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BIPOLAR DISORDERS

Four bipolar disorders are included in DSM-IV: bipolar I (manic-depressive) disorder, bipolar II disorder, cyclothymic disorder, and bipolar disorder NOS.

BIPOLAR I DISORDER

Bipolar I disorder typically begins in the teenage years, the 20s, or the 30s. The first episode could be manic, depressive, or mixed. One common mode of onset is mild retarded depression, or hypersomnia, for a few weeks or months, which then switches into a manic episode. Others begin with a severely psychotic manic episode that presents schizophreniform features; it is only when a more classic manic episode occurs that the affective nature of Bipolar Disorders, bipolar 1, bipolar II, bipolar I, bipolar 2, manic

On the average, manic episodes predominate in youth and depressive episodes in the later years. Although the overall sex ratio is about one to one, men on the average undergo more manic episodes and women experience more mixed and depressive episodes. Bipolar I disorder in children is not as rare as previously thought; however, most reported cases are boys, and mixed-manic (dysphoric-explosive) presentations are

Manic phase

Mania, typically begins acutely over a period of one to two weeks; more sudden onsets have also been described. The DSM-IV criteria stipulate (1) a distinct period that represents a break from premorbid functioning, (2) a duration of at least one week, (3) an elevated or irritable mood, (4) at least three to four classic manic signs and

Depressive phase

Psychomotor retardation, with or without hypersomnia, is the hallmark of the depressive phase of bipolar I disorder. Symptoms typically begin over a period of several weeks, although sudden onsets over one or two days are also seen. Although bipolar depressive episodes do not always acquire full-blown melancholic features, the autonomy of the episodes is a fundamental characteristic. Delusional and hallucinatory experiences are less common in the depressive phase of bipolar I disorder as compared with the manic and mixed phases. Stupor is the more common mode of

CYCLOTHYMIC DISORDER

An attenuated bipolar disorder that typically begins insidiously before the age of 21, it is characterized by alternating short cycles of subsyndromal depression and hypomania. The course of cyclothymia is continuous or intermittent, with infrequent periods of euthymia. Shifts in mood are typically endoreactive, such as suddenly falling in love or feeling profoundly dejected without adequate cause. Circadian cycles seem to play a role in the sudden mood changes, such as the person's going to sleep in good spirits and waking up early with suicidal urges.

BIPOLAR II DISORDER

Research conducted during the past 15 years has shown that between the extremes of classic manic-depressive illness defined by at least one acute manic episode (bipolar I disorder) and strictly defined major depressive disorder without any personal or family history of mania, there exists a large group of intermediary forms characterized by recurrent major depressive episodes and hypomanic episodes (variously termed as

Hypomania

The common denominator of the soft spectrum of bipolar disorders is the occurrence of hypomania. Hypomania refers to a distinct period of at least few days of mild elevation of

Rapid-cycling bipolar disorder

Rapid cycling is defined as the occurrence of at least four episodes--both retarded depression and hypomania (or mania)--a year. That means that rapid cyclers are rarely free of affective symptoms, resulting in serious vocational and

TREATMENT OF BIPOLAR DISORDER

ACUTE MANIA

Lithium carbonate

Lithium remains the paradigmatic treatment for acute mania. In comparative studies with antipsychotics, it demonstrates better overall improvement in all aspects of manic symptomatology, including psychomotor activity, grandiosity,

Carbamazepine

Several preliminary studies have suggested that some of the variables associated with a poor response to lithium may be associated with a good antimanic response to carbamazepine. Thus, the drug should be considered for

Valproate

Typical dose levels are 750 to 2,000 mg a day, to achieve blood levels between 50 and 120 mug/mL. Oral loading with 20 mg per kg a day from the outset is likely to be well tolerated and rapidly effective. In several case series patients with more typical manic

Clonazepam and lorazepam

Benzodiazepine anticonvulsants that have been studied in acute mania include clonazepam and lorazepam (Ativan). The sedating side effects of clonazepam may be problematic in some outpatients but may be useful in the management of inpatients or for bedtime medication for severely insomnic manic patients. The two anticonvulsants work at the central-type benzodiazepine receptor; in contrast, carbamazepine is not active at that

Calcium channel antagonists

A series of preliminary reports suggest that the calcium channel antagonist verapamil (Calan), and possibly also nifedipine (Procardia) and nimodipine (Nimotop), have acute