Bipolar Disorder

Clinical Features

  • Depression
  • Hypomania
    • persistent mild elevation of mood(>3 days)
    • increased energy, activity, sociability, talkativeness
    • increased feeling of well-being
    • over familiarity, increased libido
    • decreased sleep
    • irritability
    • decreased concentration
    • mild overspending
    • may interfere with work / social activity
  • Mania (also with amphetamine, cocaine)
    • greater extent
    • pressure of speech (uninterruptible)
    • flight of ideas
    • loss of social inhibitions
    • grandiose / over optimistic
    • perceptual disorders - vivid colours/textures/hyperacusis
    • irritability / suspiciousness
    • 1 week, complete disruption of work and social life
  • Mania + psychotic symptoms
    • as above
    • grandiose / persecutory delusions
    • auditory hallucinations - often mood congruent
    • sexual disinhibition
    • severe over-spending
    • aggressive acts

Epidemiology

  • lifetime risk ~1%
  • sexes equal
  • no increase in prevalence
  • first episode 20-30, commonly mania
  • 20/100,000/year
  • increased risk in higher social classes

Differential Diagnosis

  • substance abuse
    • amphetamines
    • cocaine
  • endocrine disturbance
    • Cushing's, steroids
  • epilepsy
  • severe physical illness
  • acute schizophrenia
  • attention-deficit hyperactivity disorder
  • transient psychosis

Course

  • median duration mania 4 months
  • median duration depression is 6 months
  • recovery usually complete
  • frequency variable
  • rare to regularly cycle
  • remission becomes shorter, episodes more severe
  • depressions become commoner
  • 4 or more episodes/year = rapid cycling

Aetiology

  • strong genetic
  • monozygotic 68%
  • dizygotic (together) 23%
  • 5x risk in 1st degree relatives
  • (psychodynamic) mania is defence against depression

Management

  • hospitalisation for acute mania
  • exclusion of organic causes

Treatment

  • Depression
  • Mania
    • antipsychotics
    • lorazepam
    • lithium as adjunct
  • Prevention
    • Lithium effective in 80%
    • carbamazepine / sodium valproate
    • ? social / psychological interventions

Prognosis

  • 90% recurrence over 10 years
  • long term function poor
  • rapid cycling respond poorly to lithium
  • suicide 10%
  • increase in premature mortality
 

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