Generally it is considered that bipolar affective disorder is a condition in which there areongoingmood swings. On the contrary, bipolar affective disorder has an episodic course of illness in which there may be episodes of mania/hypomania and/ or episodes of depression. In between episode of depression and mania generally there is a stable period as well. It is commonly observed that patient have particular sensitive season, which means for that person in particular season there is increased risk of particular episode.
We need to understand that bipolar affective disorder is different from borderline personality disorder in which change of thinking and behaviour is part of illness and is clearly different from person personality.
Patient with bipolar affective disorder generally experience one to two episodes of either mania or depression in one year, each lasting for a minimal period of 1-2 weeks or it may persist for even longer period like 6 months. In few individual patient may experience >4 episode per year in which it is called as Rapid Cycler.
Manic Episode:
During Manic episode there is a change in a person thinking pattern and behaviour which is noticed by people around him or by patient himself. Patient may experience following changes in behaviour in episode of hypo/ mania.
- Decreased sleep but still alert and active.
- Excessive talk with loud volume
- Increased planning and risky behaviour
- Disinhibited & authoritative behaviour increased sexual desire.
- Increased socialization,
- Increased spending & charity
- Change in religiosity
- Increased confidence and Grandiosity
- Changes of increased smoking or use of street drugs
Above symptoms must last for atleast 1 week to confirm diagnosis of Manic Episode or less duration if symptoms intensity is to extend in which admission is mandatory.
Difference between Mania and Hypomania:
In mania and hypomania generally symptoms are same however the intensity of symptoms is less. In hypomania pt or ppl around him/ her can see a clear difference in his/her personality for more than particular period (as mentioned above), however person is able to manage the daily functionality. In mania intensity of symptom gets increased to an extend that it is not only noticeable but daily functionality starts getting disturbed. Also person may experience psychotic symptoms like grandiosity or persecutory delusions etc.
Depressive Episode:
In depressive episode patient willexperience totally opposite of above. Symptoms of depressive episode will be similar to that in depressive disorder. Just like mania, depressive episode is not part of an individual personality and one can identify the change from pre morbid personality.
(link for depressive disorder)
Treatment:
Main stay of bipolar affective disorder is Mood stabilizers. Whenever a patient present with a specific episode, either mania or depression, first step is to manage that particular episode.
If a patient is having depressive episode then we need to give him anti-depressant to help him come out of depression. Once he is out of depression then mood stabilizer is given and antidepressant is tapered off after 3 months or early in case of side effect or switching to mania.
If a patient is having manic episode then we need to manage it with mood stabilizer, antipsychotic (typical or atypical) and benzodiazepine. Generally it takes 2 to 4 weeks to manage an episode of hypo/mania but at times it may take long. Once episode is over then benzodiazepine is tapered off. It is recommended that anti psychotics are to be tapered off after 3 months. In case of side effects we may taper off anti-psychotics early.
Course and Prognosis:
We need to understand that Bipolar affective disorder has a relapsing remitting course of illness and even when a particular episode gets over, there are chances to have episodes in future. So treatment needs to be continued. Common mistake done by patient and family is that once the episode gets controlled they stop medication.
Once episode is over; depending on demographic profile, previous episodes, family history, past use of mood stablizers, medicines are adjusted in a manner that chances of further episodes are reduced.
Mood Stablizers which are recommended and commonly used are as follows and decided as per individual case:
Sodium Valproate
Lithium Carbonate
Atpyical antipsychotics (eg Olanzapine and Quetiapine)
Carbamazepine
Lamotrigene
Role of Family:
Family play vital role especially in Asian culture. They need to understand this condition as an illness and not part of personal weakness or personality.
- Understand it as an illness.
- Provide support to patient and do not stigmatize illness.
- They must identify relapse signature symptoms andIfpt has a relapse,do not delay treatment seek help immediately even if patient is reluctant to visit.
- Family need to monitor compliance of medication and follow up on regular basis.
- Avoid stimulating environment during manic phase
- Ensure safety measures for patient.
Bipolar affective disorder is always a challenge for treating consultant because the ultimate target is not only to treat the episode but to adjust medicine so that episode should be prevented and if there is a relapse it should be dealt on immediate basis.
