Bipolar disorders history

O Patients presenting with depressive or elevated mood features and a history of abnormal or unusual mood swings should be assessed for bipolar disorder. 

The diagnosis of bipolar disorder is made based on clinical presentation, a careful diagnostic interview, and review of the history. There are no laboratory examinations, brain imaging studies, or other procedures that confirm the diagnosis. 

Bipolar disorder is a mood disorder characterized by one or more episodes of mania or hypomania, often with a history of one or more major depressive episodes.1 It is a chronic illness with a course characterized by relapses and improvements or remissions. Mood episodes can be manic, depressed, or mixed. They can be separated by long periods of stability or can cycle... 

A mood disorder questionnaire is completed by the patient that asks about common symptoms of bipolar disorder, problems caused by the symptoms, and family history in a yes-or-no answer format. It is then scored by the clinician. 

Patients with bipolar disorder have a high risk of suicide. Factors that increase that risk are early age at disease onset, high number of depressive episodes, comorbid alcohol abuse, personal history of antidepressant-induced mania, and family history of suicidal behavior.15 In those with bipolar disorder, 1 of 5 suicide attempts are lethal, in contrast to 1 of 10 to 1 of 20 in the general population. 

Schizophrenia and bipolar disorder often share certain symptoms, including psychosis in some patients. The prominence of mood symptoms and the history of mood episodes distinguish bipolar disorder and schizophrenia. In addition, the psychosis of schizophrenia occurs in the absence of prominent mood symptoms. 

There are, however, subgroups of young adults who may not mature out of drug problems as easily as others. Those who seem to have problems maturing out usually have other problems that preceded the onset of drug use. For instance, researchers have found that young adults who have a history of Conduct Disorder or who have other psychiatric disorders (such as schizophrenia, Bipolar Disorder, depression, Anxiety Disorder, or a major personality disorder) mature out of drug problems at much lower rates than those who do not have these additional problems. 

Terri courageously disclosed that she suffers from bipolar disorder, a mental illness which her physician attributes to MCS. It was not the first time I had heard of this theory. Terri had no history of mental illness prior to the onset of her chronic fatigue and MCS. 

The differential diagnosis of depression is organized along both symptomatic and causative lines. Symptomatically, major depression is differentiated from other disorders by its clinical presentation or its long-term history. This is, of course, the primary means of distinguishing psychiatric disorders in DSM-1V. The symptomatic differential of major depression includes other mood disorders such as dysthymic disorder and bipolar disorder, other disorders that frequently manifest depressed mood including schizoaffective disorder, schizophrenia, dementia, adjustment disorder, and post-traumatic stress disorder, and, finally, other nonpsychiatric conditions that resemble depression such as bereavement and medical illnesses like cancer or AIDS. 

The diagnosis can be clarified by collecting a retrospective history both from the patient and from a collateral source, such as a friend or family member. A history of bipolar disorder will include episodes of illness that typically arise spontaneously, last for days or weeks, and often result in a decreased need for sleep during times of hypomania or mania. The periods of affective lability in the patient with a Cluster B personality generally do not arise in this spontaneous fashion but are instead triggered by a stressful life event. In addition, they seldom last as long as the typical... 

The term "bipolar disorder" originally referred to manic-depressive illnesses characterized by both manic and depressive episodes. In recent years, the concept of bipolar disorder has been broadened to include subtypes with similar clinical courses, phenomenology, family histories and treatment responses. These subtypes are thought to form a continuum of disorders that, while differing in severity, are related. Readers are referred to the Diagnostic and Statisticial Manual of Mental Disorders of the American Psychiatric Association (DSM-IV) for details of this classification. 

Mania. Mania and hypomania can also occur in children and adolescents on SSRIs, and, again, it is not known if there is an added developmental risk (Ven-kataraman et al., 1992). In a fluoxetine treatment study for depression, 3 (of 48) patients developed manic symptoms, even after excluding patients with psychotic depression, bipolar symptoms, or a family history of bipolar disorder (Emslie et al., 1997). In a paroxetine treatment study for depression, 5 adolescents (of 93) were removed for emotional lability and 1 for eupho-ria/expansive mood (Keller et al., 2001). 

Many of the children and adolescents seen for treatment of depression are experiencing their first depressive episode. Because the symptoms of unipolar and bipolar depression are similar, it is difficult to decide whether a patient needs only an antidepressant or concomitant use of mood stabilizers. As noted above, symptoms and signs such as psychosis, psychomotor retardation, or family history of bipolar disorder may warn the clinician about the risk of the child developing a manic episode. 

It is still debated whether patients with two previous episodes should receive maintenance treatment. Overall, maintenance treatment has been recommended for adult depressed patients with two episodes who have one or more of the following criteria (Depression Guideline Panel, 1993) (1) a family history of bipolar disorder or recurrent depression, (2) early onset of the first depressive episode (before age 20), and (3) both episodes were severe or life threatening and occurred during the past 3 years. Given that depression in youth has similar clinical presentation, sequelae, and natural course as in adults, these guidelines should probably be applied for youth with two previous major depressive episodes. 

The relative absence of systematic studies of bipolar patients under age 18 forces clinicians to extrapolate data from adult studies. There are four major types of studies that provide information on subjects with bipolar disorder double-blind, placebo-controlled studies of patients with acute mania prospective open-label studies of patients with bipolar disorder (which includes mania, hypomania, manic symptoms, or bipolar NOS, people at risk for mania because of their family history, and those with a history of mania who are not currently manic) case series and anecdotal reports. 

Other factors associated with poor lithium response in mania include a history of prior lithium failure and a diagnosis of schizoaffective disorder. Bowden et al. [1994b] observed in a double-blind, placebo-controlled trial of patients with acute mania that those with a history of lithium response improved on lithium in this trial, whereas those with a history of prior lithium failure did not. Patients with a diagnosis of schizoaffective disorder may respond less well to lithium than patients with bipolar disorder, although this has not been extensively studied [Keck et al. 1994, for review]. 

Several studies suggest that valproate is effective in patients with a history of lithium treatment failure. In the study by Pope et al. [1991), 71% of patients receiving valproate exhibited an antimanic response, even though all of the patients had a history of lithium treatment failure or intolerance. Sixty-four percent of the patients with rapid-cycling bipolar disorder studied by Galabrese and Delucchi [1990) had a history of lithium failure, and the majority of these subsequently responded to valproate. Similarly, the six patients with rapid-cycling bipolar disorder described by McElroy et al. 

Consensus Development Panel 1985] confirmed that lithium salts were efficacious and should especially be considered for those considered unipolar but with a family history of bipolar disorder, because perhaps as many as 15% of patients with unipolar depression do subsequently experience hypomania or mania. Lithium may be the ideal maintenance agent for such uncertain patients for whom there is concern that administration of antidepressants may precipitate highs or increase the frequency of cycling and for those who dislike side effects of some antidepressant groups. 

A history of episodes of mania or hypomania should suggest the diagnosis of bipolar disorder. Because antidepressants can precipitate... 

Specific factors to consider are both psychiatric and physical contraindications. For example, bupropion is contraindicated in a depressed patient with a history of seizures due to the increased risk of recurrence while on this agent. Conversely, it may be an appropriate choice for a bipolar disorder with intermittent depressive episodes that is otherwise under good control with standard mood stabilizers. This consideration is based on the limited data suggesting that bupropion is less likely to induce a manic switch in comparison with standard heterocyclic antidepressants. Another example is the avoidance of benzodiazepines for the treatment of panic disorder in a patient with a history of alcohol or sedative-hypnotic abuse due to the increased risk of misuse or dependency. In this situation, a selective serotonin reuptake inhibitor (SSRI) may be more appropriate. 

A positive family history for bipolar disorder, particularly in first-degree relatives... 

It appears that a number of complications await the recovering bipolar patient after an episode of mania. For example, Lucas et al. ( 44) reported on a retrospective linear discriminant analysis of 100 manic episodes (1981 to 1985) during the recovery phase and found that the incidence of subsequent depression was 30% in the first month. Many episodes were transient, however, and did not necessarily require treatment. This phenomenon could be successfully predicted in 81% of cases in which there is a premorbid history of cyclothymia with either a personal or a family history of depression. The highly significant association between family history and postmanic depression again supports the hypothesis of a genetic basis for bipolar disorder. 

On average, symptom severity diminishes by 50% every 5 years between the ages of 10 and 25 years (55, 56). Hyperactivity declines more quickly than impulsivity or inattentiveness. However, symptoms of the condition persist into adulthood in many cases. The strongest predictors of symptomatic persistence are psychiatric co-morbidity, particularly with conduct or bipolar disorder and a family history of ADHD or substance abuse ( 57). A prospective study followed up a cohort of patients older than 16 years old with persistent ADHD symptoms and an age-matched control group and found an 11-fold increase in ongoing ADHD symptoms, a nine-fold increase in antisocial personality disorder, and a four-fold increase in substance abuse ( 58). 

The relationship between ADHD and substance abuse disorders is complex. There is no increased risk of substance abuse in ADHD patients relative to age-matched control subjects younger than 14 years old (41). Persistence of significant ADHD symptoms beyond 16 years of age coupled with both a family history of ADHD and substance abuse are significant risk factors for subsequent substance abuse. These patients frequently have co-morbid conduct or bipolar disorder. 

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