Bipolar disorder is characterized by dysregulation of mood including episodes of increased mood, low mood and mixed.
Signs and Symptoms
- Irritability and self-important ideas
- Cheerfulness
- Overactive behavior
- Easily distractible
- Starting activities and leaving them unfinished
- Spending money lavishly and in useless ways
- Reduced sleep but waking up feeling energetic
- Increased appetite
- Increased libido and rapid
- Copious speech
- Thinking pattern can also be altered by having self-expansive ideas of having super powers
- Paranoid ideas as people trying to hurt due to jealousy against their super powers
- Episodes of increased mood or else known as manic episodes include increased level of activity
Mixed mood is characterized by either a mixture or a very rapid alternation between manic and depressive symptoms on most days during a period of at least 2 weeks.
Depressed mood can be defined as a period of almost daily low mood, lack of interest in activities lasting at least two weeks accompanied by other symptoms such as reduced concentration and feelings of unworthiness.
Diagnostic Criteria According to ICD-11 Bipolar type I disorder is an episodic mood disorder defined by the occurrence of one or more manic or mixed episodes. Although the diagnosis can be made with an occurrence of a single manic or mixed episode normally, they alternate with depressive episodes over the course of disease.
Etiology
Biological Factors
Genetic factors have a predisposition towards bipolar
Antidepressants, corticosteroids and several other medications are known to precipitate manic episodes
Brain tumors, multiple sclerosis and systemic lupus erythematosus also can cause elation of mood
Psychological and Social Factors
Adverse life events and substance use can precipitate illness
Management
Main goals of management in bipolar disorder are minimizing relapses, ensuring optimal functioning in between episodes and treating acute episodes.
Risk Assessment of a Bipolar Patient
Risk for harming themselves or others, risk of social disinhibition, over spending, persecutory/ paranoid ideas and sexual disinhibition due to increased libido must be accessed. According to the risk assessment, high risk patients must be treated after admitting them to the psychiatry ward in hospital.
First step in management after admission is providing a supportive environment to the patient and minimizing harm. If the patient is severely disturbed, can be tranquilized rapidly.
Pharmacological Management
Antipsychotics as Olanzapine, Risperidone, Mood Stabilizers as Lithium carbonate, Sodium Valproate and Carbamazepine, and Benzodiazepines can be used in acute manic episodes.
In long term treatment atypical antipsychotics and a single mood stabilizer will be given as first line treatment. The first line mood stabilizer is Lithium which must be given very cautiously.
Before starting Lithium baseline investigations as Serum Creatinine, Serum Electrolytes, ECG and Thyroid Function Tests must be done. After drug is started Serum lithium level must be checked once in 6 months, thyroid and renal function must be checked once a year and weight must be checked in every clinic visit. Must be informed patients to be cautious about the effects of Lithium toxicity including vomiting, diarrhea, coarse tremor, blurred vision and muscle weakness.
Non Pharmacological Management
Relapses must be prevented by maintaining compliance to drugs, educating the patient and family about the illness, minimizing alcohol consumption, getting regular and adequate sleep and avoiding stressors. Family support must be ensured through counseling to family members or through help of social workers.
Wellbeing of patients must be maintained by providing support and counseling to deal with issues as relationship issues, problems at workplace and financial issues. Can also advice patients to maintain a mood diary where the daily mood is recorded so that an idea about mood fluctuations can be taken.
Resources
- ICD – 11 Classification of Mental and Behavioral Disorders – Diagnostic Criteria for Research
- Shorter Oxford Textbook of Psychiatry- 7th Edition- Paul Harrison , Philip Cowen, Tom Burns, Mina Fazel
