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Bipolar Disorder

Practice Essentials

Bipolar disorder, which in the ICD-10 is classified as bipolar disorder, or manic-depressive illness (MDI), is a common, severe, and persistent mental illness. This condition is a serious lifelong struggle and challenge.

Signs and symptoms

Bipolar disorder is characterized by periods of deep, prolonged, and profound depression that alternate with periods of an excessively elevated or irritable mood known as mania.

Manic episodes are feature at least 1 week of profound mood disturbance, characterized by elation, irritability, or expansiveness (referred to as gateway criteria). At least 3 of the following symptoms must also be present
:

Grandiosity

Diminished need for sleep

Excessive talking or pressured speech

Racing thoughts or flight of ideas

Clear evidence of distractibility

Increased level of goal-focused activity at home, at work, or sexually

Excessive pleasurable activities, often with painful consequences

Hypomanic episodes are characterized by an elevated, expansive, or irritable mood of at least 4 consecutive days’ duration. The diagnosis of hypomania requires at least three of the symptoms above. The difference being that in hypomania these symptoms are not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization and are not associated with psychosis.

Major depressive episodes are characterized as, for the same 2 weeks, the person experiences 5 or more of the following symptoms, with at least 1 of the symptoms being either a depressed mood or characterized by a loss of pleasure or interest:

Depressed mood

Markedly diminished pleasure or interest in nearly all activities

Significant weight loss or gain or significant loss or increase in appetite

Hypersomnia or insomnia

Psychomotor retardation or agitation

Loss of energy or fatigue

Feelings of worthlessness or excessive guilt

Decreased concentration ability or marked indecisiveness

Preoccupation with death or suicide; patient has a plan or has attempted suicide

See Clinical Presentation for more detail.

Diagnosis

Examination of patients with suspected bipolar disorder includes evaluation using the Mental Status Examination as well as assessment of the following:

Appearance

Affect/mood

Thought content

Perception

Suicide/self-destruction

Homicide/violence/aggression

Judgment/insight

Cognition

Physical health

Testing

Although bipolar disorder is diagnosed based on the patient’s history and clinical course, laboratory studies may be necessary to rule out other potential causes of the patient’s signs and symptoms as well as to have baseline results before administering certain medications.

Laboratory tests that may be helpful include the following:

CBC count

ESR levels

Fasting glucose levels

Electrolyte levels

Protein levels

Thyroid hormone levels

Creatinine and blood urea nitrogen levels

Liver and lipid panel

Substance and alcohol screening

Depending on the patient’s presentation, other laboratory tests may be indicated, which may include the following:

Urinary copper levels

Antinuclear antibody testing

HIV testing

VDRL testing

Electrocardiography is important in elderly patients and before antidepressant therapy. Electroencephalography and/or MRI may be appropriate for selected patients.

See Workup for more detail.

Management

The treatment of bipolar disorder is directly related to the phase of the episode (ie, depression or mania) and the severity of that phase, and it may involve a combination of psychotherapy and medication. Always evaluate patients with mania, hypomania, or mixed episode, and those with bipolar depression, for suicidality, homicidality, acute or chronic psychosis, or other unstable or dangerous conditions.

Pharmacotherapy

Medications used to manage patients with bipolar disorder include the following:

Benzodiazepines – for acute agitation (eg, lorazepam, clonazepam)

Antimanic agents (eg, lithium)

Anticonvulsants (eg, carbamazepine, valproate sodium, valproic acid, divalproex sodium, lamotrigine)

First-generation antipsychotics (eg, inhaled loxapine, haloperidol)

Second-generation antipsychotics (eg, asenapine, ziprasidone, quetiapine, risperidone, aripiprazole, olanzapine, olanzapine and fluoxetine, cariprazine, clozapine, paliperidone, lurasidone)

Phenothiazine antipsychotics (eg, chlorpromazine)

Dopamine agonists (eg, pramipexole)

Nonpharmacotherapy

Psychotherapy may help to decrease relapse rates, improve quality of life, and/or increase functioning, or more favorable symptom improvement.

Electroconvulsive therapy may be useful in selected patients with bipolar disorder.

See Treatment and Medication for more detail.

What is bipolar disorder? Bipolar disorder, sometimes known as manic depression, is a type of mental disorder where people experience periods of extreme lows, known as depression, as well as periods of extreme highs, or manic episodes. Courtesy of Osmosis.org (https://www.osmosis.org/).

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