Bipolar Affective Disorder: Phenomenology

Mania

Manic episode is defined as euphoric or irritable mood with 3 or more of the following criteria:

1. Decreased need for sleep/ Increased energy.
2. Distractibility
3. Grandiosity/ Inflated self- esteem
4. Flight of ideas or racing thoughts
5. Increased talkativeness/ Pressured speech (rapid,loud & challenging to interrupt)
6. Increased goal directed activities or Psychomotor agitation
7. Impulsive behaviour (e.g. sexual impulsivity or spending sprees)

If 3 or more of the above symptoms persist for 1week or longer with functional impairment, a manic episode is diagnosed.

Manic episodes can also be associated with psychotic symptoms (delusions/ hallucinations).

Hypomania

If the above symptoms are present for at least 4 days but without any functional impairment, a hypomanic episode is diagnosed.

***If patient needs hospitalization for severity of his symptoms, irrespective of duration of symptoms, a manic (not hypomanic) episode is diagnosed because hospitalization involve functional impairment.

***If Psychotic symptoms are present, then also hypomania can not be diagnosed.

Bipolar Depression

Depressive episodes in Bipolar disorder are similar to those in Unipolar depression. But some differences do exist which should be kept in mind before making a diagnosis. The characteristics seen in Bipolar depression most often are:

1. Family History of Bipolar Disorder
2. Cyclothymic Temprament
3. Early age of onset (20’s & 30’s)
4. Abrupt Onset
5. Short duration of episodes (3-6 months)
6. Hypersomnia is seen more frequently than insomnia
7. History of Post Partum episodes
8. History of Antidepressant induced hypomania

Mixed States

Mixed states have been reported to be the most common presentation of mood states. It includes:

1. Agitated Depression
2. Dysphoric mania

Temprament

Temprament is defined as mild versions of mood states that are present not only in episodes of attacks of severe symptoms, but also as mild symptoms that are present all the time, as a part of baseline personality of an individual.

1. Hyperthymia:

• Mild manic state as a part of one’s basic temprament.
• These persons are high in energy, need less sleep, have high sex drives, highly social & often workaholics.
• They dislike routinr activities & engage in risk taking behaviours.

2. Dysthymia:

• Mild depressive state as a part of one’s basic temprament.
• These persons are low in energy, need more sleep, have low sex drives, socially anxious & low in work productivity.
• They are devoted to fixed routine, can be obsessive & avoid risk taking behaviours.

3. Cyclothymia:

• Constant alternation between mild manic & depressive states on day to day basis.
• These persons go up & down in mood, energy & activity levels.
• They are generally extrovert & social. They tend to be risk-takers at times.
• They can be anxious & inattentive.

Bipolar I Disorder

For making a diagnosis of Bipolar I Disorder, it is necessary to meet the criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypomanic or depressive episodes.

Bipolar II Disorder

If hypomanic episodes are present without a single manic episode along with at least one major depressive episode, Type II Bipolar Disorder is diagnosed.

Rapid Cycling Bipolar Disorder

• Patients having at least 4 manic episodes in a year.
• External Factors such as stress or pharmacological treatment may provoke rapid cycling.
• Hereditary factors do not seem to play any role in rapid cycling.

Bipolar with Seasonal Patterns

Some studies indicate a higher prevalence of manic episodes in the spring & summer seasons.

Reference: