Bipolar Disorders, Classifications and Pathogenesis

gregorkowalnew

Dr Gregor Kowal
Senior Consultant
in Psychiatry and Psychotherapy,
German Board Certified,
Medical Director,
Clinic for Health and Medical Care
Phone: 00971-4-4574240

Bipolar disorder, or manic-depressive illness (MDI), is a severe and usually persistent mental disorder. It is a serious and often a lifelong struggle and challenge. Bipolar Disorder is characterized by episodes of mania or hypomania and episodes of more or less severe depression.

The term “mania” describes a state of extreme euphoria, unjustified optimism, and hyperactivity combined with increased speed of thinking, talking as well as increased motoric activities. The patient may stay awake for several nights not feeling tired. His sexual drive can be increased and the inhibition (conscious control of his actions) decreased. His judgment will be always impaired. Some of the patients will develop delusions and sometimes even hallucinations. Delusions are irrational thoughts; in mania this is usually the delusion of grandeur. The existence of delusional (psychotic) symptoms can be confusing and lead to a misdiagnosis of schizophrenia.

A hypomanic episode is different from full mania. The symptoms are less severe. The person can experience his state as very productive, being very optimistic and feeling happy. The hypomania doesn`t include psychotic symptoms (i.e. delusions). The patient is able to keep some level of control.

1. Types:

The current psychiatric diagnostic manuals (ICD 10 and DSM V) describe two types of bipolar disorder:

– Bipolar Disorder I is the classic manic-depressive form of the illness characterized by episodes of mania and depression

– Bipolar Disorder II shows episodes of hypomania and milder depression

A mixed episode of bipolar disorder is characterized by symptoms of both mania/hypomania and depression occurring together. The patient experiencing a mixed episode might be hyperactive, being unable to sleep or concentrate, feeling at the same time very anxious and depressed. This combination of high energy and low mood makes for a particularly high risk of suicide. Mixed bipolar episodes can resemble Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder. Although the Bipolar disorder II is a full recognized diagnostic entity, it is less reliably diagnosed than Bipolar I. The main reason is that the symptoms are less obvious then those of Bipolar Disorder I.

Bipolar disorder can manifest very different in different people. The symptoms vary in their pattern, severity, frequency and duration. Some patients are more prone to either mania or depression, while others alternate between the two types of episodes.

Some organic diseases, for example hyperthyroidism, illnesses of the central nervous system as well as intoxication, can lead to similar symptoms as bipolar disorder. The diagnosis of the Bipolar Disorder includes a profound anamnesis, physical examination, a battery of tests, EEG as well as a brain scan to exclude an organic cause.

2. Signs and symptoms:

In the manic phase of bipolar disorder the patient subjectively doesn`t feel impaired. In opposite: he feels energetic, creative frequently even euphoric. Patients experiencing a manic episode often talk a mile a minute, sleep very little, and are hyperactive. They feel usually like they`re all-powerful, invincible, or destined for greatness. While mania feels great at first, it has a tendency to spiral out of control. The patient tends to make irrational decisions including making foolish business investments, overbuying, gambling away savings, offending friends and family members or engaging in inappropriate sexual activities. Some patients become even delusional.  

Hypomania is a less severe form of mania. People in a hypomanic state feel euphoric, energetic, and productive, but usually they are still able to carry on with their daily routine, possessing some proof of reality. However, hypomania can also lead to bad decisions that harm relationships, careers, and reputations. Untreated hypomania often escalates to full-blown mania.

In the past, bipolar depression was not differentiated from regular depression. The results of research suggest that there are significant differences between the two. Despite many similarities, certain symptoms are more common in bipolar depression than in regular depression. For example, bipolar depression is more likely to involve irritability, unpredictable mood swings, and feelings of restlessness. The patients suffering from bipolar depression are more likely to develop psychotic symptoms with delusional thoughts and/or delusions. The depressive phase of bipolar disorder can be very severe including risk of suicide. In fact, people suffering from bipolar disorder are more likely to attempt suicide than those suffering from regular depression. Furthermore, their suicide attempts tend to be more lethal.

The most precise diagnostic criteria for identifying a bipolar disorder have been outlined in the DSM V (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition).

Signs and symptoms of Bipolar I Disorder (DSM V):

For a diagnosis of bipolar I disorder, it is necessary to meet the criteria for manic episode and major depressive episode.

Criteria for manic episode in BD I:

 A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day.

 B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behaviour:

1. Inflated self-esteem or grandiosity.

2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).

3. More talkative than usual or pressure to keep talking.

4. Flight of ideas or subjective experience that thoughts are racing.

5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.

6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity).

7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there a psychotic features.

D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition.

Criteria for depressive episode in BD I:

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).

3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or being slowed down).

6. Fatigue or loss of energy nearly every day.

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self- reproach or guilt about being sick).

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or another medical condition.

Signs and symptoms of Bipolar II Disorder (DSM V):

For a diagnosis of bipolar II disorder, it is necessary to meet the following criteria for a current or past hypomanic episode and the following criteria for a current or past major depressive episode:

Criteria for hypomanic episode in Bipolar II:

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.

B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms have persisted (four if the mood is only irritable), represent a noticeable change from usual behavior, and have been present to a significant degree:

1. Inflated self-esteem or grandiosity.

2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).

3. More talkative than usual or pressure to keep talking.

4. Flight of ideas or subjective experience that thoughts are racing.

5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.

6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.

7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.

D. The disturbance in mood and the change in functioning are observable by others.

E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.

F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment).

Criteria for depressive episode in Bipolar II are identical with the listed above criteria for depressive episode in Bipolar I.

3. Cause/Causes:

The cause of bipolar disorder is only partially known. A number of factors contribute in the onset and progression of bipolar disorder, including genetic, biochemical, psychodynamic, and environmental factors. It appears that certain people are genetically predisposed to bipolar disorder but not everyone with an inherited vulnerability develops the illness.

The pathophysiology of bipolar disorder has not been satisfactory determined. The genetic component of bipolar disorder appears to be complex: the disorder is likely to be caused by multiple different alleles, each of which contributes a relatively low degree of risk on its own. Recently several genome-wide association studies of large samples of subjects with bipolar disorder have been published. The analysis of the studies give combined support for 2 particular genes, ANK3 (ankyrin G) and CACNA1C (alpha 1C subunit of the L-type voltage-gated calcium channel). Another genome-wide association study of bipolar disorder detected that the strongest association signals were related to pathways regulated by lithium. The strongest hit was at a marker within the first intron of diacylglycerol kinase eta (DGKH) gene. Three of the other associated genes in this study also interact with the Wnt signalling pathway upstream and downstream of glycogen synthase kinase 3-beta (GSK3β). Other genome studies showed several common single nucleotide polymorphisms within the genes CACNA1C, ODZ4, and NCAN. Those studies suggest a complex gene interaction in bipolar disorder. Findings point also to heterogeneity, with different genes being implicated in the onset of Bipolar Disorder in different families.

The role of genetic factors was already well known. Twin, family, and adoption studies all indicate that bipolar disorder has a genetic component. In fact, first-degree relatives of a person with bipolar disorder are approximately 7 times more likely to develop bipolar disorder than the rest of the population.

External environmental and psychological factors are also believed to be involved in the development of bipolar disorder. These external factors are called triggers. Triggers can set off new episodes of mania or depression or make existing symptoms worse. Such triggering factors like stressful life events, sleep deprivation, substance abuse can trigger bipolar disorder in someone with a genetic vulnerability. These events tend to involve drastic or sudden life changes exposing an individual to a high level of emotional tension. The events could be such as going away to college, getting married or losing a partner or loved one, losing a job, etc.

Psychodynamic factors possess also an important role in Bipolar Disorder. The psychoanalytical observations suggest that the mania serves as a defence against the feelings of depression. Melanie Klein was one of the major proponents of this formulation. Other psychodynamic based studies found that personality disturbances and increased level of neuroticism are often noted in patients with bipolar disorder and may be enduring characteristics.

4. Diagnosis and treatment:

The first step to treat properly bipolar disorder is getting a correct diagnosis. This can be more difficult than it might seem because the symptoms of bipolar can be similar to other major psychiatric disorders, such as schizophrenia, schizoaffective disorder, emotionally unstable personality disorder, ADHD or major depression. The diagnostic procedure includes psychiatric exploration, physical examination, a set of laboratory tests, EEG and brain scan. Those tests can help rule out other contributing factors, especially physical illnesses such as metabolic diseases, inflammatory processes on the central nervous system or cancer.

It`s important to consult an experienced psychiatrist trained in the diagnosis and treatment of bipolar disorder. The psychiatric evaluation includes the personal and family history of the patient as well as the anamnesis from relatives or friends. Proper diagnosis and treatment helps people with bipolar disorder control the symptoms. In most cases, treatment helps reduce the frequency and severity of episodes; in the best case scenario the illness can be completely suppressed lifelong.

Untreated manic or depressive episodes can last for months. Ignoring the problem won`t make it go away. Bipolar disorder tends to worsen if it is not treated. Over time, a person may suffer more frequent and more severe episodes, than when the illness first appeared. Untreated bipolar disorder can end in developing the rapid cycling. Also, delays in getting the correct diagnosis and treatment make the patient more likely to experience personal, social, and work-related problems.

5. Basics of bipolar disorder treatment:

Bipolar disorder requires long-term treatment. Since bipolar disorder is a chronic, relapsing illness, it`s important to continue treatment even when the patient feels better. Most people with bipolar disorder need medication to prevent new episodes and stay symptom-free. Medication alone is usually not enough to fully control the symptoms. The most effective treatment strategy involves a combination of medication, therapy, lifestyle changes, and social support.

Bipolar disorder is a complex condition. Diagnosis can be tricky and treatment is often difficult. For safety reasons, medication and the health status of the patient should be closely monitored. The treatment is always more effective when patients work closely with the doctor and talk openly about his concerns and choices. The treatment plan has to be adjusted due to changing life circumstances. A psychiatrist should guide any changes in type or dose the medication cooperating with the psychotherapist involved in the treatment.

Like other serious illnesses, bipolar disorder is often difficult for spouses, family members and friends. Relatives and friends have to cope with the person`s serious behavioural problems, such as wild spending sprees during mania, extreme withdrawal during depression, poor work or school performance. In the ideal case the relatives and friends has to be integrated into the therapy plan.

6. Facts:

– Bipolar disorder can look very different in different people. The symptoms vary widely in their pattern, severity, and frequency. Some people are more prone to either mania or depression, while others alternate equally between the two types of episodes. Some have frequent mood disruptions, while others experience only a few over a lifetime.

– There are four types of mood episodes in bipolar disorder: mania, hypomania, depression, and mixed episodes. Each type of bipolar disorder mood episode has a unique set of symptoms.

– Rapid cycling describes fast occurring manic-depressive episodes. The patient experiences at least four or more episodes of mania or depression within the period of one year. Rapid cycling may last a few years and then slow down into less frequent episodes; conversely, someone may develop rapid cycling well after being diagnosed with fewer episodes.

– Bipolar disorder usually lasts a lifetime. Episodes of mania and depression can appear again and again over time. Between episodes, many people with bipolar disorder are free of symptoms, but some people may have lingering symptoms. In the best case scenario the symptoms can be fully supressed and the patient remains lifelong symptom free.

– The patient suffering from Bipolar Disorder, which is a lifelong and recurrent illness, needs long-term treatment to maintain control of symptoms. An effective maintenance treatment plan includes medication and psychotherapy for preventing relapse and reducing symptom severity.

– Treatment of patients with bipolar disorder should involve initial and ongoing patient education. For a successful treatment a strong therapeutic alliance is essential. This alliance should include not only the patient but also his family and support system. Such educational efforts increase not only patient compliance but also his quality of life.

– Factors suggesting a worse prognosis include the following: poor job history, alcohol abuse, psychotic features, depressive features between periods of mania and depression, male sex, poor general health condition, inconsistent psychiatric treatment or no treatment at all.

– Factors suggesting a better prognosis are the following: manic phases short in duration, late age of onset, few thoughts of suicide, few psychotic symptoms, good general health condition, consistent psychiatric treatment.

– The age of onset of bipolar disorder varies. For both BPI and BPII, the age range is from childhood to about 50 years, with a mean age of approximately 21 years. Most cases commence when individuals are aged 15-19 years. The second most frequent age range of onset is 20-24 years. At least half of all cases start before age 25.

– Bipolar disorder has no single cause. It appears that certain people are genetically predisposed to bipolar disorder but not everyone with an inherited vulnerability develops the illness, indicating that genes are not the only cause.

– Bipolar disorder tends to run in families. Children with a parent or sibling who has bipolar disorder are four to six times more likely to develop the illness, compared with children who do not have a family history of bipolar disorder.

– A person who has one parent with bipolar disorder has a 15 to 25 percent chance of having the condition.

– Genetics are not the only risk factor for bipolar disorder. Studies of identical twins have shown that the twin of a patient with bipolar illness does not always develop the disorder; only 50 % of the twins will develop the illness. This is important because identical twins share all of the same genes. External environmental and psychological factors are also involved in the development of bipolar disorder. These external factors are called triggers, such as stressful life events, general illnesses, seasonal changes, sleep deprivation, use of drugs.

– Race-related differences in incidence: no racial predilection exists.

– The lifelong prevalence of bipolar disorder in the United States has been noted to range from 1% to 1.6%. Studies indicate differences in lifetime prevalence estimates for BPI, and BPII: 1.0% for BPI, 1.1% for BPII.

– International statistics: lifelong prevalence rate according to the World Health Organization Composite International Diagnostic Interview, determined the aggregate lifetime prevalence for bipolar I disorder: 0.6%, for bipolar II: 0.4%.

– Approximately 25-50% of individuals with bipolar disorder attempt suicide, and 11% actually commit suicide.

7. History:

Variations in moods and the relationship between melancholy (today`s depression) and mania can be traced back to the Ancient Greeks. Aretaeus of Cappadocia, a Greek physician and philosopher from the first century AD described people who “laugh, play, dance night and day, and sometimes go openly to the market crowned, as if victors in some contest of skill” only to be “torpid, dull, and sorrowful” at other times.

The modern psychiatric concept of bipolar disorder has its origins in the nineteenth century. In 1854 two French physicians: Jules Baillarger (1809–1890) and Jean-Pierre Falret (1794–1870) independently presented descriptions of the disorder. On January 31, 1854, Jules Baillarger described to the French Imperial Academy of Medicine a biphasic mental illness causing recurrent oscillations between mania and depression, which he termed folie à double (“dual-form insanity”).  On February 14, 1854, Jean-Pierre Falret presented a description to the Academy on what was essentially the same disorder, which he called folie circulaire (“circular insanity”). Falret observed further that the disorder was more frequent among the members of the same family. He postulated that the illness has a genetic basis.

In the early 1900s the German psychiatrist Emil Kraepelin (1856–1926) studied and categorized the natural course of untreated bipolar patients and found relatively symptom-free intervals between the episodes, where the patient was able to function normally. He called the illness “manic depressive psychosis”. Kraepelin discovered that, in contrast to dementia praecox (today`s schizophrenia), the manic–depressive psychosis had a more benign outcome. Interestingly, Kraepelin didn`t notice the difference between patients with both manic and depressive episodes and people with only depressive episodes.

The terms “manic–depressive illness” and “bipolar disorder” are comparatively recent. The term “manic–depressive reaction” appeared in the first American Psychiatric Association Diagnostic Manual in 1952. Sub classification of bipolar disorder was first proposed by German psychiatrist Karl Leonhard in 1957, who also introduced the terms bipolar (for patients with mania and depression) and unipolar (for those with depression only).

Famous people whom suffered or suffer from Bipolar Disorder:

Ernest Hemingway, American writer

Richard Dreyfuss, actor

Mel Gibson, actor and director

Graham Greene, English writer

Jack Irons, drummer, formerly of Red Hot Chili Peppers and Pearl Jam

Vivien Leigh, actress

Jack London, American writer

Demi Lovato, American actress, singer

Edvard Munch, artist

Sinéad O`Connor, singer, musician

Ozzy Osbourne, singer, musician

Edgar Allan Poe, poet and writer

Jackson Pollock, American artist

Ludwig Boltzmann, physicist and mathematician

Axl Rose, lead singer and frontman best known for Guns N` Roses

Robert Schumann, German composer

Kurt Cobain, musician

Jean-Claude Van Damme, actor

Vincent Van Gogh, artist

Brian Wilson, musician, founding member of The Beach Boys

Amy Winehouse, musician

Virginia Woolf, writer

Catherine Zeta-Jones, actress