Bipolar Moood Disorder

INTRODUCTION

Mood disorders encompass a large group of disorders in which pathological mood and related disturbances dominate the clinical picture. The term mood disorders (also known as affective disorders) refer to sustained emotional states, not merely to the external expression of a transitory emotional state. Mood disorders are best considered as syndromes consisting of clusters of signs and symptoms sustained over weeks to months and which represent marked departure from a person’s habitual functioning and tend to recur often in periodic or cyclical fashion.²

CLINICAL FEATURES

A cyclical mood disorder in which episodes of major depressionare interspersed with episodes of mania or hypomania; 1.5% of the population is affected. Most patients initially present with a manic episode in adolescence or young adulthood. Antidepressant therapy may provoke a manic episode; patients with a major depressive episode and a prior history of “highs” (mania or hypomania—which can be pleasant/euphoric or irritable/impulsive) and/or a family history of bipolar disorder should not be treated with antidepressants at the start, but instead referred promptly to a psychiatrist.¹

With mania, an elevated, expansive mood, irritability, angry outbursts, and impulsivity are characteristic.¹

TYPES OF MOOD DISORDER

Manic episode

Manic episode or bipolar affective (mood) disorder, current episode hypomanic, (with or without psychotic symptoms), current episode mild or moderate depression (with or without) somatic symptoms, current episode severe depression (with or without psychotic symptoms).²

Depressive Episode

Depressive episode, mild (with or without somatic syndrome), moderate depressive episode (with or without somatic syndrome); severe (with or without psychotic symptoms), recurrent depressive disorder (moderate with or without somatic syndrome); recurrent depressive disorder (severe with or without psychotic symptoms); cyclothymia and dysthymia as per ICD-10 listing. Recurrent depressive disorder is also referred as unipolar depression. The other method to classify mood disorder is into major depressive disorder; bipolar I disorder, bipolar II disorder, bipolar III disorder, and bipolar IV disorder.²

Age and Sex Distribution

The possible reasons for increased vulnerability of depression in females are increased stress sensitivity, maladaptive coping strategies and multiple social roles. Substance use disorders are more frequently seen in males masking depressive symptoms, have been suggested for the explanation of the gender difference. Gender ratio in bipolar depression is approximately 1:1.²

Average age of onset of bipolar disorder is around 20 years of age. Bipolar illness is more frequent among divorced, separated and widowed individuals. Single women have lower rates of depression than married women do; but the opposite is true for men. Urban communities are more stressed and at risk for depression than rural ones. Despite the fact that more than two-thirds of patients with recurrent major mood disorders show irregular seasonal patterns individually and statistically, spring and fall are the peak time for depression just as summer is for mania. There is a condition known as ‘seasonal depression’ seen in cold countries where there is less of sunlight because of prolonged winters.²

AETIOLOGY

Of the biological amines, norepinephrine (NE) and serotonin (5 HT) are the two neurotransmitters most implicated in the pathophysiology of mood disorders. The correlation suggested by basic science studies between the down-regulation of beta-adrenergic receptors and clinical anti-depressant response is probably the single-most compelling piece of data indicating the direct role for the noradrenergic system in depression. Depletion of serotonin may precipitate depression and some patients with suicidal impulses have low cerebrospinal fluid (CSF) concentration of serotonin metabolite and low concentration of serotonin uptake sites on platelets. The data suggest that dopamine levels are decreased in depression and increased in mania. Other neurotransmitters like GABA and neuroactive peptides, particularly vasopressin in and endogenous opiates, have been implicated in the pathophysiology of mood disorders.²

Neuroendocrine Regulation

Major Neuroendocrine axis of interest in mood disorder is adrenal, thyroid and growth hormone axis. Other neuroendocrine abnormalities that may be implicated in patient with mood disorder include decreased nocturnal secretion of melatonin; decreased prolactin release in response to tryptophan administration, and decreased basal level of follicle stimulating hormone (FSH) and luteinizing hormone (LH).²

Genetic Factors

Adoption, linkage and twins studies also show data supporting the genetic basis for the inheritance of mood disorders.²

Cognitive Theory

Depression results from specific cognitive distortion present in persons prone to depression. Those distortion, referred to as depressogenic schemata are cognitive template data in ways that are altered by early experiences.

Learned helplessness is also another theory for depression.²

SYMPTOMS^{1, 2}

(1) Unusual talkativeness

(2) Flightof ideas and racing thoughts

(3) Inflated self-esteem that can become delusional

(4) Decreased need for sleep (often the first feature of an incipient manic episode)

(5) Increase in goal-directed activity or psychomotor agitation

(6) Distractibility

(7) Excessive involvement in risky activities (buying sprees, sexual indiscretions).

DIAGNOSIS²

In addition to diagnostic criteria for major depressive disorder and bipolar disorders, DSM-IV TR includes specific criteria for mood episodes.

DSM IV TR criteria for major depressive disorder

Bipolar ½: Schizopolar disorder.

Bipolar I disorder

DSM IV TR criteria for manic episodes Bipolar I½: Depression with protracted hypomania.

Bipolar II disorder

Criteria for bipolar II disorders include one major depressive disorder (MDD) episodes and one hypomanic episode. Bipolar II½: Depression superimposed on cyclothymic temperament.

Bipolar III disorder

Depression plus induced hypomania. Bipolar III½: Prominent mood swings occur in context of substance or alcohol use or abuse.

Bipolar IV disorder

Depression superimposed on hyperthymic temperament.²

MENTAL STATUS EXAMINATION

Manic Episodes

General description

Manic patients are excited, talkative sometime amusing and frequently hyperactive. At times, they are grossly psychotic and disorganized and require physical restraints and intramuscular sedative drugs.²

Mood, affect and feelings

Manic patients are euphoric but they can also be irritable. They also have a loco frustration. Tolerance which may lead to feeling of anger and hostility. They may be emotionally labile.²

Speech

Manic patients are difficult to interrupt. As the mania gets more intense, speech becomes louder, rapid and filled with jokes, rhymes and plays on words; sometimes loosening of association or flights of ideas may also be present.²

Perceptual disturbances

Mood congruent manic delusions are often concerned with great wealth, extraordinary abilities or power.²

Thought

Manic patient’s thought content includes themes of self confidence and self-aggrandisement.²

Sensorium and cognition

Grossly, orientation and memory are intact, although some manic patients may be so euphoric that they answer incorrectly. Kreplin called the symptom ‘delirious mania’.²

Impulse control

About 75% of all manic patients are associative or threatening. Manic patients do attempt suicide or homicide.²

Judgment and insight

Impaired judgment is a hallmark of manic patients. They may break laws about credit cards, sexual activities, finance and sometimes involve their families in financial ruin.²

Reliability

Manic patients are notoriously unreliable in their information because lying and deceit are common in mania.²

Patientswith full-blown mania can become psychotic.¹

Untreated, a manic or depressive episode typically lasts for several weeks butcan last for 8–12 months. Variants of bipolar disorder include rapid and ultrarapidcycling (manic and depressed episodes occurring at cycles of weeks, days, or hours).In many patients, especially females, antidepressants trigger rapid cycling and worsen thecourse of illness.

Bipolar disorder has a strong genetic component; the concordancerate for monozygotic twins approaches 80%.¹

TREATMENT^{1, 2}

• Bipolar disorder is a serious, chronic illness that requires lifelong monitoring bya psychiatrist.
• Acutely manic pts often require hospitalization to reduce environmental stimulation and to protect themselves and others from the consequences of theirreckless behavior.
• The recurrent nature of bipolar disorder necessitates maintenance treatment.
• Mood stabilizers are used in conventional treatment for the resolution of acute episodes and for prophylaxis of future episodes.

DIETARY SUGGESTION

Foods like fresh fruits, vegetables, legumes, whole grains, lean meats, cold-water fish, eggs, low-fat dairy, soy products, and nuts and seeds should be added to our daily diet. These foods provide the levels of nutrients necessary to maintain good health and prevent disease.³

SCOPE OF HOMEOPATHY

Homeopathy treatment for Bipolar depends on stage of case and severity of symptoms. It can be started as an adjunct at the initial phase and as treatment goes further patients, treatment can become much more defined. The treatment plan is based on a rightly chosen remedy based on totality based treatment. The additional benefit of using homeopathy is that it is a non-habit-forming medicines.

Counseling has an important role to play in such cases. The best results are got with an integrative approach where homeopathy and counseling go hand in hand. A rightly chosen homeopathic remedy corrects the neuro chemical balance and brings the patient back to normal self. The treatment is long term and needs regular follow up. Few homeopathic medicines found useful for Bipolar arebeing discussed below but should be given or taken in consultation with a registered homeopathic practitioner only. At our clinic we evaluate all such cases for the level of severity to start with and use an integrative approach with counselor and family members being a part of treatment plan wherever needed/possible.

Homeopathic Medicines³