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diagnosing bipolar affective disorder
   
• Bipolar Disorder: A Summary of Clinical Issues and Treatment Options (CANMAT Bipolar Disorder Sub-Committee, 1997)

 

Bipolar Affective Disorder
When patients experience any cyclic mood disorder that includes at least one manic episode, they are suffering from bipolar affective disorder, formerly referred to as manic-depressive disorder.

Approximately 25% of people with mood disorders experience manic or hypomanic episodes. Manic episodes, which are characterized by inflated self-esteem, grandiose mood, significantly increased motor activity and pressured speech, may be clearly identifiable by others, but may not be considered problematic by the patient. If psychotic symptoms are florid, a manic episode can be mistaken for schizophrenia. Hypomanic moods may be less clearly expressed and are often characterized by excessive irritability in the presence of marked mood lability.

Criteria for a Manic Episode
For at least one week (or less if the patient has to be hospitalized), the patient's mood is abnormally and persistently high, irritable or expansive. During this same week, the patient has also persistently had three or more of the following symptoms (four if the only abnormality of mood is irritability). Symptoms must also not be the result of substance use, including prescription medication, or a general medical disorder:

Symptoms: Manic Episode

• Grandiosity or exaggerated self-esteem
• Reduced need for sleep
• Increased talkativeness
• Flight of ideas or racing thoughts
• Easily distracted
• Speeded-up psychomotor activity or increased goal-directed activity (social, sexual, work or school)
• Poor judgement (as shown by spending sprees, sexual adventures, foolish investments).
  As well, symptom severity should result in at least one of the following:
• Causes psychotic features
• Requires hospitalization to protect the patient or others
• Impairs work, social or personal functioning

 

In evaluating an episode of bipolar disorder, the episode must represent a change of polarity (e.g., from major depression to mania) or be separated from the previous episode by a normal mood that lasts at least two months. If the patient has ever experienced a full manic episode, the illness is labeled Type 1 bipolar disorder. Type 2 bipolar disorder describes patients who have had hypomania, but who have experienced major depression as well. A third category of bipolar disorder is referred to as mixed or dysphoric mania.

Mixed mania involves the simultaneous occurrence of various symptoms of mania (elevated energy, decreased sleep and agitation) with the emotional feelings of depression (sadness, anxiety and negative thinking). Patients with mixed mania have strikingly labile moods, abruptly shifting from tears to giggles. If these mood shifts occur almost daily for at least one week, mixed or dysphoric mania should be diagnosed.

Disorder Diagnostic Tips for Bipolar Affective Disorder
Bipolar disorder is difficult to diagnose, largely because mania, especially hypomania, is often unrecognized. Here are some diagnostic tips to keep in mind when the diagnosis of bipolar affective disorder is being considered.

 
• When a patient appears depressed, they should be probed for both depression and hypomania, not just depression.
• Ask patients if they ever have periods when they donít need to sleep or where they are in an unusually upbeat mood for prolonged periods of time (i.e., 3 days).
• Past behaviours – major spending sprees, bankruptcy, a string of affairs, a cluster of speeding tickets – may reflect a history of hypomania and questions should be asked accordingly.
• Patients who are currently hypomanic may downplay their symptoms. If they insist there are "no problems", ask them to compare their behaviour now to a few months ago and reflect on why they are behaving differently now. Asking a family member whether a personís behaviour has been excessive may also help confirm the diagnosis of hypomania or mania.
• Prolonged stimulant abuse (notably with cocaine) can cause marked sleep reduction and increased energy; stimulant abuse should be ruled out.
• Depressive episodes in bipolar disorder may be indistinguishable from major depressive disorder. However, too much sleep as opposed to insomnia, and weight gain rather than weight loss are often more common in bipolar patients than they are in major depression. Extreme fatigue is somewhat more common in bipolar depression as well.
• Keep appointments short and to the point. Hypomanic and manic patients are usually in a rush so if you suspect bipolar disorder, explain it clearly and arrange a follow-up appointment within the next few days to allow for further discussion and initiation of treatment.
• Telling a hypomanic patient who doubts the diagnosis that many talented people including Winston Churchill and Ernest Hemingway also had bipolar disorder may be helpful in promoting further discussion and acceptance of the diagnosis.

 

Interview: Bipolar Affective Disorder – Text

Dr Sagar Parikh
Head, Bipolar Clinic
Centre for Addiction and Mental Health, Clarke Division
Director of Continuing Education
Assistant Professor of Psychiatry
University of Toronto.





Over one million Canadians suffer from some form of depressive illness.


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