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Epidemiologic studies report a lifetime prevalence of BPD ranging from 1% to 10% of the U.S population. The prevalence of BPD is the same in males and females, although male patients have more manic episodes and female patients have more depressive episodes. In addition to the adverse psychosocial, vocational, and societal impacts of BPD, the lifetime suicide rate associated with BPD (15.6%) is higher than corresponding rates in any other psychiatric disorder. The diagnostic criteria for a major depressive episode can be found in the chapter on depression.
A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting throughout at least 1 week (or any duration if hospitalization is necessary).
The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others or to necessitate hospitalization to prevent harm to self or others, or the mood disturbance has psychotic features.
A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features. The criteria are met both for a manic episode (Box 1) and for a major depressive episode (see Box 3 in the chapter on depression) (except for duration) nearly every day for at least 1 week. BPD is subdivided into types I and II to reflect the type of manic episodes the patient reports. Criteria, except for duration, are currently (or most recently) met for a manic, a hypomanic, a mixed, or a major depressive episode.
The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The mood symptoms in the first two criteria are not better accounted for as schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified. Adapted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text rev. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Figures 4 through 6 graphically illustrate common courses of mood episodes in patients with different subtypes of BPD.
Figure 3 depicts four separate symptom domains that can be seen in various combinations with BPD. If an active mood episode is identified, rule out mood disorder due to a general medical condition or one that is substance-related. If psychosis accompanies a mood episode, rule out schizophrenia, schizoaffective disorder, delusional disorder, or psychosis due to a general medical condition. BPD is an important consideration in the differential diagnosis of a major depressive episode. Patients who are agitated or irrational or who present a danger to themselves or others require urgent (next day) or emergent (same day) evaluation by a psychiatrist, unless the primary physician is comfortable with acute stabilization.
Mania is generally more easily managed than depression, although it requires hospitalization more often. Mixed depressive and manic episodes present a difficult treatment challenge best met by first stabilizing manic behavior and then addressing depression.
OFC is the only FDA-approved treatment for acute bipolar depression and delivers both antidepressant and antipsychotic medications simultaneously in one preparation.
Other atypical antipsychotics continue to receive attention as potential antidepressant agents in BPD. Neither is currently FDA approved for this indication, and the strength of the data supporting their use for bipolar depression is modest at best. Electroconvulsive therapy can effectively be used to treat either manic or depressive episodes, although it is generally reserved for medication-refractory cases.
Screening tools are available, although they should not be viewed as an alternative to thorough diagnostic evaluation. The literature regarding medication treatment for children and adolescents with BPD is limited, and many of the current recommendations are based on studies of adults.
Mania can be seen early in the course of human immunodeficiency virus (HIV) infection but is more common as the illness progresses. Maintaining a strong working alliance with the bipolar patient typically requires additional time, effort, and skill.
Treatment strategies must be individualized and adjusted at different phases of the mood disorder.
Olanzapine-fluoxetine combination (OFC) and mood stabilizers are first-line treatments for bipolar depression.
Ryan MM, Lockstone HE, Huffaker SJ, et al: Gene expression analysis of bipolar disorder reveals downregulation of the ubiquitin cycle and alterations in synaptic genes.
Valtonen HM, Suominen K, Mantere O, et al: Suicidal behaviour during different phases of bipolar disorder. Calabrese JR, Keck PE Jr, Macfadden W, et al: A randomized, double-blind, placebo-controlled trial of quetiapine in the treatment of bipolar I or II depression.
Ghaemi SN, Miller CJ, Berv DA, et al: Sensitivity and specificity of a new bipolar spectrum diagnostic scale.
Someone with bipolar disorder suffers from, and may be disabled by, a chronically unbalanced mood.
Run on boundless energy: More than one bipolar sufferer has confided that, when having manic symptoms, they feel like working eighty hours or more a week. Someone experiencing a mixed bipolar episode may feel simultaneously energized and debilitated. Bipolar Disorder Type II: This less extreme form alternates states of hypomania and major depression. Cyclothymia: This less severe mood disorder alternates hypomania and mild depression, with neither progressing into full-blown episodes. If you experience feelings like these, and they disrupt your life on an ongoing basis, know that there is help available.
If you need immediate help or if you are having thoughts of suicide, call 1-800-273-TALK, call 911 or go to a hospital emergency room.
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Disclaimer: The material on this web site is provided for educational purposes only, and is not to be used for medical advice, diagnosis or treatment. Mood stabilizers are a common treatment medication for Bipolar Disorder and can help prevent the swing from depression to mania or hypomania.
Along with these medications, forms of therapy such as Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), Rational Emotive Behavioral Therapy (REBT), and others are commonly used for depression, anxiety, and teen bipolar disorders. Did you know that a number of BJPsych Advances articles are translated into other languages? Randomised controlled trials and surveys of patients’ experiences indicate that the recognition and prompt treatment of early warning signs of relapse in selected patients with bipolar affective disorder are effective in lengthening the time to the next manic relapse and improving function. Teaching patients to recognise the early symptoms of an episode of a recurrent health problem so that they can seek early treatment and limit damage is a well-established secondary prevention strategy for medical disorders such as myocardial infarction. Prodrome The build-up in quantity, frequency and severity of inter-episode symptoms immediately before each manic, hypomanic, mixed affective or depressive episode. Resources requiredThe intervention might be performed by a keyworker working in a variety of mental health settings, or by a specialist nurse or psychology assistant in a specialist bipolar affective disorder clinic. Symptoms that are commonly seen in full relapse but are not diagnostic of manic or depressive relapse, e.g.
Signs that are obvious to other people (but not to the patient) and reported to the patient, e.g.

Depressive prodromesThe early warning symptoms of depressive prodromes are more difficult to detect than those of manic prodromes, because the former may be qualitatively similar to other inter-episode symptoms; patients are looking for a build-up in the severity and frequency of symptoms they experience much of the time, rather than the onset of new symptoms. The interventionSession 1The aim of the first session is to establish the patient’s history, in terms of the number, duration and content of previous manic, mixed or depressive relapses.
Session 2The patient and clinican examine the mood diary of inter-episode symptoms and identify any symptoms recorded in the diary that have been previously given as part of the manic prodrome: these should be removed from the list of warning symptoms for that prodrome (examples are shown in Fig. The disturbance of mood in BPD is episodic and recurrent, cycling at varying intervals from one mood state to another. This broad range is due at least in part to inconsistent inclusion of BPD subtypes from one study to the next. The first lifetime manifestation of BPD is typically a major depressive episode (MDE), with onset during late adolescence or early adulthood.
A higher rate of mood and anxiety disorders exists in the first-degree relatives of persons with BPD than in the general population.
Neuroimaging studies point to involvement of cortical, limbic, basal ganglia, and cerebellar structures in BPD.
In addition to episodes of either full-blown mania or major depression, patients can have episodes of subsyndromal depression, hypomania, or mixed states characterized by simultaneous occurrence of both depressive and manic features. A diagnosis of bipolar I disorder is given if there has been at least one lifetime episode of mania or a true mixed episode; a diagnosis of bipolar II disorder depends on at least one lifetime episode of hypomania, with none of the episodes achieving criteria for mania. When available, obtain collateral information from family or other associates as well as medical records that document previous treatment trials. For less-pressing cases of suspected BPD, appropriate treatment may be started while awaiting completion of the referral process to a psychiatrist. United States Food and Drug Administration (FDA)-approved agents for treating BPD are listed in Table 1. An atypical antipsychotic or a mood stabilizer is typically administered to stabilize the manic behavior, and depression is addressed with standard antidepressant treatment. Antidepressants, when prescribed alone, are not effective for bipolar depression and are not formally indicated for such use by the FDA. Investigation of quetiapine (Seroquel) as monotherapy for bipolar depression has produced promising results and might receive FDA approval in the near future. Their off-label use is nevertheless recommended, given the paucity of effective treatments for bipolar depression. Once this mood disorder has declared itself, the patient should be counseled regarding the chronic risk for relapse and recurrence; lifetime treatment is recommended. The Bipolar Spectrum Diagnostic Scale (BSDS) involves an easy-to-read, one-page story that depicts typical mood swing experiences. In contrast, the postpartum period is associated with increased risk for bipolar relapse and illness onset.
Review of the literature on major mental disorders in adult patients with mitochondrial diseases. Downregulation in components of the mitochondrial electron transport chain in the postmortem frontal cortex of subjects with bipolar disorder. He or she may cycle from mania, an excited, hyperactive state to depression, a state of despair, and back again. A state of mild mania, or hypomania, can be pleasurable and highly productive–some people with bipolar disorder report that they like it. Someone with bipolar psychosis may hallucinate (perceive products of their own fantasies as real), or experience delusions (believe things to be true that are demonstrably false). Since we all have to face challenges in life, what makes one person more mentally healthy than another? Euphoria, elation, racing thoughts, irritability, and substance use are common symptoms of mania. For instance, mania is an experience of euphoria, high energy, impulsivity, irritability, and less need for sleep. Improvements in patient coping mechanisms allied to these techniques can prevent some depressive episodes.
There is greater variability in the timing of early warning symptoms in the depressive prodrome than in the manic prodrome. If there have been numerous previous episodes, the patient is asked to recall in detail the onset and evolution of the first and the most recent, or the most serious and the most recent, manic episodes. The first episode of mania or hypomania might not occur until several years later, and until that time a diagnosis of BPD cannot be made.
Traditionally, classic BPD has been depicted as mood episodes alternating from mania to depression and back, but the variable course depicted in Figure 3 is more common.
This may have led to an overdiagnosis of BPD, which until recently was underdetected or misdiagnosed as recurrent major depressive disorder (MDD). Occasionally, the primary care physician who is familiar with the assessment and treatment of BPD may accept full responsibility for the BPD patient's management, although this typically happens after consultation with a psychiatrist. Olanzapine, used either alone or as OFC has been associated with weight gain and hyperglycemia, and there are published case reports of diabetic ketoacidosis. Periodic medical monitoring for complications is crucial in preventing unwanted outcomes, such as the metabolic syndrome.
Treatment of acute mood episodes during pregnancy requires a careful consideration of the potential teratogenic effects of medications versus the harmful effects of an ill mother on the unborn child.
If you find that these contrasting moods predominate your life, please read over this description of common bipolar disorder symptoms: it may help you to determine whether to talk to a doctor about a potentially serious medical condition. Full-blown mania, however, can put someone at risk of damaging their physical health and their relationships. To be healthy psychologically means you’re able to function at home, work, or school at a reasonable level and you’re able to emotionally and behaviorally adjust well to life when things get rocky. Some individuals will also engage in forms of self-harm, such as cutting or risky behavior as a way to take away their emotional pain and accelerate the highs.
The first type of Bipolar, also known as Bipolar I, includes one or more distinct periods of mania, and could also include a mixed period. However, hypomania is an elevated mood that is not quite full mania but does include increased energy, less sleep, clarity of vision, and strong creativity. Treatment of Bipolar Disorder and minimizing mood swings includes the use of medication and therapy, such as Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, life skills training, psycho-education, and hospitalization, if necessary. For instance, lithium more effectively works to treat the depression versus the manic episodes, while the medication commonly referred to as Depakote works well in treating mania. The intervention is described in some detail and conditions under which it is most likely to be effective or to fail are reviewed. In all cases, the intervention is likely to be maximally effective if it becomes a central feature of the care plan, with the assent of the patient’s responsible medical officer and other members of the multi-disciplinary team. However, like the early warning symptoms of the manic prodrome, the nature and order of presentation of early warning symptoms tends to be consistent from one depressive episode to the next. Symptoms appearing in the diary that have been previously identified as part of the depressive syndrome should be reviewed.
It is uncommon for the first manic episode to occur after age 30 years, although onset after age 60 years has been reported. The natural course of bipolar disorder is for episode frequency to gradually increase and for an ever-increasing percentage of episodes to be characterized by depression. In addition to mood elevation, the symptoms of mania include inflated self-esteem, decreased need for sleep, pressured and often loud speech, flight of ideas, distractibility, and increased goal-directed behavior often focused on pleasurable activities that have a high potential for becoming reckless and self destructive.
This is an error that is easily committed even by experienced clinicians, because MDEs and dysthymia constitute the predominant mood disturbance in BPD, especially BPD type II.
Clinical experience suggests, however, that agents approved for mania are generally effective for hypomania, sometimes at lower doses. These include simultaneously administering an antidepressant and an antipsychotic, administering mood-stabilizing medication, or administering the combination formulation of olanzapine and fluoxetine (OFC, Symbyax).

Because these potential adverse outcomes are not unique to olanzapine and are regarded as an effect of the atypical antipsychotic class, OFC should be considered as a first-line treatment for bipolar depression. Treatment of mania secondary to HIV-related illness should be directed toward symptoms and underlying causes. How long someone spends in each mood state varies with the individual; from less than a day at each extreme, for those with rapid-cycling bipolar, to several weeks.
When feeling low or depressed, the symptoms of depression to look for are decreased energy, insomnia, fatigue, agitation, and suicidal thoughts. For instance, if there is a period of mania, there might also be features of depression and if there is a period of depression, there might also be features of mania. In fact, Depakote seems to be more effective in treating adolescents who have four or more mood episodes per year (known as rapid cycling).
If the intervention is to be successful, patients must be carefully selected, early warning signs and symptoms must be analysed in detail, it must be a central feature of the care plan and the service must be ready to respond quickly to a patient’s early warning symptoms. However, the efficacy of using a health professional to teach patients with bipolar affective disorder to recognise the early warning symptoms of manic relapse and to seek conventional psychiatric treatment was first shown in a randomised controlled trial in 1999 (Perry et al, 1999).
The responsible medical officer should be involved in key decisions concerning the intervention if it is part of the care plan and should supervise its implementation.
Moreover, the early warning symptoms at the time of the relapse should have been memorable to the individual.
Any that are relatively mild or infrequent in the inter-episode diary, but build up in severity or frequency before a depressive relapse, may still be used as early warning symptoms for a depressive prodrome. In general, late-onset mania suggests drug toxicity or an underlying medical disorder until proved otherwise. Inquiry about a personal or family history of manic or hypomanic episodes is therefore crucial when evaluating a patient who presents with an MDE.
Mild mania and hypomania often respond to one antimanic drug, whereas acute manic crises often require two or more agents to stabilize the mood. Titration of both agents should be monitored closely to avoid lithium toxicity (tremor, nausea, diarrhea) or lamotrigine-induced rash that, if unchecked, can progress to toxic epidermal necrolysis or Stevens-Johnson syndrome. Many strategies have been advanced, therefore, to reduce the risk potential of pharmacologic treatment of BPD in the pregnant woman. Pharmacologic management of mania in HIV-infected persons often includes a combination of an anticonvulsant mood stabilizer plus an antipsychotic.
We hope to provide all the information needed for the health of your mind, body, and spirit. The second type of Bipolar is characterized by at least one episode of hypomania and at least one episode of depression. Finding the right medication, or a combination of medications, given the unique circumstances of your teenager is a necessary discussion to have with a psychiatrist.
In this trial, which involved 69 patients with the disorder, the time to the next manic episode was increased four-fold in the intervention group, with a 30% reduction in the number of manic relapses over 18 months. The moment that insight (inability to recognise that they are ill and have abnormal symptoms or to accept treatment) is lost is noted down. These have included monotherapy with the lowest effective dose of a drug for the shortest period, preconception coadministration of multivitamins with folate, and avoidance of antimanic agents during the first trimester.
Patients with primary BPD who are also HIV seropositive should receive recommended treatment for acute mood episodes, although careful attention must be paid to an increased risk for drug interactions in this population.
Fortunately, if the illness is recognized early enough, it can be treated and managed well. This diagnosis can be made only if the individual has not ever experienced a period of mania.
Additionally, as you might expect, lithium, Depakote, and other mood stabilizers come with side effects that are worthy of exploration before your teen begins any medication. There was no significant change in the time to the next depressive episode nor in the number of depressive relapses over 18 months. In the randomised controlled trial by Colom et al(2003, 2004), the specific content of the early warning system intervention took 3 hours to deliver to patients in group sessions.
The patient’s account of the evolution of the most recent manic episode is then compared with the evolution of the earlier one. Each prodromal symptom is written on a small card (or a piece of paper) together with the word ‘insight’ on a separate card. In fact, many people who live with bipolar disorder spend much of their lives symptom-free. The intervention group demonstrated clinically important improvements in function, particularly in employment. Only symptoms that recurrently and consistently appear early and before insight is lost can be used in the intervention. However, longer will be required if the patient needs to be educated about their condition or does not understand the rationale for the intervention.Barriers and drawbacksThe patient’s relapse signatures have to be ascertained for each pole of illness (mania or depression).
The patient is shown a checklist of typical early warning symptoms for manic prodromes (Fig.
Additional efficacy against depressive relapses has been achieved with the use of more experienced therapists and the provision of lifestyle advice, including teaching patients additional coping mechanisms for dealing with the first symptoms of depressive relapse (Lam et al, 2000, 2003; Colom et al, 2003, 2004). Mixed affective states can present with a different relapse signature, and this too should be identified. The results do not appear to be explained by improved adherence to drug regimens or additional time spent with therapists (Colom et al, 2003, 2004). There is no such thing as a characteristic or typical manic or depressive relapse signature that applies to all patients.Health services must be prepared to see the patient quickly (ideally within 1 week).
Frequently, patients have symptoms idiosyncratic to their own manic prodrome, and these should be added to the list. The traditional community health team approach of meeting once a week, then allocating the patient an assessment a week or more later will miss the window of opportunity to prevent a relapse. If such a false-positive health contact occurs, the opportunity should be used to explore with the patient the nature and timing of early warning symptoms.Occasionally, patients become over-confident and wish to rely on this intervention rather than taking mood-stabilising medication. 3?) for a minimum period of 7 days (or one menstrual cycle) to record normal inter-episode symptoms, the severity of the inter-episode symptoms and their relationship to mood, menstruation and life stressors.
Patients who find the recognition of elated mood difficult and easily confused with well-being may need to define each point on the mania scale more closely, according to different degrees of over-activity and to the drive to be more sociable and outgoing.
Sometimes when patients monitor their symptoms, they dwell on how depressed they are and seek further treatment for their depression.
In such cases, the patients should either be discouraged from using the intervention or taught cognitive–behavioural therapy techniques to manage their depressive symptoms.Manic prodromesThe early warning symptoms that constitute the manic prodrome are usually qualitatively different from other inter-episode symptoms experienced by patients with bipolar affective disorder. However, each symptom in the manic prodrome is too non-specific to be used alone, so the patient is taught to recognise a number of early warning symptoms occurring together. This ‘relapse signature’ is idiosyncratic to each patient and to each relapse pole (mania or depression).Both retrospective and prospective research reveals that the nature, timing and order of onset of early warning symptoms are usually consistent from one manic episode to the next.
There is usually a 2–4 week period between the patient’s first detection of early warning symptoms and the moment insight is lost (and the patient becomes unwilling or unable to seek treatment). However, there is variability in the length of the reported prodrome from one patient to another, with some patients having only a few days’ warning. Carers take about a week longer to recognise the manic prodrome, partly because they are unaware of some of the patient’s subjective experiences.Box 2? outlines a classification of early warning symptoms in manic or depressive prodromes.

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