Manic depressive psychosis (bipolar disease)

1. MANIC DEPRESSIVE PSYCHOSIS (Bipolar Disorder) VAISHNAVI SURESH NAIR

2. MDI is characterized by periods of deep, prolonged, and profound depression that alternate with periods of an excessively elevated or irritable mood known as mania; with a normal period (intermission) in between them.

3. CLINICAL PRESENTATION

4. MANIC EPISODES: Manic episodes are feature at least 1 week of profound mood disturbance, characterized by elation, irritability, or expansiveness (referred to as gateway criteria). 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

5. HYPOMANIA: Hypomanic episodes are characterized by an elevated, expansive, or irritable mood of at least 4 consecutive 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 Increased level of goal-focused activity at home, at work, or sexually Engaging in activities with a high potential for painful consequences

6. MAJOR DEPRESSIVE EPISODES: Major depressive episodes are characterized as, for the same 2 weeks , the person experiences 5 or more of the following symptoms, with at least 1 of the symptoms 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 Feelings of worthlessness or excessive guilt Decreased concentration ability or marked indecisiveness Preoccupation with death or suicide; patient has a plan or has attempted suicide

7. VARIANTS: (DSM V)

8. Bipolar I  disorder:   involves periods of severe mood episodes from mania to depression. Bipolar II  disorder:   is a milder form of mood elevation, involving milder episodes of  hypomania   that alternate with periods of  severe depression . Cyclothymic disorder   describes periods of hypomania with brief periods of depression that are not as extensive or long-lasting as seen in full depressive episodes . Mixed features: refers to the occurrence of simultaneous symptoms of opposite mood polarities during manic, hypomanic or depressive episodes. It's marked by high energy, sleeplessness, and racing thoughts . At the same time, the person may feel hopeless, despairing, irritable, and  suicidal . Rapid-cycling:   It is a term that describes having four or more mood episodes within a 12-month period . Episodes must last for some minimum number of days in order to be considered distinct episodes. Some people also experience changes in polarity from high to low or vice-versa within a single week, or even within a single day -- the full symptom profile that defines distinct, separate episodes may not be present (for example, the person may not have a decreased need for sleep), making such "ultra-rapid" cycling a more controversial phenomenon. Rapid cycling can occur at any time in the course of illness, although some researchers believe that it may be more common at later points in the lifetime duration of illness. Women appear more likely than men to have rapid cycling. A rapid-cycling pattern increases risk for severe depression and  suicide attempts .  Antidepressants  may sometimes be associated with triggering or prolonging periods of rapid cycling .

9. ETIOLOGY: A number of factors contribute to bipolar affective disorder, or manic-depressive illness (MDI), including genetic , biochemical, psychodynamic, and environmental factors . GENETIC PREDISPOSITIONS: Bipolar disorder, especially bipolar type I (BPI) disorder, has a major genetic component, with the involvement of the  ANK3,CACNA1C,  and  CLOCK   genes . First-degree relatives of people with BPI are approximately 7 times more likely to develop BPI than the general population. Remarkably, offspring of a parent with bipolar disorder have a 50% chance of having another major psychiatric disorder.  Gene expression studies also demonstrate that persons with bipolar disorder, major depression, and schizophrenia share similar decreases in the expression of oligodendrocyte-myelin-related genes and abnormalities of white matter in various brain regions .

10. NEUROPHYSIOLOGIC FACTORS: A meta-analysis by Houenou et al found : D ecreased activation and diminution of gray matter in a cortical-cognitive brain network , which has been associated with the regulation of emotions in patients with bipolar disorder.   An increased activation in ventral limbic brain regions that mediate the experience of emotions and generation of emotional responses . This provides evidence for functional and anatomic alterations in bipolar disorder in brain networks associated with the experience and regulation of emotions . PSYCHODYNAMIC FACTORS: Many practitioners see  the depression as the manifestation of losses ( ie , the loss of self-esteem and the sense of worthlessness).Therefore , the mania serves as a defence against the feelings of depression . Melanie Klein was one of the major proponents of this formulation. A study by Barnett et al found that personality disturbances in extraversion, neuroticism , and openness are often noted in patients with bipolar disorder and may be enduring characteristics .

11. ENVIRONMENTAL FACTORS: E xternal stresses or the external pressures may serve to exacerbate some underlying genetic or biochemical predisposition. For example, Pregnancy is a particular stress for women with a manic-depressive illness history and increases the possibility of postpartum psychosis. Because of the nature of their work, certain individuals have periods of high demands followed by periods of few requirements. For example, a landscaper and gardener who was busy in the spring, summer, and fall became relatively inactive during the winter, except for plowing snow. Consequently, he appeared manic for a good part of the year, and then he would crash and hibernate during the cold months BIOCHEMICAL FACTORS: A number of neurotransmitters have been linked to this disorder, largely based on patients’ responses to psychoactive agents as in the following examples. The blood pressure drug reserpine , which depletes catecholamines from nerve terminals, was noted incidentally to cause depression. This led to the catecholamine hypothesis , which holds that an increase in epinephrine and norepinephrine causes mania and a decrease in epinephrine and norepinephrine causes depression . Drugs used to treat depression and drugs of abuse (eg, cocaine) that increase levels of monoamines, including serotonin, norepinephrine, or dopamine, can all potentially trigger mania, implicating all of these neurotransmitters in its etiology .

12. Other agents that exacerbate mania include L-dopa, which implicates dopamine and serotonin-reuptake inhibitors , which in turn implicate serotonin . Evidence is mounting of the contribution of glutamate to both bipolar disorder and major depression. A post-mortem study of the frontal lobes of individuals with these disorders revealed that the glutamate levels were increased. Calcium channel blockers have been used to treat mania, which may also result from a disruption of intracellular calcium regulation in neurons as suggested by experimental and genetic data. The proposed disruption of calcium regulation may be caused by various neurologic insults, such as excessive glutaminergic transmission or ischemia. Interestingly, valproate specifically upregulates expression of a calcium chaperone protein, GRP 78, which may be one of its chief mechanisms of cellular protection . Hormonal imbalances and disruptions of the hypothalamic-pituitary-adrenal axis involved in homeostasis and the stress response may also contribute to the clinical picture of bipolar disorder.

13. DIAGNOSIS: Examination of patients with suspected bipolar Affective disorder includes evaluation using the Mental Status Examination as well as assessment of the following : Appearance Affect/mood Thought content Perception Judgment/insight Cognition Physical health Suicide/self-destruction Homicide/violence/aggression

14. APPEARANCE: Persons experiencing a depressed episode may demonstrate poor to no eye contact. Their clothes may be unkempt, unclean, holed, un ironed , and ill-fitting. If the person has lost significant weight, the garments may fit loosely. Men: poor grooming, lack of shaving, and lack of washing , may exhibit dirty fingernails and hands. Women: fingernails may show different layers of polish or one layer partially removed, and they may not have paid attention to their hair. 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 . Patients experiencing the manic phase are hyperactive and might be hypervigilant . They are restless, energized, and active. They talk and act fast. Their attire also 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. These individuals stand out in a crowd, because their dress frequently attracts attention .

15. MOOD CHANGES: 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 ).

16. THOUGHT CONTENT: Patients experiencing a depressed episode have thoughts that reflect their sadness . They are preoccupied with negative ideas and nihilistic concerns. 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 , often have a very rapid production of ideas and thoughts, perceive their minds as being very active , and see themselves as being highly engaging and creative . These individuals 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 .

17. JUDGEMENT/INSIGHT: In persons experiencing a depressive episode , the depression clouds and dims their judgment and colors their insights . They fail to make important plans/actions, because they are so down and preoccupied with their own plight. These individuals 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 act expansively and may demonstrate poor judgment by taking on too many tasks or becoming 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. For eg: they may invest the family fortune in very questionable programs, become professionally over involved in work activities or with coworkers, or start dramatically unsound fiscal or professional ventures. These individuals 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.

18. PERCEPTION: 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. 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. Some patients experience delusions that are inconsistent with the depression, such as paranoia or persecutory delusions . By definition, patients experiencing a hypomanic episode do not experience hallucinations. 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.

19. 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. However , later in the course of their illness, their cognition becomes impaired. In extremes of depression and mania, these individuals may experience difficulty in concentrating and focusing . Similar to subcortical dementia, depression impairs cognition. PHYSICAL HEALTH: 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.

20. TREATMENT: The treatment of bipolar affective disorder is directly related to the phase of the episode ( ie , depression or mania) and the severity of that phase, and it may involve a combination of psychotherapy and medication. Always evaluate patients with mania, hypomania, or mixed episode, and those with bipolar depression, for suicidality, acute or chronic psychosis, or other unstable or dangerous conditions. PHARMACOTHERAPY: Medications used to manage patients with bipolar disorder include the following: Benzodiazepines (eg, lorazepam, clonazepam) Antimanic agents (eg, lithium) Anticonvulsants (eg, carbamazepine, valproate sodium,valproic acid, divalproex sodium, lamotrigine, topiramate ) First-generation antipsychotics (eg, inhaled loxapine , haloperidol) Second-generation antipsychotics (eg, asenapine , ziprasidone , quetiapine, risperidone , aripiprazole , olanzapine, olanzapine and fluoxetine , clozapine, paliperidone ) Phenothiazine antipsychotics (eg, chlorpromazine) Dopamine agonists (eg, pramipexole )

21. NON PHARMACOTHERAPY: Psychotherapy may help to decrease relapse rates, improve quality of life, and/or increase functioning, or more favourable symptom improvement. Patients with chronic medical illnesses and depression should be treated with a comprehensive approach involving the patient, the family, the support team, the physician, other professionals, and community resources. Such models, called Collaborative Chronic Care Models (CCMs ) , have been developed to improve outcomes in chronically ill patients treated in the primary care setting who also suffer from depression. CCMs were defined a priori as interventions with at least 3 of the 6 components of the Improving Chronic Illness Care initiative, as follows : Patient self-management support Clinical information systems Delivery system redesign Decision support Organizational support Community resource linkages

22. Electroconvulsive therapy: may be useful in selected patients with bipolar disorder. Especially, When rapid, definitive medical/psychiatric treatment is needed When the risks of ECT are less than that of other treatments When the bipolar disorder is refractory to an adequate trial with other treatment strategies When the patient prefers this treatment modality Often, the severity of the patient’s symptoms, the lack of response to medications, or the presence of contraindications to certain medications necessitates the use of ECT. This treatment modality has proven to be highly effective in the treatment of acute mania. INDICATIONS FOR INPATIENT MANAGEMENT: Patients diagnosed with bipolar mania or depression and severe symptoms must be referred for urgent/emergent mental health intervention. The indications for inpatient treatment in a person with bipolar affective disorder, or manic-depressive illness (MDI), include the following: Danger to self Danger to others Delirium Marked psychotic symptoms Total inability to function Total loss of control (eg, excessive spending, undertaking a dangerous trip) Medical conditions that warrant medication monitoring (eg, substance withdrawal/intoxication

23. PROGNOSIS: Factors suggesting a worse prognosis include the following : Poor job history Substance abuse Psychotic features Depressive features between periods of mania and depression Evidence of depression Male sex Pattern of depression-mania- euthymia Factors suggesting a better prognosis include the following : Length of manic phases (short duration) Late age of onset Few thoughts of suicide Few psychotic symptoms Few medical problems

24. LIFE STYLE MODIFICATIONS: Patients in the depressed phase are encouraged to exercise. These individuals should try to develop a regular daily schedule of major activities, especially times of going to bed and waking up. Propose a regular exercise schedule for all patients, especially those with bipolar disorder. Both the exercise and the regular schedule are keys to surviving this illness. PREVENTION AND LONG TERM MONITORING: Prevention is the key to the long-term treatment of bipolar affective disorders, , or manic-depressive illness (MDI), as follows : First, use medications such as lithium serve as mood stabilizers Second, psycho education is instituted for the patient and the patient’s family; it is critical that the patient and the patient’s family understand and recognize the importance of medication compliance and the early signs of mania and depression

25. Re evaluate for treatment response every 1-2 weeks for a minimum of 6 weeks . Continue to monitor these individuals for the following situations : Depressive symptoms (or changes in), suicidal/homicide ideation Neuro vegetative symptoms New-onset/change in psychotic symptoms or manic/hypomanic symptoms Illicit substance use Medication side effects and compliance Medical stability Significant psychosocial changes Re evaluate all patients for treatment response at 4-8 weeks, after each change in treatment, and periodically until full remission is achieved. Full remission is defined in patients with mania as the absence of significant mania symptoms for 2 months; in patients with mixed episode, it is the absence of significant mania or depression symptoms for 2 months; and in those with bipolar depression, it is the absence of significant depressive symptoms for 2 months . Treat adult patients who have had an acute manic episode for a minimum of 6 months after the initial episode is controlled; encourage these individuals—as well as those who have had more than 1 manic episode or with 1 manic and 1 depressive episode, or 3 or more depressive episodes—to continue on lifelong prophylactic pharmacotherapy. Following full remission of the depressive episode, consider withdrawing antidepressant treatment after 4-6 months. Discontinuation should consist of a gradual taper over a minimum 2-4–week period, unless medically contraindicated.

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