Bipolar Disorder

Definition | Types of Bipolar Disorder | Aetiology | Risk Factors | Clinical Presentation | Investigations | Management | When to Refer | References

Definition

Bipolar Disorder is a mental health condition characterised by extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). These mood episodes can significantly affect daily functioning and quality of life. Bipolar disorder is a chronic condition that requires long-term management.

Types of Bipolar Disorder

Bipolar disorder is classified into different types based on the pattern and severity of mood episodes:

• Bipolar I Disorder: Characterised by at least one episode of mania that lasts for at least 7 days or is severe enough to require hospitalisation. Depressive episodes are also common and typically last for at least 2 weeks.
• Bipolar II Disorder: Involves a pattern of depressive episodes and hypomanic episodes (less severe than mania) but does not include full-blown manic episodes.
• Cyclothymic Disorder (Cyclothymia): A milder form of bipolar disorder, where individuals experience numerous periods of hypomanic symptoms and depressive symptoms over at least two years, but the symptoms are not severe enough to meet the criteria for hypomania or major depression.
• Bipolar Disorder Not Otherwise Specified (BP-NOS): Diagnosed when symptoms of bipolar disorder are present but do not fit the specific criteria for Bipolar I, II, or Cyclothymia.

Aetiology

The exact cause of bipolar disorder is not fully understood, but it is believed to involve a combination of genetic, biological, and environmental factors:

• Genetic Factors: Bipolar disorder tends to run in families, suggesting a genetic predisposition. First-degree relatives of individuals with bipolar disorder are at higher risk.
• Neurochemical Imbalance: Dysregulation of neurotransmitters such as dopamine, serotonin, and norepinephrine is thought to contribute to the mood swings associated with bipolar disorder.
• Brain Structure and Function: Imaging studies have shown differences in the brain structure and function of individuals with bipolar disorder, particularly in areas related to mood regulation.
• Environmental Triggers: Stressful life events, such as trauma, significant loss, or major life changes, can trigger or exacerbate mood episodes in susceptible individuals.

Risk Factors

Several factors increase the likelihood of developing bipolar disorder:

• Family History: Having a first-degree relative with bipolar disorder or another mood disorder increases the risk.
• Early Onset: Symptoms often begin in adolescence or early adulthood, and early onset is associated with a more severe course of the illness.
• Stressful Life Events: Traumatic experiences or significant life changes can act as triggers for the onset of mood episodes.
• Substance Abuse: The use of drugs or alcohol can trigger or worsen mood episodes and complicate the course of the disorder.

Clinical Presentation

Bipolar disorder presents with a range of symptoms depending on the type and phase of the mood episode:

Manic or Hypomanic Episode

• Euphoric or Irritable Mood: A period of abnormally elevated or irritable mood, lasting at least 7 days for mania and 4 days for hypomania.
• Increased Energy: Unusually high levels of energy, decreased need for sleep, and hyperactivity.
• Grandiosity: Inflated self-esteem or unrealistic beliefs in one's abilities or importance.
• Racing Thoughts: Rapid, disorganised thinking and difficulty focusing.
• Impulsivity: Engaging in risky behaviours, such as reckless spending, sexual indiscretions, or substance abuse.

Depressive Episode

• Low Mood: Persistent feelings of sadness, emptiness, or hopelessness.
• Anhedonia: Loss of interest or pleasure in activities that were once enjoyable.
• Fatigue: Lack of energy and excessive tiredness, even after adequate rest.
• Sleep Disturbances: Insomnia or hypersomnia, often with difficulty waking up or excessive sleeping.
• Feelings of Worthlessness: Excessive guilt, feelings of worthlessness, or self-blame.
• Suicidal Thoughts: Thoughts of death, suicide, or self-harm.

Investigations

The diagnosis of bipolar disorder is primarily clinical, based on a detailed history and mental health assessment. Additional investigations may be necessary to rule out other conditions:

• Psychiatric Assessment: A thorough mental health evaluation, often including structured interviews.
• Medical History and Physical Examination: To rule out medical conditions that could mimic or contribute to mood symptoms, such as thyroid disorders.
• Laboratory Tests: Blood tests, including thyroid function tests, full blood count (FBC), and electrolyte levels, to exclude physiological causes of mood symptoms.
• Imaging Studies: MRI or CT scans may be considered if there are neurological symptoms or if there is a need to rule out brain lesions or structural abnormalities.

Management

The management of bipolar disorder involves a combination of pharmacological treatments, psychological therapies, and lifestyle modifications:

Pharmacological Treatments

• Mood Stabilizers: Lithium is a first-line treatment for managing both manic and depressive episodes and for long-term mood stabilisation. Alternatives include valproate and carbamazepine.
• Atypical Antipsychotics: Medications such as olanzapine, quetiapine, and aripiprazole are used to manage acute manic episodes and as adjunctive therapy in depressive episodes.
• Antidepressants: May be used cautiously and typically in combination with a mood stabiliser to avoid triggering manic episodes.
• Anxiolytics: Benzodiazepines may be used short-term for managing agitation or anxiety during acute episodes.

Psychological Therapies

• Cognitive Behavioural Therapy (CBT): Helps individuals recognise and change negative thought patterns and behaviours, and develop coping strategies for managing mood episodes.
• Psychoeducation: Educating patients and their families about bipolar disorder, its course, and treatment options, to improve adherence and reduce relapse rates.
• Family Therapy: Involves the family in treatment, improving communication and providing support to the individual with bipolar disorder.

Lifestyle Modifications

• Regular Sleep Patterns: Maintaining a consistent sleep schedule to help stabilise mood.
• Healthy Diet and Exercise: A balanced diet and regular physical activity can improve overall well-being and reduce the impact of mood swings.
• Avoidance of Triggers: Identifying and managing potential triggers, such as stress, substance use, and sleep deprivation.
• Stress Management: Techniques such as mindfulness, meditation, and relaxation exercises to manage stress and reduce the risk of mood episodes.

When to Refer

Referral to a specialist mental health service or psychiatrist is necessary in the following situations:

• Severe or treatment-resistant bipolar disorder that does not respond to initial therapies or requires more intensive management.
• Presence of co-occurring mental health conditions, such as substance use disorders, anxiety disorders, or personality disorders.
• Risk of suicide, self-harm, or harm to others, necessitating urgent intervention and possible hospitalisation.
• Need for specialised psychological therapies, such as CBT or IPSRT, that are not available in primary care settings.

References

1. NHS (2024) Bipolar Disorder. Available at: https://www.nhs.uk/conditions/bipolar-disorder/ (Accessed: 26 August 2024).
2. National Institute for Health and Care Excellence (2024) Bipolar Disorder: Assessment and Management. Available at: https://www.nice.org.uk/guidance/cg185 (Accessed: 26 August 2024).
3. British Medical Journal (2024) Bipolar Disorder: Clinical Review. Available at: https://www.bmj.com/content/350/bmj.h568 (Accessed: 26 August 2024).

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