Bipolar 1

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The DSM IV: Major Diagnostic Criteria

Bipolar I Disorder is a disorder in which at least one manic or mixed episode clearly is or has been present.

DSM-IV Criteria for Bipolar I Disorder

  • One or more Manic or Mixed episodes.
  • Commonly accompanied by a history of one or more major depressive episodes, but not required for the diagnosis.
  • Manic or Mixed episodes cannot be due to a medical condition, medication, drugs of abuse, toxins or treatment for depression.
  • Symptoms cannot be accounted for by a psychotic disorder.

Clinical Features of Bipolar I Disorder

  • Greater than 90% of patients who have a single manic episode will have a recurrence.
  • Mixed episodes are more likely in younger patients.
  • Episodes occur more frequently with age.
  • Social and occupational consequences of Manic episodes can be severe (e.g.; violence, child abuse, excessive debt, job loss, divorce).
  • Manic episodes are more likely to receive clinical attention compared to Depressive episodes.
  • The suicide rate of bipolar patients is 10-15%.
  • Common co-morbid diagnoses include substance-related disorders, eating disorders, attention deficit hyperactivity disorder.
  • Rapid cycling pattern carries a poor prognosis and may affect up to 20% of bipolar patients.

Epidemiology of Bipolar I Disorder

  • The lifetime prevalence of bipolar disorder is approximately 0.5-1.5%.
  • Male: female ratio-- 1:1
  • The first episode in males tends to be a manic episode, while the first episode in females tends to be a depressive episode.
  • First degree relatives have higher rates of mood disorder.
  • Bipolar disorder has a 70% concordance rate among monozygotic twins.

Classification of Bipolar I Disorder

  • Classification of Bipolar I Disorder involves describing the current or most recent mood episode - Manic, Hypomanic, Mixed or Depressive. (e.g. Bipolar I Disorder - Most recent episode Mixed)
  • The most recent episode can be further classified as follows:
    1. Without psychotic features
    2. With psychotic features
    3. With catatonic features
    4. With postpartum onset

Bipolar I Disorder with Rapid Cycling

  • Diagnosis requires the presence of at least 4 mood episodes within 1 year.
  • Rapid cycling mood episodes may include Major Depressive, Manic, Hypomanic or Mixed episodes.
  • The patient must be symptom-free for at least 2 months between episodes or the patient must switch to an opposite episode.

Differential Diagnosis of Bipolar I Disorder

  • Cyclothymic Disorder: Mood episodes never meet criteria for full manic episode or full major depressive episode.
  • Psychotic Disorders
  • The clinical presentation of a patient at the height of a manic episode may be indistinguishable from an acute exacerbation of paranoid schizophrenia, making accurate diagnosis difficult unless clear history is available.
  • If history is unavailable or the patient is having an initial episode, it may be necessary to observe the patient over time to make an accurate diagnosis. A subsequent Major Depressive Episode or Manic episode that initially presents with mood symptoms prior to the onset of psychosis would indicate a mood disorder rather than a psychotic disorder.
  • Family history of mood disorder or psychotic disorder may be suggestive of diagnosis.
  • Substance-Induced Mood Disorder:drugs of abuse. Common organic causes of mania include sympathomimetics, amphetamines, steroids and blockers such as cimetidine.
  • Mood Disorder Due to a General Medical condition

 

Treatment of Bipolar I Disorder

  • Assessment of suicidality is essential, ask about suicidal ideation as well as intent.
  • Hospitalization may be necessary for either Manic or Depressive mood episodes.


      Pharmacotherapy

    1. Mood stabilizers such as lithium and the anticonvulsants have proven effective in the acute treatment as well as the prophylaxis of mood episodes.
    2. ECT is very effective for bipolar disorder (Depressed or Manic episodes) but is generally used after conventional pharmacotherapy has failed or is contraindicated.
    3. Antidepressants may be used for treatment of major depressive episodes, but should be accompanied by a mood stabilizer to prevent precipitating a manic episode.
    4. Antidepressants may induce rapid cycling.
    5. Adjunctive use of antipsychotics (if psychosis is present) or sedating benzodiazepines such as clonazepam and lorazepam (for severe agitation) may be necessary.


      Psychotherapy

    1. Therapy aimed at increasing insight and dealing with the consequences of manic episodes may be very helpful.
    2. Family/Marital therapy may also help increase the family's understanding and tolerance of the affected family member.
    3. Family support groups such as the Alliance for the Mentally Ill (AMI) and patient support groups such as Manic Depressive Association (MDA) can be very helpful.

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