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28.04.2015

Manic depressive episodes bipolar disorder, hearing ringing noise - Within Minutes

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Bipolar disorder, also known by its older name “manic depression,” is a mental disorder that is characterized by constantly changing moods.
A manic episode is characterized by extreme happiness, hyperactivity, little need for sleep and racing thoughts, which may lead to rapid speech. Bipolar disorder is recurrent, meaning that more than 90% of the individuals who have a single manic episode will go on to experience future episodes. Those with bipolar disorder often describe their experience as being on an emotional roller coaster. During severe manic or depressed episodes, some people with bipolar disorder may have symptoms that overwhelm their ability to deal with everyday life, and even reality. Identifying the first episode of mania or depression and receiving early treatment is essential to managing bipolar disorder. The bipolar II disorder is characterized by less distinct and accordingly shorter lasting manias, the so-called hypomanias, and often serious depressive episodes. In the mixed episodes the symptoms of mania and depression occur in rapid rotation to each another or exist at the same time. A weakened form of bipolar mood disorder is the so-called cyclothymia or cyclothymic disorder. 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.
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 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. Figures 4 through 6 graphically illustrate common courses of mood episodes in patients with different subtypes of 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. 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. 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. 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. 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.
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. A person with bipolar disorder experiences alternating “highs” (what clinicians call “mania“) and “lows” (also known as depression). A depressive episode is characterized by extreme sadness, a lack of energy or interest in things, an inability to enjoy normally pleasurable activities and feelings of helplessness and hopelessness. Roughly 70% of manic episodes in bipolar disorder occur immediately before or after a depressive episode. Those who experience rapid cycling can go between depression and mania as often as a few times a week (some even cycle within the same day).
Manic episodes can lead to family conflict or financial problems, especially when the person with bipolar disorder appears to behave erratically and irresponsibly without reason. In most cases, a depressive episode occurs before a manic episode, and many patients are treated initially as if they have major depression. This form of the bipolar mood disorder is very important is also very difficult to grasp since in retrospect the hypomanias are often not considered as classifiable as an illness or remembered. In these persons often mood swings of a strong degree of characterization take place continually over a period or at least two years, whereby the criteria for a depression or mania in detail are not fulfilled and which often occur independently of external influences. The disturbance of mood in BPD is episodic and recurrent, cycling at varying intervals from one mood state to another.
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. 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. 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. Both the manic and depressive periods can be brief, from just a few hours to a few days, or longer, lasting up to several weeks or even months. On average, someone with bipolar disorder may have up to three years of normal mood between episodes of mania or depression.
Treatment seeks to reduce the feelings of mania and depression associated with the disorder, and restore balance to the person’s mood.
The emotions, thoughts and behavior of a person with bipolar disorder are often experienced as beyond one’s control. Most people with bipolar disorder are of the slow cycling type — they experience long periods of being up (“high” or manic phase) and of being down (“low” or depressive phase). Thus, for example rapid thought and speech (like in mania) can occur at the same time as the anxious-depressive mood.
The transitions are however very fluent so that in people who come into a clinic or outpatients department with the suspected diagnosis cyclothymia often a bipolar (II) disorder can be determined.


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. 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.
The periods of mania and depression vary from person to person — many people may only experience very brief periods of these intense moods, and may not even be aware that they have bipolar disorder.
Once a manic episode occurs, it becomes clearer that the person is suffering from an illness characterized by alternating moods. 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. Clinical experience suggests, however, that agents approved for mania are generally effective for hypomania, sometimes at lower doses. 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.
However, if left untreated, bipolar disorder can seriously affect nearly every aspect of a person’s life. Because of this difficulty with diagnosis, family history of similar illness or episodes is particularly important. Knowledge of these phases can help persons afflicted recognise new episodes at an early stage and accordingly adapt themselves to the disorder.
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. 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. People who first seek treatment as a result of a depressed episode may continue to be treated as someone with unipolar depression until a manic episode develops.
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. Ironically, treatment of depressed bipolar patients with antidepressants can trigger a manic episode in some patients.
Sometimes there is seasonal variation or circumstances after repeated episodes could percipitate future episodes. Stress, abuse, significant loss or other traumatic experiences may trigger a bipolar disorder.TreatmentBipolar disorder requires lifelong treatment, even during periods when you feel better. People who skip maintenance treatment are at high risk of a relapse of symptoms or having minor mood changes turn into full-blown mania or depression.Hospitalization may be needed dangerous or disruptive, suicidal or psychotic behavior. Changing sleep patterns are also a common indicator of childhood bipolar disorder.Medication works best for Manic depressive psychosis. The treatment, which must be taken regularly and for a long period of time, controls the episodes with a high rate of success.




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