Picture By Booyabazooka - Wikimedia

Hi Steemians,

After a long break (mostly due to me, balancing my academic stuff), I've decided to continue making my medical-based article. Currently, I'm in Psychiatric posting and most of the clinic days were filled with interviewing, observing and treating patients with mood disorders. As mood disorder is a broad term, I would like to narrow down our topic of discussion for this article to Bipolar Disorder.

If you've read one of my articles related to Schizophrenia that I made a couple of months ago, then you know, it is hard to function socially, when you've to struggle with the disease's manifestation and at the same time, stigma from the surrounding people. Schizophrenia is the hallmark of Psychiatric illness, in which, some society thought it as being crazy.

Since it has been awhile since I made an article, talking about schizophrenia, I will re-make it soon. In this article, we will discuss some of the basic information regarding Bipolar Disorder.

Introduction

Picture Source

Trust me, this disease, even though it is not common as compared to schizophrenia, I've seen quite a number of patients come to the psychiatric's clinic for follow-up due to bipolar disease. This particular illness has been called the Manic-Depressive-Psychosis disease, but to the fact that some bipolar patients were presented at first with only one of those three, the diagnosis has been left out. Some people only came with manic without depression and psychosis while some others, come with depression, previous history of hypomania and sometimes, psychosis. We will discuss this further later in the article.

Heterogenous features in bipolar resemble the schizophrenia; about 2/3 of the total patients who have been diagnosed with bipolar disorder came with a history of other psychiatric illnesses such as anxiety disorders, substance abuse and attention deficit hyperactive disorder (ADHD) in adults. When we talk about bipolar disorder, the symptoms that have been experienced by patients were mood disorder such as mania and depressive symptoms. History is important! Taking an inadequate history will lead to misdiagnosis as some people with bipolar might be presented to the clinic during the depressive phase.

If you've been wondering how much of a difference of mood changes between a patient with bipolar disorder compare to the average people having a mood swing, then I would say, it's pretty much significant. People with mood disorders were consumed so much with their emotional upbringing which would lead to some form of deterioration in academic, social and occupational performances.

There are two types of mood disorders which are commonly associated with people having bipolar disorder which are manic episodes and depressive episodes.

Manic Episode

This period can be differentiated from the depressive episodes through a number of symptoms:

• Euphoria

• Overconfidence
• Excessive talk with "pressure of speech."
• Energetic even with reduced sleep duration
• Flight of ideas / Racing thoughts
• Increase in libido
• Spending spree
• Grandiosity (believe they have superpower)
• Irritability

Depressive Episode

The following symptoms characterise this episode:

• Low mood
• Hypersensitivity

• Crying spells
• Irritability
• Decreased in libido
• Loss of interest in a usual pleasurable activity (anhedonia)
• Social withdrawn
• Believe that the world is a place for punishment which leads them to suicidal ideation

Classification of Bipolar Disorder

Picture Source

Bipolar disorder can be classified into 5:

• Bipolar type I
• Bipolar Type II
• Cyclothymic disorder
• Substance-induced bipolar disorder
• Organic cause of bipolar disorder

Bipolar type I were usually characterised by manic episodes. There are a few criteria to diagnose someone with bipolar disorder, and all of them are written in the Diagnostic and Statistical Manual of Mental Disorders (DSM) which entails some guidelines to assist clinicians in making a diagnosis. In bipolar type I, depressive symptoms was sometimes absence, or in another word, it is not needed to make a diagnosis of bipolar disorder. To summarise, manic episodes can be confirmed by the presence of at least three out of the following symptoms for a minimum duration of one week:

• Overconfidence
• Lack of sleep but they are still energetic
• Pressure of speech
• Racing thoughts
• Easily distracted
• Psychomotor agitation
• High-risk activities pursuit
• Increased interest in certain activities

*Note: For accurate criteria, please refer to DSM-V

Bipolar type II on the hand is characterised by hypomanic and at least one major depressive episode. Well, you can refer to DSM-V to see the difference between hypomanic and manic manifestation but to make it simple, if the patient showed some symptoms which could suggest mania but doesn't fulfil the criteria needed to make a diagnosis of mania (maybe the symptoms last for less than the expected duration), then it is a hypomanic episode. Unlike bipolar type I, bipolar type II must always be accompanied by at least by one major depressive period. DSM-V is pretty neat, right? Well, DSM-VI will be out soon. The depressive episode must last at least 4 weeks with at least 4 of the following symptoms:

• Reduce energy
• A feeling of worthlessness and guilt
• Psychomotor retardation
• Changes in appetite or weight
• Sleep disturbance
• Suicidal ideation
• Reduced cognitive function

*Note: For accurate criteria, please refer to DSM-V

Cyclothymic disorder is a condition whereby the patient experiences an oscillating period of low and high mood for at least two years which doesn't meet any criteria listed for the diagnosis of bipolar type I or II. The symptoms were not severe, so it's particularly difficult to diagnose patients with this kind of diagnosis.

Substance abuse or drugs can also cause or mimic the symptoms of bipolar disorder. Mania symptoms, for example, can be caused by antidepressants and depression can be caused by antipsychotics. We have to explore all possible reasons which could potentially cause symptoms which have some similarities with what we could find in a patient with bipolar disorder. How do we know if the symptoms were caused by drugs? When the patient stops taking that particular drug, all of the symptoms disappear.

Picture Source

Organic cause such as thyrotoxicosis and hypothyroidism can cause some symptoms which resemble manic and depressive symptoms. There is no other way other than treating the underlying cause of organic diseases. A patient who shows some symptoms which are relatable to bipolar disorder at the age of 50 should be investigated for any organic reason.

So now, let's focus our attention on Bipolar type I and type II. It's difficult to differentiate those two, but there are a few characteristics which are distinct between them:

• The first one is obvious. We will be using DSM-V to differentiate between those two group of symptoms. For bipolar I, there would be manic symptoms, but for people with bipolar type II, there is a presence of hypomanic symptoms which persisted for at least 5 days.

• Symptoms are much more severe with bipolar type I compared to bipolar II. Usually people with bipolar type I presented with psychotic symptoms which include hallucinations and delusions. Socially, people with bipolar type II were slightly or not affected at all. They can mingle with other people like an ordinary person. Bipolar type I usually need admission to be monitored. Some have severe suicidal ideation which can lead to fatality if not monitored well.

• Patient with bipolar II disorder is commonly associated with major depressive symptoms which are not the case with bipolar I disorder.

• People with bipolar disorder type I were usually affected functionally. They can't function properly in the society which could lead them to some sort of financial and identity crisis. They can't work, they can't study, and every single aspect of daily activities was affected.

The suicidal rate of a patient with bipolar disorder is quite high. The rate is between 10-15% of the general population. This can be caused by various psychosocial complications which are resulted from reduced in social and occupational function which lead to getting fired from a job, excessive debt and violence.

Aetiology

Picture Source

Let me be frank; it's difficult to identify an exact cause of psychiatric illness. There are so many things that we have to study to understand the link between the brain's activity and psychiatric illnesses properly. Generally, the cause of bipolar disorder can be divided into three (well, it depends on the sources):

• Genetic predisposition
• Biochemical theory
• Social cause

Genetic Predisposition

Family history is an important component of history taking in order to detect any genetic cause which might be causing the bipolar disorder in the patient. About 50% of bipolar patients have families with psychiatric illnesses specifically, mood disorder. People with genetic predisposition, like any other psychiatric illnesses which could be caused by genetic, can manifest bipolar disorder when certain distress conditions come to light. People with first-degree relatives manifested with mood disorders are 7 times more likely to be diagnosed with bipolar in a general population.

If one parent is affected by the disease, then a child is 14% more likely to be diagnosed with bipolar disorder. If both parents are affected, the percentage will scale up to 25%. If a child from a monozygotic twin has been diagnosed with bipolar disorder then, the other child would have 46-75% of chances to develop the disorder later in life. A dizygotic twin has a concordance rate of 14% which is much lower than a monozygotic twin. The chromosomes which are associated with bipolar disorder are chromosomes 4, 6, 11, 15 and 18.

It has been proven by a few studies which indicate a pattern of similarity between bipolar disorder and schizophrenia which lack the expression of genes related to the production of oligodendrocytes and myelin.

Biochemical Theory

There are two popular theories which might be the possible explanation in regards to why people are being taunted by this ailment.

The Amine hypothesis identifies epinephrine and norepinephrine as the critical factor in causing the manifestation of the disease. People who have an excessive both epinephrine and norepinephrine show some symptoms related to mania and people who have a lower concentration of the aforementioned hormones are subject to depressive symptoms. This hypothesis was made after observing the action of certain agents which either increase or decrease the amines. People who have been taking Reserpine, an antihypertensive agent have demonstrated some depressive symptoms while people who have been taking L-dopa, a drug which is being used in the treatment of Parkinson disease could show some manic symptoms.

The hypothalamic-pituitary-adrenal axis dysregulation has been found to cause manic and depressive symptoms depending on the level of cortisol. Hypercortisolemia has been associated with depression, and hypocortisolemia has been associated with mania.

Social cause

Picture Source

The first episode of bipolar disorder is usually triggered by stressful events in life which affect an individual in some ways. Normal people should be able to shoulder the stressful implication which occurred in their own life, but for people who have the high risk of developing a mood disorder, i.e. genetic predisposition, they respond differently with the stressful event which leads to pathological consequences. This includes:

• The death of the loved one
• Loss of a status
• Problems in relationship
• Pregnancy and childbirth

Generally, people with bipolar disorder, struggle to fit in the society which is caused by the disease process. During the manic phase, they were over-familiar with everyone even if it is the first time, they meet someone, but during the depressive phase, they were socially withdrawn. Diagnosis should be established as soon as possible so that an appropriate course of treatment can be started as early as possible. We will discuss in detail about the treatment in the next article. Thank you for your attention.

References

• Hu, J., Mansur, R., & McIntyre, R. S. (2014). Mixed Specifier for Bipolar Mania and Depression: Highlights of DSM-5 Changes and Implications for Diagnosis and Treatment in Primary Care. The Primary Care Companion for CNS Disorders, 16(2), PCC.13r01599. http://doi.org/10.4088/PCC.13r01599
• Akhter, A., Fiedorowicz, J. G., Zhang, T., Potash, J. B., Cavanaugh, J., Solomon, D. A., & Coryell, W. H. (2013). Seasonal variation of manic and depressive symptoms in bipolar disorder. Bipolar Disorders, 15(4), 377–384. http://doi.org/10.1111/bdi.12072
• Singh, T., & Rajput, M. (2006). Misdiagnosis of Bipolar Disorder. Psychiatry (Edgmont), 3(10), 57–63.
• Manning, J. S. (2005). Burden of Illness in Bipolar Depression. Primary Care Companion to The Journal of Clinical Psychiatry, 7(6), 259–267.
• Center for Substance Abuse Treatment. Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2008. (Treatment Improvement Protocol (TIP) Series, No. 48.) Appendix D—DSM-IV-TR Mood Disorders. Available from: https://www.ncbi.nlm.nih.gov/books/NBK64063/
• NIMH. Bipolar Disorder. Retrieved March 25, 2018, from https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
• Healthline. Diagnosis Guide for Bipolar Disorder. Retrieved March 25, 2018, from https://www.healthline.com/health/bipolar-disorder/bipolar-diagnosis-guide
• Wikipedia. Mood disorder. Retrieved March 25, 2018, from https://en.wikipedia.org/wiki/Mood_disorder