Stephanie’s Presentation on 5/22/2007 Part I

"Good afternoon, ladies and gentlemen, as a patient in the past(maybe at present still) as well as a doctor in the future, now let me tell you  the most ironic disease of this age……"

——Pre-Dr.Stephanie Hsiao, impressive forewords that would bring down the house on her 5/22/2007 presentation

"Bipolar Affective Disorder".

 

Synonyms and related keywords

bipolar affective disorder, bipolar disorder, bipolar I, bipolar II, manic-depressive disorder, manic-depressive illness, MDI, manic depression, BPI, BPII, schizophrenia, psychosis, mood disorders, cyclothymia, suicide, mania, electroconvulsive therapy, ECT, electroshock, hypomania,psychomotor agitation, grandiosity, inflated self-esteem, racing thoughts, flight of ideas, distractibility, hypersomnia, insomnia, depression, Mental Status Examination, MSE, aggression, suicide.

Background

Bipolar disorder, or manic-depressive illness (MDI), is one of the most common, severe, and persistent mental illnesses. Bipolar disorder is characterized by periods of deep, prolonged, and profound depression that alternate with periods of an excessively elevated and/or irritable mood known as mania. The symptoms of mania include a decreased need for sleep, pressured speech, increased libido, reckless behavior without regard for consequences, grandiosity, and severe thought disturbances, which may or may not include psychosis. Between these highs and lows, patients usually experience periods of higher functionality and can lead a productive life. Bipolar disorder is a serious lifelong struggle and challenge (Bowden, 2003).

Bipolar disorder, or manic-depressive illness, has been recognized since at least the time of Hippocrates, who described such patients as "amic" and "melancholic." In 1899, Emil Kraepelin defined manic-depressive illness and noted that persons with manic-depressive illness lacked deterioration and dementia, which he associated with schizophrenia.

Bipolar disorder constitutes one pole of a spectrum of mood disorders including bipolar I (BPI), bipolar II (BPII), cyclothymia (oscillating high and low moods), and major depression. BPI also is referred to as classic manic-depression, characterized by distinct episodes of major depression contrasting vividly with episodes of mania, which lead to severe impairment of function. In comparison, BPII is a milder disorder consisting of depression alternating with periods of hypomania. Hypomania may be thought of as a less severe form of mania that does not include psychotic symptoms or lead to major impairment of social or occupational function.

Pathophysiology

The etiology and pathophysiology of bipolar disorder have not been determined, and no objective biological markers exist that correspond definitively with the disease state. However, twin, family, and adoption studies all indicate strongly that bipolar disorder has a genetic component. In fact, first-degree relatives of a person with bipolar disorder are approximately 7 times more likely to develop bipolar disorder than the rest of the population. Genetic studies of patients with bipolar disorder are ongoing and are expected to be facilitated by recent advances in information and technology developed, in part, by the Human Genome Project.  

Findings from gene expression studies of postmortem brain tissue from persons with bipolar disorder versus controls have yielded exciting new insights into the pathophysiology of the disorder. In particular, levels of expression of oligodendrocyte-myelin–related genes appear to be decreased in brain tissue from persons with bipolar disorder (Davis, 2003; Tkachev, 2003; Prabakaran, 2004).

Oligodendrocytes produce myelin membranes that wrap around and insulate axons to permit the efficient conduction of nerve impulses in the brain. Therefore, loss of myelin is thought to disrupt communication between neurons, leading to some of the thought disturbances observed in bipolar disorder and related illnesses. Brain imaging studies of persons with bipolar disorder also show abnormal myelination in several brain regions associated with this illness. Interestingly, gene expression and neuroimaging studies of persons with schizophrenia and major depression also demonstrate similar findings, indicating that mood disorders and schizophrenia may share some biological underpinnings. These types of data may also lead to the future revision of psychiatric diagnostic manuals based on a new understanding of the etiology of these disorders.  

Another approach to delineating the pathophysiology of bipolar disorder involves studying changes in gene expression induced in rodent brains after administration of pharmacological agents used to treat bipolar disorder. For example, investigators have recently demonstrated that 2 chemically unrelated drugs used to treat bipolar disorder, ie, lithium and valproate, both up-regulate the expression of the cytoprotective protein Bcl-2 in the frontal cortex and the hippocampus of rat brains. Neuroimaging studies of individuals with bipolar disorder or other mood disorders also suggest evidence of cell loss or atrophy in these same brain regions. Thus, another suggested cause of bipolar disorder is damage to cells in the critical brain circuitry that regulates emotion. According to this hypothesis, mood stabilizers and antidepressants are thought to alter mood by stimulating cell survival pathways and increasing levels of neurotrophic factors to improve cellular resiliency.

Post and associates proposed a mechanism involving electrophysiological kindling and behavioral sensitization processes, a method that also resonates with the previous hypothesis based on neuronal injury. Post asserts that an individual who is susceptible to bipolar disorder experiences an increasing number of minor neurological insults, perhaps caused by drugs of abuse, excessive glucocorticoid stimulation resulting from acute or chronic stress, or other factors, which eventually result in mania. Subsequently, sufficient brain damage might persist such that mania could recur even with no or minor environmental or behavioral stressors. This type of formulation helps explain the effective role of anticonvulsant medications, eg, carbamazepine and valproate, in the prevention of the highs and lows of bipolar disorder. It also suggests that the more episodes a person experiences, the more he or she will have in the future, underscoring the need for long-term treatment.
Frequency

In the US: The lifelong prevalence rate of bipolar disorder in the United States is 1-1.6%. The 2 types of disorders differ in adult populations, with approximately 0.8% having BPI and 0.5% having BPII.
Internationally: Lifelong prevalence rate is 0.3-1.5%.
Mortality/Morbidity: Bipolar disorder has significant morbidity and mortality rates. In lost work, the cost of lost productivity resulting from this illness in the United States during the early part of the 1990s was estimated at approximately $15.5 billion annually. Approximately 25-50% of individuals with bipolar disorder attempt suicide, and 11% actually commit suicide.

Race: No racial predilection exists. However, a point of historical interest is that clinicians often tend to consider populations of African Americans and Hispanics as more likely to be diagnosed with schizophrenia than with affective disorders and bipolar disorder.

Sex: BPI occurs equally in both sexes; however, rapid-cycling bipolar disorder (4 or more episodes a year) is more common in women than in men. Incidence of BPII is higher in females than in males.  

Age: The age of onset of bipolar disorder varies greatly. The age range for both BPI and BPII is from childhood to 50 years, with a mean age of approximately 21 years. Most cases commence when individuals are aged 15-19 years. The second most frequent age range of onset is 20-24 years. Some patients diagnosed with recurrent major depression may indeed have bipolar disorder and go on to develop their first manic episode when older than 50 years. They may have a family history of bipolar disorder. However, for most patients, the onset of mania in people older than 50 years should lead to an investigation for medical or neurological disorders such as cerebrovascular disease.

History: The diagnosis of BPI 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).

Symptoms 

Manic episodes are characterized by the following:
At least 1 week of profound mood disturbance is present, characterized by elation, irritability, or expansiveness.
Three or more of the following symptoms are 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 the following:
The patient has an elevated, expansive, or irritable mood of at least 4 days’ duration.
Three or more of the following symptoms are 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 either 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.

Physical

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 various areas of the MSE are labeled according to the particular phase of the patient.

Appearance

Depressed episode: 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.

Hypomanic episode: These patients 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 (Keck, 2003).

Manic episode: In many ways, the behavior of a patient in the manic phase reflects behavior opposite 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 often are too bright, colorful, or garish. They stand out in a crowd because their dress frequently attracts attention.

 

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