What is bipolar affective disorder?

What is Bipolar Affective Disorder?

Bipolar affective disorder is a chronic mental illness characterized by alternating episodes of mania (or hypomania) and depression, representing a significant departure from an individual's baseline functioning, with episodes typically lasting at least 7 days for mania or 4 days for hypomania. 1

Core Clinical Features

Manic Episodes

• Marked euphoria, grandiosity, and irritability are the hallmark mood changes, accompanied by racing thoughts, increased psychomotor activity, and mood lability 2
• Decreased need for sleep is pathognomonic - patients maintain high energy despite minimal sleep, distinguishing true mania from other conditions 2
• Paranoia, confusion, and florid psychosis may be present during severe episodes 1
• Episodes must last at least 7 days unless hospitalization is required 1

Depressive Episodes

• Characterized by psychomotor retardation, hypersomnia, and significant suicidality 2
• Psychotic features are often present during severe depressive episodes 2
• Approximately 20% of youths with major depression eventually develop manic episodes by adulthood 1

Mixed Episodes

• Simultaneous symptoms of both mania and depression lasting 7 or more days 1
• Particularly common in adolescent presentations 2

Diagnostic Subtypes

Bipolar I Disorder

• Requires at least one full manic or mixed episode lasting ≥7 days 1
• Depressive episodes are common but not required for diagnosis 1
• Represents the classic form of the illness 1

Bipolar II Disorder

• Requires periods of major depression and hypomania (≥4 days) 1
• No full manic or mixed episodes occur 1

Rapid Cycling Variants

• Rapid cycling: Four or more mood episodes per year, with episodes still meeting duration criteria 1
• Ultrarapid cycling: 5-364 cycles per year with episodes lasting hours to days 1
• Ultradian cycling: More than 365 cycles per year with mood shifts occurring within a single day 1

Epidemiology and Risk Factors

Prevalence

• Overall prevalence is approximately 1% in the general population 1
• Peak age of onset ranges from 15 to 30 years 1
• Rates increase with age, though symptoms often begin in childhood 1

Genetic Factors

• Four- to sixfold increased risk in first-degree relatives of affected individuals 1
• Familiality appears even higher in early-onset, highly comorbid cases 1
• Strong genetic component supported by twin, adoption, and family history studies 1

Premorbid Indicators

• Dysthymic, cyclothymic, or hyperthymic temperaments may precede bipolar disorder 1
• Premorbid psychiatric problems are common, especially disruptive behavior disorders and irritability 1
• Risk factors for developing mania in depressed patients include: rapid onset depression with psychomotor retardation and psychotic features, family history of bipolar disorder, and history of antidepressant-induced hypomania 1

Age-Specific Presentations

Adults

• Episodes represent significant departure from baseline with cyclical nature and distinct episode boundaries 2
• More classic presentation with clearer demarcation between mood states 2

Adolescents

• Frequently associated with psychotic symptoms and markedly labile moods 2
• Mixed manic and depressive features are common 2
• More chronic and refractory to treatment than adult-onset cases 2

Children

• Changes in mood, energy, and behavior are markedly labile and erratic 2
• Irritability and belligerence more common than euphoria, though elation and grandiosity must still be present for diagnosis 3
• High rates of comorbid disruptive disorders complicate diagnosis 2
• Diagnostic validity in preschool children remains unestablished 1

Critical Diagnostic Distinctions

Distinguishing from Other Conditions

• Manic symptoms represent marked changes in mental state, not reactions to situations, temperamental traits, or anger outbursts 1
• Pattern of illness, duration of symptoms, and association with psychomotor, sleep, and cognitive changes are critical diagnostic clues 1
• Illness must be evident and impairing across different realms of life, not isolated to one setting 1

Common Diagnostic Pitfalls

• Manic-like symptoms of irritability and emotional reactivity occur in disruptive behavior disorders, PTSD, and pervasive developmental disorders 1
• Many explosive, dysregulated youth may not have true bipolar disorder - irritability and impulsivity alone do not constitute mania 3
• Elation and grandiosity must be present, not just irritability 3
• High comorbidity with ADHD (up to 80% of cases) complicates diagnosis, but follow-up studies show ADHD alone does not progress to classic bipolar disorder 1, 3

Clinical Course and Prognosis

Natural History

• Bipolar disorder is a chronic, lifelong condition with frequent relapses and recurrences 4
• Early-onset cases are associated with more severe course, worse prognosis, and higher suicide rates 5
• Adolescents with bipolar disorder have high rates of suicide attempts and are at clear risk for completed suicide 1

Comorbidities

• High rates of substance abuse in this population 1
• Common comorbid conditions include anxiety disorders, ADHD, disruptive behavior disorders, and PTSD 1
• Approximately 20% overlap with borderline personality symptoms in long-term follow-up 1

Treatment Implications

Pharmacotherapy

• FDA-approved medications for manic episodes in youth include lithium, aripiprazole, quetiapine, risperidone, and olanzapine 6, 5
• For depressive episodes, combination therapy with olanzapine and fluoxetine is recommended 5
• Mood stabilizers are currently indicated only for single mood episodes - no true mood-stabilizing drugs effective for both manic and depressive episodes exist 7

Psychosocial Interventions

• Pharmacotherapy alone is insufficient - combination with psychoeducation enhances remission 4
• Evidence-based approaches include interpersonal social rhythm therapy, family-focused treatment, and cognitive-behavioral therapy 8
• Patients and families should be educated about triggers, warning signs, and effectiveness of early intervention 4

Monitoring Requirements

• Regular assessment of mood symptoms, psychosocial functioning, and suicide risk is essential 9
• Treatment plan must be continually adjusted during long-term management 9
• Comorbid psychiatric, substance use, and general medical conditions require ongoing management 9