over-activity; pressured speech ( \200\230 \202 ight of ideas \200\231); racing thoughts; reduced need for sleep. over-optimistic ideation; grandiosity; reduced social inhibitions; over-familiarity (which may be overly amorous); facetiousness. \200 excitement; irritability; aggressiveness; suspiciousness. Psychotic symptoms In its more severe form, mania may be associated with psychotic symp- to ms (usually mood-congruent, but may also be incongruent): \200 Grandiose ideas may be delusional, related to identity or role (with special powers or reli gious content). Suspiciousness may develop into well-formed persecutory delusions. Pressure d speech may become so great that clear associations are lost and speech becomes incomprehe nsible. Irritability and aggression may lead to violent behavior. Preoccupation with though ts and schemes may lead to self-neglect, to the point of not eating or drinking, and poor l iving conditions. Catatonic behavior \200\224also termed manic stupor. Total loss of insigh t. \200 \200 \200 08_Semple_Chap08.indd 306 12/7/2012 6:52:36 PM MANIA/MANIC EPISODE 307 Differential diagnosis \200 Schizophrenia, schizoaffective disorder, delusional disorder, other psychotic disorders. An xiety disorders/PTSD. Circadian rhythm disorders (see ADHD/conduct disorder. Alcohol or dru g misuse (e.g. stimulants, hallucinogens, opiates). Physical illness (e.g. hyper/hypothyroi dism, Cushing \200\231s syndrome, SLE, MS, head injury, brain tumor, epilepsy, HIV and othe r encephalopathies, neurosyphilis, Fahr \200\231s disease). Other antidepressant treatment or drug-related causes (Box 8.2). \200 \200 \200 \200 b p. 436). Management \200 \200 \200 b p. 316). Exclusion of other causes and appropriate investigations ( Address any speci \201 c psycho social stressors. For speci \201 c management, see b p. 326. 08_Semple_Chap08.indd 307 12/7/2012 6:52:36 PM CHAPTER 8 Bipolar illness 308 Box 8.2 Medications that may induce symptoms of hypomania/mania \200 Antidepressants antidepressants (or withdrawal, see b p. 964), less so with SSRIs and bupro pion (also seen with ECT and light therapy). Other psychotropic medication: \200 : drug-induced mania described with most benzodiazepines (b p. 929); antipsychotics lithium anticonvulsants gabapentin; psychostimul ants methylphenidate; \200 \200\224disul \201 ram. other Anti-Parkinsonian medication: procyclidine. Cardiovascular drugs: hydralazine, methyldopa withdrawal, procainamide, propr anolol (and withdrawal), reserpine. Respiratory drugs: pseudoephedrine. Anti-infection: dap sone, isoniazid, zidovudine. Analgesics: pentazocine, tramadol. cimetidine, metoclopramide, ranitidine. GI drugs: Steroids: ACTH, beclometasone, corticosteroids, cortisone, dexametha sone, DHEA, hydrocortisone, prednisolone, testosterone. Other: \200\224may be confused with \200\230paradoxical \200\231 reactions \200 \200 \200\224olanzapine, risperidone; \200\224toxicity, and when combined with TCAs; (rare) \200\224carbamazepine (and withdrawal), valproate, \200\224fen \202 uramine, amfetamine, dexamfetamine, amantadine, bromocriptine, levodopa, captopril, clonidine, digoxin, diltiazem, aminophylline, ephedrine, salbutamol, terfenadine, anti-TB medication, chloroquine, clarithromycin, buprenorphine, codeine, indometacin, nefopam (IM), \200 baclofen (and withdrawal), cyclizine, ciclosporin, interferon. 08_Semple_Chap08.indd 308 12/7/2012 6:52:36 PM This page intentionally left blank CHAPTER 8 Bipolar illness 310 Hypomania/hypomanic episode Essence Three or more characteristic symptoms (see Clinical features) lasting at least 4 da ys (DSM-IV), and are clearly different from \200\230normal \200\231 mood (third-party corr oboration). By de \201 nition, not severe enough to interfere with social or occupational functioning, require admission to hospital, or include psychotic features. Clinical features Hypomania shares symptoms with mania, but these are evident to a lesser d egree and do not signi \201 cantly disrupt work or lead to social rejection: \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 Mildly elevated, expansive, or irritable mood. Increased energy and activity. Marked feelin gs of well-being, physical, and mental ef \201 ciency. Increased self-esteem. Sociability. Talkativeness. Over-familiarity. Increased sex drive. Reduced need for sleep. Dif \201 cu lty in focusing on one task alone (tasks often started, but not \201 nished). Differential diagnosis \200 Agitated depression. \200 OCD/other anxiety disorders. \200 Circadian rhythm disorders (see \200 Substance misuse/physical illness/medication-r elated (see Box 8.2). b p. 436). b p. 308, Management \200 Exclusion of other possible causes with appropriate investigations (see b p. 316). Address any speci \201 c psychosocial stressors. If sleep disturbance is a problem, consider use o f an hypnotic. If episode is prolonged, discuss medication possibilities (see and the possi bility of prophylaxis (b p. 330). \200 \200 b p. 326) 08_Semple_Chap08.indd 310 12/7/2012 6:52:37 PM This page intentionally left blank CHAPTER 8 Bipolar illness 312 Bipolar spectrum disorder One view of the affective disorders is that they consist of a con tinuum (see Box 8.3) with bipolar spectrum sitting uneasily between cyclothymia and bipolar II. Whether or not such \200\230subsyndromal \200\231 disorders are of clinical rel- evan ce remains controversial and there are other unexpected diagnostic concerns (see b p. 318). Proposed clinical features Bipolar spectrum disorder is characterized by:1 \200 \200 At least one major depressive episode. No spontaneous hypomanic or manic episodes. The history will include some of the following: \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 A family history of bipolar disorder in a \201 rst-degree relative. Antidepressant-induce d mania or hypomania. Hyperthymic personality Recurrent major depressive episodes (>3). Bri ef major depressive episodes (on average, <3mths). Atypical depressive symptoms (DSM-IV cri teria). Psychotic major depressive episodes. Early age of onset of major depressive episode (<age 25). Post-partum depression. Antidepressant \200\230wear-off \200\231 (acute but no t prophylactic response). Lack of response to up to 3 antidepressant treatment trials. 2 (at baseline, non-depressed state). Management Patients with features of bipolar spectrum disorder may represent a sub- set of patients who do not respond well to antidepressants (often pre- cipitating a switch to a hy pomanic or manic episode) and for whom an anticonvulsant may be the drug of choice (e.g. va lproate, see b p. 342). Box 8.3 The \200\230affective continuum \200\231 Dysthymia Unipolar depression Atypical depression Psychotic depression Recurrent depression Cyclothymia Bipolar spectrum disorder Bipolar II Bipolar I } Unipolar spectrum disorder 1 Ghaemi SN, Ko JY, Goodwin FK (2002) \200\230Cade \200\231s disease \200\231 and beyond: misdiagnosis, antidepressant use, and a proposed de \201 nition for bipolar spectrum disor der. Can J Psychiat 47: 125 \200\22334. 2 Characterized by cheerful, optimistic personality style, tendency to become easily irritated, extroverted and sociable, and requiring little sleep (less than 6hrs/night) \200\224a lifelong disposition, unlike short-lived hypomania. Neither in ICD-10 nor DSM-IV, but signi \201 cant overlap with narcis- sistic or antisoci al personality. 08_Semple_Chap08.indd 312 12/7/2012 6:52:37 PM This page intentionally left blank CHAPTER 8 Bipolar illness 314 Bipolar (affective) disorder 1: classi \201 cation Diagnostic classi \201 cation (see Box 8.4 and Table 8.1) ICD-10 Requires at least 2 episodes, one of which must be hypomanic, manic, or mixed, with recovery usually complete between episodes. Criteria for depressive episodes are the same a s unipolar depression (see b p. 236). Separate category (manic episode) for hypomania or ma nia (with or without psychotic symptoms) without history of depressive episodes. Cyclothymi a included with dysthymia in persistent mood disorders section. DSM-IV Allows a single manic episode and cyclothymic disorder to be consid- ered as part of bipolar disorder, and de \201 nes two subtypes (with additional speci \201 ers): \200 Bipolar I disorder mixed episodes, with or without a history of one or more depressive epis odes. Bipolar II disorder accompanied by at least one hypomanic episode. Severity speci \201 ers: features); in partial or full remission. Special syndrome speci \201 ers: featur es; with post-partum onset. Longitudinal course speci \201 ers: recovery; with seasonal pa ttern; with rapid cycling. : the occurrence of one or more manic episodes or : the occurrence of one or more depressive episodes mild, moderate, severe (with or without psychotic with catatonic, melancholic, or atypical with or without full inter-episode Mixed episodes (DSM-IV and ICD-10) \200 The occurrence of both manic/hypomanic and depressive symptoms in a single episode, present every day for at least 1wk (DSM-IV) or 2wks (ICD-10). Typical presentations include: \200 \200 \200 \200 depression mania dysphoria rapid cycling ( \202 uctuating between mania and depression \200\2244 or more episodes/yr) plus over-activity/pressure of speech; plus agitation and reduced energy/libido; plus manic symptoms (with exception of elevated mood); Note: \200\230Ultra-rapid \200\231 cycling refers to the situation when \202 uctuations are over days or even hours. 08_Semple_Chap08.indd 314 12/7/2012 6:52:37 PM BIPOLAR (AFFECTIVE) DISORDER 1: CLASSIFICATION 315 \200\230The clinical reality of manic-depressive illness is far more lethal and in \201 n itely more complex than the current psychiatric nomenclature, bipolar disorder, would sugge st. Cycles of \202 uctuating moods and energy levels serve as a background to constantly changing thoughts, behaviors, and feelings. The illness encompasses the extremes of human e xperi- ence. Thinking can range from \202 orid psychosis, or \200\234madness \200\235, t o pat- terns of unusually clear, fast and creative associations, to retardation so profound that no meaningful mental activity can occur. Behavior can be frenzied, expansive, bizarre , and seductive, or it can be seclusive, sluggish, and dangerously suicidal. Moods may swin g erratically between euphoria and despair or irritability and desperation. The rapid oscil la- tions and combinations of such extremes result in an intricately textured clinical pict ure. Manic patients, for example, are depressed and irritable as often as they are euphoric ; the highs associated with mania are gener- ally only pleasant and productive during the e arlier, milder stages. \200\231 Dr Kay Red \201 eld Jamison (1993) Touched with \201 re: manic-depressive illness and th e artistic temperament, pp. 47 \200\2238. New York: Free Press, Macmillan Box 8.4 ICD-10 bipolar affective disorder \200 \200 \200 \200 \200 \200 \200 \200 \200 Current episode, hypomanic. Current episode, manic without psychotic symptoms. Current epis ode, manic with psychotic symptoms. Current episode, mild or moderate depression. Current e pisode, severe depression without psychotic symptoms. Current episode, severe depression wi th psychotic symptoms. Current episode, mixed. Currently in remission. Other bipolar affect ive disorders: bipolar affective disorder, unspeci \201 ed. Table 8.1 DSM-IV bipolar disorder Bipolar I disorder Bipolar II disorder Single manic episode Most recent episode, hypomanic Most recent episode, hypomanic Most recent episode, depressed Most recent episode, manic Most recent episode, mixed Cyclothymic disorder Most recent episode, depressed Most recent episode, unspeci \201 ed Bipolar disorder not otherwise speci \201 ed 08_Semple_Chap08.indd 315 12/7/2012 6:52:37 PM CHAPTER 8 Bipolar illness 316 Bipolar (affective) disorder 2: clinical notes Epidemiology Lifetime prevalence 0.3 \200\2231.5% (0.8% bipolar I; 0.5% bipolar II); 4 = 5 (bipo- lar II and rapid cycling more common in 5; 1st episodes: 4 tend to be manic, 5 depre ssive); no signi \201 cant racial differences; age range 15 \200\22350+ yrs (peaks at 15 \200\22319yrs and 20 \200\22324yrs; mean 21yrs). Course Extremely variable. First episodes may be hypomanic, manic, mixed, or depressive. Th is may be followed by many years (5 or more) without a further episode, but the length of t ime between subsequent episodes may begin to narrow. There is often a 5 \200\22310-yr inter val between age at onset of illness and age at \201 rst treatment or \201 rst admission to hospital. Often patients with recurrent depression have a \201 rst manic episode in l ater life (>50yrs). It is known that untreated patients may have more than 10 episodes in a lifetime, and that the duration and period of time between episodes stabilizes after the 4 th or 5th episode. Although the prognosis is better for treated patients, there still remai ns a high degree of unpredictability. Morbidity/mortality Morbidity and mortality rates are high, in terms of lost work, lost pro ductivity, effects on marriage (increased divorce rates) and the family, with attempted sui cide in 25 \200\22350%, and completed suicide in 10% (4 > 5, usually during a depressive ep isode). Often signi \201 cant comorbidity \200\224esp. drug/alcohol misuse and anxiety dis orders (both increase risk of suicide). Differential diagnosis Depends upon the nature of the presenting episode (See Mania/manic e pisode, b p. 306, Hypomania/hypomanic episode, b p. 310, and Depressive illness, b p. 428). Investigations As for depression; full physical and routine blood tests to exclude any trea table cause, including FBC, ESR, glucose, U&Es, Ca2+, TFTs, LFTs, drug screen. Less routine tests: urinary copper (to exclude Wilson \200\231s disease [rare]), ANF (SLE), infection s creen (VDRL, HIV test). CT/MRI brain (to exclude tumor, infarction, hemorrhage, MS) \200 \224may show hyperintense subcortical structures (esp. temporal lobes), ventricular enlarge ment, and sulcal prominence; EEG (baseline and to rule out epilepsy). Other baseline tests prior to treatment should include ECG and creatinine clearance. 08_Semple_Chap08.indd 316 12/7/2012 6:52:37 PM BIPOLAR (AFFECTIVE) DISORDER 2: CLINICAL NOTES 317 Management See speci \201 c sections (b p. 322) for management principles, other issues, t reatment of acute manic episodes, depressive episodes, prophylaxis, and psychotherapeutic i nterventions. Prognosis Within the \201 rst 2 years of 1st episode, 40 \200\22350% of patients experien ce another manic episode. 50 \200\22360% of patients on lithium gain control of their sympt oms (7% no recurrence; 45% some future episodes; 40% persistent recurrence). Often, the cyc ling between depression and mania acceler- ates with age. Poor prognostic factors: poor emp loyment history; alcohol abuse; psychotic features; depressive features between periods of mania and depression; evidence of depression; male sex; treatment non-compli- ance. Good pr ognostic factors: manic episodes of short duration; later age of onset; few thoughts of sui cide; few psychotic symptoms; few comorbid physical problems, good treatment response and c ompliance. 08_Semple_Chap08.indd 317 12/7/2012 6:52:37 PM