Bipolar disorder: symptoms

Bipolar disorder begins with an acute phase of symptoms, followed by cycles of exacerbations and remissions. Exacerbations - episodes with more severe symptoms last from 3 to 6 months. Episodes are manic, depressive, hypomanic or mixed (symptoms of depression and mania). Cycles - periods of time from the beginning of one episode to the next, vary in duration. Cyclism is particularly enhanced in bipolar disorder with rapid cycling (usually defined as> 4 episodes per year). Often there are problems of development and social functioning, especially if the disease begins at the age of 13-18 years.

There may be psychotic symptoms. With unfolded manic psychosis, the mood is usually increased, but often there is irritability, open hostility with faultiness.

Symptoms characteristic of bipolar disorder can be observed in many other diseases. Without the exception of these conditions, the correct diagnosis and adequate therapy are impossible. Bipolar disorder should be differentiated with affective disorders caused by somatic or neurological diseases, abuse of psychotropic substances, major depression, dysthymia and cyclotomy, psychotic disorders. In addition, obsessive-compulsive disorder with numerous compulsions can mimic pathologically purposeful actions in bipolar affective disorder. Affective lability in patients with borderline personality disorder may also resemble some features of bipolar affective disorder. In young patients, depression can be the first affective episode, which later develops into bipolar affective disorder. According to DSM-IV, in the diagnosis of mania, the duration and nature of the symptoms, the extent to which they affect the daily life of the patient, the presence of other causes that can explain this condition (general diseases, substance abuse, drug effects) are taken into account.

List of widely used drugs, which are substrates of isoenzymes 1A2, 2C, 2D6 or ZA of cytochrome P450

1A2

• Antidepressants: tertiary tricyclic antidepressants, fluvoxamine
• Neuroleptics: clotapine, haloperidol, olanzapine, thioxanthenes, phenothiazides. Others: caffeine, theophylline, tacrine , verapamil, acetaminophen

2C

• Antidepressants: amitriptyline, imipramine, clomipramine, moclobemide, citalopram. Others: hexobarbital, diazepam, pheniton, tolbutamide

2D6

• Antidepressants: amitriptyline, desipramine, imipramine clomipramine, nortriptyline, trazodone, sertraline, fluoxetine, paroxetine, venlafaxine
• Neuroleptics: chlorpromazine, clozapine, perphenazine, haloperidol, risperdone, hyoridazine, olanzapine
• Antiarrhythmics: encainamide, flecainide, propafenone, mexiletine
• Beta-blockers: labetalol, metoprolol, propranolol, timolol
• Opioids: codeine, hydrocodone oxycodone
• Protease inhibitors: ritonavir
• Others: dextromethorphan, amphetamine, diphenhydramine, loratidine
• Benzodiazepines: alprazolam, clonaeepam, midazolam, triazolam, diazepam
• Antihistamines: astemizole. Terfenadine, loratidine
• Calcium antagonists: diltiazem, felodipine, nifedipine, verapamil
• Antidepressants: tertiary tricyclic antidepressants, nefazodone, sertraline, venlafaxine
• Antiarrhythmics, amiodarone, disopyramide, lidocaine, quinidine
• Protease inhibitors: ritonavir, indinavir, saquinavir
• Others: clozapine, carbamazepine, cisapride, dexamethasone, cyclosporine, cocaine, tamoxifen, estradiol, macrolide antibiotics

Some drugs, such as tertiary tricyclic antidepressants or clozapine, are metabolized along several routes.

Bipolar affective disorder differs from unipolar affective disorder by the presence of various phases: mania, hypomania and depression. The clinical picture of the episode of mania includes the following: heightened mood, speech excitement, accelerated thinking, increased physical and mental activity, a surge of energy (with a decreased need for sleep), irritability, a special brightness of sensations, paranoid ideas, hypersexuality, impulsiveness.

[1], [2], [3], [4]

Mania (manic episode)

A manic episode is defined as 1 week or more of constantly elevated, incontinent or irritable mood accompanied by 3 or more additional symptoms, including increased self-esteem or ideas of greatness, decreased need for sleep, talkativeness, constantly upbeat mood, flight of ideas or a jump in thoughts, increased distraction, increased targeted activity, excessive involvement in pleasure-giving activities with a high risk of undesirable consequences (for example, trauma, waste of money). Symptoms interfere with functioning.

Usually patients in a manic state dress brightly, brightly and colorfully; behave authoritatively, speech is accelerated. The patient establishes associations by consonance: new thoughts are caused by the sound of words, and not by their meaning. Easily distracted patients can constantly move from one topic or activity to another. However, they tend to believe that they are in a beautiful mental state. Reducing criticism and increasing activity often lead to intrusive behavior and can be a dangerous combination. Interpersonal disagreements develop that can lead to paranoid ideas about unfair treatment and persecution. Accelerated mental activity is perceived by the patient as an acceleration of thoughts, the doctor can observe a jump in ideas, which in extreme manifestations is difficult to differentiate from the disruption of associative connections in schizophrenia. In some patients with type I bipolar disorder, psychotic symptoms develop. The need for sleep is reduced. Manic patients are inexhaustible, overly and impulsively involved in various activities without recognizing the inherent social danger.

Diagnostic criteria for manic episode

• A clearly delineated period characterized by excessively or invariably upbeat mood, expansiveness or irritation that persists for at least 1 week (or require hospitalization, regardless of duration)
• At the time of mood disturbance, at least three are persistently present (if mood changes are limited only to irritation - but not less than four) of the symptoms listed below, and their severity reaches a significant degree:
• Overestimated self-esteem, exaggerated sense of self-worth
• Reduced need for sleep (3 hours of sleep are enough for a sense of proper rest)
• Unusual talkativeness or constant need to talk
• An idea jump or a subjective feeling of an overflow with thoughts
• Egginess (attention easily switches to non-essential or occasional external stimuli)
• Enhancement of targeted activity (social, at work or school, sexual) or psychomotor agitation
• Excessive enthusiasm for activities that bring pleasure, despite the high likelihood of unpleasant consequences (for example, participation in binges, unscrupulous sexual intercourse or unsustainable financial investments)
• Symptoms do not meet the criteria for a mixed episode
• Affective disorder is so pronounced that it significantly disturbs a patient's professional activity, or his usual social activity, or his relationships with other people, or requires hospitalization because of the dangers of his actions or others, or psychotic symptoms are revealed.
• The existing symptoms are not caused by the direct physiological action of exogenous substances (including addictive substances or drugs) or common diseases (eg, thyrotoxicosis)

According to DSM-IV, bipolar disorder is further classified according to clinical characteristics. Thus, in accordance with DSM-IV, bipolar disorder of type I is isolated with a single (recent or current) manic (hypomaniacal, mixed, depressed or unspecified) episode; bipolar II disorder with a current or recent hypomanic or depressive episode; cyclothymia. In addition, according to DSM-IV, two aspects related to the course of the disorder should be clarified, namely: whether there is complete recovery between episodes or not, and whether there are seasonal patterns in the development of depressive episodes or a rapid phase change.

The severity of mania can vary widely.

Carlson and Goodwin (1973) identified the following stages (severity) of mania.

• Stage I. Increased psychomotor activity, affective lability, incontinence, exaggerated sense of self-worth, excessive self-confidence, sexual preoccupation; the criticism is preserved.
• Stage II. Speech and psychomotor agitation, expressed depressive or dysphoric manifestations, open hostility, a jump in ideas, paranoid delusions or delirium grandeur.
• Stage III. Despair, panic attacks, a sense of hopelessness, violent inadequate actions, the disintegration and incoherence of thinking, hallucinations.

According to another terminology, these variants are distinguished, that stage I corresponds to hypomania, stage II - mania, stage III - delirious mania. Differential diagnosis of stage III bipolar disorder and schizophrenia is often difficult, if there is no additional source of information about the patient.

Mixed or dysphoric form of mania

Mixed or dysphoric form of mania is relatively common, but is less well understood than other forms of bipolar disorder. Mixed mania is detected in 40-50% of hospitalized patients with bipolar disorder. According to DSM-IV, mixed mania is characterized by affective lability and a combination of manic and depressive symptoms that occur almost daily for at least 1 week. A mixed episode is closely associated with a depressive episode. Since the prognosis for mixed mania is less favorable than with "pure" mania, its recognition is important for determining therapy - in the treatment of this variant of bipolar disorder, anticonvulsants are more effective than lithium.

In a mixed episode, there are signs of depression and mania or hypomania. The most typical examples are an instant transition to tearfulness at the height of mania or a jump in ideas in a depressive period. At least 1/3 of patients with bipolar disorder have a mixed episode. The most frequent manifestations are a dysphorically upbeat mood, tearfulness, a shortened dream, a jump in ideas, ideas of greatness, psychomotor anxiety, suicidal thoughts, delusions of persecution, auditory hallucinations, indecisiveness and confusion. This condition is called dysphoric mania (that is, severe depressive symptoms are imposed on manic psychosis).

Bipolar disorder with short cycles

Each attack of mania, depression or hypomania is treated as a separate episode. Short (rapid) cycles are observed in 1-20% of patients with bipolar disorder, and in 20% of cases such a course occurs from the very beginning of the disease, and in 80% of cases develops later. Short cycles are more often observed in women, and in most cases they begin with a depressive episode. In some patients, short cycles alternate with long ones. As in the case of mixed mania, recognition of this form is important for the choice of treatment.

[5], [6]

Bipolar II disorder

Bipolar II disorder is manifested by episodes of hypomania and depression. Diagnosis is often complicated because of. Overlapping personality traits, and also by the fact that the patient during the hypomaniac episode feels vivacity, energy and optimism and seeks medical help only when this state is replaced by depression. In addition, when these patients go to the doctor in a depressive phase, they often can not accurately describe their condition during the previous hypomanic episode.

The difference between mania and hypomania is only in the degree of mental disorders. Hypomanic abnormalities are so minimal that they are often not considered a patient pathology. In this regard, it is important to obtain information about the patient from an additional source of information. Nevertheless, many patients have noted during the hypomaniac episodes changes in criticism that could have serious consequences. The median age of onset of bipolar affective disorder type II is approximately 32 years. Thus, it occupies an intermediate position between bipolar affective disorder type I and unipolar depression. The number of episodes of affective disorders in type II bipolar affective disorder is greater than in unipolar depression, and the duration of the cycle (i.e., the time from the onset of one to the beginning of the next episode) is greater in type II bipolar affective disorder than in type I bipolar affective disorder.

If the patient is in the depressive phase, then in favor of bipolar affective disorder type II testify: the early age of onset of the disease, the presence of bipolar disorder in immediate relatives, the effectiveness of lithium preparations in previous episodes, high incidence of episodes, medical induction of hypomania.

[7], [8]

Hypomania

Episode hypomania is a separate episode lasting 4 days or more, which is clearly different from the patient's usual mood outside of depression. This episode is characterized by 4 or more symptoms that are observed during the manic episode, but these symptoms are less intense, so the functioning is not significantly impaired.

Diagnostic criteria of the hypomaniac episode

• A clearly delineated period, characterized by invariably upbeat mood, expansiveness or irritation, which clearly differ from the usual normal (not depressive) mood for the patient and persist for at least 4 days
• In the period of mood disturbance, at least three (if mood changes are limited to irritation - then at least four) of the following symptoms are persistently present, and their severity reaches a considerable degree:
• Overestimated self-esteem, exaggerated sense of self-worth
• Reduced need for sleep (3 hours of sleep are enough for a sense of proper rest)
• Unusual talkativeness or constant need to talk
• A leap of ideas or a subjective feeling of an overflow with thoughts
• Distractibility (attention easily switches to non-essential or occasional external stimuli)
• Enhancement of targeted activity (social, at work or school, sexual) or psychomotor agitation
• Excessive enthusiasm for activities that bring pleasure, despite the high likelihood of unpleasant consequences (for example, participation in binges, unscrupulous sexual intercourse or unsustainable financial investments)
• The episode is accompanied by a clear change in the life of the patient, not typical for him in the absence of symptoms. Disorders of mood and changes in the life of the patient are noticeable to others
• The disorder is not so severe that it is essential to disrupt the patient's professional activity, his social activity, does not require hospitalization and is accompanied by psychotic symptoms.
• The existing symptoms are not caused by the direct physiological action of exogenous substances (including addictive substances or drugs) or common diseases (eg, thyrotoxicosis)

Cyclothemia

Cyclotymia is a bipolar disorder in which mood swings and mental disorders are much less pronounced than in Type I BPAR. Nevertheless, cyclothymia, as well as a dysthymic disorder, can be the cause of severe mental disorders and disability.

Diagnostic criteria for cyclothymia

• Presence of periods of psiomaniac symptoms and periods of depressive symptoms (not satisfying the criteria of a major depressive episode), which are repeated many times for at least 2 years. Note: in children and adolescents, the duration of the symptoms should be at least 1 year.
• For 2 years (in children and adolescents for 1 year) the above symptoms were absent for no more than 2 months in a row.
• During the first 2 years from the onset of the disease, there were no major depressive, manic or mixed episodes.

Note: after the first 2 years (in children and adolescents after 1 year) the disease may cause manic or mixed episodes of discomfort (in this case, bipolar I disorder and cyclothymia are diagnosed simultaneously) or major depressive episodes (in which case bipolar disorder type II is diagnosed at the same time and cyclothymia).

• Symptoms indicated in the first criteria can not be better explained by schizoaffective disorder, they do not arise in the presence of schizophrenia, schizophrenia, schizophrenia disorder, delusional disorder or unspecified psychotic disorder
• The existing symptoms are not caused by the direct physiological action of exogenous substances (including addictive substances or drugs) or common diseases (eg, thyrotoxicosis).

[9]

Comorbid disorders and other factors affecting treatment

On the course of the disease, the patient's compliance and choice of drugs are significantly affected by comorbid diseases and a number of other factors.

Substance Abuse

According to epidemiological studies, in patients with bipolar disorder, comorbid dependence or abuse of psychoactive substances is more frequent than in other basic mental illnesses. Bipolar disorder is detected in 2-4% of patients with alcoholism undergoing treatment under a special program, as well as in 4-30% of patients undergoing treatment for cocaine dependence. Typically, bipolar disorder and cyclothymia are more common among people who abuse psychostimulants than those who are dependent on opioids and sedatives or hypnotics. On the other hand, 21-58% of hospitalized patients with bipolar disorder experience substance abuse. With a combination of bipolar disorder and substance abuse, lower compliance is indicated, longer hospitalizations; Diagnostic difficulties are also common, since the abuse of psychostimulants can imitate hypomania or mania, and their reversal - many manifestations of depression.

[10], [11], [12],

Other disorders

Epidemiological study showed that 8-13% of patients with bipolar disorder have obsessive-compulsive disorder, 7-16% have panic disorder, and 2-15% have bulimia.

Treatment of all these three states with antidepressants in patients with bipolar disorder is difficult. If a patient with bipolar disorder has a comorbid panic disorder, the use of benzodiazepines is limited by a high risk of developing dependence on psychotropic drugs. In patients with bipolar disorder, migraine is more common than the average for the population. On the other hand, in one study, it was noted that among patients with migraine, bipolar disorder occurs 2.9 times more often than in the population. Of particular interest in this connection is the fact that valproic acid was effective in both states.

Secondary Mania

Secondary mania is a condition caused by a somatic or neurological disease, exposure to drugs, substance abuse. Secondary mania usually begins at a later age with a history of family history. One of the causes of secondary mania may be traumatic brain injury, and more often it occurs when the right subcortical structures (the thalamus, the "caudate" nucleus) are damaged or those areas of the cortex that are closely related to the limbic system (basal parts of the temporal cortex, orbitofrontal cortex).

Cases of secondary mania are described in cases of multiple sclerosis, hemodialysis, correction of hypocalcemia, hypoxia, tick-borne borreliosis (Lyme disease), polycythemia, cerebrovascular diseases, neurosarcoidosis, tumors, AIDS, neurosyphilis, and also with corticosteroids, amphetamines, baclofen, bromides, bromocriptine , captopril, cimetidine, cocaine, cyclosporine, disulfiram, hallucinogens, hydralazine, isoniazid, levodopa, methylphenidate, metrizamide, opioids, procarbazine, procyclidine, yohimbine. In favor of the secondary nature of mania may indicate: late onset, the absence of mental illness in a family history, physiological changes associated with somatic or neurological pathology, the recent appointment of a new drug.

Bipolar disorder, nowhere else classified

Bipolar disorder, nowhere else classified, refers to disorders with clear bipolar traits that do not meet the criteria for other bipolar disorders.

[13], [14],