Bipolar Disorder Comprehensive Study Guide

Overview of Bipolar Disorder

This lecture, part of the BSc (Hons) Psychology program at the University of METROPOLITAN (East London College), focuses on Bipolar Disorder (Διπολική Διαταραχή) as part of Week $7$, Lecture $7$ (PY5015). The discussion centers on the diagnostic criteria for various clinical episodes, the classification of bipolar disorders, their epidemiology, clinical course, etiology, and the range of therapeutic interventions available.

Diagnostic Criteria and Types of Episodes

To diagnose a specific disorder within the bipolar spectrum, it is first necessary to identify and link various clinical episodes. The DSM-5 characterizes these based on distinct patterns of mood and functioning. There are four primary types of episodes discussed: Major Depressive Episode, Manic Episode, Mixed Episode, and Hypomanic Episode.

Major Depressive Episode (MDE)

A Major Depressive Episode is defined by at least $5$ of the following symptoms occurring during a continuous $2$-week period, representing a significant change from previous functioning. These symptoms must be present most of the day, nearly every day. Crucially, at least one of the symptoms must be either a depressed mood or a loss of interest or pleasure. The symptoms include:

1. Depressed mood most of the day, nearly every day, indicated by subjective report (e.g., feeling sad or empty) or observation by others (e.g., appearing tearful). In children and adolescents, this may manifest as an irritable mood.

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.

3. Significant weight loss when not dieting, or weight gain.

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation nearly every day, observable by others and not merely subjective feelings of restlessness or being slowed down.

6. Fatigue or loss of energy nearly every day.

7. Feelings of worthlessness or excessive/inappropriate guilt nearly every day.

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or observation by others).

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Manic Episode

A Manic Episode is a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least $1$ week (or any duration if hospitalization is necessary). During this period of mood disturbance, at least $3$ (or more) of the following symptoms must persist and be present to a significant degree:

1. Inflated self-esteem or grandiosity.

2. Decreased need for sleep (e.g., the individual feels rested after only $3$ hours of sleep).

3. More talkative than usual or pressure to keep talking.

4. Flight of ideas or subjective experience that thoughts are racing.

5. Distractibility (i.e., attention is too easily drawn to unimportant or irrelevant external stimuli).

6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.

7. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

A critical diagnostic note is that the mood disturbance must be sufficiently severe to cause marked impairment in social or occupational functioning, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

Mixed Episode

A Mixed Episode is characterized by meeting the full criteria for both a Manic Episode and a Major Depressive Episode nearly every day for a period of at least $1$ week.

Hypomanic Episode

A Hypomanic Episode is a distinct period of persistently elevated, expansive, or irritable mood lasting at least $4$ consecutive days, which is clearly different from the individual's usual non-depressed mood. According to DSM-5, the diagnosis requires at least $3$ of the following symptoms ($4$ if the mood is only irritable) to be present to a significant degree:

1. Inflated self-esteem or grandiosity.

2. Decreased need for sleep (e.g., feeling rested after $3$ hours of sleep).

3. Greater talkativeness than usual or pressure to continue talking.

4. Flight of ideas or subjective feeling that thoughts are racing.

5. Distractibility (attention is easily drawn to irrelevant stimuli).

6. Increase in goal-directed activity (social, occupational/academic, or sexual) or psychomotor agitation.

7. Excessive involvement in pleasurable activities with a high likelihood of painful consequences.

Distinct from a full manic episode, a hypomanic episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when asymptomatic. Both the mood disturbance and the change in functioning must be observable by others. However, the episode is NOT severe enough to cause marked impairment in social or occupational functioning, does not require hospitalization, and has no psychotic features. Furthermore, the symptoms must not be due to the physiological effects of a substance (e.g., drug abuse, medication) or a general medical condition (e.g., hyperthyroidism).

Classification of Bipolar Disorders

Diagnostic classification depends on the specific type, duration, and combination of the episodes described above. The three main disorders are:

1. Bipolar I Disorder (Διπολική διαταραχή Ι): Characterized by a clinical course of one or more Manic or Mixed Episodes. It often includes comorbid conditions such as Anorexia Nervosa, Bulimia, Substance-related disorders, Panic Disorder, Social Phobia, and Attention-Deficit/Hyperactivity Disorder (ADHD). Its epidemiology ranges from $0.4-1.6\%$ and is equally common in men and women. The average age of onset is around $20$. Episodes often begin suddenly with rapid escalation, frequently following psychosocial stress, and typically last from a few weeks to several months, ending relatively abruptly. $90\%$ of individuals will experience a recurrence.

2. Bipolar II Disorder (Διπολική διαταραχή ΙΙ): Characterized by one or more Major Depressive Episodes accompanied by at least one Hypomanic Episode. The hypomania must not be severe enough to cause significant functional impairment. This disorder has an epidemiology of approximately $0.5\%$, is more common in women, and carries a suicide risk of $10-15\%$ of cases.

3. Cyclothymic Disorder (Κυκλοθυμική διαταραχή): This is a chronic mood disturbance characterized by continuous fluctuations for at least $2$ years. It involves numerous periods with hypomanic symptoms and numerous periods with depressive symptoms. Common comorbidities include substance-related disorders and sleep disorders. It typically begins early in adolescence and is equally common in men and women. The onset is insidious, and the course is chronic, with $15-20\%$ of individuals eventually developing Bipolar Disorder.

Prognosis and Clinical Course

The prognosis for Bipolar Disorder varies, with only $15\%$ of patients having a benign course. Approximately $50-60\%$ recover partially, experiencing multiple relapses but maintaining relatively good functioning between episodes. About $1/3$ of patients face chronicity and functional or cognitive decline.

Negative prognostic factors include:

• Low premorbid occupational functioning

• Alcohol dependence

• Psychotic features

• Depressive symptoms between episodes

• Male gender

Positive prognostic factors include:

• Short duration of manic symptoms

• Older age of onset

• Absence of suicidality

• Absence of psychiatric or physical comorbidity

Etiological and Psychosocial Factors

The causes of Bipolar Disorder are multifaceted, involving biological and psychological elements:

1. Heredity: There is a significant genetic component, with a $5-10\%$ risk for close relatives and a $40-70\%$ risk for monozygotic (MZ) twins.

2. Brain Injuries: Concussions or other brain injuries can trigger the onset of symptoms.

3. Substance Abuse: Alcohol or drug abuse is very common among patients and can complicate the disorder.

4. High-Stress Periods: Stressful life events like the death of a family member, surviving rape, abuse, or other traumatic experiences can trigger symptoms.

5. Psychosocial Factors: These include stressful life events and early childhood instability/insecurity, often stemming from a disturbed mother-child relationship, which creates vulnerability to separation later in life. While no specific personality trait is proven to cause the disorder, negative or erroneous evaluations of oneself, the world, and the future contribute to the depressive phase.

6. Psychodynamic Perspective: Mania is often viewed as a psychological defense (denial) against underlying depression.

Therapeutic Interventions

Management of Bipolar Disorder requires a combination of pharmacological and psychotherapeutic approaches.

Pharmacotherapy involves:

• Mood Stabilizers: Such as Lithium (Λίθιο).

• Antiepileptics: Including Valproic acid (Βαλπροϊκό οξύ), Carbamazepine (Καρβαμαζεπίνη), Oxcarbazepine (Οξκαρβαζεπίνη), Lamotrigine (Λαμοτριγίνη), and Gabapentin (Γκαμπαπεντίνη).

• Antipsychotics: Both typical (e.g., Haloperidol/Αλοπεριδόλη) and atypical (e.g., Aripiprazole/Αριπιπραζόλη, Olanzapine/Ολανζαπίνη, Quetiapine/Κουετιαπίνη, Risperidone/Ρισπεριδόνη).

• Anxiolytics: Such as benzodiazepines (e.g., Lorazepam/Λοραζεπάμη and Clonazepam/Κλοναζεπάμη).

• Antidepressants: Used cautiously as they can induce mania or rapid cycling (\text{taquifasicity}).

Psychotherapeutic interventions include:

• Cognitive Behavioral Therapy (CBT): Researched for its ability to increase compliance with lithium treatment. It is effective during hospitalization for mania, using techniques like positive and negative reinforcement to set limits on impulsive and inappropriate behavior.

• Systemic-Family Therapy: Highly important due to the genetic nature of the disorder (increased prevalence in first-degree relatives). Manic episodes are highly disruptive to interpersonal and professional relationships. This therapy provides a space to express and manage the anger and shame often felt by family members, making these emotions manageable.