Bipolar and Related Disorders - Study Notes

Overview

• Bipolar Disorder is a mood disorder characterized by periods of depression and periods of abnormally elevated mood that last from days to weeks. Previously known as manic depression.
• Mood episodes include depressive episodes, manic episodes, and hypomanic episodes, with symptom patterns defining different bipolar subtypes.
• Core idea: cycling between lows (depression) and highs (mania/hypomania) with variable duration and impairment.

Types of Bipolar Disorder

• Bipolar I Disorder
  • Represents the modern understanding of the classic manic-depressive disorder; unlike the historical description, a manic episode is central, but a major depressive episode is not a requirement for diagnosis.
• Bipolar II Disorder
  • Requires lifetime experience of at least one major depressive episode and at least one hypomanic episode; not milder but often more time spent in depression than Bipolar I.
• Cyclothymic Disorder
  • Adults: at least 2 years of both hypomanic and depressive periods without meeting criteria for a manic, hypomanic, or major depressive episode;
  • Children: at least 1 year.

Profiles (Mania and the bipolar experience)

• Descriptive portrayal: There is a particular kind of pain, elation, loneliness, and terror involved in this kind of madness. When you're high it's tremendous. Ideas and feelings are fast and frequent, like shooting stars, and you follow them to brighter ones. Shyness disappears; the right words and gestures appear; the power to seduce and captivate others feels certain. Interests may be found in unlikely people. Sensuality becomes pervasive; the desire to seduce and be seduced seems irresistible. Feelings of ease, intensity, power, well-being, financial omnipotence, and euphoria pervade.
• Yet this often shifts: ideas become too fast and numerous; overwhelming confusion replaces clarity; memory fails; humor fades; fear and concern replace absorption in others. What was once moving with the grain may turn against you; irritability, anger, fear, and uncontrollable behavior emerge; you may become completely enveloped in dark mental spaces. The sense of inevitability that it will never end is common. (Goodwin & Jamison, 1990, pp. 17-18)
• Source: Abnormal Psychology 8th Edition by Nolen-Hoeksema

What is Mania? (Definitions)

• Mania: State of intense elation or irritability.
• Hypomania: Less intense mania; does not involve significant impairment.

Overview

• The material distinguishes Bipolar I, Bipolar II, and Cyclothymia; emphasizes DSM-5 criteria and clinical features, risk factors, and treatment considerations.

DSM-5 Criteria for Manic Episode

• A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and increased goal-directed activity or energy, lasting at least $1\ \text{week}$ and present most of the day, nearly every day.
• B. During the mood disturbance and increased energy/activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
  • 1. Inflated self-esteem or grandiosity
  • 2. Decreased need for sleep
  • 3. More talkative than usual or pressure to keep talking
  • 4. Flight of ideas or subjective sensation that thoughts are racing
  • 5. Distractibility
  • 6. Increase in goal-directed activity or psychomotor agitation
  • 7. Excessive involvement in activities with high potential for painful consequences
• C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning.
• D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse or medication).

DSM-5 Criteria for Hypomanic Episode

• A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least $4\ \text{consecutive days}$.
• B. During the period, three (or more) of the following symptoms (four if the mood is only irritable) have persisted:
  • 1. Inflated self-esteem or grandiosity
  • 2. Decreased need for sleep
  • 3. More talkative than usual or pressure to keep talking
  • 4. Flight of ideas or subjective experience that thoughts are racing
  • 5. Distractibility
  • 6. Increase in goal-directed activity or psychomotor agitation
  • 7. Excessive involvement in activities with high potential for painful consequences
• C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.
• D. The disturbance in mood and the change in functioning are observable by others.
• E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is manic by definition.
• F. The episode is not attributable to the physiological effects of a substance.

DSM-5 Criteria for Major Depressive Episode

• A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure (anhedonia):
  • 1. Depressed mood most of the day, nearly every day
  • 2. Marked diminished interest or pleasure (Anhedonia)
  • 3. Significant weight loss when not dieting or weight gain; or decrease or increase in appetite
  • 4. Insomnia or hypersomnia
  • 5. Psychomotor agitation or retardation
  • 6. Fatigue or loss of energy
  • 7. Feelings of worthlessness or excessive or inappropriate guilt
  • 8. Diminished ability to think or concentrate, or indecisiveness
  • 9. Recurrent thoughts of death, suicidal ideation, or a suicide attempt
• B. Distress or impairment
• C. Not attributable to the physiological effects of a substance or other medical condition

Subtypes of Major Depressive Episode (MDE)

• Anxious Distress
• Mixed Features (presence of at least three manic/hypomanic symptoms without meeting criteria for a manic episode)
• Melancholic Features (inability to experience pleasure, distinct depressed mood)
• Psychotic Features (mood-congruent or mood-incongruent delusions or hallucinations)
• Catatonic Features (catatonic behaviors)
• Atypical Features (mood reactivity, significant weight gain or increased sleep, sensitivity to rejection)
• Seasonal Pattern (history of MDE in a seasonal pattern for at least two years, remitting when season ends)
• Peripartum Onset (onset during pregnancy or within 4 weeks after delivery)

Bipolar I Disorder: Criteria and Features

• A. Criteria have been met for at least one manic episode (A-D) (the manic episode is central to diagnosis).
• B. The occurrence of manic and major depressive episodes is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified/unspecified schizophrenia spectrum and other psychotic disorder.
• C. Rapid Cycling and other course modifiers may be present (see notes below).
• D. Note: A major depressive episode may occur, but is not required for diagnosis.

Bipolar II Disorder: Criteria and Features

• A. Criteria have been met for at least one hypomanic episode (A-F) and at least one major depressive episode (A-C).
• B. There has never been a manic episode.
• C. The occurrence of the hypomanic and major depressive episodes is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified/unspecified schizophrenia spectrum and other psychotic disorder.
• D. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania cause clinically significant distress or impairment.

Table 7.4: Bipolar I vs Bipolar II (Criteria and Diagnosis)

• Bipolar I: Major depressive episodes can occur but are not necessary for diagnosis; episodes meeting full criteria for mania are necessary for diagnosis; hypomanic episodes can occur between episodes but are not necessary for diagnosis.
• Bipolar II: Major depressive episodes are necessary for diagnosis; mania episodes are not necessary; hypomanic episodes are necessary for diagnosis; episodes can occur between more severe mood states but are not required for diagnosis.

Associated Features (Development and Clinical Presentation)

• Resistance to treatment: many individuals do not perceive they are ill or in need of treatment.
• Flamboyant presentation: changes in dress, makeup, or personal appearance toward a more provocative style.
• Sharper senses: some report heightened smell, hearing, or vision.
• Impulsivity: risk-taking behaviors such as gambling and antisocial behaviors may accompany mania.
• Hostility: individuals may be physically threatening to others; in some cases, delusions may lead to violent or suicidal acts.

Development and Course: Bipolar I

• More than 90% of individuals with a single manic episode go on to have recurrent mood episodes.
• Approximately 60% of manic episodes occur immediately before a major depressive episode.
• Mean age at onset of the first manic, hypomanic, or major depressive episode is approximately 18 years for bipolar I disorder.
• Rapid Cycling: defined as four or more mood episodes (major depressive, manic, or hypomanic) within 1 year.

Development and Course: Bipolar II

• The illness most often begins with a depressive episode and is not recognized as bipolar II until a hypomanic episode occurs; this occurs in about 12% of individuals initially diagnosed with major depressive disorder.
• Onset can be in late adolescence to adulthood; average onset in the mid-20s.
• Approximately 5–15% of individuals with bipolar II have multiple mood episodes (four or more) within the previous 12 months.

Cyclothymic Disorder: Criteria and Course

• A. For at least 2 years (at least 1 year in children/adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.
• B. During the above 2-year period, the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time.
• C. Criteria for a major depressive episode, manic, or hypomanic episode have never been met.
• D. The symptoms are not better explained by schizophrenia or other psychotic disorder.
• E. The symptoms are not attributable to the physiological effects of a substance.
• F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Environmental, Genetic, and Prognostic Risk Factors

• Environmental and economic factors: more common in high-income than in low-income countries.
• Strongest and most consistent risk factors with a substantial impact on risk: a roughly 10-fold increased risk for developing bipolar disorder in vulnerable individuals.
• Prognostic note: subsequent manic episodes are more likely to include psychotic features.

Comorbidity

• Anxiety disorders
• Eating disorders
• Attention-deficit/hyperactivity disorder (ADHD)
• Alcohol or drug problems
• Physical health problems (e.g., heart disease, thyroid problems, headaches, obesity)

Biological Perspective

• The exact cause and mechanism are not yet known; research is ongoing.
• Neuroimaging and postmortem studies show abnormalities in several brain regions, most commonly including the ventral prefrontal cortex and amygdala.
• Evidence suggests abnormalities in neurotransmission, intracellular signaling, and cellular functioning may contribute to bipolar disorder.

Neurotransmitters

• Dopamine is a focus of research, particularly in relation to manic episodes, atypical depression, or depression with psychotic features.
• The dopamine agonist L-dopa can induce hypomania in bipolar patients, along with other dopamine agonists.

Stress and Bipolar Disorder

• Negative stressful life events can trigger depression.
• A somewhat different, more positive set of stressful life events can trigger mania, often linked to goal-striving, achievement, popularity, or financial aspirations in vulnerable individuals.

Treatment Plan

• Medications: Often necessary to balance mood early; mood stabilizers (e.g., lithium) are common.
• Day treatment programs: may be recommended to provide support and counseling while symptoms are controlled.
• Substance abuse treatment: may be integrated into the plan.

Medications (Key categories and examples)

• Mood stabilizers: e.g., lithium (Lithobid).
• Antipsychotics: may be added if symptoms persist (e.g., olanzapine, risperidone, quetiapine, aripiprazole).
• Antidepressants: used carefully due to risk of triggering mania; typically used in combination with mood stabilizers or antipsychotics.
• Anti-anxiety medications: benzodiazepines may help with anxiety and sleep but are usually short-term.

Psychotherapy and Behavioral Interventions

• Interpersonal and Social Rhythm Therapy (IPSRT)
• Cognitive Behavioral Therapy (CBT)
• Psychoeducation
• Family-focused Therapy

Summary Notes and Practical Implications

• Early recognition of manic/hypomanic vs depressive episodes is critical to prevent escalation and impairment.
• Treatment often involves a combination of pharmacotherapy and psychotherapy to stabilize mood, improve functioning, and prevent relapses.
• Consider comorbidity in assessment and treatment, as overlapping disorders (anxiety, ADHD, substance use) influence prognosis and plan.

Rapid Cycling and Course Modifiers (Recap)

• Rapid cycling: four or more mood episodes within a 12-month period.
• Most individuals experience recurrent mood episodes after the first manic episode.

Quick Reference: Key Distinctions in Criteria (Table Recap)

• Mania requires full criteria for a manic episode (A-D) with episodes being a distinct mood disturbance; hypomania is a lower-intensity form (lasting at least 4 days) that does not cause marked impairment and does not include psychotic features.
• Bipolar I diagnosis requires manic episodes; depressive episodes may occur but are not necessary. Bipolar II requires hypomanic and major depressive episodes, with no history of a manic episode.
• Hypomanic episodes are observable by others and represent a change in functioning, but do not cause severe impairment requiring hospitalization (unless there are other factors).

Closing Notes

• The material emphasizes the DSM-5 criteria for manic, hypomanic, and depressive episodes, the course and prognosis of each bipolar subtype, and a comprehensive approach to treatment including medications and psychotherapy.