Hypomanic episodes

Bipolar disorders have been categorized into bipolar I disorder, bipolar II disorder, and bipolar disorder, not otherwise specified (NOS). Bipolar I disorder is characterized by one or more manic or mixed mood episodes. Bipolar II disorder is characterized by one or more major depressive episodes and at least one hypomanic episode. Hypomania is an abnormally and persistently elevated, expansive, or irritable mood, but not of sufficient severity to cause significant impairment in social or occupational function and does not require hospitalization. Most epidemiologic studies have looked at bipolar disorder of all types (bipolar I and bipolar II), or the bipolar spectrum, which includes all clinical conditions thought to be closely related to bipolar disorder. The lifetime prevalence of bipolar I disorder is estimated to be between 0.3% and 2.4%. The lifetime prevalence of bipolar II disorder ranges from 0.2% to 5%. When including the bipolar spectrum, the lifetime prevalence is between 3% and 6.5%.1... 

Bipolar disorder can be conceptualized as a continuum or spectrum of mood disorders and is not comprised solely of bipolar I disorder.9 They include four subtypes bipolar I (periods of major depressive, manic, and/or mixed episodes) bipolar II (periods of major depression and hypomania) cyclothymic disorder (periods of hypomanic episodes and depressive episodes that do not meet all criteria for diagnosis of a major depressive episode) and bipolar disorder, NOS. The defining feature of bipolar disorders is one or more manic or hypomanic episodes in addition to depressive episodes that are not caused by any medical condition, substance abuse, or other psychiatric disorder.1... 

The distinguishing feature of bipolar II disorder is depression with past hypomanic episodes that often are not recalled by the individual as being unusual. Irritability and anger episodes are also common. Collateral information is essential to obtain the entire history (i.e., there cannot have been a prior full manic episode).1,14... 

D. There has never been a manic episode, a mixed episode, or a hypomanic episode. 

During a hypomanic episode, some patients may be more productive and creative than usual, but 5% to 15% of patients may rapidly switch to a manic episode. 

Two or more major depressive episodes Manic episode major depressive or mixed episode Major depressive episode + hypomanic episode Chronic subsyndromal depressive episodes Chronic fluctuations between subsyndromal depressive and hypomanic episodes (2 years for adults and 1 year for children and adolescents) Mood states do not meet criteria for any specific bipolar disorder... 

The essential feature of major depressive disorder is a clinical course that is characterized by one or more major depressive episodes without a history of manic, mixed, or hypomanic episodes. Dysthymic disorder is a chronic disturbance of mood involving depressed mood and at least two other symptoms, and it is generally less severe than major depressive disorder. This chapter focuses exclusively on the diagnosis and treatment of major depressive disorder. 

The distinction between major depression and bipolar depression is an important one. Treating a depressed bipolar patient with antidepressant monotherapy (i.e., withont a concomitant mood stabilizer) can propel such a patient into a manic or hypomanic episode. Although it may not be prudent to initiate a mood stabilizer when the evidence for bipolar illness is equivocal, the clinician should be particularly vigilant for the emergence of manic or hypomanic symptoms when starting antidepressant treatment for the first time in a depressed patient. 

More controversial is the occurrence of antidepressant-induced mania or hypo-mania. DSM-IV specifically states that manic or hypomanic episodes triggered by antidepressant treatment should not count toward the diagnosis of BPAD. However, clinicians have traditionally viewed antidepressant-induced switching from depression into mania as an unmasking of a preexisting BPAD that had previously been unrecognized and undiagnosed. 

As a rule, we prefer lithium when treating bipolar patients who most often manifest classic euphoric mania. We also prefer lithinm for patients whose illness consists of a preponderance of depressive episodes with less freqnent manic or hypomanic episodes. We typically initiate lithium at 300-900mg/day given in a single bedtime dose or two divided doses. The target therapentic level is 0.8-1.2mEq/L. 

Excessive central stimulation, usually exhibited as tremors, insomnia and hyperhidrosis, can occur following therapeutic doses of the MAOIs, as can agitation and hypomanic episodes. Peripheral neuropathy, which is largely restricted to the hydrazine type of MAOI, is rare and has been attributed to a drug-induced p)n idoxine deficiency. Such side effects as dizziness and vertigo (presumably associated with hypotension), headache, inhibition of ejaculation (which is often also a problem with the TCAs), fatigue, dry mouth and constipation have also been reported. These side effects appear to be more frequently associated with phenelzine use. They are not associated with any antimuscarinic properties of the drug but presumably arise from the enhanced peripheral sympathetic activity which the MAOIs... 

Antidepressants do not prevent relapses into mania and may even precipitate a manic phase. For these reasons, a mood stabilizer (with or without concomitant antidepressants) is the prophylaxis of choice for bipolar depressions. If there is a reasonable hint of bipolarity (e.g., a family history of bipolar illness, a prior hypomanic episode, or drug-induced hypomania), a mood stabilizer should be considered (see Chapter 10 for more detailed discussion). 

Bipolar affective (manic- depressive) Characterized by episodes of mania. Cyclic mania alone, rare depression alone, occasional mania-depression, usual. About 10-15% of all depressions. May be misdiagnosed as endogenous if hypomanic episodes are missed. Lithium carbonate stabilizes mood. Mania may require antipsychotic drugs as well depression managed with antidepressants. 

The natural course of bipolar disorder is episodic and highly recurrent. Initially, it can present with one or more episodes of depression before the first frankly hypomanic or manic episode occurs. In many cases, manic and hypomanic episodes may precede or follow a depressive episode. Episodes usually last several months and may resolve spontaneously, without treatment. Recurrences every 2 years or so are not uncommon, and over time the frequency and intensity of episodes may actually worsen. In general, there is great variability in its course from patient to patient. A graphic rendition of the median life course of affective illness (based on the life course of 82 patients), including episodes of mania and depression, treatments, and hospitalizations, is illustrated in Figure 3.3. 

About half of patients vdth bipolar disorder experience v hat are referred to as hypomanic, rather than manic, episodes. Hypomanic episodes are cUfferen dated from manic episodes by being briefer, in that only four days of symptoms are required, and by not having psychodc symptoms, nor marked impairment in funcdoning, nor requiring hospitalizadon. 

Persons who experience manic episodes are classified as having Bipolar I Disorder, while those who experience only hypomanic episodes are classified as having Bipolar II Disorder. 

Technically, having one or more depressive episodes is not required for a diagnosis of bipolar disorder. In other words, a person with bipolar disorder may only experience manic or hypomanic episodes and be classified as bipolar. Pracdcally speaking, virtually all bipolar pa dents experience depressive episodes at some point during the course of illness. 

Some evidence supports the idea that a manic or hypomanic episode may be induced in vulnerable padents by and-depressant medic a dons (Goldberg and Truman, 2003). This phenomenon, known as the switch effect, has been clinically observed in many cases. Some data suggest that dreat-ment with anddepressants, pardcularly those with dual acdon at both norepinephrine and serotonin, may precipitate a manic episode in bipolar padents (Stoner et al., 1999 Shulman et al., 2001 Yuksel et al., 2004). Though widely accepted from a clinical perspecdve, this phenomenon is sdll somewhat con-d oversial from a research perspecdve. 

Cyclothymic disorder— An illness in which there are many hypomanic episodes and many periods of depression during a period of time lasting at least two years. 

A hypomanic episode, defined as lasting at least throughout a four-day period, is marked by an observable change in functioning and disturbance in mood that is uncharacteristic of the individual s usual nondepressed mood and level of functioning. Hypomania is distinguished from mania by the absence of the significant impairment, or hospitalization, described above. 

One or more manic or hypomanic episodes with one or more major depressive episodes generally constitute the diagnosis of bipolar I disorder. Depression in bipolar disorder meets diagnostic criteria for major depression, with the exceptions of shorter duration and increased frequency. Depending on the cmrent presentation, bipolar disorder is subclassified as one of the following (DSM-IV) ... 

Most recent episode manic—current (or most recent) episode manic with either at least one previous major depressive episode or at least one previous manic or hypomanic episode. 

Hypomania is a less severe form of mania, and by dehnition does not cause a marked impairment in social or occupational functioning, and no delusions or haUucinations are present. " Patients with hypomania often do not seek treatment imtil they have a depressive episode, thus hypomania may not be recognized or reported. Symptoms found in hypomanic episodes are similar to those of cocaine- or antidepressant-induced mood disorders thus the differential diagnosis should rule out any substance-induced or medical conditions that present with elevated mood. Hypomanic states should be closely monitored, because 5% to 15% of patients may rapidly switch to a manic episode." ... 

Chronic fluctuations between subsyndromal depressive and hypomanic episodes (2 years for adults and 1 year for children and adolescents)... 

Bipolar I after two manic episodes, after one severe manic episode, in the presence of a strong family history of bipolar disorder or major depressive disorder, with frequent episodes (more than one per year), or with rapid onset of manic episodes Bipolar II after three hypomanic episodes or if the patient becomes hypomanic with antidepressant therapy... 

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