Bipolar Affective Disorder

Chronic episodic illness associated with behavioural disturbances; patients suffer bouts of both depression and mania

Aetiology

• Onset usually late teens/early 20s

• A family history of BPAD often early results in earlier onset and episodes are precipitated by lower levels of stress

• There is often a delay between first presentation and diagnosis

• Onset after the age of 60 is rare and is often associated with treatment-resistance, progressive decline in functioning, and an underlying organic cause

• High comorbidity with other psychiatric disorders (anxiety disorders, substance misuse, personality disorders, eating disorders, schizoaffective disorder, schizophrenia)

Pathophysiology

• Bipolar I: this type presents with manic episodes (most commonly interspersed with major depressive episodes)
• The manic episodes are severe and result in impaired functioning and frequent hospital admissions

• Bipolar II: patients do not meet the criteria for full mania and are described as hypomanic
• This type is often interspersed with depressive episodes
• Represents the most common form of illness

Clinical presentation

ICD-10 hypomanic episode

• The mood is elevated or irritable to a degree that is definately abnormal for the individual concerned and sustained for at least 4 consecutive days

• At least 3 of the following signs must be present, leading to some interference with personal functioning in daily living
• Increased activity or physical restlessness
• Increased talkativeness
• Difficulty in concentration or distractibility
• Decreased need for sleep
• Increased sexual energy
• Mild spending sprees, or other types of reckless or irresponsible behaviour

• Hypomania in comparison to mania has no psychotic symptoms and results in less associated dysfunction

ICD-10 manic episode

• Mood must be predominantly elevated, expansive or irritable, and definately abnormal for the individual concened
• The mood change must be prominent and sustained for at least 1 week (unless it is severe enough to require hospital admission)

• At least 3 of the following signs must be present (4 if the mood is merely irritable), leading to severe interference with personal functioning in daily living
• Increased activity or physical restlessness
• Increased talkativeness ('pressure of speech')
• Flight of ideas or the subjective experience of thoughts racing
• Loss of normal social inhibitions resulting in behaviour which is inappropriate to the circumstances
• Decreased need for sleep
• Inflated self-esteem or grandiosity
• Distractibility or constant changes in activity or plans
• Behaviour which is foolhardy or reckless and whose risks the subject does not recognise e.g. spending sprees, reckless driving
• Marked sexual energy or sexual indiscretions

Signs - quick mental state examination

• Bright clothes

• Distractibility

• Loss of normal social inhibitions/overfamiliarity

• Increased talkativeness (hard to interrupt)

• Punning and clang associations

• Increased flow (lots of thoughts)

• Flight of ideas and loosening of associations

• Grandiosity

Management

Acute manic episode

• First line - atypical antipsychotic e.g. olanzapine, quetiapine or risperidone

• Second line - valproate, lamotrigine, or lithium

• Benzodiazepines or Z-drugs can be used for symptom control e.g. agitation and insomnia

Acute bipolar depression

• First line - atypical antipsychotic e.g. quetiapine or olanzapine

• Antidepressants usually avoided - can cause rapid cycling mood
• Antidepressants should not be prescribed without an antimanic drug
• Avoid antidepressants in those with a recent manic/hypomanic episode or history of rapid cycling
• SSRIs (particularly fluoxetine) may be suitable in some cases

Bipolar maintenance

• Lithlium is gold standard (+ valproate if primarily manic/hypomanic)

• If the patient does not want regular monitoring: various combinations or sole use of valproate, quetiapine and olanzapine

• Psychoeducation is very important - good evidence for group psychoeducation