Bipolar Disorders(Manic Depressive Illness)

Larry Labbate, M.D.

Mania sometimes brings Euphoria

All Things Possible

What is bipolar disorder?

• Cyclic mood disorder

• Extremes of euphoria and depression during episodes

• Mania and depression

• May include psychosis, paranoia, hallucinations

• Suicide common (>10%)

• Alcohol and drug addiction common (50%)

Mania Descriptions

• “When you’re high it’s tremendous”

• “The ideas and feelings are fast and frequent like shooting stars.”

• “Sensuality is pervasive. Shyness goes”

• “I bounce checks, think I can do anything, get wild ideas.”

• “When will it happen again?”

Mania Descriptions

• “Too much of everything is just enough”

• “Rock music played far too loud is what satisfies”

• “Emotions tear me apart. I can laugh and cry at the same time”

Mania Descriptions

• “A feeling of intimate personal relationship with God is perhaps its paramount feature”

• “I was God!”

• “I could find the cure for cancer.”

Language Changes in Mania

• Puns and Rhymes common:

• “God is a Herbivore/ Thyme passes/ Mixed with long grasses of herbs in the field/

Rosemary weeps into meadow sweeps”

Depression in Bipolar

• “My life is in ruins. Look what I did when I was manic”

• “I just want to be in bed all the time”

• “I can’t do anything”

• “I just want to be by myself and cry”

• “What is the use of this life”

Recurrent Illness

• Long lived illness that often starts in 20s

• May start any time in life span

• .5% - 1% population; milder forms more common?

• Most have depression and mania, 10% pure mania (one manic episode buys the diagnosis)

• Episodes come more frequently over time

Kindling

• Seizure model: low level electrical impulses start with no effect, then seizures in response to same impulse. Eventually spontaneous seizures follow without impulse.

• Bipolar first related to environmental changes, loss, stress, drugs, sleep deprivation

• Ultimately: autonomous cycling

Manic Symptoms - DSM IV• Inflated self esteem • Decreased need for sleep• Distractibility• Pressured/rapid speech• Flight of ideas or racing thoughts• Increased goal directed behavior• Excessive involvement in pleasurable activities (sex,

cars, money) that may have painful results.

Soft signs of mania

• Large hats on men

• Multiple rings on men

• Excessive visible cleavage on women or exposed chest on men

• Public nudity

• Public masturbation

Thought disorder: mania vs schizophrenia

• May appear to have schizophrenia because of prominent delusions or hallucinations and thought disorder

• Thoughts often disorganized, abundant, elaborate, and sometimes playful

• Schizophrenia thoughts more bland, fragmented, bizarre with affect less intense

Illness Affects Many

• Family and friends

• Work disrupted

• Legal system involved

Bipolar Disorder Types

• Bipolar I - Manic episode, with or without an episode of major depression.

• Bipolar II - Major depression & hypomania (hypo means below)

Bipolar diagnosis

• One episode of mania gets the diagnosis of Bipolar 1 because 90% go on to have depression

• Only called Bipolar II if you have hypomania and another episode of major depression

• Some have “mixed episodes” with depression and mania at the same time

Bipolar Spectrum

Bipolar Epidemiology

• Lifetime prevalence (adults)– Bipolar I 1 %

– Bipolar II 1 %

– (May be underestimates)

• Age of onset– Mean age 21 years

– Peak age 15-19 years

• Gender– Bipolar I male =

female

– Bipolar II female > male

Model of Evolution of Bipolar Course

Modified from: Post RM, Rubinow DR, Ballenger JC. Conditioning and sensitization in the longitudinal course of affective illness. Br J Psychiatry. 1986;149:191-201

Range of Illness

• Some patients may do very well between episodes: true cycles

• Mild mania (hypomania) may be helpful in work• Many have residual signs/symptoms of illness• Psychotic mania predicts poor outcome

Range of Illness

• Depression is commonly chronic

• Sometimes looks like schizophrenia (e.g. with prominent psychotic signs) in acute mania

• Substance abuse worsens course

• Suicide in 15%

Secondary Mania

• Mania due to… or substance induce mood disorder

• Early onset mania is usually idiopathic bipolar

• Onset of mania after 40 is often related to some medical cause – drugs (dopamine agonists – cocaine, antidepresants, amphetamine; steroids – anabolic or glucocorticoids; brain trauma, HIV, stroke, multiple sclerosis, epilepsy, brain tumor)

Mania precipitants

• Post-partum state• Sleep deprivation• Dopamine agonist drugs (amphet/L-Dopa)• Antidepressants• Stroke or brain injury• Jet lag; especially West to East• Severe life stress

Hypomania vs. Mania

• Hypo (below)

• Less intense form of mania – not hospitalized

• Paranoia, delusions, hallucinations, need for hospitalization = mania

• Hypomania may be effective (in business)

• Hypomanic patients diagnosed Bipolar II

Insight

• Patients are often unaware in mania

• Feels too good to be an illness

• Family, friends, legal system, bring them to attention

• False positives on retrospective questions (“yeah I had periods of feeling good, didn’t sleep”)

Course of Bipolar

• Most people who experience mania will have a recurrence and have depressive episodes

• Up to 40% may experience a mixed state or dysphoric mania (both mania and major depression simultaneously).

• 10-15% develop Rapid Cycling, defined as 4 or more mood episodes/year.

Course of Bipolar

• Mania or depression may last for 4-8 months and remit spontaneously

• May go from mania directly into depression or vice-versa

• May go for years without episodes

• Depressions usually more common than manias

• Depression may be chronic, last years

Bipolar Disorder Symptoms AreChronic and Predominantly Depressive

53%32%

9%6%

Asymptomatic

Depressed

Manic/hypomanic

Cycling/mixed

% of Weeks

146 bipolar I patientsfollowed 12.8 years

86 bipolar II patientsfollowed 13.4 years

46%*50%

1% 2%

Judd LL, et al. Arch Gen Psychiatry. 2002;59:530-537.Judd LL, et al. Arch Gen Psychiatry. 2003;60:261-269. *%s do not add to 100 due to rounding

Bipolar Depression

• Often have “atypical depression”

• Excessive sleeping

• Increased eating

• Suicide risk

• Teen atypical depression may be first sign of bipolar disorder

Bipolar Depression

• Early teen onset depression may mark start of bipolar disorder

• Often “atypical” features (increased sleeping, increased eating)

• May be seasonal (winter depressions)

• May have psychosis (hearing voices, delusions)

Bipolar Depression

• Suicide happens in this phase

• Hypothyroidism may result from Li+ use

• Hypothyroid symptoms similar to depression

• Alcohol use may start during depressed phase

Bipolar Depression

• Most patients have more depression than mania

• Depression often more debilitating

• Treatment more difficult for depression

• Antidepressant treatment tightrope

Cyclothymia

• For at least 2 years, the presence of hypomania and numerous periods of depressive symptoms that do not meet criteria for major depression.

• Results in distress or functional impairment.

• A chronic, smoldering form of bipolar illness.

Addiction and Bipolar

• Drug or alcohol addiction are common (>50%)

• Ethanol or benzodiazepines may slow the high. ?brain structures underlying addiction and mania linked?

• Cocaine or amphetamine intoxication may mimic mania; patients may seek the intoxicating manic rush

• Crash from stimulants looks like depression

Addiction and Bipolar

• Some patients not diagnosed until they “dry out”

• Need to treat addiction and mood disorder

• Patients often harder to treat because the drug “payoff” is greater in those with bipolar

Living with Bipolar

• When is the next episode coming?

• Is what I’m feeling normal or part of my illness?

Le Joie de Vivre