(PSYCHIATRIC TIMES) - Patients with psychiatric disorders often present a diagnostic challenge— even for psychiatrists. Their demeanor may not readily reveal the nature or severity of the problem. Nevertheless, there are clues that can help you sort through the differential and arrive at the correct diagnosis.
Here, I focus on how to recognize bipolar disorder, and I also offer recommendations for treatment.
PREVALENCE AND IMPACT
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR), characterizes mood disorders as primarily disturbances of emotions and feelings. The 2 principal mood disorders are major depressive disorder and bipolar disorder. Patients with bipolar disorder have recurrent episodes of both depression and mania (and sometimes the 2 combined— called a “mixed episode”).
Bipolar disorder will develop in approximately 1% of Americans at some point in their lives.1,2 The age of onset is typically young adulthood— with 30 years the mean—and the disorder affects men and women equally. 1,2 Genetics play a significant role in transmission of this illness. If one parent in a couple has bipolar disorder, there is a 25% risk that their children will have a mood disorder. If both parents have bipolar disorder, the risk increases to between 50% and 75%.2
Persons with bipolar disorder tend to be bright, driven, and quick-witted. However, the effects of their illness often prevent them from fulfilling their potential. The disorder also contributes to the disruption of social relations and marriages; divorces are common. Between 10% and 15% of persons with bipolar disorder commit suicide.1
TYPES OF BIPOLAR DISORDER
There are several types of bipolar disorder, which are distinguished by the nature of the episodes and by the pattern with which they recur.
Bipolar I disorder. This is “classic” bipolar disorder and is also referred to as manic-depressive illness. Diagnosis requires the occurrence of one or more manic episodes or mixed episodes and at least one major depressive episode. (A mixed episode is one in which the patient experiences quick shifts in mood over a week or more, and the opposite poles of these rapid fluctuations meet the criteria for manic and depressive episodes. Clinical signs of a mixed episode include agitation, insomnia, psychosis, and suicidal speculation.) Patients who have bipolar I disorder usually exhibit significant social and occupational dysfunction.
Bipolar II disorder. Affected patients have had a mood cycle or cycles that range from a major depressive episode to hypomania, yet never extend beyond hypomania to mania. (Hypomania is a persistently energized, elevated, or irritable mood that lasts several days and is not related to ingestion of a particular substance or to a medical condition. Hypomanic patients do not have psychotic symptoms— which are common in those with mania—and they are able to maintain self-control.)
Bipolar I or II disorder with rapid cycling. Patients have 4 or more episodes of mood disturbance within 1 year. The chaotic mood instability seen in these patients can mimic borderline personality disorder. Women are more likely to have rapid-cycling bipolar disorder than men.
DIAGNOSIS OF MANIA
The diagnosis of mania or hypomania depends almost entirely on the clinical history and presentation. There are no pathognomonic laboratory tests to identify bipolar disorder. However, certain laboratory tests should be ordered if bipolar disorder— manic or hypomanic phase—is suspected. These include a complete blood cell count, comprehensive metabolic panel, and urine drug screen. The purpose of such tests is primarily to rule out medical conditions in the differential (Table 1).
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