Bipolar spectrum disorder: differential diagnosis and treatment

Bipolar disorder commonly presents as a recurrent mood disorder characterized by frequent depressive episodes. Although manic or hypomanic phases are required for the diagnosis to be made based on current diagnostic criteria, a wider expression of mood instability and other historical features or family history may suggest the presence of a bipolar spectrum illness. This article covers the diagnostic issues related to bipolar disorder and the spectrum concept of the illness. A new definition of bipolar spectrum disorder is suggested, and treatment principles and options are discussed. Primary care providers often encounter patients who have depression and mood problems, placing them in a key position for the diagnosis and treatment of this psychiatric illness.     

Distinct Roles of Emotion Reactivity and Regulation in Depressive and Manic Symptoms Among Euthymic Patients

Investigating differences in the ways that people react to mood-evoking stimuli and regulate subsequent emotions may help to elucidate important mechanisms underlying depressed or hypomanic mood states. Euthymic young adults with bipolar disorder (n = 23) or depression (n = 21) were recruited for a study of emotion and mood. Two mood inductions assessed for differences in mood reactivity. Participants completed measures of current symptoms and emotion regulation strategies. Maladaptive (B = 0.42, p = .021) and adaptive (B = ?0.26, p = .011) emotion regulation strategies were significantly associated with depressive symptoms. Bipolar diagnosis (B = 5.51, p = .035), and threat mood reactivity (B = ?0.26, p = .015) were associated with hypomanic symptoms. Interaction terms for mood reactivity and emotion regulation were not significant in either model, although net regression indicated significant differences in two trends. Depressed moods, associated with MDD or BD, may be initiated and maintained primarily due to poor choice of emotion regulation strategies. Elevated mood states are more specific to bipolar disorder, and may be triggered by mood reactivity, rather than regulation.     

Bipolar Disorders in Mentally Retarded Persons With Pervasive Developmental Disorders

To examine clinical features of mentally retarded patients with pervasive developmental disorders (PDD) with a comorbid bipolar disorder, 23 PDD patients (mean age = 23.5 years, SD = 4.2) with an episode satisfying modified DSM-IV criteria for manic/hypomanic episode (PDD-B), and 23 age, sex, diagnosis, and retardation matched control PDD patients without a mood episode (PDD-C) were compared on 26 variables (e.g., family history, development, autistic symptoms, epilepsy). Although many of the variables did not show a significant difference, autistic symptoms tended to be more severe in the PDD-B than PDD-C patients, and epilepsy tended to occur earlier in 14 PDD-C than 13 PDD-B patients. Twenty two of the 23 PDD-B patients had taken mood stabilizers clinically judged effective. Bipolar disorders are not rare and are diagnosable in mentally retarded PDD patients with modified DSM-IV criteria consisting of items observable by others, and their treatment by mood stabilizers seems worthy for further research.     

Diagnosing and managing psychosis in primary care

Psychosis is broadly defined as the presence of delusions and hallucinations. It can be organic or functional. The former is secondary to an underlying medical condition, such as delirium or dementia, the latter to a psychiatric disorder, such as schizophrenia or bipolar disorder. The identification and treatment of psychosis is vital as it is associated with a 10% lifetime risk of suicide and significant social exclusion. Psychosis can be recognised by taking a thorough history, examining the patient's mental state and obtaining a collateral history. The history usually enables a distinction to be made between bipolar disorder, schizophrenia and other causes. Early symptoms often include low mood, declining educational or occupational functioning, poor motivation, changes in sleep, perceptual changes, suspiciousness and mistrust. The patient's appearance, e.g. unkempt or inappropriately attired, may reflect their predominant mental state. There may be signs of agitation, hostility or distractibility. Speech may be disorganised and difficult to follow or there may be evidence of decreased speech. Mood may be depressed or elated or change rapidly. Patients may describe abnormal thoughts and enquiry into thoughts of suicide should be routine. Disturbances of thought such as insertion or withdrawal may be present along with perceptual abnormalities i.e. illusions, hallucinations. Insight varies during the course of a psychotic illness but should be explored as it has implications for management. All patients presenting with first episode psychosis for which no organic cause can be found should be referred to the local early intervention service. In patients with a known diagnosis consider referral if there is: poor response or nonadherence to treatment; intolerable side effects; comorbid substance misuse; risk to self or others.     

Stigma experiences in bipolar patients: the impact upon functioning

The aim of this study was to investigate the impact of self-rated stigma and functioning in patients with bipolar disorder in South Brazil. This is a cross-sectional study. Sixty participants with bipolar disorder were recruited from an outpatient Bipolar Disorder Program. Experiences with and impact of perceived stigma were evaluated using the Inventory of Stigmatizing Experiences. Functional impairment was assessed with the Functioning Assessment Short Test (FAST). Higher scores of self-perceived stigma were correlated with higher FAST scores, indicating more disability. After linear correlation analysis, current depressive symptoms, age at onset of treatment, age at diagnosis and functioning were correlated with self-perceived stigma. The study demonstrated a correlation between stigma and poor functioning in bipolar disorder. Perceived stigma is really important to individuals with bipolar disorder, both to how they experience their illness and to its results on functioning. Potential consequences of such results for mental health care professionals are discussed. Differential clinical features, sociocultural factors and the sample size limit the generalization of the present findings.     

软双相的早期诊断识别并文献复习

目的探讨有转躁倾向的抑郁症(软双相)患者的人口学、症状学特征及其他相关因素,以早期诊断识别双相障碍。 方法回顾性分析于2016年7月5日就诊于济宁市精神病防治院精神科,有转躁倾向并最终进展为双相情感障碍的1例抑郁症患者的临床资料,并复习相关文献。 结果患者入院时表现为心烦、少语、情绪低落、兴趣下降,但该患者起病年龄小,家族史阳性,抑郁发作时心境波动性较大,且精神病性症状突出,伴有强烈自杀观念,不排除软双相可能。患者入院3 d便出现明显躁狂症状,遂修改诊断为"双相情感障碍",并调整治疗方案后很快达临床痊愈。 结论对起病年龄小、家族史阳性、伴精神病性症状、自杀观念等特征的抑郁症患者应格外重视,警惕软双相可能,治疗上应以情感稳定剂为主,慎用抗抑郁剂。     

Possible reduction in posttraumatic stress disorder symptoms with oxcarbazepine in a patient with bipolar disorder

OBJECTIVE: To report the effect of oxcarbazepine in a patient with bipolar illness and posttraumatic stress disorder (PTSD). CASE SUMMARY: A 38-year-old white woman with PTSD and bipolar disorder who had partially responded to carbamazepine was treated with oxcarbazepine. Within a month of initiation of treatment with oxcarbazepine, she reported progressive improvement in her PTSD symptoms. As oxcarbazepine monotherapy with 750 mg twice daily continued, she reported significant reduction of her PTSD symptoms and stabilization of her mood. She tolerated oxcarbazepine without adverse effects. DISCUSSION: PTSD symptoms tend to wax and wane. Spontaneous remission also occurs in some patients with PTSD. There are a few reports indicating that carbamazepine alleviates PTSD symptoms. Since oxcarbazepine is an analog of carbamazepine, it is theorized that oxcarbazepine also has efficacy in significantly reducing PTSD symptoms. CONCLUSIONS: There are case reports and uncontrolled studies suggesting that antiepileptic drugs (AEDs) alleviate PTSD symptoms. Oxcarbazepine may also benefit patients with PTSD. However, controlled studies are needed to investigate the use of AEDs in patients with PTSD and bipolar disorder.     

Prevalence, clinical correlates, and treatment of migraine in bipolar disorder

OBJECTIVE: To investigate the prevalence, clinical correlates, and treatment of migraine in bipolar disorder. BACKGROUND: The relationship between migraine and mood disorders has been of long-standing interest to researchers and clinicians. Although a strong association has been demonstrated consistently for migraine and major depression, there has been less systematic research on the links between migraine and bipolar disorder. METHODS: A migraine questionnaire (based on International Headache Society criteria) was administered to 108 outpatients with bipolar disorder. Information on the clinical course of bipolar illness was also collected. RESULTS: The overall lifetime prevalence of migraine was 39.8% (43.8% among women and 31.4% among men). In the subgroup of patients with bipolar II disorder, the lifetime prevalence of migraine was 64.7%. The bipolar with migraine group was younger, tended to be more educated, was more likely to be employed or studying, and had fewer psychiatric hospitalizations. Their initial presentation for psychiatric treatment was more often for symptoms of depression, rather than hypomania or mania. They were more likely to have a family history of migraine and psychiatric disorders, and a greater number of affected relatives. They were less likely to use mood stabilizers, and more likely to use atypical antidepressants. Migraine was assessed by a neurologist in only 16% of affected patients. The prevalence of the use of specific antimigraine medications (triptans) was 27.9%. CONCLUSIONS: This study confirms the higher prevalence of migraine among those with bipolar disorder compared to the general population. Migraine in patients with bipolar disorder is underdiagnosed and undertreated. Bipolar disorder with migraine is associated with differences in the clinical course of bipolar disorder, and may represent a subtype of bipolar disorder.     

Pediatric Bipolar Disorder: Evidence-Based Psychopharmacological Treatments

TOPIC: Pediatric bipolar disorder can cause severe disturbances in global functioning. Diagnosing pediatric bipolar disorder is challenging due to the range of symptom expression, developmental differences as compared to adults, presence of comorbid disorders, and developing diagnostic criteria. Treating this disorder can be equally challenging due to frequent symptom relapse and the dearth of research until recently on effective psychopharmacological interventions that guide clinical prescribing practices. PURPOSE: This paper will help child psychiatric nurses have a better understanding of the unique presentation of pediatric bipolar disorder to facilitate selection of appropriate medication treatment options, taking into account symptom presentation, presence of comorbid diagnosis, drug efficacy, adverse effects, and drug-drug interactions based on research findings. SOURCES: Literature specific to assessment and psychopharmacological treatment of pediatric bipolar disorder was reviewed. CONCLUSIONS: Screening of youth with mood spectrum problems for bipolar disorder should occur in every diagnostic assessment and should be ongoing due to range of mood symptoms and the cyclical and episodic nature of this disorder. Youth with bipolar disorder may manifest symptoms and course that differ from adults. Additionally, co-occuring disorders are common in this population, which can complicate medication selection. Psychopharmacological treatment with the use of specific mood stabilizers and/or atypical antipsychotic medications is warranted depending on symptom presentation; however, monotherapy with mood stabilizers has not demonstrated effectiveness in long-term remission of pediatric bipolar symptoms. Recent research indicates that a combined treatment with two mood stabilizers or a mood stabilizer and an antipsychotic holds promising results for pediatric bipolar I, for youth with acute manic symptoms plus psychosis, and for long-term remission of symptoms.     

Identifying patients at risk of perinatal mood disorders

Perinatal mental illness influences obstetric outcomes, mother-baby interactions and longer term emotional and cognitive development of the child. Psychiatric disorders have consistently been found to be one of the leading causes of maternal deaths, often through suicide. Postnatal depression and puerperal psychosis are two disorders most commonly associated with the perinatal period. The most efficient strategy to identify patients at risk relies on focussing on clinically vulnerable subgroups: enquiries about depressive symptoms should be made at the usual screening visits. Attention should be paid to any sign of poor self-care, avoidance of eye contact, overactivity or underactivity, or abnormalities in the rate of speech. Particular care should be taken to ask about suicidal ideation and thoughts of harming others, including the baby. One of the most important risk factors is a previous history of depression. The degree of risk is directly correlated with severity of past episodes. Both antenatal and postnatal depression are being increasingly recognised in men. Puerperal psychosis is rare (1 to 2 per 1,000). Sixty per cent of women with puerperal psychosis already have a diagnosis of bipolar disorder or schizoaffective disorder. Women with a personal history of postpartum psychosis or bipolar affective disorder should be considered as high risk for postpartum psychosis. All pregnant women who are identified as being at high risk should have a shared care plan for their late pregnancy and early postnatal psychiatric management. Women with current mood disorder of mild or moderate severity who have a first-degree relative with a history of bipolar disorder or postpartum psychosis should be referred for psychiatric assessment.     

The relationship between bipolar disorder and type 2 diabetes: More than just co-morbid disorders

Abstract

Type 2 diabetes mellitus (T2DM) rates are three times higher in patients with bipolar disorder (BD), compared to the general population. This is a major contributing factor to the elevated risk of cardiovascular mortality, the leading cause of death in bipolar patients. There may be shared pathophysiology linking the two disorders, including hypothalamic-pituitary-adrenal and mitochondrial dysfunction, common genetic links, and epigenetic interactions. Life-style, phenomenology of bipolar symptoms, and adverse effects of pharmacotherapy may be contributing factors. Patients with BD and T2DM have a more severe course of illness and are more refractory to treatment. Control of their diabetes is poorer when compared to diabetics without BD, and an existing disparity in medical care may be partly responsible.

Glucose abnormalities in bipolar patients need to be screened for and treated. Metformin appears to have the best benefit/risk ratio, and the dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists and analogues also appear promising, although these agents have not been specifically studied in populations with mood disorders. Physicians need to be aware of the increased risk for T2DM and cardiovascular disease in bipolar patients, and appropriate prevention, screening, case finding, and treatment is recommended.     

The many faces of bipolar disorder. How to tell them apart

Bipolar disorder is a chronic disease characterized by depressive, manic or hypomanic, and mixed episodes. Bipolar disorder may be confused with unipolar depression, because patients with bipolar disorder are usually symptomatic with depression rather than mania. Bipolar disorder may also be misdiagnosed as schizophrenia, since both disorders can present with psychotic symptoms. For children, the principal differential diagnostic consideration is ADHD. Making the correct diagnosis has important prognostic and treatment implications. Comorbidities with personality disorders, substance and alcohol abuse or dependence, and anxiety disorders complicate assessment, treatment, and recovery. Effective pharmacotherapy and maintenance monitoring are critical in order to minimize the risk of relapse and associated disability, morbidity, and mortality.     

Bipolar disorder

Bipolar disorder (manic-depressive illness) is a common, recurrent, and severe psychiatric disorder that affects 1% to 3% of the US population. The illness is characterized by episodes of mania, depression, or mixed states (simultaneously occurring manic and depressive symptoms). Bipolar disorder frequently goes unrecognized and untreated for many years without clinical vigilance. New screening tools have been developed to assist physicians in making the diagnosis. Fortunately, several medications are now available to treat the acute mood episodes of bipolar disorder and to prevent further episodes with maintenance treatment.     

The Diagnosis and Management of Bipolar I and II Disorders: Clinical Practice Update

Bipolar disorders, including bipolar I disorder (BP-I) and bipolar II disorder (BP-II), are common, potentially disabling, and, in some cases, life-threatening conditions. Bipolar disorders are characterized by alternating episodes of mania or hypomania and depression, or mixtures of manic and depressive features. Bipolar disorders present many diagnostic and therapeutic challenges for busy clinicians. Adequate management of bipolar disorders requires pharmacotherapy and psychosocial interventions targeted to the specific phases of illness. Effective treatments are available for each illness phase, but mood episode relapses and incomplete responses to treatment are common, especially for the depressive phase. Mood symptoms, psychosocial functioning, and suicide risk must, therefore, be continually reevaluated, and, when necessary, the plan of care must be adjusted during long-term treatment. Many patients will require additional treatment of comorbid psychiatric and substance use disorders and management of a variety of commonly co-occurring chronic general medical conditions.     

The effects of an ambulatory collaborative practice model on process and outcome of care for bipolar disorder

Background: Bipolar disorder is a chronic mental illness that affects 1% of the population. Persons with bipolar disorder have substantial rehabilitative potential, although research has shown that such mood disorders are undertreated.Objectives: The objective was to determine the effect of a high-intensity collaborative practice ambulatory program on process and outcome of care: specifically, patient satisfaction, intensity of medication treatment, and the amount and patterns of service use.Study Design: The Bipolar Disorders Program was structured for easy patient access by assigning clinical nurse specialists as primary caregivers to each patient supported by psychiatrist backup. The first 76 patients enrolled in the Bipolar Disorders Program who completed 6 months served as the sample. A quasiexperimental study was used. A mirror image design was used where relevant measurements before admission to the Bipolar Disorders Program were compared with data during the first 6 months of enrollment.Results: Patients showed significant increases in satisfaction with care, increases in intensity of medication treatment, and trends toward decreases in neuroleptic exposure. Annualized service use data revealed significant decreases in emergency department use, psychiatric triage use, and psychiatric hospitalization days.Conclusions: These data indicated that high-intensity ambulatory treatment for bipolar disorder may have increased both treatment intensity and patient satisfaction and decreased use of costly mental health services.     

Behavioral Approach System (BAS)-Relevant Cognitive Styles in Individuals with High Versus Moderate BAS Sensitivity: A Behavioral High-Risk Design

This study used a behavioral high-risk design to evaluate cognitive styles relevant to the Behavioral Approach System (BAS) among individuals at high (n = 171) versus low (n = 119) risk of first onset of bipolar disorder based on BAS sensitivity, a known risk factor for bipolar disorder. Cognitive styles in high-BAS participants paralleled those implicated in bipolar disorder. Linear regressions indicated that individuals with high BAS sensitivity exhibited greater levels of goal striving, positive overgeneralization, rumination on positive affect, depressive brooding, perfectionism, and hypomanic personality. Furthermore, of the cognitive styles, emotion-focused rumination on positive affect mediated the association between BAS sensitivity and current levels of hypomanic symptoms. These results provide evidence that individuals at risk for the development of bipolar disorder have higher levels of BAS-relevant cognitive styles and hypomanic personality than do individuals with lower risk, indicating that these styles are not simply markers of prior (hypo)manic episodes.     

Insulin resistance takes center stage: a new paradigm in the progression of bipolar disorder

Abstract

Bipolar Disorder (BD) is a major psychiatric illness affecting up to 5% of the population. BD can progress over time to a chronic “neuroprogressive” course with cognitive and functional impairment. Currently, there are no validated predictors indicating which patients will develop a neuroprogressive course and there are no specific treatments.

This review presents data supporting a novel hypothesis on the mechanisms underlying bipolar neuroprogression. Insulin resistance (IR) is present in 52% of BD patients and is associated with chronic course, treatment nonresponse, adverse brain changes and cognitive impairment. Further, bipolar morbidity increases 12-fold following the onset of IR indicating that IR may modify disease progression. I review evidence that IR is a testable and treatable modifying factor in neuroprogression and that reversing IR may be an efficient (and perhaps the only) means of obtaining remission in some patients. I draw a parallel with Helicobacter pylori in peptic ulcer disease (a novel mechanism that brought together two previously unrelated phenomena that uncovered a new treatment approach).

This model of bipolar progression combines shared dysregulated mechanisms between IR and BD, allowing for early screening, case finding, and monitoring for neuroprogression, with the potential for intervention that could prevent advanced bipolar illness.

• KEY MESSAGES

• Neuroprogression in bipolar disorder is defined by a more severe form of illness and poor outcome. Currently, there are no validated predictors of neuroprogression, which could help inform treatment and improve prognosis.

• Insulin resistance is present in more than half of all bipolar patients and is associated with a chronic course of illness, lack of response to mood stabilizing treatment, cognitive impairment and poor functional outcomes.

• Insulin resistance may modify the course of bipolar disorder and promote neuroprogression. Insulin resistance may be a testable and potentially modifiable risk factor for neuroprogression in bipolar disorder.

     

Dysfunctional Attitudes,Attributional Styles,and Phase of Illness in Bipolar Disorder

Whereas an abundance of studies have been devoted to the study of cognitive vulnerability in unipolar depression, comparatively less is known regarding the cognitive styles of patients with bipolar disorder. This study examined the cognitive styles of 395 of the first 500 bipolar patients enrolled in the NIMH Systematic Treatment Enhancement Program for Bipolar Disorder as a function of mood state at study entry. Patients completed diagnostic and mood assessments and two measures of cognitive style: The Dysfunctional Attitudes Scale (DAS) and the Attributional Style Questionnaire (ASQ). Patients in mixed episodes exhibited significantly more negative dysfunctional attitudes and negative attributional styles than euthymic patients and significantly more dysfunctional attitudes than manic/hypomanic patients. The implications of these findings are discussed in relation to episode vulnerability, mood-state dependency of cognitive style, and cognitive-behavioral treatment.     

Delirium, depression, and anxiety

Patients who are critically ill often develop a variety of psychiatric symptoms, which require assessment and treatment. The most common psychiatric disorder in the intensive care unit is delirium. Depressed mood and anxiety also occur, at times as discrete disorders, but more often secondary to delirium. Patients with severe mental illnesses, such as schizophrenia and bipolar affective disorder, also may become critically ill--assessment and management of these patients often requires specialized psychiatric care and is not addressed here.     

A Novel Home Sleep Monitoring Device and Brief Sleep Intervention for Bipolar Disorder: Feasibility, Tolerability, and Preliminary Effectiveness

Sleep disturbance is common in bipolar disorder and negatively impacts its course of illness. The purpose of this study is to assess the feasibility and tolerability of a novel EKG-based home sleep monitoring device (M1) as well as a brief (two session) psychosocial sleep intervention for individuals with bipolar disorder. The sleep intervention is individually tailored for patients with insomnia or hypersomnia and extends skills designed for non-psychiatric populations as well as includes specific considerations for sleep disturbance in bipolar disorder. We found that both the M1 device and the sleep intervention were feasible and well tolerated. Participants’ sleep duration improved after the brief sleep intervention, but their sleep was more unstable as measured by the M1. Self-reported sleepiness, sleep quality, and mood symptoms improved; however, only some measures reached statistical significance (i.e., duration of sleep, dysfunction due to sleepiness). These data suggest that the M1 device is a feasible means to obtain objective sleep quality and quantity data in individuals with bipolar disorder. A brief sleep intervention may be helpful in improving sleep in a bipolar population at risk for substantial sleep disturbance, but larger, longitudinal studies are warranted.