or pressure to keep talking • flight of ideas or racing thoughts • distractibility • increased goal-directed activity or psychomotor agitation • excessive involvement in pleasurable activities likely to cause negative consequences, such as spending sprees and sexual indiscretions. Untreated, a manic episode can last 3 to 6 months. Psychotic signs and symptoms, including hallucinations and delusions, may occur and require hospitalization.Risk factors for bipolar disorderWhen evaluating a patient for bipolar disorder(BD),assess for risk factors and associated factors to help identify BD triggers and comorbid conditions. These factors in clude:• first-degree relative with BD or major depressive disorder • anxiety disorder • eating disorders,thyroid disease,migraines,uremia,epilepsy,brain trauma, or stroke • substance abuse • use of such drugsassteroids,antidepressants,bronchodilators,dopamine agonists,or pseudoephedrine • stressful life events,environmental stressors,andlifestyle factors,such as poor sleep hygiene and nutritional habits.Hypomanic episodesA hypomanic episode is an abnormally elevated, expansive, or irritable mood lasting at least 4 days that doesn’t severely impair the ability to function. It’s marked by three or more of the features listed above for manic episodes. During this time, the person may appear extremely happy and believe he or she is functioning well, with high productivity and creativity. No psychotic features are present and hospitalization rarely is requiredDiagnosis Diagnosis rests on a thorough history and exclusion of other conditions. Depending on symptom severity, the patient’s perceptions may be incomplete or inaccurate. You may need to interview family members or significant others to obtain a clearer picture of the patient’s signs and symptoms, medical history (including previous bipolar episodes), and family history.Many clinicians administer the Mood Disorder Questionnaire, a short self-report instrument, to screen for BD and augment a complete mental status assessment. This tool asks whether the patient has experienced symptoms, if multiple symptoms have occurred during the same time period, and how much of a problem the symptoms have caused. The patient’s responses help guide treatment.PharmacologictreatmentAcute treatment focuses on decreasing symptoms and restoring the patient’s coping and functioning ability. After stabilization, the goal is to prevent relapse and limit symptom duration and severity. The odds of a relapse are 85% to 95%, with medication noncompliance a major cause.Mood-stabilizing drugs are the mainstay of treatment. Algorithms developed from randomized controlled drug trials and expert opinion guide treatment. Severe manic or mixed states typically call for either lithium (an antimanic agent) or valproate (an anticonvulsant), plus an antipsychotic. For less severe manic episodes, lithium, valproate, or an antipsychotic may be used alone.Twotypesofbipolar disorder Thetwomostcommontypesofbipolardisorder(BD)areBDIandBDII. • BDI is characterized by at least one manic or mixed episode, with most subsequent episodes either manic or depressive. • BDII is marked by at least one major depressive episode and one hypomanic episode, but never by manic or mixed episodes.Anticonvulsants Anticonvulsants, such as valproate, carbamazepine, and lamotrigine, are first-line drugs used alone or in combination with each other or second-generation antipsychotics, because of their mood-regulating efficacy (especially in mania). Valproate and carbamazepine are recommended for mania; both require regular monitoring of plasma drug levels and liver function. Carbamazepine must be used cautiously because it can cause agranulocytosis and anemia; oxcarbazepine can be substituted if needed.Benzodiazepines are used to manage BD in patients with severe anxiety or insomnia. Some experts recommend clonazepam for its anticonvulsant and GABA-enhancing effects
Lithium
Lithium is still recommended for BD, although it’s less commonly used today than in the past because of its extensive adverse effects, such as polydipsia, polyuria, weight gain, hypothyroidism, acne, and toxicity risk.
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