ORGANUM
Patients with both maniac and depressive episodes or patients with manic episodes are said to have bipolar disorder. The term unipolar mania and pure mania are sometimes used for patients who are bipolar but who do not have depressive episodes.
Three additional categories:
Cyclothymia
Hypomania
Dysthymia
Cyclothymia and dysthymia are disorders that represent less severe form of bipolar disorder and major depression, respectively.
The symptoms of mania or hypomania are:
Abnormally increased or irritable mood (required)
Grandiose thoughts
Decreased need for sleep
Pressured speech
Racing and expansive thoughts
Distractibility
Hyperactivity
Impulsivity/high-risk activties
The patient should have at least one manic episode, where they should have an abnormally increased or irritable mood. 3 or more (4 or more if irritable mood) is a diagnosis of hypomania.
Exlucsions are drug abuse, mediciation effect, other medical conditions or psychiatric illness.
We can differeinate mania and hypomania by the impairement on daily living. If the 'manic' episode is with impaired functioning or needing hospitalisation, it is a manic episode. In a hypomanic epiosde, there is no impairment or need for hospitlisation.
Bipolar I is defined by at least one manic episode. Patients with this disorder may have a single or recurrent epiosde. Manic episodes are distinct when they are separated by at least 2 months without significant symptoms of mania or hypomania. The episodes should not be due to another apparent cause such as the use of antidepressant.
Bipolar patients have hypomania rather than mania. It is easy to confuse with other disorders, including dramatic but normal moods, with hypoamnia. Many mediciations, including anti-depressants, can induce hypomanic symptoms.
Rapid cycling : Some patients experience frequent mania episodes. When a patient has at least four such episodes in a year, we diagnose them with the rapid cycling subtype of bipolar disorder. Patients with rapid cycling Bipolar I disorder are likely to be female and to have had depressive and hypomanic episodes.
With seasonal : As with depression, mania can occur primarily during certain seasons. Some studies have found a higher prevalence of manic episodes in the spring and summer months, however available research is most convincing for the seasonality of depressive episodes.
With peripartum onset: Mania occuring after pregancny is a critical issue due to risks to the child
With cataonia: Clinicals do not often associate cataonic symptoms with Bipolar I due to the symptoms of stuporous catonia and the classic symptoms of mania. They are associated with depressive episodes, howeever
Cyclothymic disorder has been appericated clinically for some time as a less severe form of bipolar disorder. Patients with cyclothymic disorder have at least 2 years of frequently occuring hypoamnic symptoms that cannot fit the diagnosis of a manic episode and of depressive episodes that cannot fit the criteria for major depressive disorder.
Medical:
AIDS/HIV
Delirium
Hyperthyroidism
Postencephalitic syndrome
Substance:
Antidepressant
Steroid
Amphetamine
Cocaine
Phencyclidine ()
Alcohol
L-DOPA
Bronchodilator
Decongestant
Psychiatric:
Atypical psychosis
Bipolar disorder
Catatonic schizophrenia
Schizoaffective disorder
Patients with bipolar I disorder have a poorer prognosis than do patients with major depressive disorder. About 40 to 50% of patients may have a second manic episode within 2 years of the first episode. Although lithium prophylaxis improves the course and prognosis of bipolar I disorder, probably only 50 to 60% achieve significant control of their symptoms with lithium.
7% of bipolar patients (type I) do not have a recurrence of symptoms. 45% have more than one episode, and 40% have a chronic disorder. Patients may have from 2 to 30 manic episodes, although the mean number is about 9. 40% of patients have more than 10. On long term follow up, 15% are well, 45% are well but have multiple relapses, 30% are in partial remission, and 10% are chronically ill. 1/3 of all patients have chronic symptoms and evidence of significant social decline.
One 4-year follow up found that poor occupational status, alcohol use disorder, psycjotic features, depressive features, and male gender were al factors that contributed to a poor prognosis. A short duration of manic episodes, advanced age of onset, few sucidial thoughts, and few coexisting psychiatric or medical problems predict a better outcome.
It is best to treat patients with severe mania in the hospital when aggressive dosing is possible, and it is possible to achieve an adequate response relatively quickly. Manic patients may test the limits of ward rules, shift responsibility for their actions and exploit the weaknesses of others, and they can create conflict among staff members.
We can divide the pharamcologic treatment of bipolar into acute and mainteance phases. Bipoalr treatments, however, involves the formulation of different strategies for the patient who is experiencing mania or hypomania or depression. Lithium and is augmentation by antidepressants, antipsychotic, and benzodiazepines have been the princpial approach to the illness. However, three anticonvulsant mood stabilizers - carbamazepine, valproate, and lamotrigine - are commonly used options, as well as a series of atypical antipsychotics.
Acute mania
The treatment of acute mania or hypomania, is the most straightforward to treat. We can use agents alone or in combination to bring the patient down from a high.
Lithium: Although Lithium is considered the typical mood stabilizer, the o nset of antimanic action can be slow, we often supplement it in the early phases of treatment by atypical antipsychotics, mood-stabilising anticonvulsants, or high-potency benzodiazepines. Therapeutic lithium levels are between 0.6 and 1.2 mE1/L.
Anticonvulsants: The use of valproate has surpassed lithium for its use in acute mania. Unlike lithium, valproate is only indicated for acute mania, although most experts will agree it also has prophylactic effects. Carbamazepine has been used worldwide for decades as a first-line treatment for acute mania. A cochrane review concluded that there is insufficient evidence for this medication in acute mania.
Antipsychotics: Compared with older agents, such as haloperidoal and chlorpromazine, atypical antipsychotics have a lesser laibility for tardive dyskinsea; many do not increase prolactin. Quetiapine has the best evidence, in a modest dose (300mg/day), is siffucient to improve symptoms. Prophylactic efficacy was demonstrated with Risperdal Consta but no studies with oral risperidone.