30 Bipolar Disorder

This vignette provides an example of a patient initially presenting with depression, and in a seeming clinical paradox, becoming manic after initiation of antidepressant therapy. This “switch” from depression may be the first indication that the patient has an underlying bipolar disorder. The presence of a strong family history of similar psychiatric illness is typical.

Typically mania has a unique presentation. The patient is often colorfully dressed and wearing too much jewelry, is excessively cheerful, overly familiar, brimming with schemes and ideas, and does not stop talking (Fig. 30-1). One of the surest sign of mania is the physician feeling the need to interrupt the patient. In the extreme, manic patients lose touch with reality; they may declare themselves an emperor, suddenly relocate to another state, or flirt dangerously with strangers. These patients often become irritable and sometimes aggressive. They may stop sleeping. In contrast to schizophrenic patients, who seem odd and distant, manic patients are often humorous, and frequently engaging.

Figure 30-1 Personality Disorders.

Almost all manic patients eventually have serious depressions. (In contrast to unipolar depression, unipolar mania is uncommon.) With time, episodes of bipolar illness become more frequent, more autonomous—less clearly tied to external stresses—and more difficult to treat. Patients are at high risk for repeated hospitalizations, suicide, and drug and alcohol abuse.

Clinical Presentation

Bipolar disease typically has its onset in the teens or twenties; however, on occasion a childhood onset may occur. The child who develops depression has a 50% chance of eventually becoming bipolar. There is no sexual predisposition.

Although classic clinical mania is hard to miss, it is an uncommon initial presentation. Early on bipolar disorder is often misdiagnosed. In most studies, the time from initial presentation to correct diagnosis is over 5 years. There are several reasons for this high rate of misdiagnosis:

1. Patients most often seek treatment when they are depressed. They may not yet have suffered a manic episode or, if they have, may not have recognized it as a problem.

2. Previous “high episodes” may have been either relatively mild or of “hypomanic” intensity, and not easily recognized as beyond the realm of normal behavior. A life history characterized by depressive episodes and mild or subsyndromal periods of elevated mood is known as Bipolar-2 Disorder. In fact, this variant may actually be the commonest variant of bipolar disorder. This form of bipolar disorder is thought to carry a high risk for development of substance abuse.

3. Although mania and depression seem to be polar opposites: happy/sad, accelerated/slowed, etc., the two states are more alike than different at a neurobiologic level. Patients often present with simultaneous features of mania (Fig. 30-2) and depression. In these atypical mood states, variously described as mixed states, dysphoric mania, or agitated depression, affected individuals present a confusing mix of symptoms. These patients are excited and restless but also sad or irritable, rapidly oscillating between elation and sadness. Most likely, such atypical states are actually more common than classic, euphoric mania.

Figure 30-2 Bipolar Disorder: Manic Episode.

A careful history is the essential diagnostic key in bipolar disorder as the very complex presentations may initially mask the primary psychiatric nature of this affliction. Patients’ reluctance to see or acknowledge their own mania mandates that the physician take the time to inquire for more details from observant, reliable family members, friends or colleagues, and prior health care professionals.

As bipolar disorder is the most genetically determined of all major psychiatric illnesses, many of these patients have at least one affected relative. Conversely, anyone with a first-degree bipolar relative has at least a 10% chance of developing bipolar disorder. When individuals with this background present with a complaint of depression or alcohol abuse, suspicion of bipolar disorder must be high.