bipolar disorder meaning

I. Introduction to Bipolar Disorder

Mental health includes a person’s emotional, psychological and social well-being. According to WHO , Mental health is a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well, work well, and contribute to their community .So, a good mental health helps to cope with life’s stresses, maintain healthy relationships, better productivity and a higher quality of life. Any kind of mental illness badly affects a person in all aspects of life.

A. Defining Bipolar Disorder

If we talk about Bipolar Definition then we can say that, Bipolar Disorder is a kind of mental illness characterized by episodic disturbance with interspersed periods of decreased and elevated mood, the latter is known as hypomania when mild or short lived, or mania when very severe or chronic. The lifetime risk of developing bipolar disorder is approx., 1-2 %.Mostly it has been observed that bipolar disorder starts at the age of twenty.

B. Historical Perspective

If we talk about history of bipolar disorder, then in 19th century i-e in 1851,a French psychiatrist Jean-Pierre Falret introduced a term “folie circulaire” (circular insanity)which meant a disease that is characterized by both depression and manic episode in a continuous cycle.

Then, in 1957, another classification of bipolar disorder was made by German psychiatrist Karl Leonhard, for the first time he used word Bipolar for people who are having manic symptoms and unipolar for people who experienced depression.

C. Prevalence and Statistics

About prevalence ,different studies and data collected shows that the estimated rate if incidence of bipolar disorder is around 14.3% .There is no difference or any clear demarcation between male and females however ,people aged 20-21 years are mostly the victims of this disorder.

II. Understanding Bipolar Disorder

A. Types of Bipolar Disorder

Types of bipolar disorder are identified to be as:

Bipolar I Disorder

Bipolar I –we say bipolar I where there is at least 1 episode of mania.

Bipolar II Disorder

Bipolar II means 1 episode of depression with may be 1 episode of hypomania of at least 4 days.

Cyclothymic Disorder

Cyclothymia is another type of bipolar disorder but with less severe episodes of depression and hypomania. Another type is bipolar-unspecified type which includes some episodes of usually elevated mood.

B. Causes and risk factor

Genetic Factors

Generally, bipolar disorder strongly heritable (approx., 70%).There are increased chances of having bipolar disorder if you have a first degree relative like parents or siblings with bipolar disorder.

Environmental triggers such as high stress causing life events or major traumas like death of a loved one, or some physical ailment, medication abuse, alcohol abuse can also trigger episodes of bipolar disorder.

Neurochemical Imbalance

Some chemicals called neurotransmitters are released that control functions of our brain. Some studies suggest that sometimes the imbalance in release and control of these chemicals may also cause disturbances in daily mood, sleep cycle, alertness and may contribute to pathogenesis of bipolar disorder. These include Dopamine, Serotonin and noradrenaline .So impaired regulation of these chemicals may also cause some symptoms of bipolar disorder.

III. Signs and Symptoms

First of all, what are the features present in a person affected with bipolar disorder so, its diagnosis is made when a patient presents with episodes of depression and mania. Symptoms include, at times feeling extremely happy, person will have feeling of grandiosity (sense of superiority), excessively talking, less or no sleep, engaging in risky behaviors.

On the other hand, when person has depressive symptoms, then he will be feeling sad or hopeless, lack of energy, concentration problems, thinking of even suicide, sleeping too much. Psychotic symptoms may also occur like delusions and hallucinations.

Latest study about bipolar disorder shows that early warning signs of bipolar disorder include disturbance of sleep pattern, substance misuse, previously episodic depression, increasing self-harm. So if these signs are identified earlier and on time, then it will improve the delay between its diagnosis and starting management.

IV. Diagnosis and Assessment

A. DSM-5 Criteria

There is a criteria for diagnosing bipolar disorder given by American Psychiatric Association in their “Diagnostic and statistical manual of mental disorders (DSM-S)”.According to this criteria ,diagnosis of bipolar disorder is made when there is at least one episode of mania or hypomania. To be considered mania, the elevated, expansive, or irritable mood must last for at least one week and be present most of the day, nearly every day.

To be considered hypomania, the mood must last at least four consecutive days and be present most of the day, almost every day. During this period, three or more of the following symptoms must be present and represent a significant change from usual behavior:

  • Inflated self-esteem or grandiosity
  • Decreased need for sleep
  • Increased talkativeness
  • Racing thoughts
  • Distracted easily
  • Increase in goal-directed activity or psychomotor agitation
  • Engaging in activities that hold the potential for painful consequences e.g., unrestrained buying sprees

The depressive side of bipolar disorder is characterized by a major depressive episode resulting in depressed mood or loss of interest or pleasure in life. The DSM-5 states that a person must experience five or more of the following symptoms in two weeks to be diagnosed with a major depressive episode:

  • Depressed mood most of the day, nearly everyday
  • Loss of interest or pleasure in all, or almost all, activities
  • Significant weight loss or decrease or increase in appetite
  • Engaging in purposeless movements, such as pacing the room
  • Fatigue or loss of energy
  • Feelings of worthlessness or guilt
  • Diminished ability to think or concentrate ,or indecisiveness
  • Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt.

B. Medical Evaluation

A proper history and physical examination should be carried out to rule out any other disorder and to establish a strong and early diagnosis. Symptoms checklist should be checked and observed, it is essential in diagnosing bipolar disorder.

C. Differential Diagnosis

In Bipolar Disorder treatment, Differential diagnosis of bipolar disorder include:

  • Major depressive disorder
  • Attention deficit hyperactivity disorder(ADHD)
  • Schizophrenia
  • Borderline personality disorder(BPD)
  • Substance use disorder
bipolar disorder disorder

V. Treatment Approaches

A. Medication

Mood Stabilizers

Management of bipolar disorder is very important and it all depends on establishing early and good diagnosis and then treating it with proper follow up. The primary management therapies include: Medication and psychological therapy. Main goal should be to achieve anthemia i-e balance of emotions.

Treatment plan depends on thorough assessment, which treatments should be used, which areas need to be most addressed and the plan should be re-evaluated from time to time so that modification can be done according to needs.

Treatment options include pharmacotherapy .Main drugs to be used include mood stabilizers, antidepressants, and antipsychotic medications. Mood stabilizers include Lithium, valproate, lamotrigine, carbamazepine and topiramate. Lithium carbonate is drug of first choice and oldest drug. Side effects include nausea, vomiting, tremors.

Long term can cause weight gain, hypothyroidism, nephrogenic diabetes insipidus and renal failure. Lithium is teratogenic, it affects growth and development of enlarge fetus so it should not be prescribed during first few months of pregnancy. Prophylactic medications include anticonvulsants such as sodium valproate lamotrigine.

Antidepressants

SSRI Antidepressants for Bipolar Disorder

  • Citalopram (Celexa)
  • Escitalopram(Lexapro)
  • Fluoxetine(Prozac)
  • Fluvoxamine(Luvox)
  • Paroxetine(Paxil)
  • Sertraline(Zoloft)

A. Antipsychotics

These are also used in combination if one category is not working for some patients. These include:

  • Chlorpromazine
  • Haloperidol
  • Aripiprazole
  • Olanzapine

B. Psychotherapy

Non-pharmacological therapy includes psychoeducation for patients and for family and caregivers. Psycho education involves simple explanations about nature of illness, treatment options, length of treatment, and side effects of medications identifying early signs. It should be in session, before every new session, feedback should be taken and psycho education should be modified according to needs of patients and caregivers.

Cognitive behavior Therapy (CBT) involves educating patient about illness, about strategies and some analytical skills so that they can better manage their stress and illness.

Interpersonal and social rhythm therapy involves making the routine and social rhythms of patients to a regular level and improving their interpersonal relationships. Basic goal is to teach patient how to prevent a new episode. So, we should be educating them about precipitating factors like stressful life events, poor medication compliance, and interpersonal issues.

In Lifestyle and dietary modification; Patients taking antipsychotic medications are more prove to developing cardiovascular complications and also some metabolic abnormalities so, they should be advised to improve their diet and lifestyle.

C. Family focused Therapy

It involves getting family in touch with psychiatrist who will educate whole family about bipolar disorder, its management by improving their communication, problem solving skills. For this sessions should be told and family members are encouraged to attend every session.

VI Bipolar Disorder across the Lifespan

A. Bipolar Disorder in Children

Well, bipolar disorder is very rare in children but it is possible in younger children generally. In this case, a child will be very much elated, happy with full energy and very active than previous days (Mania). Sometimes child will be less active, looks sad, down (Depression).

B. Bipolar Disorder in the Elderly

Sometimes bipolar disorder starts late like in people aged 50 years and above so its late onset bipolar disorder .Its percentage is low i-e may be 10% .Symptoms will be more towards irritability and agitation in older age. So, about managing it in elderly, medications should be given very carefully considering a drug’s clearance ,elimination, interaction with other medications e.g in case of Lithium, its neural eliminations higher in old age so dose should be adjusted accordingly .Also, it may interact with thiazide diuretics and ACE inhibitors. So these things should be kept in mind while managing bipolar disorder in elderly.

VII Co-occurring Disorders and Complications

People suffering from bipolar disorder may also be a victim of some other mental disorders like anxiety disorder, substance abuse, eating disorder, suicidal behavior disorder .So, managing such patients is very challenging and management goals should be set to cover all these aspects of this disease.

VIII Coping Strategies and Self-Help Techniques

Stress Management

People should be encouraged to engage in stress relaxation techniques like deep breathing, muscle relaxation and medication. Finding about their hobbies and engaging in these activities may also help. Finding the stressors and their cause and trying to treat that cause will also help.

Healthy Habits

It involves active jobs, exercise, yoga, swimming, maintaining a consistent sleep timetable, eating healthy.

Building a support network

Family, friends, healthy get together all these things form a healthy social support network.

IX Stigma and Advocacy

A. Destigmatizing Bipolar Disorder

There is negative impression among people and they have made mental disorders a big stigma in society. These negative cultural opinions and narratives should be discouraged and de-stigmatization should be done .Because stigma increases the risk of suicide in these people and also makes condition more badly. So, efforts should be done to make society aware of this big issue.

Advocacy

Advocacy includes efforts that we can put e.g. posts, share articles, news, stories, sponsoring programs and seminars that highlights these disorders, its diagnosis, and its management.

Conclusion

In summing up, Bipolar disorder is a serious mental disorder which has significant negative impact on life of sufferer and their family. Patients of bipolar disorder can encounter educational and employment problems, psychosocial dysfunctional, marital issues, multiple suicidal attempts and side effects of medications .There are high rates of physical and psychiatric co-morbidities in these patients.

So, seminars and educational conferences should be conducted to spread awareness about this and how to manage it. Treatment teams should be devised that will engage in management of patients affected by these serious mental disorders. Only then, we will be able to improve life of people with mental disorders.

Author: BUSHRA JAVED

BS Human Nutrition and Dietetics, National University of Medical Sciences, Rawalpindi

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