BIPOLAR DISORDER (TYPE 1 AND 2): SYMPTOMS, CAUSES, TREATMENTS - ECONOMÍA - 2024

The bipolar disorder is a mental illness characterized by the tendency of a person to alternate between depressive episodes and manic episodes. In type 1, the person alternates depressive episodes with full manic episodes, and in type 2, the person alternates between depressive episodes and hypomanic episodes (less severe).

The symptoms of this disorder are severe, different from the normal ups and downs of mood. These symptoms can result in problems in personal relationships, work, school, financial, or even suicide.

During the depression phase, the person may experience negative perception of life, inability to feel pleasure in life, lack of energy, crying, self-harm, and in extreme cases, suicide.

During the manic phase the person may experience denial that they have a problem, act energetic, happy or irritable, make irrational financial decisions, feel great enthusiasm, not think about the consequences of their actions or lack of sleep.

Although there are cases of onset in childhood, the normal age of onset for type 1 is 18 years of age, while for type 2 it is 22 years. About 10% of cases of bipolar 2 disorder develop and become type 1.

The causes are not clearly understood, but genetic and environmental factors (stress, childhood abuse) play a role. Treatment usually includes psychotherapy, medication, and in unresponsive cases, electroconvulsive therapy may be helpful.

Symptoms

-Symptoms of depressive episodes

Signs and symptoms of the depressive phase of bipolar disorder include:

• Persistent sadness
• Lack of interest in participating in pleasant activities.
• Apathy or indifference.
• Anxiety or social anxiety.
• Chronic pain or irritability.
• Lack of motivation.
• Guilt, hopelessness, social isolation.
• Lack of sleep or appetite.
• Suicidal thoughts.
• In extreme cases there may be psychotic symptoms: delusions or normally displacental hallucinations.

-Manic symptoms

Mania can occur in different degrees:

Hypomania

It is the least severe degree of mania and lasts at least 4 days. It does not cause a marked decrease in the person's ability to work, socialize, or adapt. It also does not require hospitalization and lacks psychotic characteristics.

In fact, general functioning can improve during a hypomanic episode and is thought to be a natural anti-depression mechanism.

If a hypomanic event is not followed or preceded by depressive episodes, it is not considered a problem, unless that mood is uncontrollable. Symptoms can last from a few weeks to several months.

It is characterized by:

• Greater energy and activation.
• Some people may be more creative and others may be more irritable.
• The person may feel so good that they deny that they are in a state of hypomania.

Mania

Mania is a period of euphoria and high mood of at least 7 days. If left untreated, a mania episode can last 3 to 6 months.

It is characterized by showing three or more of the following behaviors:

• Speak fast and uninterrupted.
• Racing thoughts
• Agitation.
• Easy distance.
• Impulsive and risky behavior.
• Excessive spending of money.
• Hypersexuality

A person with mania may also have a lack of need for sleep and poor judgment. On the other hand, maniacs can have problems with alcohol or other substance abuse.

In extreme cases, they may experience psychosis, breaking contact with reality while in high spirits. Something usual is that the person with mania feels unstoppable or indestructible and feels chosen to achieve a goal.

About 50% of people with bipolar disorder experience hallucinations or delusions, which can lead to violent behaviors or psychiatric admission.

Mixed episodes

In bipolar disorder, a mixed episode is a state in which mania and depression occur at the same time. People who experience this state may have thoughts of greatness as well as having depressive symptoms such as suicidal thoughts or guilt.

People who are in this state are at a high risk of committing suicide, since depressive emotions are mixed with mood changes or difficulties in controlling impulses.

Causes

The exact causes of bipolar disorder are unclear, although it is believed to depend primarily on genetic and environmental causes.

-Genetic factors

It is believed that 60-70% of the risk of developing bipolarity depends on genetic factors.

Several studies have suggested that certain genes and regions of chromosomes are related to susceptibility to developing the disorder, with each gene having a greater or lesser importance.

The risk of TB in people with family members with TB is up to 10 times higher compared to the general population. Research points to heterogeneity, meaning that different genes are involved in different families.

-Environmental factors

Research shows that environmental factors play an important role in the development of TB, and psychosocial variables can interact with genetic dispositions.

Recent life events and interpersonal relationships contribute to the likelihood of manic and depressive episodes.

It has been found that 30-50% of adults diagnosed with TB report abusive or traumatic experiences in childhood, which is related to an earlier onset of the disorder and greater suicide attempts.

-Evolutionary factors

From evolutionary theory, it could be thought that the negative consequences that bipolar disorder has on the ability to adapt, causes genes to be not selected by natural selection.

However, high rates of TB remain in many populations, so there may be some evolutionary benefit.

Proponents of evolutionary medicine propose that high rates of TB throughout history suggest that changes between depressive and manic states had some evolutionary advantage in ancient humans.

In people who have a high degree of stress, the depressed mood could serve as a defensive strategy with which to move away from the external stressor, reserve energy and increase the hours of sleep.

Mania could benefit from its relationship to creativity, confidence, high energy levels, and increased productivity.

Hypomanic and moderately depressed states may have certain advantages for people in a changing environment. The problem would be whether the genes responsible for these states are over-activated and lead to mania and major depression.

Evolutionary biologists have proposed that TB could be an adaptation of ancient humans to extreme northern climates during the Pleistocene. During the hot summer, hypomania may allow you to do many activities in a short period of time.

On the contrary, during the long winter, excessive sleep, excessive eating and lack of interest could help survival. In the absence of extreme weather conditions, TB would be maladaptive.

One piece of evidence for this hypothesis is the correlation between seasonality and mood swings in people with TB and low rates of TB in African Americans.

-Physiological, neurological and neuroendocrine factors

Brain imaging studies have shown differences in the volume of various brain regions between TB patients and healthy patients. Increases in the volume of the lateral ventricles, the globe pallus, and an increase in the rate of white matter hyperintensities have been found.

Magnetic resonance studies have suggested that there is abnormal modulation between the ventral prefrontal area and the limbic regions, especially the amygdala. This would contribute to poor emotional regulation and mood-related symptoms.

On the other hand, there is evidence that supports the association between early stressful experiences and dysfunction of the hypothalamic-pituitary-adrenal axis, which leads to its overactivation.

A less common TB can occur as the result of a neurological injury or condition: brain trauma, stroke, HIV, multiple sclerosis, porphyria, and temporal lobe epilepsy.

A neurotransmitter responsible for regulating mood, dopamine, has been found to increase its transmission during the manic phase and decrease during the depressive phase.

Glutamate is increased in the left dorsolateral prefrontal cortex during the manic phase.

Diagnosis

Bipolar disorder is not often recognized and is difficult to distinguish from unipolar depression.

Its diagnosis requires taking into account several factors: experiences of the person, behavioral abnormalities observed by other people and signs evaluated by psychiatrists or clinical psychologists.

The most widely used diagnostic criteria are the DSM and the WHO ICD-10.

Although there are no medical tests to confirm TB, it is advisable to do biological tests to ensure that there is no physical disease, such as hypothyroidism or hyperthyroidism, metabolic disorders, HIV or syphilis.

It is also advisable to rule out brain lesions and perform an electroencephalogram to rule out epilepsy. According to DSM-IV, there are the following types of disorders within bipolar disorders:

• Bipolar I Disorder, Single Manic Episode
• Bipolar I Disorder, Most Recent Hypomanic Episode
• Bipolar I Disorder, Most Recent Manic Episode
• Bipolar I Disorder, Most Recent Mixed Episode
• Bipolar I disorder, most recent depressive episode
• Bipolar I disorder, most recent episode unspecified
• Bipolar II disorder
• Cyclothymic disorder
• Unspecified bipolar disorder.

In this section, Bipolar II Disorder, the manic episode and the major depressive episode will be described.

Diagnostic criteria for Bipolar II Disorder

A) Presence of one or more major depressive episodes.

B) Presence of at least one hypomanic episode.

C) Criteria A and B affective symptoms are not better explained by the presence of schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or unspecified psychotic disorder.

E) Symptoms cause clinically significant distress or impairment of the individual's social, occupational, or other important areas of activity.

Specify the current or most recent episode:

• Hypomanic: If the current (or most recent) episode is a hypomanic episode.
• Depressive: if the current (or most recent) episode is a major depressive episode.

Diagnostic criteria for manic episode (DSM-IV)

A) A distinct period of an abnormal and persistently elevated, expansive, or irritable mood, lasting at least a week (or any duration if hospitalization is necessary).

B) During the period of mood alteration, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and there has been a significant degree:

1. Exaggerated self-esteem or grandiosity.
2. Disminution of necesity of sleep.
3. More talkative than usual or verbose.
4. Flight of ideas or subjective experience that thinking is accelerated.
5. Distraction
6. Increased purposeful activity or psychomotor agitation.
7. Excessive involvement in enjoyable activities that have a high potential for serious consequences.

C) The symptoms do not meet the criteria for the mixed episode.

D) The mood alteration is serious enough to cause impairment of work, habitual social activities, relationships with others, or to require hospitalization to prevent harm to oneself or others, or there are psychotic symptoms.

E) The symptoms are not due to the direct physiological effects of a substance or a general medical condition.

Diagnostic Criteria for Major Depressive Episode (DSM-IV)

A) Presence of five or more of the following symptoms during a period of 2 weeks, representing a change from previous activity; one of the symptoms must be 1. depressed mood, or 2. loss of interest or capacity for pleasure:

1. Depressed mood most of the day, almost every day as indicated by the subject himself (sad or empty) or the observation made by others (crying). In children or adolescents the mood can be irritable.
2. Marked decrease in interest or in the capacity for pleasure in all or almost all activities, most of the day.
3. Significant weight loss without dieting, or weight gain, or loss or increase in appetite almost every day. In children, the failure to achieve the expected weight gains must be assessed.
4. Insomnia or hypersomnia every day.
5. Feelings of worthlessness or excessive or inappropriate guilt almost every day.
6. Decreased ability to think or concentrate, or indecision, almost every day.
7. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan or a suicide attempt or a specific plan to commit suicide.

B) Symptoms do not meet criteria for a mixed episode.

C) Symptoms cause clinically significant discomfort or impairment of the individual's social, occupational, or other important areas of activity.

D) The symptoms are not due to the direct physiological effects of a substance or a general medical condition.

E) Symptoms are not better explained by the presence of grief, symptoms persist for more than two months or are characterized by marked functional disability, morbid worries of worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Comorbid disorders

Some mental disorders co-occurring with TB can occur: obsessive compulsive disorder, attention deficit and hyperactivity disorder, substance abuse, premenstrual syndrome, social phobia or panic disorder.

Treatment

Although TB ​​cannot be cured, it can be controlled effectively in the long term with medication and psychotherapy.

-Psychotherapy

Combined with medication, psychotherapy can be an effective treatment for TB.

Some psychotherapeutic treatments for TB are:

• Family therapy: it allows to improve the family's coping skills, such as helping the affected person or recognizing new episodes. It also improves problem solving and family communication.
• Cognitive-behavioral therapy: allows the affected person to change negative or maladaptive thoughts and behaviors.
• Interpersonal and social rhythm therapy: improves the person's personal relationships with others and helps control their daily routines, which can prevent depressive episodes.
• Psychoeducation: educates the affected person about the disorder and its treatment.

According to research, medication along with intensive psychotherapy (weekly cognitive behavioral therapy) has better results than just psychotherapy or psychoeducation.

-Medication

The symptoms of TB can be controlled with different types of medications. Because not everyone responds in the same way to the same medication, different drugs may have to be tried before finding the right one.

Keeping notes of daily symptoms, treatments, sleep patterns, and other behaviors will help you make effective decisions. The drugs commonly used for TB are antidepressants, mood stabilizers, and atypical antipsychotics.

Mood stabilizers

They are normally the first line of treatment for TB and are generally taken for years.

Lithium was the first stabilizer approved to treat manic and depressive episodes. There are anticonvulsants that are also used as mood stabilizers:

• Valproic Acid: This is a popular alternative to lithium, although young women should be careful.
• Lamotrigine: It is effective in treating depressive symptoms.
• Other anticonvulsants: oxcarbazepine, gabapentin, topiramate.

The use of valproic acid or lamotrigine can increase suicidal thoughts or behaviors, so caution must be exercised in its use and people who take it should be observed.

Also, valproic acid can increase testosterone levels in teenage girls, which can lead to a condition called polycystic ovary syndrome, which has symptoms such as excessive body hair, obesity, or an irregular menstrual cycle.

The side effects of lithium can be: dry mouth, restlessness, indigestion, acne, discomfort at low temperatures, muscle or joint pain, brittle nails or hair.

When taking lithium, it is important to check your blood levels, as well as the function of your liver and thyroid gland.

In some people, taking lithium can lead to hypothyroidism.

Side effects of other mood stabilizers can be:

• Dizziness
• Drowsiness.
• Diarrhea.
• Headache.
• Acidity.
• Constipation.
• Stuffy or runny nose
• Humor changes.

Atypical antipsychotics

These drugs are often used together with antidepressants to treat TB. Atypical antipsychotics can be:

• Aripiprazole: used to treat manic or mixed episodes as well as to maintain treatment.
• Olanzapine: May relieve symptoms of mania or psychosis.
• Quetiapine, respiridone, or ziprasidone.

The side effects of atypical antipsychotics can be:

• Blurry vision.
• Dizziness
• Tachycardia.
• Drowsiness.
• Sensitivity to the sun
• Skin rash.
• drowsiness
• Menstrual problems in women.
• Changes in metabolism.
• Weight gain.

Due to changes in weight and metabolism, it can increase the risk of developing diabetes or high cholesterol, so it is important to control glucose levels, weight and lipids.

In rare cases, long-term use of atypical antipsychotics can lead to a condition called tardive dyskinesia, which causes uncontrollable muscle movements.

Antidepressants

The antidepressants commonly prescribed to treat the symptoms of bipolar depression are: paroxetine, fluoxetine, sertraline, and bupropion.

Taking antidepressants alone can increase the risk of mania or hypomania. To prevent it, the use of mood stabilizers is usually required along with antidepressants.

Side effects of antidepressants can be:

• Sickness.
• Headaches.
• Agitation.
• Sexual problems

Patients taking antidepressants should be watched carefully, as suicidal thoughts or behaviors can increase.

-Other treatments

• Electroconvulsive therapy - May be helpful if psychotherapy and medication are not working. It can include side effects such as disorientation, memory loss, or confusion.
• Sleep medications: although sleep usually improves with medication, if it does not, sedatives or other drugs can be used to improve sleep.

To properly treat TB you need to make certain lifestyle changes:

• Stop drinking or using illegal drugs.
• Get away from toxic personal relationships and build healthy personal relationships.
• Get regular physical exercise and stay active.
• Maintain healthy sleep habits.

epidemiology

Bipolar disorder is the sixth leading cause of disability in the world and has a prevalence of 3% of the general population.

Its incidence is the same in women and men, as well as across different cultures and ethnic groups. Late adolescence and early adulthood are the ages when TB appears most.

Risk factor's

Risk factors that can increase the chance of developing TB are:

• Having a close relative with bipolar disorder.
• Periods of high stress.
• Alcohol or drug abuse.
• Life events, such as the death of a loved one or traumatic experiences.

Complications

If left untreated, TB can result in several problems that affect all vital areas:

• Suicide attempts.
• Legal issues.
• Financial problems.
• Alcohol or drug abuse.
• Problems with family or couple relationships.
• Social isolation.
• Low productivity at work or at school.
• Absences from work or training.

Tips if you have bipolar disorder

A healthy lifestyle is necessary to keep TB symptoms under control, reduce symptoms, and prevent relapse. Besides psychotherapy and medication there are other things you can do:

• Self-education: Learn about your disorder so you can make better decisions and control it.
• Have a commitment to your treatment: Treatment requires a process to see improvement and requires a long-term commitment. Be patient, take medication as prescribed, and continue therapy.
• Observe your symptoms and mood: if you are aware of when a mood change is taking place, you can prevent it from developing completely. Try to identify what is causing the manic or depressive episodes to begin (stress, arguments, seasonal changes, lack of sleep…).
• Create healthy habits: interact with healthy people, get enough sleep, exercise, eliminate alcohol, caffeine or sugar, go to therapy and take medication…
• Create an emergency plan: There may be times when you slip into a depressive or manic episode. Having a plan for these crises will help you better control them.
• Seek social support: Having social support is important to staying happy and healthy. Build your relationships with family and friends, go to support groups and build new personal relationships.
• Manage stress: practice relaxation techniques and do leisure activities.

Tips to help a family member

The mood swings and behaviors of a person with TB affect those around them.

They may have to face irresponsible decisions, exaggerated demands, explosive outbursts, or bombastic behavior. Once the mania ends, it will be necessary to face the lack of energy of the family member to continue with a normal life.

However, with correct treatment, most people can stabilize their mood. Here are some ways you can help:

• Encourage your family member to receive treatment: TB is a real disease and the sooner treatment is started, the better the prognosis.
• Be understanding: remind the other person that you are willing to help them.
• Learn About Bipolar Disorder - Learn about symptoms and treatment to be better prepared to help.
• Be patient: after the start of treatment, improvement takes some time.
• Accept the limits of the affected person: People with TB cannot control their moods with self-control.
• Accept your own limits: you can't force anyone to improve if they don't want to. You can offer support, even if the recovery is in the hands of the other person.
• Reduce stress: Stress makes TB worse.
• Watching for signs of relapse: If treated early, an episode of depression or mania can be prevented from fully developing.
• Prepare for destructive behaviors: The person with TB may act irresponsibly or destructively in mania or depression. Being prepared for it will allow you to better cope with the situation.
• Know what to do in a crisis: Knowing what to do in a crisis will help you act correctly when one appears. Know the emergency numbers for suicidal or violent behavior.
• In mania: avoid arguments, be close, prepare simple meals, avoid giving the person a lot of stimulation.

And what experience do you have with bipolar disorder?

References

1. Furukawa TA (2010). "Assessment of mood: Guides for clinicians." Journal of Psychosomatic Research 68 (6): 581–589. doi: 10.1016 / j.jpsychores.2009.05.003. PMID 20488276.
2. "APA Practice Guidelines for the Treatment of Psychiatric Disorders: Comprehensive Guidelines and Guideline Watches" 1. 2006.
3. Jamison KR (1993). Touched With Fire: Manic-depressive illness and the artistic temperament. New York: The Free Press. ASIN B002C47A0K.
4. Sherman JA (2001). "Evolutionary Origin of Bipolar Disorder (eobd)". Psycoloquy 12 (028).
5. Price AL, Marzani-Nissen GR (March 2012). "Bipolar disorders: a review". Am Fam Physician 85 (5): 483–93. PMID 22534227.