Bipolar Disorder

Published on 03/03/2015 by admin

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Last modified 03/03/2015

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30 Bipolar Disorder

Kenneth Lakritz

Clinical Vignette

An 18-year-old woman, currently a first-year college student, was admitted to an inpatient psychiatric unit after a deliberate overdose with acetaminophen. She complained of sadness and anxiety “for as long as I can remember,” but in the preceding 3 months she had suffered from feeling of hopelessness, severe anhedonia, extreme fatigue, and hypersomnia. Her family history was positive for depression in three of five first-degree relatives and manic-depressive psychosis in her maternal grandmother.

Treatment with a selective serotonin reuptake inhibitor (SSRI) was initiated, and the patient participated in individual and group psychotherapy. After 1 week, she announced that her energy had returned and that her need for sleep had decreased dramatically. She told staff that she was “cured,” and developed a plan to move to Los Angeles with a fellow patient; they were both going to become movie stars. When she was prevented from leaving, she became agitated and threw chairs at the nursing staff, accusing them of a plot to keep her from succeeding. Despite this, she promised to buy everyone she knew a new car as soon as she left the hospital.

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:

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