Chapter 67: Bipolar Disorder

INTRODUCTION

Bipolar disorder is a common, lifelong, often severe cyclic mood disorder characterized by recurrent fluctuations in mood, energy, and behavior. The mania or hypomania is not substance-related or caused by other medical or psychiatric disorders.

PATHOPHYSIOLOGY

Table 67-1 lists medical conditions, medications, and treatments that may induce mania.
Bipolar disorder is influenced by developmental, genetic, neurobiological, and psychological factors. Multiple gene loci are likely involved in the heredity of mood disorders.

TABLE 67-1Secondary Causes of Mania

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TABLE 67-1 Secondary Causes of Mania

Medical conditions that induce mania

CNS disorders (brain tumor, strokes, head injuries, subdural hematoma, multiple sclerosis, systemic lupus erythematosus, temporal lobe seizures, Huntington disease)
Infections (encephalitis, neurosyphilis, sepsis, human immunodeficiency virus)
Electrolyte or metabolic abnormalities (calcium or sodium fluctuations, hyperglycemia or hypoglycemia)
Endocrine or hormonal dysregulation (Addison disease, Cushing disease, hyperthyroidism or hypothyroidism, menstrual-related or pregnancy-related or perimenopausal mood disorders)

Medications or drugs that induce mania

Alcohol intoxication
Drug withdrawal states (alcohol, α₂-adrenergic agonists, antidepressants, barbiturates, benzodiazepines, opiates)
Antidepressants (MAOIs, TCAs, 5-HT and/or NE and/or DA reuptake inhibitors, 5-HT antagonists)
DA-augmenting agents (CNS stimulants: amphetamines, cocaine, sympathomimetics; DA agonists, releasers, and reuptake inhibitors)
Hallucinogens (LSD, PCP)
Marijuana intoxication precipitates psychosis, paranoid thoughts, anxiety, and restlessness
NE-augmenting agents (α₂-adrenergic antagonists, β-agonists, NE reuptake inhibitors)
Steroids (anabolic, adrenocorticotropic hormone, corticosteroids)
Thyroid preparations
Xanthines (caffeine, theophylline)
Nonprescription weight loss agents and decongestants (ephedra, pseudoephedrine)
Herbal products (St. John’s wort)

Somatic therapies that induce mania

Bright light therapy
Deep brain stimulation
Sleep deprivation

CNS, central nervous system; DA, dopamine; 5-HT, serotonin; LSD, lysergic acid diethylamide; MAOI, monoamine oxidase inhibitor; NE, norepinephrine; PCP, phencyclidine; TCA, tricyclic antidepressant.

CLINICAL PRESENTATION

Different types of episodes may occur sequentially with or without a period of normal mood (euthymia) between them. There can be mood fluctuations that continue for months or after one episode, and there can be years without recurrence of any type of mood episode.

DIAGNOSIS

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition classifies bipolar disorders into five subtypes:
- (1) Bipolar I disorder: At least one manic episode, which may have been preceded by and may be followed by hypomanic or major depressive episode(s).
- (2) Bipolar II disorder: At least one hypomanic episode and a current or past major depressive episode.
- (3) Cyclothymic disorder: Chronic fluctuations between subsyndromal depressive and hypomanic episodes.
- (4) Other specified bipolar and related disorder.
- (5) Unspecified bipolar and related disorder.
See Table 67-2 for diagnostic criteria for major depressive episode, manic episode, and hypomanic episode.
A medical, psychiatric, and medication history; physical examination; and laboratory testing are necessary to rule out organic causes of mania or depression.
Delusions, hallucinations, and suicide attempts are more common in bipolar depression than in unipolar depression.
Acute mania usually begins ...

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