Bipolar Disorder

Key Features

Essentials of Diagnosis

• Episodic mood shifts into mania, major depression, hypomania, and mixed states

• Bipolar I is diagnosed in individuals who have manic episodes

• Bipolar II is diagnosed in individuals who experience hypomanic episodes without frank mania

General Considerations

• Manic episodes

  • Begin abruptly and may be triggered by life stresses

  • Last days to months—generally shorter than depressive episodes

• Cyclothymia

  • Chronic mood disturbances with episodes of subsyndromal depression and hypomania

  • Symptoms are milder than those in a manic or depressive episode, but have at least a 2-year duration

  • Symptoms occasionally escalate to a full-blown manic or depressive episode, warranting a diagnosis of bipolar I or II

Clinical Findings

Symptoms and Signs

• Manic episodes

  • Mood ranging from euphoria to irritability

  • Over-involvement in life activities

  • Flight of ideas with distractibility

  • Sleep disruption, little need for sleep

  • Racing thoughts

  • Behaviors may initially attract others

  • Irritability, mood lability, aggression, and grandiosity usually lead to problems in relationships

  • Excessive spending, resignation from a job, hasty marriage or divorce, sexual acting out, or exhibitionism may occur

  • Atypical episodes involve gross delusions, paranoid ideations, and auditory hallucinations

  • Patients with four or more discrete episodes of a mood disturbance in 1 year have "rapid cycling"

• Most depressions

  • Lowered mood, varying from mild sadness to intense feelings of guilt, worthlessness, and hopelessness

  • Difficulty in thinking, including inability to concentrate, ruminations, and lack of decisiveness

  • Loss of interest, with diminished involvement in work and recreation

  • Somatic complaints such as

    • Headache

    • Disrupted, lessened, or excessive sleep

    • Loss of energy

    • Change in appetite

  • Anxiety

• Some severe depressions

  • Psychomotor retardation or agitation

  • Delusions of a hypochondriacal or persecutory nature

  • Withdrawal from activities

  • Physical symptoms of major severity, eg,

    • Anorexia

    • Insomnia

    • Reduced sexual drive

    • Weight loss

    • Various somatic complaints

  • Suicidal ideation

Differential Diagnosis

• Schizophrenia and other psychotic disorders

• Intoxication with stimulants

• Major depressive episode

• Hypothyroidism

• Persistent depressive disorder (dysthymia)

Diagnosis

Laboratory Tests

• Consider thyroid-stimulating hormone

• Consider toxicology screen

Treatment

Medications

• Antipsychotics

  • Initial treatment for acute manic symptoms includes

    • Olanzapine, 5–20 mg orally

    • Risperidone, 2–3 mg orally

    • Aripiprazole, 15–30 mg orally

    • A benzodiazepine (eg, clonazepam) may be used in conjunction with these agents, if indicated

  • When behavioral control is immediately necessary, the following may be used until symptoms subside

    • Olanzapine, 2.5–10 mg intramuscularly or

    • Haloperidol, 5–10 mg orally or intramuscularly

  • The dosage of the antipsychotic may be gradually reduced after lithium or another mood stabilizer is started

  • Maintenance treatments for bipolar disorder to prevent subsequent cycles of mania and depression include

    • Olanzapine

    • Quetiapine

    • Ziprasidone

    • Aripiprazole

    • Risperidone (the long-acting injectable)

• Valproic acid ...