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INTRODUCTION Section 2 of 10
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MDI has been recognized for a long time. Hippocrates described patients as
"amic" and "melancholic." In 1899, Emil Kraepelin defined MDI. He noted that
persons with this problem did not suffer the deterioration and dementia
associated with schizophrenia.
Other molecular genetic approaches also are being used to gain insight into the
pathophysiology of bipolar disorder. For instance, investigators have
demonstrated recently that 2 chemically unrelated drugs used to treat bipolar
disorder, lithium and valproate, both up-regulate the expression of the
cytoprotective protein bcl-2 in the frontal cortex and the hippocampus of rat
brains. Neuroimaging studies of individuals with bipolar disorder or other mood
disorders also suggest evidence of cell loss in these same brain regions. Thus, a
suggested cause of bipolar disorder is abnormal programmed cell death, or
apoptosis, in critical brain circuitry that regulates emotion. According to this
hypothesis, mood stabilizers and antidepressants are thought to alter mood by
stimulating cell survival pathways and increasing levels of neurotrophic factors to
improve cellular resiliency.
Post and associates proposed a mechanism involving electrophysiological
kindling and behavioral sensitization processes, a method that also resonates
with the previous hypothesis based on neuronal injury. Post asserts that an
individual who is susceptible to bipolar disorder experiences an increasing
number of minor neurological insults, perhaps caused by drugs of abuse,
excessive glucocorticoid stimulation resulting from acute or chronic stress, or
other factors, which eventually result in mania. Subsequently, sufficient brain
damage might persist such that mania could recur even with no or minor
environmental or behavioral stressors. This type of formulation helps explain the
effective role of anticonvulsant medications, eg, carbamazepine and valproate, in
the prevention of the highs and lows of bipolar disorder. It also suggests that the
more episodes a person experiences, the more he or she will have in the future,
underscoring the need for long-term treatment.
Frequency:
In the US: Lifelong prevalence rate of bipolar disorder in the United States
is 1-1.6%. The 2 types of disorders differ in adult populations, with
approximately 0.8% having BPI and 0.5% having BPII.
Sex: BPI occurs equally in both sexes; however, rapid-cycling bipolar disorder (4
or more episodes a year) is more common in women than in men. Incidence of
BPII is higher in females than in males.
Age: The age of onset of MDI varies greatly. The age range for both types of
bipolar disorders is from childhood to 50 years, with a mean age of approximately
21 years. Most cases commence when individuals are aged 15-19 years. The
second most frequent age of onset is 20-24 years. Some patients diagnosed as
having recurrent major depression may indeed have bipolar disorder and go on
to develop their first manic episode after age 50 years. They may have a family
history of bipolar disorder. However, for most patients, the onset of mania after
age 50 years should lead to an investigation for medical or neurological disorders
such as cerebrovascular disease.
CLINICAL Section 3 of 10
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History: The diagnosis of BPI disorder requires the presence of a manic episode
of at least 1 week's duration that leads to hospitalization or other significant
impairment in occupational or social functioning. The episode of mania cannot be
caused by another medical illness or by substance abuse. These criteria are
based on the specifications of the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision (DSM-IV-TR).
o Persons must meet both the criteria for mania and major
depression; the depressive event is required to be present for 1
week only.
Appearance
Their attire reflects the mania. Their clothes might have been put on
in haste and are disorganized. Alternately, their garments often are
too bright, colorful, or garish. They stand out in a crowd because
their dress frequently attracts attention.
Affect/mood
Thought content
Perceptions
Suicide/self-destruction
Homicide/violence/aggression
Judgment/insight
Genetics
Biochemical causes
Psychodynamic
o They see the depression as the manifestation of the losses, ie, the
loss of self-esteem and the sense of worthlessness. Therefore, that
mania serves as a defense against the feelings of depression.
(Melanie Klein was one of the major proponents of this formulation.)
Environmental
DIFFERENTIALS Section 4 of 10
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Anxiety Disorders
Cushing Syndrome
Head Trauma
Hyperthyroidism
Hypothyroidism
Posttraumatic Stress Disorder
Schizoaffective Disorder
Schizophrenia
Systemic Lupus Erythematosus
Cancer
Neurosyphilis
Epilepsy
Fahr disease
AIDS
Multiple sclerosis
Medications (eg, antidepressants can propel a patient into mania; other
medications may include baclofen, bromide, bromocriptine, captopril,
cimetidine, corticosteroids, cyclosporine, disulfiram, hydralazine, isoniazid,
levodopa, methylphenidate, metrizamide, procarbazine, and procyclidine)
Circadian rhythm desynchronization
Attention-deficit/hyperactivity disorder (ADHD), especially in children and
adolescents
Cyclothymic disorder
Multiple personality disorder
Oppositional defiant disorder (in children)
Substance abuse disorders (eg, with alcohol, amphetamines, cocaine,
hallucinogens, opiates)
WORKUP Section 5 of 10
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Lab Studies:
o CBC count with differential: This test is used to rule out anemia as a
cause of depression. Treatment, especially with certain
anticonvulsants, may depress the bone marrow, hence, the need to
check the red and white blood counts for signs of bone marrow
suppression. Lithium may cause a reversible increase in the WBC
count.
o Urine copper level: This test is used to rule out Wilson disease,
which produces mental changes. It is a rare disease that can be
missed easily.
Imaging Studies:
Other Tests:
Medical Care: The treatment of bipolar disorder is directly related to the phase of
the episode, eg, depression or mania, and the severity of that phase. For
example, a person who is extremely depressed and exhibits suicidal behavior
requires inpatient treatment. In contrast, an individual with a moderate
depression who still can work would be treated as an outpatient.
MEDICATION Section 7 of 10
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Appropriate medication depends on the stage of the bipolar disorder the patient
is experiencing. Thus, a number of drugs are indicated for an acute manic
episode, primarily the antipsychotics and benzodiazepines (eg, lorazepam,
clonazepam). The choice of agent depends on the presence of symptoms such
as psychotic symptoms, agitation, aggression, and sleep disturbance. Atypical
antipsychotics are being used increasingly for treatment of both acute mania and
mood stabilization. The broad range of antidepressants and ECT are used for an
acute depressive episode (ie, major depression). Finally, another set of
medications is chosen for the maintenance and preventive phases of treatment.
Drug Category: Mood stabilizers -- Lithium is the drug commonly used for
prophylaxis and treatment of manic episodes. A recent study suggests that lithium may
also have a neuroprotective role (Bauer, 2003).
All patients with bipolar disorder need outpatient monitoring for both
medications and psychotherapy. In addition, they need education. The
schedule must be regular, with great flexibility if they need extra sessions.
Fortunately, most patients recover from the first manic episode, but their
course beyond that is variable (Tohen, 2003).
Transfer:
If the patient is in a short-term inpatient care unit and has not made
significant progress, transfer to a long-term inpatient care unit might be in
order.
If the patient is in a depressed or manic phase and is not responding to
medications, transfer the patient to a facility where ECT can be
administered.
Deterrence/Prevention:
Complications:
Prognosis:
Patients with BPI fare worse than patients with a major depression. Within
the first 2 years after the initial episode, 40-50% of patients experience
another manic attack.
Only 50-60% of patients with BPI who are on lithium gain control of their
symptoms. In 7% of these patients, symptoms do not recur. Forty-five
percent of patients experience more episodes and 40% go on to have a
persistent disorder.
Often, the cycling between depression and mania accelerates with age.
o Evidence of depression
o Male sex
Indicators of a better prognosis include the following:
Patient Education:
o Finally, inform the patient about relapses within the total context of
the disorder.
MISCELLANEOUS Section 9 of 10
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Medical/Legal Pitfalls:
Special Concerns: