Introduction

In the previous chapter we considered depressive disorders and we now turn to bipolar disorders, another group of conditions in which depressive episodes are prominent. In bipolar disorder, however, the course is marked by at least one episode of mania or hypomania. Kraepelin (1921) brought mania and depression together as manic depressive psychosis, because he believed that the longerterm clinical course, with its tendency to recurrence of mood disturbance, was similar, whether patients presented with mania or depression. However, Leonhard et al. (1962) pointed out that bipolar disorder tends to show a distinct familial clustering. In addition, there

are other epidemiological differences between unipolar depression and bipolar disorder (Table 10.1). However, the differences are not great and there must be overlap between the two groups, because a patient who is classified as having unipolar depression at one time may have a manic disorder subsequently. In other words, the unipolar group inevitably contains some bipolar cases that have not yet declared themselves. Despite this limitation, the division into unipolar and bipolar cases is a useful classification because it has implications for treatment, particularly that of bipolar depression.

Clinical features

Mania

The central features of the syndrome of mania are elevation of mood, increased activity, and self-important ideas.

Mood

When the mood is elevated, the patient appears cheerful and optimistic, and may have a quality described

by earlier writers as ‘infectious gaiety’. However, other patients are irritable rather than euphoric, and this irritability can easily turn to anger. The mood often varies during the day, although not with the regular ‘diurnal’ rhythm that is characteristic of many severe depressive disorders. In patients who are elated, it is not uncommon for high spirits to be interrupted by brief episodes of depression

Appearance and behaviour

The appearance of patients often reflects their prevailing mood. Their clothing may be brightly coloured and ill assorted. When the condition is more severe, the patient’s appearance is often untidy and dishevelled. Manic patients are overactive. Sometimes the persistent overactivity leads to physical exhaustion. Manic patients start many activities but leave them unfinished as new ones attract their attention. Appetite is increased, and food may be eaten greedily with little attention to conventional manners. Sexual desires are increased, and sexual behaviour may be uninhibited and quite out of character. Women may neglect precautions against pregnancy, a point that calls for particular attention if the patient is of childbearing age. Sleep is often reduced. Patients wake early, feeling lively and energetic, and often get up and busy themselves noisily, to the surprise (and sometimes annoyance) of other people.

Speech and thought

The speech of manic patients is often rapid and copious as thoughts crowd into their minds in quick succession. When the disorder is more severe, there is flight of ideas (see Chapter 1), with such rapid changes that it is difficult to follow the train of thought. However, the links are usually understandable if the speech can be recorded and reviewed. This is in contrast to thought disorder in schizophrenia, where changes in the flow of thought may not be comprehensible even on reflection.

Expansive ideas are common. Patients believe that their ideas are original, their opinions important,

and their work of outstanding quality. Many patients become extravagant, spending more than they can afford (e.g. on expensive cars or jewellery). Others make reckless decisions to give up good jobs, or embark on plans for ill-considered and risky business ventures.

Sometimes these expansive themes are accompanied by grandiose delusions. Some patients may believe that they are religious prophets or destined to advise statesmen about major issues. At times there are delusions of persecution, when patients believe that people are conspiring against them because of their special importance. Delusions of reference and passivity feelings also occur. Schneiderian first-rank symptoms (see Box 11.3) have been reported in around 10–20% of manic patients. Neither the delusions nor the first-rank symptoms last for long, most of them disappearing or changing in content within a period of days.

Perceptual disturbances

Hallucinations occur. These are usually consistent with the mood, taking the form of voices speaking to the patient about their special powers or, occasionally, of visions with a religious content.

Other features

Insight is invariably impaired in more severe manic states. Patients see no reason why their grandiose plans should be restrained or their extravagant expenditure curtailed. They seldom think of themselves as ill or in need of treatment.

Most patients can exert some control over their symptoms for a short time, and many do so when the question of treatment is being assessed. For this reason it is important to obtain a history from an informant whenever possible. Henry Maudsley (1879, p. 398) expressed the problem well:

Just as it is with a person who is not too far gone in intoxication, so it is with a person who is not too far gone in acute mania; he may on occasion pull his scattered ideas together by an effort of will, stop his irrational doings and for a short time talk with an appearance of calmness and reasonableness that may well raise false hopes in inexperienced people.

Manic stupor

In this unusual disorder, patients are mute and immobile. Their facial expression suggests elation, and on recovery they describe having experienced a rapid succession of thoughts typical of mania. The condition is rarely seen now that active treatment is available for mania. Therefore an earlier description by Kraepelin (1921, p. 106) is of interest:

The patients are usually quite inaccessible, do not trouble themselves about their surroundings, give no answer, or at most speak in a low voice ... smile without recognizable cause, lie perfectly quiet in bed or tidy about at their clothes and bedclothes, decorate themselves in an extraordinary way, all this without any sign of outward excitement.

On recovery, patients can remember the events that occurred during their period of stupor. The condition may begin from a state of manic excitement, but at times it is a stage in the transition between depressive stupor and mania.

Criteria for manic episode in ICD-10 and DSM-5

The symptoms that are required to make a diagnosis of ‘manic episode’ in ICD-10 are listed in Box 10.1. The criteria for manic episode in DSM-5 are very similar, although the number of manic symptoms required for diagnosis is specified more precisely. In DSM-5, manic symptoms that occur during treatment with antidepressant medications and persist at a syndromal level despite the antidepressant being stopped are regarded as meeting criteria for a manic episode rather than being coded as a drug-induced manic illness.

ICD-10 notes that some patients with mania present with psychotic symptoms, in which case the clinical picture described in Box 10.1 is typically more severe, with inflated self-esteem and grandiose ideas developing into grandiose delusions. At the same time irritability and suspiciousness may result in delusions of persecution. Sustained physical activity and excitement may result in aggression or violence, and neglect of eating and drinking and personal hygiene can lead to a dangerous state of dehydration and self-neglect

Criteria for hypomanic episode in ICD-10 and DSM-5

Hypomania refers to a state of elevated mood that is of lesser extent than mania. The criteria in ICD-10 and DSM-5 are similar:

● There is persistent mild elevation of mood for at least

several days (in DSM-5, at least 4 days) with increased

energy and activity and feelings of wellbeing.

● There is increased sociability, talkativeness and overfamiliarity, increased sexual energy, and decreased need

for sleep.

● The mood disturbance, although associated with an

unequivocal change in function, which is observable

to others, is not sufficiently severe to cause marked

impairment in social or occupational activities, or to necessitate hospital admission.

● Psychotic features are absent.

Other clinical presentations of bipolar disorder

Mixed mood (affective) states

Depressive and manic symptoms sometimes occur at the same time. Patients who are overactive and overtalkative may be having profoundly depressive thoughts. In other patients, mania and depression follow each other in a sequence of rapid changes—for example, a manic patient may become intensely depressed for a few hours and then return quickly to his manic state. These changes were mentioned in early descriptions of mania by psychiatrists such as Wilhelm Griesinger (1817–1868), and have been re-emphasized in recent years because they appear to predict a better response to certain mood stabilizers, such as valproate.

Rapid cycling disorders

Some bipolar disorders recur regularly, with intervals of only days or weeks between episodes. In the nineteenth century these regularly recurring disorders were designated folie circulaire (circular insanity) by the French psychiatrist Jean-Pierre Falret (1794–1870). At present, the frequent recurrence of mood disturbance in bipolar patients is usually termed rapid cycling disorder. These recurrent episodes may be depressive, manic, or mixed. The main features are that recurrence is frequent (by convention at least four distinct episodes a year), and that episodes are separated by a period of remission or a switch to an episode of opposite polarity. A number of clinical features of rapid cycling disorder are important in management and prevention.

● They occur more frequently in women.

● Concomitant hypothyroidism is common.

● They can be triggered by antidepressant drug treatment.

The lifetime risk of rapid cycling in bipolar populations varies between studies, but is probably in the range 15–30%. Rapid cycling may be a temporary phenomenon, and in most patients it remits within about 2 years. For a review, see Datta and Cleare (2009).

Cyclothymia

The term cyclothymia disorder refers to a persistent instability of mood in which there are numerous periods of mild elation or mild depression that do not meet severity criteria for either major depression or hypomania. It is seen as a milder variant of bipolar disorder. It is not unusual, however, for episodes of more severe mood disorder to supervene in the course of the disorder.

Depression

Depressive episodes are common in the course of bipolar disorder and most patients with bipolar disorder present initially with an episode of major depression. The ability to predict which patients first presenting with depression will eventually develop bipolar illness is currently limited, although family history of bipolar disorder can provide a useful clue. The presence of any hypomanic or mixed symptomatology at initial presentation has some predictive value, but the majority of depressed patients who convert to bipolar illness do not have hypomanic symptoms during the initial episodes of depression. Other clinical features associated with subsequent development of bipolar illness include early age of onset and clinical severity, particularly the presence of psychosis (see Fiedorowicz et al., 2011).

There is a high degree of overlap between the clinical symptomatology of unipolar and bipolar depression; however, psychomotor retardation, early morning awakening, morning worsening, and psychotic features are reportedly more common in patients with bipolar disorder (Mitchell et al., 2011).