Bipolar Affective Disorder Clinical Presentation

Correct diagnosis of a disorder leads to proper effective treatment. Nowhere is that more relevant than in diagnosing a patient with bipolar affective disorder. Wolkenstein et al have pointed out the advantages of applying all DSM-specific criteria in order to make the correct diagnosis.^[36]

The diagnosis of bipolar I (BPI) disorder requires the presence of a manic episode of at least 1 week’s duration that leads to hospitalization or other significant impairment in occupational or social functioning. The episode of mania cannot be caused by another medical illness or by substance abuse. These criteria are based on the specifications of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR).^[37]

Manic episodes are characterized by at least 1 week of profound mood disturbance, characterized by elation, irritability, or expansiveness. At least 3 of the following symptoms must also be present:

• Grandiosity
• Diminished need for sleep
• Excessive talking or pressured speech
• Racing thoughts or flight of ideas
• Clear evidence of distractibility
• Increased level of goal-focused activity at home, at work, or sexually
• Excessive pleasurable activities, often with painful consequences

The mood disturbance is sufficient to cause impairment at work or danger to the patient or others. The mood is not the result of substance abuse or a medical condition.

Hypomanic episodes are characterized by an elevated, expansive, or irritable mood of at least 4 days’ duration. At least 3 of the following symptoms are also present:

• Grandiosity or inflated self-esteem
• Diminished need for sleep
• Pressured speech
• Racing thoughts or flight of ideas
• Clear evidence of distractibility
• Psychomotor agitation at home, at work, or sexually
• Engaging in activities with a high potential for painful consequences

The mood disturbance is observable to others. The mood is not the result of substance abuse or a medical condition.

Major depressive episodes are characterized by the following: For the same 2 weeks, the person experiences 5 or more of the following symptoms, with at least 1 of them being either a depressed mood or characterized by a loss of pleasure or interest:

• Depressed mood
• Markedly diminished pleasure or interest in nearly all activities
• Significant weight loss or gain or significant loss or increase in appetite
• Hypersomnia or insomnia
• Psychomotor retardation or agitation
• Loss of energy or fatigue
• Decreased concentration ability or marked indecisiveness
• Preoccupation with death or suicide; patient has a plan or has attempted suicide
• The symptoms cause significant impairment and distress.
• The mood is not the result of substance abuse or a medical condition.

Mixed episodes are characterized by the following:

• Persons must meet both the criteria for mania and major depression; the depressive event is required to be present for 1 week only.
• The mood disturbance results in marked disruption in social or vocation function.
• The mood is not the result of substance abuse or a medical condition.

The mixed symptomatology is quite common in patients presenting with bipolar symptomatology. This often causes a diagnostic dilemma.^[38]

Use the Mental Status Examination (MSE) to diagnose bipolar disorder. This section highlights the major findings for a person with bipolar disorder. Because the patient’s mental status depends on whether he or she is depressed, hypomanic, manic, or mixed, the following discussions of the various areas of the MSE include consideration of each of these particular phases

Appearance

Persons experiencing a depressed episode may demonstrate poor to no eye contact. Their clothes may be unkempt, unclean, holed, unironed, and ill-fitting. If the person has lost significant weight, the garments may fit loosely.

The personal hygiene of individuals experiencing a depressed episode reflects their low mood, as evidenced by poor grooming, lack of shaving, and lack of washing. In women, fingernails may show different layers of polish or one layer partially removed. They may not have paid attention to their hair. Men may exhibit dirty fingernails and hands. When these individuals move, their depressed affect is demonstrated. They move slowly and very little. They show psychomotor retardation. They may talk in low tones or in a depressed or monotone voice.

Persons experiencing a hypomanic episode are busy, active, and involved. They have energy and are always on the go. They are always planning and doing things. Others notice their energy levels and mood changes.

In many ways, the behavior of a patient in the manic phase is the opposite of that of a person in the depressed phase. Patients experiencing the manic phase are hyperactive and might be hypervigilant. They are restless, energized, and active. They talk and act fast. Their attire reflects the mania. Their clothes might have been put on in haste and are disorganized. Alternately, their garments are often too bright, colorful, or garish. They stand out in a crowd because their dress frequently attracts attention.

Affect/mood

In persons experiencing a depressed episode, sadness dominates the affect. These individuals feel sad, depressed, lost, vacant, and isolated. The "2 Hs"— h opeless and h elpless—often accompany their mood. When in the presence of such patients, one comes away feeling sad and down.

In persons experiencing a hypomanic episode, the mood is up, expansive, and often irritable.

In persons experiencing a manic episode, the mood is inappropriately joyous, elated, and jubilant. These individuals are euphoric. They also may demonstrate annoyance and irritability, especially if the mania has been present for a significant length of time.

Persons experiencing a mixed episode exhibit both depression and mania within a brief period (1 wk or less).

Thought content

Patients experiencing a depressed episode have thoughts that reflect their sadness. They are preoccupied with negative ideas and nihilistic concerns, and they tend to "see the glass as half empty." They are likely to focus on death and morbid persons. Many think about suicide.

Patients experiencing a hypomanic episode are optimistic, forward thinking, and have a positive attitude.

Patients experiencing a manic episode have very expansive and optimistic thinking. They may be excessively self-confident or grandiose. They often have a very rapid production of ideas and thoughts. They perceive their minds as being very active and see themselves as being highly engaging and creative. They are highly distractible and quickly shift from one person to another.

Patients experiencing a mixed episode can oscillate dramatically between depression and euphoria, and they often demonstrate marked irritability.

Perceptions

Two forms of a major depression are described, one with psychotic features and the other without. With psychosis, the patient experiences delusions and hallucinations that are either consistent or inconsistent with the mood.

In the former, the patient’s delusions of having sinned are accompanied by guilt and remorse, or the patient feels he or she is utterly worthless and should live in total deprivation and degradation; hence, the delusional content remains consistent with the depressed mood. In the latter, some patients experience delusions that are inconsistent with the depression, such as paranoia or persecutory delusions.

Patients experiencing a hypomanic episode do not experience perceptual disturbances.

Approximately three fourths of patients experiencing a manic episode have delusions. As in major depression, the delusional content is either consistent or inconsistent with the mania. Manic delusions reflect perceptions of power, prestige, position, self-worth, and glory.

Patients experiencing a mixed episode might exhibit delusions and hallucinations consistent with either depression or mania or congruent to both.

Suicide/self-destruction

Patients experiencing a depressed episode have a very high rate of suicide. They are the individuals who attempt and succeed at killing themselves. Query patients to determine if they have any thoughts of hurting themselves (suicidal ideation) and any plans to do so. The more specific the plan, the higher the danger.

As patients emerge from a period of depression, their suicide risk may increase. This may be because, as the illness remits, executive functions are improved to the point where the person is again capable of making and carrying out a plan while the subjective feeling of depression and accompanying suicidal thoughts persist.

Patients experiencing a hypomanic or manic episode have a low incidence of suicide.

In mixed episodes, the depressed phases put the patient at risk for suicide.

Homicide/violence/aggression

In patients experiencing a depressed episode, suicide generally remains the paramount issue. However, certain persons in the depths of a depression see the world as hopeless and helpless not only for themselves but also for others. Frequently, that perspective can create and lead to a homicide followed by a suicide.

As an example, a 42-year-old mother of 2 was experiencing a significant depression as part of her bipolar disorder. She believed the earth was doomed and was a terrible place to dwell. Furthermore, she thought that if she died, her children would be left in a wretched place. Because of this view, she planned to kill her 2 children and then herself. Fortunately, her family recognized the state of affairs, which led to an emergency intervention and her hospitalization.

Patients who are hypomanic frequently show evidence of irritability and aggressiveness. They can be pushy and impatient with others.

Persons experiencing a manic episode can be openly combative and aggressive. They have no patience or tolerance for others. They can be highly demanding, violently assertive, and highly irritable. The homicidal element is particularly likely to emerge if these individuals have a delusional content to their mania. They are acting out of the grandiose belief that others must obey their commands, wishes, and directives. The patient may become violent toward those "disordent" subjects. If their delusions become persecutory in nature, they may defend themselves against others in a homicidal fashion.

Persons experiencing a mixed episode may exhibit aggression, especially in the manic phases.

Judgment/insight

In persons experiencing a depressed episode, the depression clouds and dims their judgment and colors their insights. They fail to make important actions, because they are so down and preoccupied with their own plight. They see no tomorrow; therefore, planning for it is difficult. Frequently, persons in the middle of a depression have done things such as forgetting to pay their income taxes. At that time, they have little insight into their behavior. Often, others have to persuade them to seek therapy because of their lack of insight.

Persons experiencing a hypomanic episode generally have good but expansive judgment. They may take on too many tasks or become overinvolved. Often, their distractibility impairs their judgment, and they have little insight into their driven qualities. They see themselves as productive and conscientious, not as hypomanic.

In patients experiencing a manic episode, judgment is seriously impaired. These persons make terrible decisions in their work and family. They may invest the family fortune in very questionable programs, become professionally overinvolved in work activities or with coworkers, or start dramatically unsound fiscal or professional ventures. They ignore feedback, suggestions, and advice from friends, family, and colleagues. They have no insight into the extreme nature of their demands, plans, and behavior. Often, commitment proves the only way to contain them.

In persons experiencing a mixed episode, major shifts in affect during short lengths of time severely impair their judgment and interfere with their insight.

Cognition

Impairments in orientation and memory are seldom observed in patients with bipolar disorder unless they are very psychotic. They know the time and their location, and they recognize people. They can remember immediate, recent, and distant events. In some cases of hypomanic and even manic episodes, their ability to recall information can be extremely vivid and expanded. In extremes of depression and mania, they may experience difficulty in concentrating and focusing.

Physical health

Although the MSE has been used here to highlight key aspects of the examination, the clinician must pay particular attention to the patient’s physical health. As Fagiolini points out, patients with bipolar disorder have a high incidence of endocrine disorders, cardiovascular disorders, and obesity, and these factors must be considered when medications are prescribed.^{[39, 40]}

The main complications of bipolar disorder are suicide, homicide, and addictions.

Suicidal patients remain at risk for suicide. Patients emerging from a depression are thought to be at an increased risk for suicide. The risk of self-destructive behavior and death is lifelong. Hong’s 2003 study demonstrates a genetic link between bipolar disorder and suicidal behavior, especially in white individuals.^[41] According to one study, men with bipolar disorder are at higher risk for suicide.^[42]

The European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM) study, a 2-year prospective, observational study, suggests the following characteristics found in patients with bipolar disorder who are suicidal, may help identify subjects at risk for suicidal behavior:^[43]

• Female gender
• A history of alcohol abuse
• A history of substance abuse
• Young age at first treatment for a mood episode
• Longer disease duration
• Greater depressive symptom severity (HAMD-5 total score)
• Current benzodiazepine use
• Higher overall symptom severity (CGI-BP: mania and overall score)
• Poor compliance

Homicidal patients, often in the manic phase, can be very demanding and grandiose. In this context, they are angered if others do not immediately comply with their wishes. This can make them turn dramatically violent. In addition, they can become homicidal by acting on delusions.

Individuals with bipolar disorder are at risk for an addiction. This creates the problem of a dual diagnosis and, therefore, complicates treatment.

One area of major concern is the relationship between violent crime and bipolar disorder. This danger is particularly present and prominent with patients who have a substance abuse problem.^[44] Although some persons with bipolar disorder may become violent, clinicians must be vigilant when treating patients with the dual diagnosis of substance abuse.

Quality of life (QOL) has been an important way to look at the effects of mental illness. BPI results in diminished quality of life as measured by health utility and QOL and utility-based health-related quality of life. The QOL losses in patients with BPI were less than those in persons with schizophrenia. The patients with depression sustained the greatest loss in QOL.^[45]

In a study by Fiedorowicz et al, hypomania symptoms were frequently associated with progression to bipolar disorder, even when symptoms were low intensity; however, most patients did not have hypomania symptoms at baseline.^[46] The study concluded that monitoring for progression to bipolar disorder is necessary in patients with long-term major depressive disorder.

Some of the most challenging situations involve children and adolescents with severe emotional lability. Often, psychiatrists have applied the bipolar diagnosis to this group. Leibenluft reviewed this situation and concluded that children have increasingly been diagnosed with bipolar disorder.^[47] In some cases, the criteria were clearly met, whereas other cases were less clear.

Severe mood dysregulation is a syndrome formulated to describe the symptoms of children who do not clearly meet the criteria for bipolar disorder. Leibenluft’s findings revealed that nonepisodic irritability in youths is common and is associated with an elevated risk for anxiety and unipolar depressive disorders (not bipolar disorders) in adulthood. In fact, data suggest that children and adolescents with severe mood dysregulation have lower familiar rates of bipolar disorder than children and adolescents with bipolar disorder.