Bipolar disorder history and symptoms

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Nuha Al-Howthi, MD[2]

History and Symptoms

Bipolar disorder is a cyclic illness where people periodically exhibit elevated (Manic) and depressive episodes. Most people will experience a number of episodes, averaging 0.4 to 0.7 a year with each lasting 3-6 months. Late adolescence and early adulthood are peak years for the onset of the illness. These are critical periods in a young adult's social and vocational development, and they can be severely disrupted by disease onset.

Prodrome

Prodromal signs and symptoms such as irritability, anxiety, mood liability (“mood swings”), agitation, aggressiveness, sleep disturbance, and hyperactivity may precede onset of bipolar disorder.

Manic episodes

The course of illness in mania may be marked by a sudden onset, and episodes progress quickly over a few days. The duration of manic episodes ranges from weeks to months.

• Involve clinically significant changes in mood, energy, activity, behavior, sleep, and cognition.
• Abnormally elevated, irritable, and labile mood is a core symptom required to diagnose mania.
• Classic mania is marked by an unusually good, euphoric, or high mood, which may be accompanied by disinhibition, disregard for social boundaries, expansiveness.
• Another core diagnostic symptom of mania is persistently increased energy and activity.
• Increased planning and activity is typically marked by impulsivity, poor judgement.
• Patients are often unable to complete the many tasks or projects that are started.
• Manic patients generally have an exaggerated sense of wellbeing and self-confidence, which may extend to grandiosity of psychotic proportions.
• There is decreased need for sleep.
• Common cognitive symptoms of mania include increased mental activity, racing thoughts, distractibility, and difficulty distinguishing between relevant and irrelevant thoughts; these symptoms result in flight of ideas.
• In addition, patients may not recall events that occur during manic episodes.
• Manic speech is generally loud, pressured or accelerated, and difficult to interrupt.

Hypomania

• Hypomanic episodes are characterized by changes in mood, energy, activity, behavior, sleep, and cognition that are similar to those of mania, but less severe.
• psychotic symptoms do not occur in hypomania, and hypomania never necessitates hospitalization.
• The course of hypomania is such that it generally begins suddenly and progresses quickly over one to two days. Episodes typically resolve within several weeks.

Major depression

• Episodes of major depression involve clinically significant changes in mood, behavior, energy, sleep, and cognition.
• Bipolar major depression is generally characterized by dysphoria, as well as slowing in the pace of mental and physical activity (eg, speech is slow and soft, and output reduced).
• Interest in pleasurable activities (eg, sex) is minimal, energy is low, and memory and concentration are impaired.
• Appetite is typically diminished and accompanied by weight loss.
• Sleep disturbances (insomnia or hypersomnia) often occur in bipolar depression.
• Other features of major depression include poor eye contact, poor hygiene, messy appearance, feelings of hopelessness and helplessness,

Mixed features

• Episodes of bipolar mania, hypomania, and major depression can be accompanied by symptoms of the opposite polarity, and are referred to as mood episodes with mixed features (eg, major depression with mixed features or hypomania with mixed features).
• Manic or hypomanic episodes with mixed features are characterized by episodes that meet full criteria for mania or hypomania, and at least three of the following symptoms during most days of the episode:
  • Depressed mood
  • Diminished interest or pleasure in most activities
  • Psychomotor retardation
  • Low energy
  • Excessive guilt or thoughts of worthlessness
  • Recurrent thoughts about death or suicide, or suicide attempt

• Major depressive episodes with mixed features are characterized by episodes that meet full criteria for major depression, and at least three of the following symptoms during most days of the episode:
  • Elevated or expansive mood
  • Inflated self-esteem or grandiosity
  • More talkative than usual or pressured speech
  • Flight of ideas
  • Increased energy
  • Decreased need for sleep

• Red flags for mixed features include the presence of clinically significant agitation, anxiety, or irritability.
• Patients with mixed features are at greater risk for suicidal ideation and comorbid anxiety disorders and substance use disorders.
• The esponse to treatment is often poorer in mood episodes with mixed features than in pure bipolar major depression or pure mania.