Bipolar disorder (manic-depressive psychosis) is a mental illness of an endogenous nature, manifested by a change of affective phases: manic, depressive. In some cases, bipolar depression occurs in the form of various variants of mixed states, which are characterized by a rapid change in manic and depressive manifestations, or the symptoms of depression and mania are clearly expressed at the same time (for example, melancholy, combined with strong agitation, mental retardation with euphoria).
Separate episodes (phases) of bipolar disorder immediately follow each other or manifest themselves through a “bright” gap in the mental state of an individual, called an intermission (or interphase). This asymptomatic period proceeds with a full or partial resumption of mental functions, with the restoration of personal qualities and individual character traits of the patient. Numerous scientific studies have identified in 75% of patients with BAR the presence of other concomitant mental pathologies, in most cases - anxiety-phobic disorders.
The study of manic-depressive psychosis, as an independent nosological unit, has been conducted since the second half of the 19th century. For the first time this disease was described as a circular psychosis, later interpreted as "mental insanity in two phases." With the introduction of the International Classification of Diseases (ICD 10) in 1993, the disease was renamed to the more correct and scientific essence of the name - bipolar affective disorder. However, to this day, psychiatry lacks both a single definition and a research-confirmed understanding of the likely clinical limits of this depression due to pronounced heterogeneity (the presence of completely opposite parts in the structure) of the disease.
Currently in the medical environment for the classification of a specific type of disorder using differentiation justified by the predicted clinical development. The division is carried out on the basis of factors indicating the prevalence of one or another phase of affective disorder: a unipolar form (manic or depressive), a bipolar form with a predominance of either manic or depressive episodes, a clearly bipolar form with approximately equal manifestations of conditions.
It is rather difficult to assess the real prevalence of bipolar depression due to the presence of various criteria for its diagnosis. However, analyzing various sources of both domestic and foreign studies, it can be assumed that, even with a conservative approach to the criteria of pathology, from 5 to 8 people out of 1000 suffer from bipolar disorder. Moreover, the percentage of sick people is approximately the same in both men and women There is also no significant dependence among people suffering from the disorder, from being in a particular age group, social status, or belonging to a particular ethnic group. According to the WHO, the probability of falling ill with bipolar depression in life is from 2 to 4%, while the debut of the disease in 47% percent of patients diagnosed with BAR is between 25 and 45 years old. Scientific studies have established that the bipolar form of the disorder develops, as a rule, at the age of up to 30 years, the unipolar form - after the thirty-year threshold, and the depressive phases prevail in persons who have stepped over the 50-year mark.
Bipolar depression: options for leaks
In the light of modern interpretations of the varieties of bipolar disorder, we can distinguish variants of the disease:
- unipolar view;
- periodic mania (the patient manifests only manic episodes);
- recurrent depression (in the individual phases of depression are expressed). Although according to ICD-10 and DSM-IV, this type is attributed to the states of recurrent depression, most psychiatrists believe that such an allocation is unjustified;;
- intermittent correctly interleaved type: regular alternation and successive alternation of manic phase and depressive episode through intermission;
- irregular-intermittent appearance: alternation of depressive and manic states through an interphase without observing a certain sequence;
- double form: change of one phase to another without observing the period of "rest", after the manifestation of which intermission follows; circular form (psychosis circularis continua) - successively intermittent states without gaps of a stable mental state.
Among the clinically recorded cases, the most common intermittent type of manic-depressive psychosis, reflecting the characteristic essence of the disorder - its circular rhythm.
Bipolar Depression: Causes
To date, the probable causes of the occurrence of bipolar disorder have not been established and have not been fully studied, but some scientific hypotheses have been confirmed. Among the theories, the most likely factors in the formation of pathology are: genetic inheritance (predisposition) and neurochemical processes occurring in the body. Thus, the disease can be triggered by disturbances in the metabolism of biogenic amines, pathologies in the endocrine system, disorder of circadian rhythms, failure in water-salt metabolism. The likelihood of developing BAR is also influenced by the specificity of the course of the childhood period and the constitutional features of the organism of the individual. Accumulated scientific data have shown that the proportion of genetic factors in the formation of mental pathology reaches 75%, and the contribution of the “environment” does not exceed 25%.
Factor 1. Genetic predisposition
The mechanism of transmission of the predisposition to the disorder has not been fully studied, but there are scientific facts indicating hereditary transmission of the disease through a single dominant gene with partial penetration linked to the X chromosome. Another genetic marker of affective disorders is the deficiency of G6PD (cytosolic enzyme glucose-6-phosphate dehydrogenase).
Genetic studies conducted by mapping (determining the location of various polymorphic regions of the genome) demonstrated a high risk (up to 75%) of inheritance of bipolar disorder in the family history. In the course of scientific work carried out at Stanford, hereditary susceptibility to the formation of pathology in offspring was confirmed (over 50%), even in cases where one of the parents suffers from this ailment.
Factor 2. Features of the childhood period
The conditions of upbringing and attitude to the child from the side of the close environment plays a significant role on the formed features of the mental sphere. All the studies conducted in this segment confirmed that the vast majority of children raised by parents with mental pathologies have a significant risk of developing BAR in the future. A long stay of a child with persons prone to intense and unpredictable mood changes, suffering from alcohol or drug addiction, sexually and emotionally unrestrained is a strong chronic stress, fraught with the formation of affective states.
Factor 3. Parents age
The results obtained in the course of modern scientific work “Archives of Psychotherapy” showed that children born to elderly parents (over 45) have a significantly greater risk of falling ill with mental pathologies, including bipolar depression.
Factor 4. Gender
According to modern data, monopolar types of affective disorders most often develop in women, and the bipolar form is more often affected by the stronger sex. It has been established that the debut of manic-depressive psychosis in women more often occurs during the period of menstruation, when entering into the menopausal phase, it may appear later or be provoked by postnatal depression. Any psychiatric episode of endogenous nature (associated with changes in the hormonal background) increases the risk of BAR by 4 times. In a special risk group, women who in the previous 15 years suffered from some form of mental disorder and were treated with psychotropic drugs.
Factor 5. Personality characteristics
The facts that establish a direct relationship between the development of affective disorders and the peculiarities of the individual's mental activity are well studied. The risk group includes persons of a melancholic, asthenic, depressive, static-chemical constitution. Many authoritative experts indicate that such features as: accentuated responsibility, pedantry, exaggerated demands on his personality, conscientiousness, diligence, acting as the main factors of personality activity, combined with the lability of the emotional background, are ideal grounds for the occurrence of BAR. Also, persons with mental deficiency are predisposed to bipolar disorder - subjects who do not have personal resources necessary to meet basic (life-supporting) needs, to set and then achieve goals, to achieve well-being (in the sense of human awareness).
Factor 6. Biological theory
According to numerous studies, one of the leading factors in the formation of bipolar disorder is an imbalance of neurotransmitters, whose functions are the transmission of electrical impulses. Neurotransmitters: catecholamines (norepinephrine and dopamine) and monoamine - serotonin have a direct effect on the functioning of the brain and the whole body, in particular, "control" the mental sphere.
The lack of these neurotransmitters leads to serious mental pathologies, provoking a distortion of reality, illogical way of thinking, antisocial behavior. The deficiency of these biologically active substances causes deterioration of cognitive functions, affects the mode of wakefulness and sleep, changes the eating behavior, reduces sexual activity, activates the lability of the emotional background.
Factor 7. Violations of jet lag
According to experts, the failure of the circadian rhythm plays a significant role in the formation of bipolar disorder - violations in the cyclical fluctuation of the speed and intensity of biological processes. Problems with falling asleep, loss of sleep, or frequent intermittent sleep can provoke the formation of both a manic state and a depressive phase. Also, the patient’s concern about the lack of sleep leads to increased arousal and increased anxiety, which worsens the course of affective disorder and intensifies its symptoms. Disruptions in circadian rhythms were noted in most cases (over 65%) as clear precursors to the onset of the manic phase in patients with bipolar disorder.
Factor 8. Substance Abuse
Drug abuse and alcohol abuse are common causes of bipolar symptoms. Static data obtained from studying the lifestyle of patients and the presence of harmful addictions in them show that about 50% of people with this diagnosis have or have problems in the form of addiction to narcotic, toxic or other psychoactive substances.
Factor 9. Chronic or one-time intense stress.
Many clinical cases are recorded when the diagnosis of bipolar disorder was made to a person after recent stressful events. Moreover, traumatic events can be not only serious negative changes in a person’s life, but also ordinary events, for example: change of season, period of vacation or holidays.
Bipolar Depression: Symptoms
It is impossible to predict with how many phases, of what nature a bipolar disorder manifests itself in a given patient: the disease can manifest itself in a single episode, or it can proceed according to different schemes. Ailment can show only manic or depressive states, manifest their correct or incorrect replacement.
The duration of a separate phase in the case of an intertrophied version of the disease can vary over a wide time range: from 2-3 weeks to 1.5-2 years (on average from 3 to 7 months). As a rule, the manic phase lasts three times shorter than the depressive episode. The duration of the intermission period can vary from 2 to 7 years; although the "bright" segment - interphase in some patients is completely absent.
Possible atypical variant of the course of the disease in the form of incomplete disclosure of phases, disproportionality of core indicators, the addition of symptoms of obsession, hypochondria, senesthopathy and paranoid, hallucinatory, catatonic syndromes.
Main symptoms of the manic phase:
Hyperthymia - persistent high mood, accompanied by increased social activity, increased vitality. In this state, an individual is characterized by anomalous, inappropriate to the actual situation, cheerfulness, a feeling of complete well-being, excessive optimism. A person may experience distorted high self-esteem, confidence in his uniqueness and superiority. The patient significantly embellishes or attributes nonexistent own advantages, does not accept any criticism.
Psychomotor agitation is a pathological condition in which painful fussiness, anxiety, incontinence in statements and inconsistency in actions are clearly manifested. An individual can simultaneously take up several cases, but none of them can be brought to a logical conclusion.
Tachypsychia is the acceleration of the speed of thought processes with characteristic spasmodic, inconsistent, illogical ideas. The patient is distinguished by verbosity, and the spoken phrases are of bright emotional coloring, often of an angry, aggressive content.
In the clinical course of manic syndrome, psychiatrists conditionally distinguish five phases, which are characterized by specific manifestations.
Bipolar depression: treatment
Essential to the successful treatment of bipolar disorder is its timely diagnosis in the early stages of the development of pathology, since the effectiveness of therapy depends on the number of episodes suffered by the patient. It is necessary to differentiate this pathology from other types of mental diseases, in particular: unipolar depression, schizophrenic spectrum disorders, oligophrenia, diseases of infectious, toxic, traumatic genesis.
Treatment of bipolar affective disorder requires competent psychopharmacological therapy. Suffering from this disease is usually prescribed several potent drugs of different groups, which creates certain difficulties to prevent their side effects.
To relieve both manic and depressive phases, an “aggressive” drug therapy is carried out in order to prevent the development of resistance to pharmacological drugs. It is recommended that at the initial stages of treatment, patients should be given the maximum allowable doses of drugs and, focusing on the therapeutic response from their intake, increase the dosage.
However, the “cunning” of this disease consists in the fact that with excessively active use of drugs, inversion (direct change) of one phase to the opposite state is possible, therefore, pharmacological therapy should be carried out with constant monitoring by competent specialists of the clinical picture of the ailment. The scheme of pharmacological treatment is chosen exclusively on an individual basis, taking into account all the features of the course of the disease in a particular patient.
Preparations of the first line of choice in the treatment of manic phase - a group of mood stabilizers, represented by lithium preparations, carbamazepine, valproic acid. In some cases, doctors resort to the appointment of atypical antipsychotics.
In contrast to the classic treatment of depressive conditions, it should be borne in mind that therapy with tricyclic antidepressants and irreversible monoamine oxidase inhibitors increases the risk of a depressive episode passing into a manic phase. Therefore, in modern psychiatry for the treatment of bipolar depression resort to SSRIs (selective serotonin reuptake inhibitors), the use of which is much less likely to cause the inversion of conditions.
Bipolar depression is a disease that is difficult to diagnose and is long in treatment, which requires close cooperation between the doctor and the patient and impeccable patient compliance with the drugs prescribed to him. In the case of an acute course of the disease (in the event of suicidal thoughts and attempts, the individual commits socially dangerous actions and other conditions that threaten the life of the individual and others), the patient is required to be hospitalized immediately in a hospital.