Bipolar disorder guide: what to pay attention to when diagnosing and treating it?

Bipolar disorder, formerly known as manic-depressive psychosis, is a mental disorder characterized by the alternation of manic periods with depressive ones. In the intervals between them, there may be a "lull", remission, when neither one nor the other pronounced symptoms are observed, and the person feels absolutely healthy.

Thus, one of the main diagnostic criteria, in this case, is the presence of cyclical, alternating, polar mood swings from depression to manic (excessive) activity. The diagnostic importance of such periodicity was noted back in the nineteenth century by German scientist E. Kraepelin. Although the disorder is known for centuries, currently, there is no definitive list of the causes of bipolar disorder.
However, cyclicality is characteristic not only of bipolar disorder but also of a number of other mental disorders.

Despite the change in terminology, what bipolar personality disorder is has been known for a long time, and a description of this condition can be seen already in ancient authors. However, there is some discrepancy in terms of diagnostic criteria in various classifiers.  Europe uses the ICD 10 classifier, while in the American countries DSM-IV guidelines are used, where the differential criteria are somewhat different.

Bipolar disorder in short facts

Diagnosis of bipolar disorder - practices

Diagnosis of a bipolar mental disorder requires a strict differential approach since many of the manifestations can also be characteristic of a number of other mental disorders. Thus, the symptoms of bipolar disorder are manifested in anxiety, psychotic, and personality disorders. A sharp change in affect is characteristic of schizophrenia, which must also be taken into account when diagnosing bipolar disorder. Disputes of this kind were resolved when a compromise decision was made and a separate diagnostic unit, schizoaffective disorder, was singled out.

Besides bipolar disorder of the types I and II, experts mention cyclothymia - mild mood swings - as a bipolar affective disorder since there is a picture of intermittent, albeit indistinct, hypomania, and depression.

Difficulties in diagnosing bipolar personality disorder lie in the fact that the patients themselves are inclined to pay more attention to depressive episodes since they are experienced as unpleasant, but periods of mania are not perceived as such and subjectively disturb the patient a little. They can, even after their lapse, evoke pleasant memories and be desired in the future. In the repetition of such a state, in general, there would be nothing wrong if it were not for the tendency of this disorder to progress as more and more cycles repeat, when hypomania also turns into a more severe mania (in which a person tends to commit rash, sometimes dangerous, actions), and depressive episodes become more and more prolonged and difficult and can pose a danger not only to mental but also to physical well-being and human life itself since it is depression that leads among the causes of suicide on Earth.

By the time the cycles of bipolar mental disorder change are distinguished:

- Fast cyclicality (4 or more episodes during the year);
- Ultra-fast cyclicality (more than 4 episodes per month);
- Ultradian BPAD (more than 4 times a week).

To make a preliminary diagnosis before you go to a doctor, check the main symptoms of depression and manic phase based on this table:

According to the degree of the destructive effect on the psyche and personality, bipolar disorder is one of the most intact types of disorders, i.e. it doesn’t cardinally change the personality of a person. Nevertheless, it requires close attention from specialists and timely treatment. Indeed, even with the roughest estimates, the patient can spend about half of their life in a painful state, which eventually leads to his maladjustment, problems in professional activity, and introduces disharmony in family relations.

Separating bipolar personality disorder and ADHD (attention deficit hyperactivity disorder) can be difficult during childhood and puberty. Inadequate treatment, which can be the result of poor-quality diagnostics, can be not only futile but even harmful.

Taking into account all of the above, special and close attention should be paid to the issues of diagnostics in case of suspected bipolar disorder. Only experienced specialists with a sufficient amount of knowledge and practical experience are able to carry out high-quality differential diagnostics and prescribe treatment adequate to the diagnosis.

Treatment for bipolar disorder

Successful treatment of bipolar disorder should be based on a set of approaches and timely (preferably, early) correct diagnosis.

One of the methods is supportive psychopharmacotherapy, aimed at preventing the unfolding of manic and depressive episodes, as well as preventing their uncontrolled alternation. It should be understood that with inadequate pharmacological treatment, an unfavorable, rapid alternation of cycles can occur. That is why it is important to carefully select the drug and start from the lowest dosage increasing it gradually for the achievement of the optimal result with minimal side effects.

The first group of medicines is mood stabilizers, i.e. stabilizers of the affective state, capable of preventing a rapid phase change. There is a large number of mood stabilizers so their careful selection based on a preliminary diagnostic examination, as well as taking into account the phase in which the patient is at the moment, is very important.

It is also necessary to control the level of the drug in the blood to determine its optimal dosage.

In addition, doctors practice the use of anticonvulsants, atypical antipsychotics, antipsychotics (for instance, Olanzapine) for the manic phase, and antidepressants (for instance, Paroxetine, Sertraline, and others) for the relief of depressive episodes. In some cases, hypnotics and tranquilizers can be prescribed for a short time.

Various directions and forms of psychotherapy are one of the main methods of treating the bipolar mental disorder, since it is with the help of them that the patient gets the opportunity to function normally, adequately assess their own condition, timely recognize the onset of the unfolding of a manic or depressive episode and undertake necessary measures.

The therapy process is complemented by various instrumental methods: specially designed biofeedback programs (BFB), transcranial magnetic stimulation, phototherapy (light therapy), and others.

Psychiatrists and psychologists carry out work aimed at educating the patient and family members since it is very important to have an adequate attitude towards the disease and the patient. It is important for others to understand that the patient cannot always cope with their own affective state and cannot control their mood. That is why it is crucial for a patient to be willing to fight the disease and receive family support.

If periods of depression and mania become prolonged or the patient is not receiving adequate treatment, then subsequent social rehabilitation may be necessary. This type of therapeutic work is carried out both on an outpatient basis and in a hospital.
If you or your close ones are facing the diagnosis of bipolar disorder, try to find a specialist who prefers a holistic approach, i.e. conducts multifaceted testing and approaches therapy from various aspects and not only drug therapy.

Post by: John De Vries, clinical pshychiatrist, Amsterdam, Netherlands