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  3. Bipolar Disorders
  • Cited by 19
Publisher:
Cambridge University Press
Online publication date:
August 2009
Print publication year:
2005
Online ISBN:
9780511544019
DOI:
https://doi.org/10.1017/CBO9780511544019
Subjects:
Psychiatry and Clinical Psychology, Medicine, Psychiatry
Information

Book description

Bipolar disorder manifests itself in a variety of forms. It can coexist with other psychiatric conditions, and treatment efficacy can depend on the type of bipolar state. This book covers the full range of atypical, rapid cycling and transient forms of bipolar disorder, from atypical and agitated depression to schizoaffective mixed states. The most recent ICD category is covered, and the authors also look at the biology and genetics of bipolar disorder, along with issues relating to age (children and the elderly), comorbidity, choice of drug treatment and investigational strategies.

Reviews

'This is a very useful reference for those dealing with patients with atypical features of bipolarity. The authors have done an excellent job of presenting the difficult to treat but commonly prevalent forms of bipolar disorder.'

Source: Doody's Reviews

'… this is a book to have and to read, appropriate for, and likely to be enjoyed by, both interested clinicians and learned 'Bipolarologists' alike.'

Source: Journal of Clinical Psychiatry

'The strength of this book lies in the way it details the historical development of these forms of bipolar disorder, provides a thorough description of their manifestations, critically reviews the latest empirical evidence, and discusses the implications for diagnosis, pharmacological intervention and future research.'

Source: Journal of Mental Health

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Contents

Contents
  • 1 - Bipolar disorders beyond major depression and euphoric mania
    pp 1-44
  • View abstract

    Summary

    The early descriptions and roots of mixed states are very closely connected with the history and development of concepts regarding bipolar disorders. These concepts have their roots in the work and theories of the Greek physicians of the classical period, especially of the school of Hippocrates and, later, of the school of Aretaeus of Cappadocia. Most of the studies of the families of patients with rapid-cycling bipolar disorder show no difference between rapid- and non-rapid-cycling patients. Schizoaffective disorders present as unipolar or bipolar forms in a way similar to mood disorders, as is reflected in both diagnostic and statistical manual of mental disorders (DSM-IV) and tenth revision of the international classification of diseases (ICD-10). ICD-10 and DSM-IV handle the definition of schizoaffective disorder differently. These differences present a difficulty for cross-national research. For a long time, agitated depression has been considered to be a type of mixed state.
  • 2 - Emerging concepts of mixed states: a longitudinal perspective
    pp 45-60
    • By Giulio Perugi, University of Pisa, Pisa, Italy, Hagop S. Akiskal, University of California at San Diego and Veterans Administration Medical Center, La Jolla, CA, USA
  • View abstract

    Summary

    This chapter reviews the empirical literature on different definitions of mixed state (MS) focusing on their clinical validity. A large literature is available indicating that the Diagnostic and Statistical Manual, 4th edn. (DSM-IV) threshold for syndromal depression during mania is too restrictive, and suggesting that few depressive symptoms would suffice in validating the clinical diagnosis of mixed mania. Depressive-MS patients can be distinguished from non-mixed bipolar depressives by the fact that they have fewer episodes of longer duration, and frequently begin their illness with a mixed episode. Among the (hypo) manic symptoms reported in depressive MS, flight of ideas, racing thoughts, and distractibility belong to the same dimension of psychic excitement. Affective instability, fluctuation, lability, irritability, and diurnal variation emerge as the core phenomenologic features of mixed bipolar states; perplexity, psychotic experiences, and grossly disorganized behavior seem to arise from this protracted instability.
  • 3 - Rapid-cycling bipolar disorder
    pp 61-87
    • By Omar Elhaj, Case Western Reserve University, University Hospitals of Cleveland, Cleveland, OH, USA, Joseph R. Calabrese, Case Western Reserve School of Medicine and University Hospitals of Cleveland, Cleveland, OH, USA
  • View abstract

    Summary

    The frequent recurrence of treatment-refractory depression is emerging as the greatest unmet need in the clinical management of patients with rapid-cycling bipolar disorder, and particularly those comorbid presentations with alcohol and drug abuse. The age-corrected risk of major affective disorder was 23.5% in 179 relatives of rapid cyclers and 31% in 189 relatives of matched non-rapid cyclers, suggesting that rapid cycling is not genetic and does not aggregate within families. Findings from neuroimaging studies continue to enrich our understanding of the pathophysiology of mood disorders generally and rapid-cycling bipolar disorder particularly. Researchers found that the clinical presentation of bipolar disorder I (BP-I) was similar in children and adolescents. Despite being the oldest among the pharmacological armamentarium in the treatment of bipolar disorder, lithium continues to draw attention to its utility as an effective agent in the treatment of different aspects and phases of this disorder.
  • 4 - Bipolar I and bipolar II: a dichotomy?
    pp 88-108
  • View abstract

    Summary

    Bipolar disorder occurs in multiple forms and degrees of severity. A still unresolved issue is whether bipolar II disorder represents an autonomous type of bipolar disorder or a transitory condition between unipolar and bipolar I disorder. This chapter focuses on the distinctions and similarities between bipolar I and bipolar II disorders, and draws some conclusions about the validity of such a dichotomy. Family studies are useful for an understanding of the pathophysiology of bipolar disorders. In bipolar I patients the treatment aims to prevent manic relapses; consequently, lithium is the primary treatment in bipolar I patients because of its prophylactic effect on mania. On the other hand, in bipolar II patients it is very important to control and prevent depressive episodes; consequently, lamotrigine and antidepressant treatment, which have less propensity for hypomania induction, may be useful.
  • 5 - Recurrent brief depression as an indicator of severe mood disorders
    pp 109-130
    • By Jules Angst, Zurich University Psychiatric Hospital Zurich Switzerland, Alex Gamma, Zurich University Psychiatric Hospital Zurich Switzerland, Valadeta Ajdacic, Zurich University Psychiatric Hospital Zurich Switzerland, Dominique Eich, Zurich University Psychiatric Hospital Zurich Switzerland, Lukas Pezawas, Zurich University Psychiatric Hospital Zurich Switzerland, Wulf Rössler, Zurich University Psychiatric Hospital Zurich Switzerland
  • View abstract

    Summary

    This chapter begins by analyzing the associations between recurrent brief depression (RBD), recurrent brief hypomania (RBM), and recurrent brief anxiety (RBA). All three recurrent brief psychiatric syndromes share an ultrarapid cycling pattern of mood symptoms. In association with major depressive episodes (MDEs), they clearly increase impairment and worsen treatment outcomes. Given this greater clinical severity of combined depression (CD), it is reasonable to hypothesize that bipolar II (BP-II) disorders combined with RBD also represent more severe clinical conditions than pure BP-II forms. The main goal of the chapter is to test this hypothesis by comparing diagnostic subgroups of mood disorders with and without RBD in a large number of validating clinical variables, including family history, course, personality, and comorbidity. The relationship of the two mood spectra with recurrent brief psychiatric syndromes (RBD, RBM, and RBA), with particular emphasis on RBD is focused in this chapter.
  • 6 - Atypical depression and its relation to bipolar spectrum
    pp 131-156
    • By Franco Benazzi, Hecker Psychiatry Research Center University of California in San Diego (USA) collaborating center Ravenna Italy; University of Szeged (Hungary) National Health Service Forli Italy
  • View abstract

    Summary

    The relationship between atypical depression (AD) and bipolar (BP) spectrum is the relationship between BP-II and AD, because BP-II is the most common and best-studied disorder of the BP spectrum disorders. BP-II major depressive episode (MDE) versus unipolar (UP) MDE had a significantly higher frequency of AD, persisting when controlled for age. In BP-II MDE with a history of hypomania lasting less than 4 days, frequency of AD was significantly higher in comparison with UP MDE suggesting that a strong bipolarity may not be required to have more AD in BP-II. UP MDE switchers into hypomania during antidepressant treatment had features similar to the BP-II MDE switchers. Early-onset versus late-onset AD was significantly associated with female gender (+), number of MDE recurrences (+), BP-II (+), UP (-). Depressive mixed state was significantly more common in AD versus non-AD, and the association persisted when controlled for BP-II by logistic regression.
  • 7 - Agitated depression: spontaneous and induced
    pp 157-186
    • By Athanasios Koukopoulos, Centro Lucio Bini Center for the Treatment and Research of Affective Disorders Rome Italy, Gabriele Sani, Centro Lucio Bini Center for the Treatment and Research of Affective Disorders Rome Italy, Matthew J. Albert, Centro Lucio Bini Center for the Treatment and Research of Affective Disorders Rome Italy, Gian Paolo Minnai, Centro Lucio Bini Center for the Treatment and Research of Affective Disorders Rome Italy, Alexia E. Koukopoulos, Centro Lucio Bini Center for the Treatment and Research of Affective Disorders Rome Italy
  • View abstract

    Summary

    Depression is understood as a morbid entity and every physician is entitled to offer antidepressant treatment to nearly all patients with despondent mood diagnosed as meeting the DSM-III criteria for a major depressive episode with or without agitation. Normal human behavior, and especially behavior during affective episodes, has created the impression that good mood is allied with good drive and fluent thinking and vice versa. Hypomania with euphoric mood with hyperactivity, and depression with retardation are typical examples of this parallelism. It is ironic that today agitated depression has lost its status as a mixed state, whereas manic stupor and dysphoric mania are still considered as such. Clinical forms of agitated depression include psychotic agitated depression, agitated depression with psychomotor agitation, and minor agitated depression. The anxiety observed in agitated depression seems to be of a different kind, inherent in the agitation itself.
  • 8 - Schizoaffective mixed states
    pp 187-206
  • View abstract

    Summary

    The paradox of the extremely rare research on schizoaffective mixed states can be better understood when one considers the development of the definitions, concepts, and nosological allocations of schizoaffective disorders. In Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), schizoaffective disorders belonged to the category "other psychotic disorders" with almost the same diagnostic criteria and the same subtypes as in DSM-III-R. In the Tenth Revision of the International Classification of Diseases (ICD-10), schizoaffective disorders landed in a category of their own within schizophrenia and delusional disorders, with five subcategories: schizoaffective disorders, at the present manic, schizoaffective disorders, at the present depressive, mixed schizoaffective disorder, other schizoaffective disorders, and schizoaffective disorders not otherwise specified. The age at onset is lower, the duration of schizoaffective mixed episodes can be longer, and the patients having schizoaffective mixed episodes exhibited more inability to work at a younger age.
  • 9 - Acute and transient psychotic disorder: an atypical bipolar disorder?
    pp 207-236
  • View abstract

    Summary

    This chapter longitudinally compares patients diagnosed as having acute and transient psychotic disorder (ATPD) from the Halle Study on Brief and Acute Psychotic Disorder (HASBAP) with patients diagnosed as having affective or schizoaffective mixed states belonging to the Halle Bipolarity Longitudinal Study (HABILOS) group. The distinction between "abrupt" and "acute" onset is recommended because there is some evidence that the prognosis of ATPD with abrupt onset could be more favorable. The most essential predecessors of ATPD are cycloid psychosis and bouffée délirante, which show relevant similarities to the subgroup of ATPD "acute polymorphic psychotic disorders". The anxiety-happiness psychosis is characterized by continuous changing between severe all-pervasive anxiety and ecstatic happiness. Anxiety is often associated with delusions and hallucinations. The main characteristic of the hyperkinetic-akinetic motility psychosis is a disturbance of motility. Cycloid psychoses are bipolar disorders, but differ from manic-depressive illness.
  • 10 - Bipolar disorder in children and adolescents
    pp 237-251
    • By Boris Birmaher, University of Pittsburgh Medical Center Pittsburgh PA USA, David Axelson, University of Pittsburgh Medical Center Pittsburgh PA USA
  • View abstract

    Summary

    Children and adolescents with bipolar disorder (BP) usually have poor psychosocial outcome, increased risk for suicide, substance abuse, and psychosis, indicating the need for accurate diagnosis and prompt treatment of this illness. In clinical samples the incidence of BP disorder in children and adolescents has ranged from 2% to 15% depending on the nomenclature system, assessment instruments, and methodology used to diagnose patients' psychiatric disorders and sample origin. Patients with Kraepelinian or diagnostic and statistical manual of mental disorders (DSM-IV) classical BP disorder display the cognitive, emotional, and behavioral BP symptomatology described in adult BP populations, with a great proportion having mixed and rapid cycles. Early-onset BP disorder has severe negative psychosocial and academic consequences that can be potentially ameliorated by proper diagnosis and treatment. Patients with mixed presentations and/or rapid cycles appear to have a poorer response to the mood stabilizers.
  • 11 - Atypical features of bipolarity in old age
    pp 252-262
  • View abstract

    Summary

    Studying an elderly cohort confers several special advantages compared to younger or mixed-age populations. Atypical features described in this chapter include: late age of onset, prolonged latency from first depression to first mania, high prevalence of neurologic comorbidity presence of cognitive impairment, and poor outcome characterized by increased mortality. Age of onset can be an important variable that distinguishes subtypes of mania and bipolar disorder in order to improve understanding of underlying pathogenesis. Retrospective cohort studies of mania in late life have established a very clear association between bipolarity in old age and a heterogeneous group of neurological disorders. While pharmacokinetic and pharmacodynamic factors dictate a significant alteration in dosage, the general approach to treatment of bipolarity is not fundamentally different in an elderly population. The narrow therapeutic range for pharmacological therapies in old age is an important consideration in ongoing management.
  • 12 - Comorbidity in mixed states and rapid-cycling forms of bipolar disorders
    pp 263-276
    • By Peter Brieger, Martin-Luther-University Halle-Wittenberg Halle Germany
  • View abstract

    Summary

    In recent years, much has been written on the comorbidity of bipolar disorders with other mental illnesses. The comorbidity of medical conditions and bipolar affective disorders is a topic that warrants systematic research. Rapid cycling has been reported in various other neuropsychiatric disorders, such as head injury, stroke, learning disability, or rarer illnesses, such as cerebral sarcoidosis or tuberous sclerosis. Rapid-cycling bipolar affective disorders may concur with higher rates of substance-abuse disorders, but such an idea is mainly based on clinical observation or preliminary data. There is an overall tendency that mixed states and rapid-cycling forms of bipolar affective disorder constitute more unfavorable forms of the underlying illness. Mixed affective episodes have a link with anxiety disorders and anxious-dependent personality disorders. Rapid cycling may have a link with substance abuse and with certain neuropsychiatric disorders, or, perhaps, these neuropsychiatric disorders may mimic rapid cycling.
  • 13 - Challenges in the genetics of bipolar disorder
    pp 277-310
    • By Kathleen Marikangas, National Institute of Mental Health National Institutes of Health Bethesda, MD USA, Kelly Yu, National Institute of Mental Health National Institute of Mental Health Bethesda, MD USA
  • View abstract

    Summary

    The role of genetic factors in the etiology of bipolar disorder has been suspected for more than a century. Despite the abundance of well-controlled family and genetic studies that have employed sophisticated methodology to investigate the transmission of mood disorders among adults, there are only a limited number of controlled family studies that have focused on the manifestation of mood disorders among adolescents. The role of genetic factors underlying the familial aggregation of depression has been investigated by several twin studies of depressive symptoms and disorders among youth. Gene-environment interaction characterizes a broad range of human diseases such as cancer and birth defects. Seasonal affective disorder (SAD) applies explicitly to the major depressive episode in bipolar I, bipolar II, or major depressive disorder (MDD) at characteristic times of the year, occurring more commonly in females.
  • 14 - Biological aspects of rapid-cycling and mixed states
    pp 311-323
    • By Heinz Grunze, Department of Psychiatry, LMU Munich, Germany, Jörg Walden, Department of Psychiatry, University of Freiburg, Germany
  • View abstract

    Summary

    Rapid cycling includes some rare manifestations which appear to have a highly biological background, probably coupled to the circadian rhythm and Zeitgeber. Increased cortical norepinephrine (noradrenaline) and decreased 5-hydroxytryptamine and dopamine turnover has been described in bipolar patients. Concerning an impact of the serotonergic system, a very high and, compared to bipolar disorder in general, increased comorbidity has been described between mixed states, obsessive-compulsive disorder, and anxiety disorders, which are generally considered as serotonergic disorders. Besides acting on different neurotransmitters, antiepileptic drugs mainly target transmembranous ion fluxes. Mobilization of calcium is a key event in presynaptic and postsynaptic signalling and also in lasting neuronal changes, as long-term potentiation. The effects of antiepileptic drugs that are efficacious in mixed states and rapid cycling also include a variety of intracellular action targeting the protein kinase activity, the inositol phosphate metabolism, and finally the expression of early genes and cytoprotective proteins.
  • 15 - The treatment of bipolar mixed states
    pp 324-352
  • View abstract

    Summary

    Mixed states may represent a mixture of different elements of depressed and manic conditions. The most common mixed states are depressive or anxious mania, excited depression, and depression with flight of ideas. Others were manic stupor, mania with poverty of thought, and inhibited mania. Treatment of mania would be predicted to improve the depressive symptoms. Drugs such as lithium and lamotrigine may have the advantage of treating or preventing the depressed phase of bipolar disorder with less risk of triggering secondary mania and may be particularly useful in depression with hypomania (DMI) (bipolar: BP-II) disorder. Bipolar disorder is associated with an increased risk of comorbid conditions, including personality disorder, alcohol or drug misuse, and anxiety states. For rapid cycling bipolar patients, depot antipsychotics such as haloperidol decanoate stabilize mood swings. The use of antidepressants in bipolar depression is controversial, because of the suspected risk of triggering mania.
  • 16 - The use of atypical antipsychotic agents in the treatment of diagnostic subgroups of bipolar disorder: mixed and pure states, psychotic and non-psychotic
    pp 353-368
  • View abstract

    Summary

    This chapter reviews controlled findings regarding the impact of variant bipolar presentations to predicting treatment response with atypical antipsychotic agents. In the case of atypical antipsychotic medications, some findings are available regarding their use in patients with rapid-cycling bipolar disorder, as well as mania complicated by depression or psychosis. Antipsychotic agents may have unidirectional antimanic properties, tending to accelerate switch to depression or to cause dysphoria even in those without a primary mood disorder. The chapter primarily focuses on the relative response within diagnostic subgroups, especially psychotic versus non-psychotic, mixed versus manic, and rapid versus non-rapid cycling. Clozapine was the first of the atypical antipsychotic agents, with clinical trials in schizophrenia starting over three decades ago. Cerain other antipsychotic agents include risperidone, olanzapine, and aripiprazole. A diverse array of atypical antipsychotic medications has evidence of usefulness in mania, including lithium, anticonvulsants, antipsychotics, atypical antipsychotics, benzodiazepines, and calcium channel blockers.
  • 17 - Investigational strategies: treatment of rapid cycling, mixed episodes, and atypical bipolar mood disorder
    pp 369-385
    • By Gary Sachs, Massachusetts General Hospital Partners Bipolar Treatment Center Boston, MA USA, Mandy Graves, Massachusetts General Hospital Partners Bipolar Treatment Center Boston, MA USA
  • View abstract

    Summary

    Rapid cycling, mixed episodes, and atypical bipolar mood disorder each challenge clinical researchers in distinctly different ways. This chapter explores the issues as they relate to study design in general and offers suggestions for study methodology. The Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV) definition of mixed episodes requires a period of at least 1 week during which a patient meets full criteria for mania and major depression. Addressing factors related to the specificity of diagnosis and treatment outcome has great potential to improve the prospects for research on mixed episodes. The DSM-IV classifies rapid cycling as a course specifier rather than a subtype of bipolar disorder. Although rapid cycling is associated with relatively poor response to treatment and persistence of higher rates of cycling than non-rapid cycling, bipolar illness, indices such as family history, and age of onset do not separate rapid-cycling from non-rapid-cycling patients.

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