Manic Depressive Illness (MDI) is a common medical condition affecting approximately 6% of the population (Epidemiology).
MDI can cause periods of excitation (Mania) or inhibition (Depression). Both affect emotions (mood), thoughts (cognitive functions), and activity (motor functions).
The Diagnosis of MDI is clinical -- there are no blood tests available for this purpose, and relies on a combination of several factors: Symptoms, Family History, Course of Illness, and Response to Treatment.
Diagnostic criteria have been developed and used to diagnose Bipolar Disorder, a form of MDI.
The most common Symptoms are mood swings, including depression, anxiety, irritability and anger.
-Mood varies from euphoric and grandiose or irritable in Mania to anxious, sad or melancholic during periods of Depression.
-Thoughts are many and quick in mania, few or sluggish in depression.
-Self-esteem changes from self-confidence to worthlessness, demeanor from overconfident to insecure.
-Activity: a manic person is agitated and restlessness, while a depressed person might move slowly or little.
MANIA (UP) EUTHYMIA (NORMAL) DEPRESSION (DOWN)
HIGH/HAPPY/ANGRY NORMAL MOOD FLAT/SAD/BLUE
HIGH SELF-ESTEEM SHAKY SELF-ESTEEM LOW SELF-ESTEEM
QUICK THOUGHTS NORMAL THOUGHTS SLOW THOUGHTS
MANY INTERESTS NORMAL INTEREST LACKS INTEREST
LESS SLEEP NORMAL SLEEP MORE SLEEP
HIGH ENERGY NORMAL ENERGY LOW ENERGY
FAST MOVEMENTS NORMAL MOVEMENTS SLOW MOVEMENTS
Mania and Hypomania are states of emotional, physical and cognitive excitement with increased activity, interest and marked euphoria or irritability depending on the mood.
Manic movements are rapid, effortless, energetic, and sometimes destructive or dangerous. The ideas are flowing easily and distracted by many interests. As Mania accelerates thinking, thought can become crowded, and sometimes disorganized and confused.
In Depression feelings of sadness, lack of interest and low self-esteem accompany a slowing down of motor and cognitive activity. The movements are few, slow and the product of effort. The mind often ruminates over past events, mostly in guilt or sorrow. There is a feeling of lack of wellbeing, or dis-ease.
Mixed States are the result of overlapping or coexisting symptoms of Depression and Mania. In the course of a Mixed State, depressed mood and negative thinking can be present, along with motor agitation, and at times restlessness and aggressive behavior.
Psychosis can be present during episodes of both Mania and Depression, often leading to Misdiagnosis. The Differential Diagnosis from conditions that can mimic Mania and/or Depression is extremely important in order to provide appropriate treatment.
MDI can Onset at an early age, in childhood, adolescence or early adulthood. It can remain silent until late in life until a medical or neurological illness might precipitate an episode of illness in someone with the genetic vulnerability. The study of predisposing or premorbid Temperament has revealed the importance of baseline conditions on the development and evolution of this illness.
The cause(s) of MDI remain unknown. As MDI patients usually have a positive Family History: a genetic or hereditary predisposition is considered likely. The role of biological and environmental factors in the development and course of MDI has been suggested by many observations but remains unclear.
Comorbidity is the presence of two disorders at the same time yet independent from one another. The most common comorbid diagnosis occurring in patients with MDI are Alcohol/Substance Abuse and Anxiety Disorders. Less common are eating disorders and impulse dyscontrol disorders.
Many patients with MDI attempt to self-medicate, mostly with mood altering drugs, either legal (i.e., alcohol, tobacco and caffeine) or illegal (i.e., hashish, marijuana, amphetamines, cocaine, opiates, ecstasy). Patients with MDI are often diagnosed with other disorders, a phenomenon called comorbidity.
Precipitants and life-events can have a very profound effect on a sensitive person like the person with MDI. It is not uncommon to see a life event, including losses, emotionally charged events, alcohol or substance abuse be in close temporal relationship to an episode.
Several Forms or subtypes of MDI can be defined based on symptoms and on the course over time of clinical manifestations.
MDI is a chronic illness and follows a recurrent Course. Phases of illness (episodes) can switch from one to the other or be separated by symptom-free intervals. Over 90% of those that experience an episode of mania experience a recurrence of either mania or depression.
MDI can cause major disruptions in one’s life involving family, social and occupational (Quality of life).
-Outcome measures or estimates of the impact of MDI on an individual’s life have differentiated between symptomatic and functional outcome.
-The presence of symptoms and their severity has a profound impact on their life (symptomatic outcome). Outcome studies show major impairment of a person’s ability to function (functional outcome) even when the symptoms have remitted.
MDI causes significant disability and mortality, and is a leading cause of Suicide.
The Cost to society has been estimated at $ 45 billion/year in the US alone (1994 estimate).
MDI can remain in remission -- spontaneous or due to treatment, or follow a severe course with brief or no intervals.
The Treatment of MDI can require hospitalization or intensive outpatient treatment during acute phases of illness. Treatments used in MDI include medications, psychotherapy and changes of lifestyle. If stabilization is achieved, maintenance treatment can be effective in preventing recurrences, and often result in prolonged remission of symptoms.
Obtaining and maintaining remission often requires careful management of medications and through psychotherapy, the development of ways to reduce the impact of life events or residual mood swings on a person’s life.
The number of people classified as suffering with Mania, Hypomania and other forms of MDI with recurrent mood changes depends on the diagnostic criteria used.
The DSM (Diagnostic and Statistical Manual), used to make the diagnosis requires a minimum duration of four days of manic symptoms for a diagnosis to be made, if the patient is not hospitalized.
In two large studies using DSM criteria, the rate of Mania and Hypomania was 1.2% and 1.6%. (-Regier, -Kessler)
When DSM duration criteria for Mania and Hypomania are removed, to include sub-threshold manifestations of MDI, rates of 5.0-8.3% have been reported. (-Lewinsohn, -Szadoczky, -Angst)
Among researchers, forms of illness that fall short of meeting all criteria are called sub-threshold. Inclusion in the broader umbrella of MDI of sub-threshold forms of Mania and Hypomania are justified by several similarities between patient meeting the duration criteria for these symptoms and those that do not. These similarities include:
-the presence of a positive family history of mood disorders,
-a history of suicide attempts and treatment for depression, and
-comorbidity with anxiety and substance abuse disorders.
The follow-up of subjects with Hypomania, Cyclothymia and other sub-syndromal forms -- not meeting the duration criteria of DSM, has revealed the continuity of these forms with those meeting the diagnostic criteria. The evidence appears to justify the use of a broader definition of MDI than the narrow one used by DSM.
To grasp some of the complexities of MDI it is best to focus our attention on the following aspects of this illness.
Polarity of MDI is the predominant clinical feature. Mania and Depression are the ones that have been studied most extensively.
Mixed States are the result of coexisting and overlapping symptoms of Mania and Depression. One can observe forms of MDI where the polarity alternates from Mania to Depression, others where the presentation is consistently of the same polarity (i.e., chronic Mania/Hypomania, recurrent Depression or recurrent Mixed States).
Severity of the symptomatic and functional impairment determines the severity of MDI. One can encounter forms where the symptoms are so mild that might go undetected while the extent of the disability produced is severe. Also, common forms are where extremely severe symptoms during episodes remit completely, causing limited disability.
Duration of symptomatic phases can range from minutes, hours, days, months or years. In children and adolescents it is common to observe very rapid shifts of mood and energy lasting only minute. While in older patients, phases of MDI can last for years. Modern treatments have significantly affected the duration of MDI’s phases and its course.
Cyclicity describes the tendency of MDI to manifest in cycles of episodes or phases, with or without intervals, and to recur with different frequency. Some forms only recur every few years. Others recur regularly with a seasonal pattern or follow a rapid-cycling pattern (four or more episodes in 12 months).
Polarity and Severity are symptomatic variables.
In the course of a manic or depressive episode, one can experience symptoms of different severity causing different degrees of disability.
Duration and Cyclicity are course variables.
Short phases tend to occur in a rapid cycling course, as opposed to phases lasting for months in those with a seasonal course of illness.
“Manic-depressive insanity…(includes) certain slight and slightest colourings of mood, some of them periodic, some of them continuously morbid, which on the one hand are to be regarded as the rudiment of more severe disorders, on the other hand pass without sharp boundary into the domain of personal predisposition. In the course of the years I have become more and more convinced that all the above mentioned states only represent manifestations of a single morbid process.”
-Kraepelin
The diagnosis of MDI is based on several factors:
• Symptoms
• Family History of a Mood Disorder or Substance Abuse
• Course of Illness
• Response to Treatment
Many illnesses and drugs can produce symptoms of Mania, Hypomania or Depression and need to be distinguished and adequately treated. The most common causes are listed in the Differential Diagnosis Section.
It is almost always possible to find a history of Mood Disorders or Substance Abuse/Dependence among relatives of subjects with MDI. However, the extraordinary variability of symptom caused by MDI and the common failure to diagnose non-classic or milder forms of MDI can interfere with documenting a family history of Mood Disorders. For example: a parent or relative might suffer from pathological gambling or have a criminal history, common examples of poor impulse control.
These forms are very often undiagnosed and untreated, and rarely their connection with MDI is recognized.
The presence of cycling or recurrences of mood instability, the continuous or recurrent instability of mood and activity are quite distinctive of MDI. It is the constant change that appears to be the only constant in the variable course of this illness. For this reason, the observation of these symptoms, over time, might be the only way to document a recurrent course of illness. This was well known since antiquity and has been emphasized by Kraepelin in his seminal work on MDI.
The beneficial response to mood stabilizing agents confirms the diagnosis. The induction of hypomanic or manic symptoms with stimulants, antidepressants and other substances has been considered evidence of a ‘latent’ form of MDI, requiring an external precipitant to become apparent.
"Manic-depressive insanity…includes on the one hand the whole domain of the so called periodic and circular insanity, on the other hand simple mania, the greatest part of the morbid states termed melancholia"
-Kraepelin
The symptoms of MDI can be extremely variable from person to person, remaining fairly consistent over time in the same person. Some will experience both Mania and Depression. Others only or mostly Mania, Depression, or Mixed States.
MDI is an illness affecting energy level and mood. Mood and energy changes occur often but not always in the same direction. In general, Mania manifests as an increase of energy with cognitive and physical activation, while depression usually results in decreased mental and physical activity.
Mania can occur in a variety of clinical manifestations, including a classic, euphoric form, a dysphoric or irritable form, a mixed state, a mild form (hypomania), or a subsyndromal form (hyperthymia), often referred to as Temperament. A general feeling of wellness and eutonia is quite common in the euphoric forms but not in dysphoric mania.
Mania causes impaired judgment and poor impulse control. A manic patient might seek out dangerous, risk-taking behaviors, including impulsive spending, sexual promiscuity, aggressive driving and speeding, substance abuse, and violent or criminal behavior.
While most forms of mania are polysymptomatic -- many signs and symptoms occur at the same time, it is possible to observe manic phases with very few symptoms.
Manic symptoms are:
-"High," extremely happy or euphoric mood
-Irritable mood - provocative, explosive
-Self-importance - attention-seeking behavior, grandiosity
-Increased energy, restlessness or increased activity level
-Little need for sleep - up for a couple of nights straight
-Talkative, uninterrupted, vulgar or loud speech
-Need to use dramatic language/gestures - theatrical
-Lots of thoughts and ideas or projects
-Aggressive - verbally or physically violent
-Short attention span - distractibility and poor concentration
-Risky activities - speeding, gambling, substance abuse
-Poor judgement with impulsive behavior - overspending
Inability to recognize change from baseline - denial of illness
-Increased sexual drive, desire and/or activity
MANIA SIGNS SYMPTOMS
ACTIVITY HYPERACTIVE RESTLESS/RUSHED
PRESSURED SPEECH TALKATIVE/CHATTY
ANIMATED MULTIPLE ACTIVITIES
LITTLE NEED FOR SLEEP INSOMNIA
PROMISCUITY HIGH SEXUAL DRIVE
COGNITION DISTRACTIBLE RACING THOUGHTS
POOR CONCENTRATION CONFUSION
CREATIVE CREATIVE
PUNS/JOKES NEED TO SOCIALIZE
MOOD ELATED EUPHORIC
LAUGHS/SMILES A LOT LAUGHS/SMILES A LOT
GRANDIOSE SELF-CONFIDENT
The presence of a depressed or unpleasant mood during an episode of Mania produces a clinical picture called Dysphoric Mania. This term has been used to describe several different clinical conditions, including Irritable, Mixed and Anxious Mania. (McElroy, Hantouche)
In these syndromes, manic symptoms are prominent and often severe. The lack of euphoria however, confers to these forms a particularly painful quality. The patient suffering from these forms of Mania is highly irritable, hostile, and prone to angry outbursts or rage. When contradicted or confronted with the consequences of his behavior, the patient can become abusive, violent and destructive.
It has been suggested that Dysphoric Mania may represent a more severe form of Mania (progressing from Hypomania to Euphoric Mania and to Dysphoric Mania). Others consider Dysphoric Mania a separate, independent form of illness with characteristic clinical and therapeutic features.
Depressive symptoms are almost always present in people suffering from MDI. Depressive symptoms can vary in severity, type and duration, occurring in alternation with manic/hypomanic symptoms, in combination with them, or in their absence. Different forms or subtypes of MDI can be identified. Different types of depression have been described from a subtle, lingering form called Dysthymia to the short-lived depressive phases of Cyclothymia or the full-blown Major Depression in its recurrent, chronic or Atypical forms. For a review on Depression, see Preskorn.
During a depressed phase a person may:
feel "blue, sad or down" for most of the day, almost every day;
feel worthless or guilty every day, or nearly every day;
cry a lot -- often or for no apparent reason;
loose interest in or feel little pleasure during all or most daily activities, almost every day;
experience trouble sleeping and/or sleeping too much;
feel weak, tired or lack energy almost every day;
be unable to concentrate;
have trouble making decisions, nearly every day;
gain or loose weight without wanting to;
think often about death or suicide.
DEPRESSION SIGNS SYMPTOMS
ACTIVITY INACTIVE RESTLESS/RUSHED
DECREASED SPEECH QUIET
DULL APATHY
GREATER NEED FOR SLEEP LETHARGY
WITHDRAWAL LOW SEXUAL DRIVE
COGNITION LACKS INTEREST BORED
POOR CONCENTRATION CONFUSION
INDECISIVE DOUBTS
POOR SELF ESTEEM SELF BLAME
MOOD SAD DOWN
TEARFULNESS TEARFULNESS
DESPONDENT DESPONDENT
Depression is by far the most common diagnosis given to people with MDI, as it is almost always the reason for seeking treatment in those suffering from the forms of MDI without Mania. Studies of depression in the primary setting confirm this trend. (Manning)
The symptoms are usually those of an Atypical Depression. The bias of many clinicians towards diagnosing Depression and the relative ease of diagnosing Depression with DSM Criteria has allowed many patients with MDI to be diagnosed as “Unipolar”.
In a large study of patients diagnosed with DSM IV Major Depression (Hantouche), 40% were re-diagnosed as MDI on the basis of a semi-structured interview eliciting hypomanic symptoms -- information obtained by further questioning of patients and significant others or based on observed Hypomania.
Characterized by increased sleep and appetite with carbohydrate craving, Atypical Depression is the most common among patients with MDI. Decreased energy, impaired concentration and low sexual drive are prominent features. The increased emotional reactivity and the preferential response to some antidepressants (MAOI) point to MDI as the underlying cause of these symptoms.
Growing evidence about the differences between the depressive phase of MDI and other forms of depression have been collected in research studies. Parker documented the differences between forms of Depression among patients with or without MDI. The presence of psychomotor retardation, melancholic and psychotic features are consistently more common in MDI than in other forms of depression.
Loss of interest, anhedonia, guilt, hallucinations, non-reactivity, and variability of mood were all statistically differentiating traits.
Neurobiological differences include abnormalities in the Hypothalamic-Pituitary Axis both during an acute episode of depression and after its remission.
"We observe also clinical 'mixed forms'in which the phenomena of Mania and melancholia are combined with each other, so that states arise, which indeed are composed of the same morbid symptoms as these, but cannot without coercion be classified either with the one or with the other. Our customary grouping into manic and melancholic attacks does not fit the facts, if it is to reproduce nature."
Kraepelin, 1921
The co-occurrence of manic and depressive symptoms in MDI are referred to as Mixed State.
The presence of different admixtures of manic and depressive symptoms led Kraepelin to distinguish six types of mixed states.
In 1953, J.D. Campbell wrote: "Manic-depressive (psychosis) is a dynamic, constantly changing process which, at times, may manifest symptoms of both phases simultaneously. It is in the mixed forms that the observer graphically realizes the homogeneity of the entire process." (p. 146)
Mixed states occur during the transition from one phase to another, or as stable clinical manifestations of overlapping symptoms.
A recent review of the literature on Mixed States examined diagnostic criteria used reported rates of 30-40% among patients with MDI, and described clinical features and neurobiological characteristics. (McElroy)
Like all MDI manifestations, Mixed States are distributed on a continuum, from severe manic symptoms with mild depressive features (Mixed Mania and Dysphoric Mania) to severe depressive symptoms with hypomanic features (Agitated Depression and Mixed Depressive Syndromes, Kukopulos).
The relationship between these syndromes, illness subtype and premorbid temperament has been the subject of intensive study by Akiskal and colleagues.
Among the Mixed States, forms of Depression with severe agitation and excitatory symptoms of Hypomania are extremely common. These forms are often called Anxious or Agitated Depression. Their importance lies in the severity of these conditions due to:
a great risk of suicidal behavior, and in
the frequent worsening of symptoms with antidepressant agents.
We found the most common symptoms reported in these forms include:
racing, crowded thoughts;
restlessness, pacing, agitation;
increased speech with continuous complaining;
suicidal ideation with plan and often intent;
extreme mood lability;
dramatic, vivacious expression of suffering;
reversed diurnal mood variations (worsening in p.m. hours);
sleep disturbances, decreased sleep;
anxiety and panic symptoms -- nervousness, tension.
The rapid worsening of these symptoms in response to treatment with antidepressant or exposure to stimulants confirms the presence of an excitatory process underlying these presentations.
As suggested by Koukopoulos, these forms require treatment of the hypomanic symptoms with sedatives and antimanic agents, and only later, if necessary, treatment of depressive symptoms. It is not unusual to see complete remission of symptoms with antimanic agents or sedatives.
The presence of psychotic features in the course of MDI is a well-known phenomenon. Psychotic symptoms like delusions, hallucinations or catatonia/disorganized behavior can occur during episodes of Mania, Depression and Mixed States. If psychotic symptoms persist for two weeks or more after the resolution of mood symptoms, a diagnosis of Schizoaffective disorder is made.
Psychotic symptoms might be more common in those forms with an earlier age of onset.
The psychotic symptoms might be congruent with the mood state experienced (grandiose delusions in the course of euphoric mania) or non-congruent (delusions of guilt during mania).
In general, psychotic symptoms have been associated with a worse outcome in adults with MDI.
From the Greek ‘alternating mood’, the term Cyclothymia was first used in psychiatry by E. Hecker in 1877 and was used by Emil Kraepelin as a synonym for the newly defined category of Manic-Depressive Insanity. Kraepelin described as subjects with a cyclothymic temperament ”…people who constantly oscillate hither and tither between the two opposite poles of mood, sometimes ’rejoicing to the skies, sometimes sad as death.”
Diagnostic Criteria
Cyclothymic Disorder (DSM IV, US)
• For at least 2 years the presence of numerous periods with hypomanic symptoms and numerous periods with depressive symptoms not meeting the criteria for a Major Depressive Episode.
Note: In children and adolescents the duration must be at least 1 year.
• During the above 2-year period (1 year in children and adolescents), the person has not been without the symptoms in Criterion A for more than 2 months at a time.
• No Major Depressive Episode, Manic Episode or Mixed Episode has been present during the first 2 years of the disturbance.
Note: After the initial 2 years (1 year in children and adolescents) of Cyclothymic Disorder, there may be superimposed Manic or Mixed Episodes, in which case both Bipolar I Disorder and Cyclothymic Disorder may be diagnosed, or Major Depressive Episodes, in which case both Bipolar II Disorder and Cyclothymic Disorder may be diagnosed.
• The symptoms in Criterion A are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder or Psychotic Disorder not otherwise specified.
The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).
The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.
Cyclothymia (ICD 10)
A persistent instability of mood, involving numerous periods of mild depression and mild elation. This instability usually develops early in adult life and pursues a chronic course, although at times the mood may be normal and stable for months at a time. The mood swings are usually perceived by the individual as being unrelated to life events. The diagnosis is difficult to establish without a prolonged period of observation or an unusually good account of the individual's past behavior. Because the mood swings are relatively mild and the periods of mood elevation may be enjoyable. Cyclothymia frequently fails to come to medical attention. In some cases this may be because the mood change, although present, is less prominent than cyclical changes in activity, self-confidence, sociability or appetite behavior. If required, age of onset may be specified as early (in late teens or the twenties) or late.
Diagnostic Guidelines
The essential feature is a persistent instability of mood involving numerous periods of mild depression and mild elation, none of which have been sufficiently severe or prolonged to fulfil the criteria for Bipolar Affective Disorder or Recurrent Depressive Disorder. This implies that individual episodes of mood swings do not fulfil the criteria for any of the categories described under Manic Episode or Depressive Episode.
Includes:
affective personality disorder
cycloid personality
cyclothymic personality
Differential Diagnosis
This disorder is common in relatives of patients with Bipolar Affective Disorder and some individuals with Cyclothymia eventually develop bipolar affective disorder themselves. It may persist throughout adult life, cease temporarily or permanently, or develop into more severe mood swings meeting the criteria for bipolar affective disorder or recurrent depressive disorder.
MDI has so many different presentations that a high rate of missed diagnosis and wrong diagnosis is not surprising. Several factors account for the high rate of misdiagnosis in MDI. These include:
Hypomania is difficult to diagnose clinically.
Patients are not reliable historians regarding manic/hypomanic symptoms.
Short-term follow-up precludes observation of manic/hypomanic phases.
Strict criteria make the diagnosis of hypomania difficult.
Clinicians’ bias towards diagnosing depression and anxiety disorders.
The stigma associated with MDI.
The routine use of research criteria has deprived a majority of people with MDI of proper diagnosis and treatment. For example, a survey conducted by the National Alliance for the Mentally Ill (NAMI) in 1992 reports that 48% of the patients with BPD received a correct diagnosis only after being evaluated by more than 3 psychiatrists over 5-10 years after symptoms’ onset. (Lish)
A new survey repeated recently using the same methodology in 2000 revealed that the average delay between symptoms’ onset and treatment is still more than 10 years, 69% were misdiagnosed, mostly (3/4) by psychiatrists, and the average number of doctors seen was 4.4.
As BPD is a subset of MDI, current statistics represent only the tip of the iceberg of the effects of MDI in the general population.
The age at onset of symptoms, the clinical presentation and the presence of comorbid conditions lead to different types of diagnostic errors.
Some diagnostic errors occur in patients of any age depending on the clinical presentation. Common misdiagnoses are:
Schizophrenia when psychotic symptoms are present.
Depression and Dysthymia when depressive symptoms dominate the clinical picture.
Anxiety Disorders when panic, obsessive-compulsive, social phobias or generalized anxiety symptoms are prominent.
Alcohol or Substance abuse when self-medicating behavior is most evident.
Borderline, Narcissistic or Dependent Personality Disorder when symptoms affect mostly interpersonal relationships.
Gambling, Shoplifting and other Impulse-dyscontrol symptoms are common in a subgroup of patients with MDI.
Other diagnostic errors are somewhat more age specific:
• Attention Deficit Disorder, Oppositional Defiant Disorder, Conduct Disorder and Separation Anxiety in children and young adolescents.
These children are over-represented in most psychiatric clinics and often receive antidepressants and stimulants without protection from the possible precipitation of manic or mixed states.
• Substance Abuse, Antisocial Personality Disorder, Borderline Personality Disorder, Eating Disorders, Intermittent Explosive Disorders in older adolescents and young adults.
Many adolescents fail school, have chaotic social, work and family life, often incur in serious debt or are the victim of impulsiveness. Many commit criminal acts either to support their substance abuse or to pay debt or due to poor judgement and impulsiveness.
C.F. Flemming first used Dysthymia (from the Greek abnormal mood) in psychiatry in 1844. In 1882 K.L Kahlbaum used the term Dysthymia to describe a predominantly depressive temperament that with Cyclothymia and Hyperthymia, belonged to subthreshold manifestation of Manic-Depressive Psychosis.
E. Kraepelin, in his conceptualization of Manic-Depressive Insanity preferred the term depressive temperament, a “…permanent gloomy emotional stress in all the experience of life.”
More recently, introduced in the DSM III (1980) as a diagnostic category for mild to moderate forms of chronic depression. Dysthymic Disorder has substituted previous categories such as Neurotic Depression and Depressive Personality Disorder. Criteria for Dysthymia can be viewed here (Link).
When a depressive syndrome is superimposed on a dysthymic disorder the term ‘Double Depression’ is used. The return to a dysthymic baseline after recovery from an episode of full-blown Depression is often referred to as ‘partial remission’.
Dysthymia affects about 3% of the population, runs in families and has an early age of onset. In spite of its mild symptoms, Dysthymia causes significant disability. It is a risk factor for the development of Depression and responds to antidepressant treatment. Its relationship with MDI remains unclear. A study by Klein and colleagues showed an increased frequency of antidepressant-induced Hypomania among patients treated for Double Depression.
It has been hypothesized that a dysthymic temperament occurs frequently among patients who suffer from Mania, and might lead to the development of mixed manic or dysphoric states.
Substance abuse:
Cocaine
Amphetamine
Hallucinogens
Caffeine
Over-the-counter diet pills (i.e. phenylpropanolamine)
Drug withdrawal states:
Alcohol
Antidepressants
Medications:
Steroids
Ritalin
Disulfiram (Antabuse)
Isoniazid
Sympathomimetic agents
Dopaminergic agents: L dopa, Bromocriptine
Infections:
Encephalitis
Neurosyphylis
AIDS
Endocrine:
Hyperthyroidism
Addison’s Disease
Cushing’s Disease
Other neurological diseases:
Complex partial seizure
Strokes, especially right frontal
Lupus cerebritis
Multiple sclerosis
Head injury
Tumors/Metastases
Huntington’s Disease
Psychiatric Disorders
Adjustment disorders
Alcohol/substance abuse/dependence
Anxiety disorders
Eating disorders
Major Depression, Dysthymia
Schizophrenia and Schizophreniform disorders
Somatoform disorders
Neurologic disorders
Extrapyramidal diseases (e.g., Parkinson's, Huntington's, Progressive Supranuclear Palsy)
Dementia (Alzheimer's, Pick’s, vascular)
Cerebral neoplasms
Cerebral trauma
Cerebrovascular disease
CNS infections (e.g., neurosyphilis, viral encephalitis, AIDS)
Seizure Disorders
Hydrocephalus
Migraine
Multiple sclerosis
Narcolepsy
Sleep Apnea
Wilson's disease
Endocrine disorders
Adrenal diseases (Cushing's, Addison's, Hyperaldosteronism)
Hypo- or hyperparathyroidism
Hypo- or hyperthyroidism
Premenstrual Dysphoric Disorder
Post-partum disorders
Inflammatory disorders
Rheumatoid arthritis
Sj�gren's syndrome
Systemic lupus erythematosus (SLE)
Temporal arteritis
Infections
AIDS
Hepatitis
Tuberculosis
Mononucleosis
Vitamin deficiencies
Folate
Niacin
Thiamine
Vitamin B12
Vitamin C
Other disorders
Cancer
Cardiopulmonary disease
Klinefelter's syndrome
Porphyria
Postoperative mood disorders
Renal insufficiency and uremia
Medications
-Cardiac and Antihypertensive drugs
Bethanidine
Clonidine
Digitalis
Guanethidine
Hydralazine
Lidocaine
Methoserpidine
Methyldopa
Oxprenolol
Prazosin
Procainamide
Propranolol
Reserpine
Veratrum
-Sedatives and hypnotics
Atypical Antipsychotics
Barbiturates
Benzodiazepines
Butyrophenones
Chloral hydrate
Ethanol
Phenothiazines
-Steroids and other hormones
Corticosteroids
Danazol
Oral contraceptives
-Stimulants and appetite suppressants
Amphetamines
Diethylpropion
Fenfluramine
Phenmetrazine
-Neurological agents
Amantadine
Baclofen
Bromocriptine
Carbamazepine
Levodopa
Methsuximide
Phenytoin
Tetrabenazine
-Analgesics and anti-inflammatory drugs
Benzydamine
Fenoprofen
Ibuprofen
Indomethacin
Opiates
Phenacetin
Phenylbutazone
Pentazocine
-Antibacterial, antiviral, and antifungal drugs
Ampicillin
Clotrimazole
Cycloserine
Dapsone
Ethionamide
Griseofulvin
Interferon
Metronidazole
Nalidixic acid
Sulfonamides
Streptomycin
Tetracycline
Trimethoprim
Zidovudine
-Antineoplastics
L-Asparaginase
Azidouridine
Bleomycin
Plicamycin
Vincristine
-Miscellaneous drugs
Acetazolamide
Anticholinesterases
Choline
Cimetidine
Cyproheptadine
Diphenoxylate
Disulfiram
Isotretinoin
Lysergide
Mebeverine
Meclizine
Methysergide
Metoclopramide
Salbutamol
The first symptoms of this illness are often recognized in childhood or adolescence but more classic presentations of MDI are most common in early adulthood. It is rare to observe the onset of MDI in late life unless earlier episodes went undiagnosed or a medical condition contributes to its onset. (McDonald)
In a study of age at onset in 211 patients with DSM IV Bipolar Disorder (BD), Bellivier et al. reported a distribution of cases consistent with different ages of onset. In this study, age of onset was defined as the age when DSM IV criteria were first met for either depression or mania. In 41.4% of the population studied, this occurred at 16.9 years.
In a survey of 500 adults diagnosed with Bipolar Disorder, the age of onset of mood symptoms was traced to age 19 or less by 59% of responders (17% before 10 years of age and 14% before 14 years). Those with early onset had (statistically significant) higher rates of family history of BD, greater rates of High School dropout and financial difficulties, divorce and marital difficulties, more alcohol and substance abuse, more injuries to self and to others, and more recurrences.
It is estimated that 60% of the children with manic/hypomanic symptoms only meet criteria for Bipolar Disorder NOS, as they do not satisfy the episode duration requirement. (Geller)
Pediatric precursors of MDI are not always symptoms or manifestations of adult MDI. Depressive symptoms including tearfulness, self-loathing, lack of interest and social withdrawal are often combined with prominent anxiety symptoms with a characteristic tendency to wax and wane, confusing parents and clinicians alike. The variability of clinical presentation and the intermittent course of illness often lead parents and clinicians to disregard or minimize the significance of the symptoms. Often, multiple diagnoses are given as Symptoms change over time or due to the emphasis given by different clinicians to different symptoms. Only the prolonged follow-up of these cases confirms the common cause of these manifestations, especially when more classic symptoms of MDI begin to appear.
Childhood onset is often subtle with temper tantrum and other mood symptoms combined often with intense separation anxiety or phobic, panic and OCD symptoms. Depressive symptoms in a prepubertal child should always be regarded with suspect, as a high percentage of prepubertal children with depressive episodes will experience Mania or Hypomania in the course of their illness, either spontaneously or following treatment with antidepressants.
In childhood MDI, the episodes are short and very frequent. The variability of the behavioral manifestations can lead to misdiagnosis and inadequate or inappropriate treatment.
Adolescent forms of MDI are common, possibly due to:
Expression of genetic vulnerability increases with age;
Destabilizing effect of hormonal changes at puberty;
Increased use of alcohol and other drugs.
Adolescent-onset MDI might be more similar to adult-onset than forms with prepubertal onset. The high rate of comorbid diagnoses and low compliance with treatment are complicating factors in diagnosing and treating MDI in adolescence.
Late-onset MDI remains fairly uncommon and the presence of medical or neurological conditions is often a contributing factor, if not a cause for manic syndromes in the elderly. In many cases, however, the onset of MDI dates back many years. Earlier episodes might have gone undiagnosed and untreated, and give the impression that the illness has onset late in life.
“Temperament …refers to an individual’s emotional nature, including his susceptibility to emotional stimulation, his customary strength and speed of response, the quality of his prevailing mood, and all peculiarities of fluctuation and intensity in mood, these phenomena being regarded as dependent upon constitutional make-up, and therefore largely hereditary in nature.”
-GW Allport
“It may be said, simply, that severe emotional upsets ordinarily tend to subside, but that mild emotional states, when often provoked or long maintained, tend to persist, as it were, autonomously…a dramatic attack of mania or melancholia…may have far less effect on the course of a man’s life than some deceptively mild affective illness which goes on so long that it becomes inveterate.”
-AJ Lewis
Temperament describes the baseline setting of mood and energy of an individual. Temperament is probably inherited and precedes personality development, determining, according to Allport, “the ‘internal weather’ in which personality evolves.”
Kraepelin described temperaments as ‘rudiments’ of MDI and distinguished a dysthymic (depressive), a hyperthymic (manic), a cyclothymic, and an irritable temperament. (Akiskal)
One of the most consistent findings in people suffering from MDI is a history of MDI, mood disorders and/or substance abuse in blood relatives.
A first-degree relative (parent, sibling or child) of a patient with Mania has a risk of suffering from Mania 8-18 times greater than a normal control (someone without a family history of Mania).
If one parent has Mania, the risk for the offspring is 25%. This means that 1/4 of children are likely to be ill. If both parents have a history of Mania, the risk for the offspring raises to 50-75% (2-3/4 of children are likely to be ill).
A study by Cytryn of 30 children (6-15 years old) of 14 families where one parent had a history of Mania or recurrent Depression found that 57% suffered from Depression, a common initial presentation of MDI (onset). This is also seen among children of patients with Mania that have been raised in adoptive families.
Twin, adoption and family studies have provided evidence that vulnerability to this illness is transmitted genetically.
Twin studies compare the rate of MDI in identical twins, which share the same genes, with that of fraternal twins, who are siblings of the same age. The concordance rate is the presence of MDI in the twin of a patient with MDI or the absence of illness in the twin of a healthy person. For identical twins (monozygotic, MZ) the concordance rate is 67% (33-90%), while for fraternal twins (dizygotic, DZ) is 20% (5-25%).
MDI can occur with other psychiatric or medical illnesses. The co-occurrence of two or more diseases is called Comorbidity. The most common diagnoses associated with MDI are other psychiatric conditions including Substance Abuse/Dependence (40%) and Anxiety Disorders (40%). -Brady
Approximately 20% of patients diagnosed with BPD suffer from Obsessive Compulsive Disorder, another 20% from Panic Disorder.
-McElroy
In children Attention, Conduct, Oppositional-defiant and Anxiety Disorders are common. In adolescents, substance abuse, Conduct and Anxiety Disorders are most prevalent. Eating Disorders are also quite common. -Johnson
The occurrence of a medical or psychiatric condition together with MDI can complicate treatment (i.e., OCD requiring antidepressant treatment or Multiple Sclerosis requiring treatment with steroids).
“We must regard all alleged injuries as possible sparks for the discharge of individual attacks, but…the real cause of the malady must be sought in permanent internal changes, which at least very often, perhaps always, are innate.
…The attacks of manic-depressive insanity may be to an astonishing degree independent of external influences.”
-Kraepelin
Often environmental factors play a role in the onset of an episode of MDI. This is commonly found early in the course of MDI, less often after the illness has followed his course for many years.
Losses, like deaths, romantic break-ups or disappointments, or career changes can be linked to an episode. For example, powerful environmental factors include the changes of season, the effect of drugs or medications, as well as the amount of stimulation or stress. Stimulants and all the conditions affecting sleep (shift work, jet lag) or traumatic events have a destabilizing effect on the fragile balance of a patient with MDI.
Sleep deprivation has been hypothesized as a common pathway to decompensation in Mania, but episodes of Depression, Mixed States or a psychotic episode can also be precipitated. The term Funeral Mania was coined to describe the onset of a manic episode following the death of a loved one.
When the illness has established a pattern of recurrence the role of life events in recurrences is not clear. Research seems to suggest that the role of a precipitant in later episodes is not as firmly established as for initial or earlier episodes. (McPherson)
The effect of hormones on mood has been well known since antiquity. Menarche or the onset of menstrual cycles can be a dramatic change in the overall chemical and hormonal balance.
The period post-partum, with the combined effect of powerful emotions and sudden hormonal changes, is a powerful precipitant for women predisposed to mood swings. (Krucksman)
Temperament and/or family history of MDI can sometimes help identify women at risk for the onset of a mood disorder, especially MDI.
Menopause, once again exposing a vulnerable disposition may result in the precipitation of mixed or agitated Depression
A medical illness, like Multiple Sclerosis or the pharmacological treatments for an independent medical condition (steroids for asthma), can be sufficient to precipitate an episode. Sometimes, it is another psychiatric condition that requires treatment with antidepressants (OCD, Panic Disorder) and this can precipitate an episode.
Substance abuse can have a powerful destabilizing factor for someone with a predisposition to MDI. This is especially true for stimulants such as cocaine and amphetamines. The onset of psychotic episodes of MDI associated with the use of hallucinogens like LSD and PCP has been well documented.
“The modes of mania are infinite in species, but one alone in genus…”
-Aretaeus
Several attempts were made at defining subtypes of MDI based on severity of symptoms, recurrence rate and phases of illness. For example, the most common forms have the following features:
Mania alternating with severe to mild depression (MD or Md), also called Bipolar I.
Depression alternating with mild Mania or Hypomania (Dm) also called Bipolar II.
Hypomania alternating with mild Depression or Cyclothymia.
Recurrent Depression with antidepressant-induced Hypomania is often referred to as Bipolar III.
Recurrent Depression with Hyperthymia, or a family history of Mood disorders is sometimes called Bipolar IV
For a review of different subtypes of MDI see an excellent review by Akiskal.
Traditionally Mania has been considered the defining feature of MDI. It must be clearly understood that the majority of forms of MDI do not present with Mania but rather with Hypomania and other excitatory symptoms rarely severe enough to be clinically prominent. Even depressive phases might be the result of excitatory phenomena, as postulated in 1861 by Griesinger:
“By using the expression ‘psychic depressive states’ we did not mean to imply that the basic nature of these states is inactivity and weakness ... We have much more reason to assume that very intense states of irritation of the brain and excitation of the psychic processes are very often the cause of such states. But the end result…as far as mood is concerned is a state of depression
MDI is an illness where episodes and intervals alternate in cycles, sometimes with a regular pattern.
The cycle of MDI is made of episodes and intervals and they cannot be separated and studied apart, as they constitute the basic unity of this illness. The longitudinal (long-term) observation of MDI in each person can reveal patterns of recurrence, clarify the relationship of episodes to psychosocial or pharmacological or environmental stressors and guide short- and long-term treatment.
Manic/hypomanic and Depressive episodes are present in a majority of patients, but in a minority of cases only manic symptoms are present (Unipolar Mania).
Recurrent episodes of depression with mild hypomanic periods can be easily misdiagnosed as Recurrent (Unipolar) Depression.
An interval is defined as a period of four weeks or longer without symptoms. In some cases the intervals only last days or hours so that the illness seems to run a continuous and uninterrupted course.
We distinguish between a Continuous Cycling and an Intermittent Course based on the absence or presence of intervals.
In Continuous Cycling there are no intervals between episodes. The episodes can follow a long-cycles course or a rapid-cycles course. In the intermittent forms there are symptom-free intervals and the sequence of intervals and episodes can be evaluated. The distinction between Mania-Depression-Interval (M-D-I) and Depression-Mania-Interval (D-M-I) can be made in some cases.
Kukopoulos initially reported a positive response to lithium among those patients with Mania-Depression-Interval more often than in those with Depression-Mania-Interval. This finding has been replicated by several studies in independent groups of patients.
Regular Irregular
Intermittent Continuous
M-D-I Long Cycles
D-M-I Rapid Cycles
Seasonal
Patterns of recurrence can sometimes be recognized: some patients suffer from seasonal recurrences of Mania and/or Depression (Faedda), others only experience episodes every few years or in response to specific precipitants (i.e. post-partum).
Some patients have four or more episodes in the course of a year, a course of illness defined as Rapid-Cycling by Dunner and Fieve.
When the number of episodes per year is more than four but less than 365, the course is described as Ultra-Rapid Cycling. If the number of episodes per year is equal or greater than 365, the course is described as Ultradian Cycling. These are commonly observed in children and adolescents (Geller) or among some adult patients treated with antidepressants (Altshuler).
MDI causes disability during symptomatic and during symptom-free periods. In the past it was assumed that once the symptoms were controlled, the person would return to a premorbid or baseline level of functioning without much delay. Longitudinal studies of interepisodic functioning among patients with MDI revealed a very different reality.
In order to clarify the effect of MDI on various aspects of life, a distinction has been made between symptomatic versus functional recovery.
One of the best studies focused on patients recovering from Mania (Tsuang). One hundred patients were evaluated 35 years after they were hospitalized. Marital, occupational, residential and symptomatic (psychiatric) status were evaluated and combined. In 64%, the outcome was good, fair in 14%, and poor in 22%. When compared to two control groups, MDI patients did better than schizophrenic patients but not as well as a group admitted for minor surgical procedures.
The tendency of mixed episodes and depressive episodes to last longer and to recover slowly has been well documented, especially among those who cycle continuously. (Keller)
Chronicity or the tendency of the illness to remain symptomatic for periods of 2 years or more without remission has been evaluated in several studies and appears to occur in about 20% of the patients.
Kraepelin wrote: “…when the disease has lasted for some time, and the attacks have been frequently repeated, the psychic changes usually become more distinct during the intervals also.”
This is confirmed by more recent studies of outcome, such as a study by Dion. Manic patients at a six month follow-up had reached symptomatic recovery in 80% of cases, but only 43% were employed, and only 21% working at their perceived level of employment. Tohen and colleagues have studied the outcome of patients admitted with a psychotic first episode of MDI and found the functional recovery to lag behind symptomatic recovery.
Family life is very commonly affected, leading to conflict with parents and siblings during childhood and adolescence with spouses (or partners) and children in adulthood.
Tumultuous romantic lives -- extreme and sudden passions, multiple divorces or affairs testify to the emotional instability of many people with MDI.
In children we often observe frequent changes of school, school failures or dropouts, as the emotional instability can interfere with adequate or consistent functioning in school. Among adults, the work history is chaotic with frequent moves from job to job due to the person quitting or being fired.
Instability is also clear in the handling of finances: debt, impulsive spending, gambling and sometimes bankruptcy is common in the history of patients with MDI.
Interpersonal relationships suffer a great deal being affected by the recurrent episodes of illness. Friendships and family ties can often end due to an episode of MDI. The periods of Depression with social isolation and withdrawal can strain some relationships, but is usually the irritability and aggressiveness of Mania/Hypomania that creates the greatest difficulties. The overall effect is the loss of social support, the accumulation of losses and the social isolation that results from it.
When this chaotic pattern is life long, the changes are usually attributed to circumstances or external events by the patient and often also by family and friends. This contributes to the common belief that the problems are not due to a disease but to bad luck or a ‘personality disorder’. Sometimes, one can appreciate the devastating effect of MDI only after a person is diagnosed with this illness.
The best estimate to date of the cost to society of Bipolar Disorder comes from a study published by Wyatt and colleagues in 1995.
Of the total estimated cost of $45 billion in 1991, only $7 billion were direct costs. Almost $38 billion was the indirect cost of this illness due to the loss of productivity, suicide and caregivers’ loss of productivity. These figures are estimates based on a prevalence rate for BPD of 1.3%.
More recent data (Simon) on utilization of specialty mental health or substance abuse services by patients with BPD, Unipolar Depression, Diabetes and general medical outpatients in a health maintenance organization (HMO) revealed that BPD is the most expensive illness among outpatients.
It is estimated that almost 20% of untreated patients with MDI commit suicide and 20-50% attempt suicide at least once.
For an excellent overview on Suicide see Tondo et al., and the WHO Resources for Teachers on Suicide
The risk of suicide is highest among patients suffering from Depression with Hypomania (BP-II), followed by Mania with Depression (BP-I) and Unipolar Depression.
Mixed States, Chronic or Rapid-Cycling forms seem to increase the risk of suicidal behavior. Forms of agitated depression and Mixed Depressive Syndromes can lead to suicidal gestures, especially when active alcohol or substance abuse increases impulsiveness and impairs judgment.
The stabilization of a patient with MDI is a long and delicate process that requires close collaboration between the patient and his/her physician, therapist or possibly, the treatment team.
Factors affecting the treatments’ outcome include patients’:
- illness type and course;
- environment (external factors);
- psychological make-up (internal factors);
- response to specific treatments or interventions.
The goal of any intervention is to decrease the instability of the system regulating mood, activity and cognition. The balance of forces affecting this system can be destroyed by a number of events. Like the process of decreasing the swings of a pendulum, it is important to always make small and gentle changes rather than abruptly disturbing the system. Every intervention aimed at decreasing manic symptoms can produce a worsening of depressive symptoms and every antidepressant treatment can worsen manic symptoms. It is also important to keep in mind that MDI is an illness in constant change and that it can respond differently to the same event or treatment at different times.
Several steps are necessary to begin successful treatment of MDI:
- Observation
- Correlation
- Stabilization
- Adaptation
The first step is to recognize the presence of changes of mood, energy and thought, both spontaneous and in response to a precipitant.
The second step is to study the effect of factors like sleep, exercise and diet, on the illness.
The third step is to stabilize mood symptoms by use of appropriate treatment.
The fourth and final step is to adjust to a new level of emotional stability and undo the effects of MDI on self-esteem, as well as family, social and occupational life.
The process is similar to the repair of a car. Let’s imagine that a car is working on three cylinders only and this primary problem has caused, over time, a series of secondary problems.
- The first step involves a survey of the car and how it functions or malfunctions as it is.
- The second step requires careful understanding of the effects of the different variables on the functioning of the car.
- The third step requires fixing the broken cylinder.
- The fourth and final step is the fine-tuning of the engine and of all the minor malfunctions caused by the broken cylinder.
Step 1-OBSERVATION
Observing behavior and mood changes is not easy. Most of the time, rather than observe and describe mood and behavior, we label and judge what we observe. It is also quite difficult to observe one’s own behavior and remain objective.
Events and reactions to events occur constantly, and it is unusual for someone to remember carefully how one behaved or felt just a few days before. Also, patterns of behavior or mood change can be quite difficult to identify if one is not able to observe these changes over extended periods of time.
For all these reasons, it is very useful to keep notes and organize them chronologically. This process is called keeping a mood chart.
Charting changes of mood, physical and mental activity is extremely useful in order to have a clear idea of the severity of the problem. Only careful observation over time can provide evidence that changes of mood or energy are causing problems to the individual. Over time, it becomes clear what areas of one’s life is affected (family, work, finances etc). (Life chart)
If this process is conducted with an experienced clinician, patterns of recurrence of symptoms can be identified. The process of observation can also provide clear targets for treatment interventions by clearly defining baseline functioning and symptoms.
Several areas require monitoring and multiple daily entries are often needed. For instance, one might rate sleep in the morning, while the memory of the last night’s sleep is still fresh in the mind. By lunchtime, one can rate mood, activity and thinking for the morning, and before going to bed take notes on the afternoon and evening hours.
The areas that require observation can roughly be grouped in Mood, Activity and Thinking.
Mood states can change rapidly, spontaneously or in response to an event. The change can be sudden or gradual and the new mood state can last for minutes, hours or days. One should always try to identify the precipitant to a mood change, both external (an event) or internal (a memory or an association).
Activity levels can be observed more easily, as one can better rate productivity, physical energy and endurance, or lack thereof.
Thinking needs to be rated in quantity (many vs. few thoughts), quality (racing vs. sluggish, sharp vs. confused) and focus (good vs. poor concentration, distractibility vs. attention). The quality of our mood affects the content of our thoughts: many thoughts would translate in multiple worries during depression or in many projects and ideas during euphoric hypomania or mania.
Step 2-CORRELATION
By observing the effect of several variables on the intensity of symptoms, the individual might begin to recognize that sleep deprivation increases irritability or anxiety or that exercise improves mood and sleep. For many people, the effect of caffeine becomes apparent only when caffeine intake and sleep duration or quality are correlated. Mood changes in relation to changes of sleep pattern or changes of season might come as a surprise and also result in lifestyle changes with beneficial effects. The effect of alcohol and other drugs on mood swings can become apparent over time and might provide the motivation for sobriety.
Step 3-STABILIZATION
Remission of symptoms can be a temporary change in the course of the illness, brought about by treatment or occurring spontaneously. Remission does not mean that the illness is cured, as it can become active again. However, obtaining remission of MDI allows the patient to live a relatively normal life and is the goal of most treatments used.
As MDI manifests with different and sometimes opposite clinical presentations, it is important to distinguish between antimanic, antidepressant and mood-stabilizing treatments. Treatment modalities can be broadly classified as pharmacological and non-pharmacological.
Pharmacological treatments include:
Lithium Salts
Anticonvulsants
Antidepressants
Antipsychotics
Miscellaneous
Non-pharmacological treatments include:
Psychotherapy
Lifestyle
Light treatment
ECT
r-TMS
Lithium salts were first reported to be effective in the treatment of Mania by Cade in 1949. Lithium is effective both as an antimanic and as a mood-stabilizing agent.
The use of Lithium as an antimanic agent often requires doses higher than those required for maintenance treatment. Cade's rapid titration has been recently found to be effective in controlling manic symptoms among inpatients with Mania.
The efficacy Lithium as a maintenance treatment in all forms of MDI has been demonstrated by reduced rates of hospitalization, decrease in frequency and severity of symptoms, improved psychosocial functioning, decreased rate of suicide, and worsening of course of illness after treatment discontinuation.
Anticonvulsants, like Carbamazepine and Valproic Acid and Valproate have been studied and used as antimanic and mood stabilizing agents since the late '70's and early '80's. More recently other anticonvulsants have been used in combination with other treatments for MDI.
Valproic Acid and Sodium Divalproex have been studied as maintenance treatment for patients with Bipolar disorder, and found to be more effective than Lithium in mixed manic states and in some rapid cycling forms of MDI.
The Pharmacological Treatment of Pediatric BD
Controlling the intensity, the duration and the frequency of episodes of MDI usually requires the use of medications. However, psychotherapy can help the patient with MDI learn how to manage their illness.
Several areas of treatment are included in the broad category of psychotherapy:
• Development of insight and self-monitoring of behavior and mood are the most important task of psychotherapy.
• Education about the illness and its treatment is often necessary to create the conditions for treatment compliance and lifestyle changes (sobriety, regular sleep schedule) to help mood stabilization.
• Support and assistance in managing stressful events and in addressing the consequences of MDI on one’s social, occupational, educational and financial life.
One of the most fascinating aspects of MDI is the patients’ lack of awareness of the illness. The medical term for this ‘deficit’ is anosognosia (from the Greek, lack of awareness of one’s illness).
The inability to recognize that changes of mood and behavior are due to an illness is an obstacle to seeking or continuing treatment.
This blind spot is often the cause of confusion and anger among relatives and friends, as it appears to be willful denial of the obvious. In a letter to a patient, a relative wrote:
“It’s all so predictable that it seems impossible you can’t see it. When you’re depressed you insist you’ll never feel better and when you’re manic you insist you’ll never feel depressed again. When you’re depressed, you insist you never had any real friends and when you’re manic you feel that everyone you know is a good friend. When you’re depressed you believe you’re utterly worthless and without redemption. And, when you’re manic you believe you’re God’s gift to mortals.
Why are you unwilling to accept the fact that it is your body, perhaps exacerbated by real events in your life, that throws you into highs and lows? When you’re in a manic phase you persistently condemn Lithium as something totally artificial and hypocritical, yet you eagerly smoke grass.
The reason I feel so utterly convinced that this is biochemical is because your patterns have been so predictable and you live your life swinging from high to low.”
A powerful tool in developing insight is observation and recording of mood and behavior over time. See Observation.