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Bipolar Disorders - Coggle Diagram
Bipolar Disorders
What is Bipolar?
ancient greece
- physicians described three main primary mental illnesses:
- phrenitis: close to our understanding of delirium
- melancholia: syndrome characterised by lethargy, loss of appetite, fear, and low mood.
- mania: characterised by excess energy and agitation, sometimes accompanies by bizarre behaviour > where the term 'maniac' originated.
1801
- phillipe pinel described a disorder where episodes of manic and melancholic states appeared to cycle with periods of sanity in between.
- called it "melancholia with delirium", because of delusions of grandeur and losing touch with reality.
- around the same time, german psychiatrists were attempting to make sense of the diseases of the mind and group them according to the clusters of symptoms shared by their patients.
- emil kraepelin described "manic-depressive insanity" in 1899: episodic in nature, with an inter-episode period of full recovery.
- now known as bipolar disorder.
dsm-5
- under the dsm-5 criteria, a manic episode lasts at least a week, whereas a hypomanic (hypo-"under") state lasts at least 4 days and the symptoms are usually less severe.
- the person will get little, if any sleep, but they don't feel tired.
- dsm-5 describes a manic episode as:
- a distinct period of abnormally and persistently elevated, expansive, or irritable mood.
- the person shows a number of symptoms such as inflated self-esteem, decreased need for sleep, excessive talkativeness, racing thoughts, distractibility, increase in goal-directed behaviour, psychomotor agitation, and/or excessive involvement in high-risk behaviours.
- at least 3 of these symptoms must be seen to an abnormal degree
- how typical the behaviour is for a person for their age, education level, and ethnicity, how distressing the behaviour is to the person and those around them, and how much the behaviour impairs their ability to work and maintain social relationships are all considered by mental health professionals when they make a diagnosis.
- in recent years, it's been recognised that bipolar tends to progress over the course of a person's life.
- early episodes, depressive (usually depressive) or manic, are usually preceded by a stressful life event.
- when the early episodes subside, the person enters an inter-episodic period with full remission of their symptoms
- mental health professionals will sometimes call this "inter-episode recovery" or a eurythmic state.
- the presence of the inter-episode recovery sets bipolar apart from another disorder called cyclothymia > patients experience alternating episodes of hypomania and then sub-clinical depression (doesn't meet the criteria for MDD)
- if the person doesn't receive treatment and the disorder progresses, the episodes of depression and mania begin to appear more spontaneously, rather than being triggered by life stressors. full-remission of symptoms also becomes rarer and rarer as time goes on.
- it has been noted that if a patient comes into an office for a single consultation while in a manic state, it can be difficult to know if the person is experiencing unipolar mania, bipolar disorder, or something different like schizophrenia.
- in order to make a proper distinction, the clinician needs to observe the person for a long time or have a reliable history of the person's mental health.
- bipolar is significantly misdiagnosed for this reason
prevalence
- bipolar disorder is relatively rare and affects about 1% of the population.
- it is highly heritable and most people diagnosed have either a parent or other first-degree relative with bipolar or some other mood disorder.
- there doesn't seem to be a familial risk of both bipolar and schizophrenia > the family will usually show mood OR psychotic disorders.
Models of
Bipolar
- one of the issues with categorical diagnostic systems like the DSM and ICD is that risk factors and sub-clinical issues can get overlooked.
- bipolar usually develops in early adulthood but some of the risk factors can be identified in childhood and adolescence. these include a range of anxieties, moodiness, as well as symptoms like flattened emotion, anhedonia, apathy, and social withdrawal.
- seen in lots of young people. few will go on to develop bipolar, some other disorders, but if they receive appropriate support, then most young people will have these issues resolved of their own accord.
- genetics and family history play an important role > if a young person is showing bipolar symptoms and a relative has been diagnosed with bipolar, it's important to support them in order to minimise the risk of the disorder progressing.
- early detection is important because bipolar is a progressive disorder > a person with bipolar will usually go through "stages" as the untreated disorder gets worse and worse.
- a number of theories propose that the disorder's progression is because structural damage occurs to the brain during untreated episodes. if the manic and depressive episodes are left untreated, then, over time, they can cause damage to certain areas of the brain.
- the research suggests that this damage occurs in areas of the brain that are responsible for mood regulation, making the person more reactive to mild life stressors which then trigger subsequent episodes.
- disease progression is not inevitable > in virtually all cases, it can be halted if its diagnosed and treated early > not all people progress through all stages
- some researchers don't even like using stage models
proposed stages
stage 2
- the person experiences their first depressive (or sometimes manic) episode.
- this usually happens during adolescence or early adulthood.
stage 3
- the person is experiencing episodes of depression and mania but there are still periods of complete symptom remission in between.
- as this stage progresses, the person usually finds that where episodes were previously triggered by emotional stressors, they're now appearing much more spontaneously.
stage 1
- the person starts experiencing episodic anxiety and/or sleep disorders.
- this is the stage when risk factors start to show in children and adolescents.
stage 4
- the person is now experiencing those same manic and depressive episodes but they now have what's referred to as residual symptoms.
- could be in the form of cognitive and functional decline, issues keeping a job, problems with interpersonal relationships or difficulties maintaining financial independence.
- at this stage, people with bipolar also show a higher rate of comorbidities like substance abuse disorder, they're hospitalised more often, and they have poorer responses to treatment.
- some people will just keep cycling from depression to mania and back again, and some will lose their independence altogether as they're admitted to a full-time inpatient facility, or require a full-time carer.
stage 0
- the person is well but they have a family history of bipolar, usually a parent or other first-degree relative
Treating
Bipolar
lithium
- the most well-known and effective treatment for bipolar is a biological intervention > the mood-stabilising medication lithium.
- has up to an 80% success rate, especially when the condition is diagnosed early.
- some of the best outcomes are also achieved when it is used in combination with psychosocial interventions that help the person with interpersonal and practical problems like managing finances.
- people who don't respond to lithium usually have psychotic features, and so they're often prescribed antipsychotic medication or anticonvulsants.
- as with all mood disorders, relapse and recurrent episodes are common, particularly in the long term
treatments at each stage
- treatment is most effective when the approach is tailored towards the particular stage the individual is currently in
stage 1
- promodal stage. people begin showing mild, non-specific, but still identifiable symptoms of psychological distress.
- begins in adolescence.
- because the symptoms are so broad, and there is still a very good chance that people showing these symptoms do not, in fact, have bipolar, the interventions are still broad.
- usually cbt and family counselling
stage 3
- the episodes of depression and either mania/hypomania keep recurring, but the person still experiences periods of remission in between.
- intervention consists of lithium and talking therapies like cbt, but quiet often the person will also require treatment for other comorbid conditions.
- episodes start to develop spontaneously when previously they had always been triggered by life stressors.
- at the end of stage 3 and the beginning of stage 4, the person has usually had about four manic episodes or roughly a dozen manic and depressive episodes combined. they tend to move from the "recurrent" stage 3 to the "resistant" stage 4
stage 0
- describes people who have risk factors such as a family history of bipolar, but haven't started showing any obvious symptoms.
- other risk factors include problems during childbirth, physical, psychological and sexual abuse during childhood, and substance abuse > these risk factors are not exactly rare and we can't treat every person as if they're going to develop bipolar.
- some generic interventions for these people can be encouraging self-help strategies, counselling, encouraging safe use of substances, and educating people so they are aware of the early signs and symptoms they should look out for.
stage 4
- the illness becomes unrelenting, so the person is almost always in a state of either depression or mania,
- treatment options are limited > they must be aggressive and targeted to have any hope of the person maintaining independence
- ECT intervention may be recommended at this stage because, despite the inherent risks, the alternative may be worse.
stage 2
- people with bipolar usually experience depressive episodes first, but both the DSM and ICS criteria specify that at least one manic or hypomanic episode is required for a bipolar diagnosis.
- some researchers call the first depressive episode "stage 2a", while some researchers say the person has reached stage 2 during their first hypomanic or manic episode.
- **a person with bipolar stands the best chance of living a healthy, independent life if they begin appropriate, targeted treatment following their first depressive episode, or at least after their first manic/hypomanic episode > these early episodes don't appear to cause significant or enduring structural damage to the brain.
- misdiagnosing a person with unipolar depression and prescribing them antidepressant medication is bad because, in people with bipolar, antidepressants can trigger mania or rapid cycling between depression and mania.
- bipolar depression has some characteristic features, including biological differences in a chemical called brain-derived neurotrophic factor (BNDF)
- neurochemical that helps support the growth and health of nerve cells
- BNDF levels are different in people with unipolar depression vs people with bipolar depression.
- very early research, may be a useful diagnostic tool
- most often, stage 2 treatment consists of lithium and cbt