23 April 2020 Author : Manuela Abreu The possibility of suffering bipolar disorder is a frequent concern in people who, over weeks or days, have mood swings, from eutymia to states of irritability or joy with no apparent reason or trigger. But these variations do not characterize bipolar disorder. Are there several types of bipolar disorder? The disease is characterized by manic episodes alternating with depressive episodes, more or less severe, and in the most popular classification (DSM), at least 3 forms occur: Type I bipolar disorder, the most serious, in which episodes of mania and depressive episodes alternate; Type II bipolar disorder, in which episodes of hypomania and depressive episodes alternate; Cyclothymia, which is alternation between hypomanic symptoms and depressive symptoms, in the same patient and at different time points, which are not sufficient to meet criteria for episodes of mania, hypomania, or depression. What are manic, hypomanic and depressive episodes? Maniac episodes Mania, episode of mania or manic episode, is a state of expansive mood and euphoria or, on the contrary, of extreme irritability and dysphoria, with accelerated thinking, a high flow of ideas, increased psychomotor activity and energy, feeling of greatness and decreased need for sleep. The speech becomes verborreic, difficult to interrupt and with a high tone. In the most severe cases, the conversation may not be coherent and jump from idea to idea. The patient jokes and use of word games with puns and rhymes are also common. In the initial stages, the professional performance may be higher, but with the progression of the episode the patients easily become inefficient. They tend to start multiple tasks without finishing it. Self-esteem is increased, with feelings of grandiosity and excessive self-confidence. There is a high social and sexual disinhibition, with excessive familiarity. The behavior disinhibition with sexual disinhibition makes seductive behaviors frequent, insinuating themselves, saying inappropriate courtships. Overly extroverted behavior can also be manifested in appearance, with bright clothing and bright colors, or in the most serious cases, carelessness. During manic episodes, patients sleep little, if not at all, and do not feel the need to sleep due to their state of excitement. The lack of criticism that characterizes these episodes prevents patients from correcting errors. When confronted by others, they quickly move from a good mood to anger, with hostile manifestations. There may be discussions and physical violence, often enhanced by excessive alcohol consumption. Alcoholism is a disease that often coexists in bipolar disorder. The absence of criticism and self-analysis of their condition can impel bipolar patients to perform activities that give them an immediate pleasure, without being aware of the possible consequences. Examples are dangerous driving, excessive spending on purchases of repeated or irrelevant articles, or even risky or ruinous businesses. In the most severe cases, patients are agitated and psychotic symptoms may appear. In these cases the delusional ideas have various contents such as: Delusion of affiliation, for example, they believe they belong to a royal family; Delirium of greatness, feeling that they have exceptional physical and mental abilities, supernatural powers such as seeing or anticipating the future; Messianic delirium, when they think they have been assigned a mission to save the world. However, delusional production can still be of a persecutory theme, if they form the conviction that their previous abilities or qualities have made them the object of envy and prejudice for those around them. Hypomania or hypomanic episodes Hypomanic or hypomanic episodes are distinguished from mania for their shorter duration, absence of psychotic symptoms and mild to moderate degree of disruption that induces the patient relationship life. The hypomanic patient is optimistic and expansive, but not as intensely as in mania. Psychomotor activity is also increased, the patient feels more energetic and is more productive at work. He is more talkative than usual and this is noticed by colleagues or family with whom he usually lives. What about depressive episodes? In most cases, after a manic episode, the patient becomes depressed when confronted with the consequences of his behavior. The transition between depressive, manic and hypomanic states is not an instantaneous phenomenon, but a gradual one, in which symptoms of both can coexist. In bipolar disorder, depressive episodes are similar to unipolar depression (“normal” depression), but with some distinctive characteristics: Higher psychomotor inhibition, that is, greater slowness of thought and movement. A lot of sleep instead of insomnia. The feeling of excessive and inadequate guilt is frequent, and can reach the delusional form with the theme of: Ruin, that he will remain in misery, everyone will abandon him; Guilt, that all the evils in the world are because of you; There are several forms of transition between mania and depression, mixed affective states, which take particular gravity because are present in the same patient and in the same time interval feelings of sadness and anguish that coexist in a background of restlessness and agitation and that in moments of greater impulsivity can lead to suicide. Comorbidity with alcoholism, which is common, further increases the risk of suicide. The deterioration of marital relationship is common, with divorce being frequent, given the context of the previous sexual disinhibition, promiscuous relationships, excessive spending or ruinous businesses that may have led to financial losses and squandering of family assets. Employment is also often compromised as a result of prolonged absenteeism. How is the diagnosis made? Most often, the age of onset of bipolar disorder is around 30 years old. From the age of 60, manic episodes may also occur for the first time, although in this age group it is necessary to exclude other causes that justify them, such as dementia, tumors or brain trauma, effects of some treatments with corticosteroids and antidepressants or hormonal changes, such as for example hyperthyroidism or Cushing's syndrome. Family history of psychiatric illness should be considered. The evolution of bipolar disorder does not have a homogeneous pattern. However, it is known that the risk of recurrence increases with the number of manic episodes. The number and severity of these episodes are also associated with a worsening of subsequent episodes and the risk of dementia. Treatment of bipolar disorder Treatment of bipolar disorder is performed with: Medication; Regular psychiatric follow-up to adjust medication in cases of ineffectiveness or side effects that may contribute to reducing medication adherence; Psychosocial interventions for the patient to accept that he has the disease and that he can and must be treated. One of the main problems in these patients is that they do not feel sick. When they are in a manic or hypomanic phase, they feel healthy and therefore naturally refuse any treatment. Therefore, they hardly accept taking medication. Adherence to treatment in the manic stages is generally very low, only when patients are depressed accept to be treated. Thus, relapses or decompensation of the disease are frequent. The family has a decisive role in the treatment of bipolar patients, for their support in taking medication and going to consultations. Family members are also the first to identify some of the changes described above, especially the lesser need for hours of sleep, which may indicate the approach of a turning point, and who must inform the psychiatrist so that they can act more quickly. and so try to abort the crisis. Medication in bipolar disorder Medication is the basis of treatment for bipolar disorder, both in relapse prevention, or maintenance treatment, in any of the disease types and episodes. The most important drugs in the maintenance treatment of bipolar disorder are the so-called mood stabilizers,like lithium carbonate, sodium valproate or carbamazepine. Some atypical antipsychotics, with less adverse effects, are used in episodes of mania due to agitation or psychotic symptoms, such as aripiprazole, quetiapine, olanzapine, risperidone, cariprazine. In depressive episodes, antidepressant drugs are prescribed, usually selective inhibitors of serotonin reception, always associated with mood stabilizers to reduce the risk of "manic turning". Psychosocial interventions Psychosocial interventions are important adjuvants to medication in depressive episodes and in maintenance treatment as prophylaxy of relapses and maintenance of quality of life. There are several recommended interventions, carried out by mental health professionals: psychoeducation, cognitive-behavioral therapy, family-focused therapy, interpersonal therapy, group support therapy. Of these, psychoeducation is assumed to be the most relevant, given its proven effectiveness in preventing relapses, especially in the early stages of the disease. It is aimed at all patients and family members and it seeks to provide all information about the disease, possible treatments and key strategies to deal with it. Main factors of bipolar patients that determine treatment success. Acknowledge and accept that they are sick; Ensure adherence to therapy; Keep regular follow-up in consultation; Make suicide prevention intervention; Identify and treat possible associated alcoholism; Monitor sleep hours and quality. Meet the psychiatry team from Hospital da Luz network. The content published in the Health Guide is intended for the general public and is provided for informational and educational purposes only. It does not replace individual medical assessment, diagnosis, or personalized clinical advice from a qualified healthcare professional. The content is produced or reviewed by physicians and other healthcare professionals at Hospital da Luz and is based on the knowledge available at the time of publication or the most recent update, as indicated at the beginning of each item.
