Wednesday, January 27, 2010

Bipolar Disorder Part 2

This is the second part of a series on bipolar disorder which is a common mood disorder affecting about 1% of the population. I indicated that the hallmark of this disorder is episodes of mania that are not due to substance abuse or medical problems. So what exactly is mania?

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision(DSM-IV-R) defines mania as follows;

Manic episodes are characterized by at least one week of profound mood disturbance characterized by elation, irritability, or expansiveness that causes significant impairment in occupational or social functioning or represents a danger to self or others that has at least three of the following symptoms;

Diminished need for sleep
Excessive talking or pressured speech
Racing thoughts or flight of ideas
Clear evidence of distractibility
Increased level of goal directed activity at home, at work, or sexually
Excessive pleasurable activities, often with painful consequences

This definition I suppose is ok but it doesn't capture the essence of mania which includes significant impairments in appearance, mood, thought content, perceptions, self destructiveness, aggression and judgment and insight so I will try to describe common changes we see in these areas.

Appearance - we see hyperactivity, hypervigilance, restlessness, excessive energy and activity. Thinking and talking are very fast, the person will often interrupt or talk over everyone else, will have no sense of social boundaries and be behaviorally intrusive. Attire may be very disorganized or very bright, colorful, or garish and they frequently attract attention because of the way they dress. Being with a manic person makes you want to find the "off button".

Mood - we see a tendency to be inappropriate in terms of being elated, jubilant, or euphoric or a high degree of easy annoyance or irritability that seems totally out of proportion to what is actually happening.

Thought content - We see expansive and overly optimistic thinking, inappropriate self confidence or grandiosity, high distractibilty, quickly shifting from one thought to another and, can be very hard for one to follow their train of thought. Often there are thoughts that the manic person has of being special or having some sort of special knowledge and these can become very delusional. There is an apparent need to excitedly tell others about this specialness or the grandiose insights.

Perceptions - We often see overt delusions which reflect perceptions of power, prestige, self worth, or glory and will sometimes move to extreme paranoia or hallucinations.

Self destructiveness - there can be suicidality although most suicide attempts in bipolar disorder occur in the depressed phase of the illness.

Aggression - we see at times aggression and combativeness, demandingness, and acting out of the grandiose belief that others need to obey their commands or wishes with anger and irritability when someone doesn't obey.

Judgment and Insight - It is the impaired judgment that really differentiates mania from normal "highs". Patients with mania have generally no insight. They rarely see anything wrong with themselves and resist efforts at treatment not seeing any need for it. Serious mistakes are frequently made in regard to finances, marriage and relationships, and occupation, refusing to listen to any one's advice often with devastating consequences.

This is a rather long post but I wanted to describe what mania is really like and I don't think the DSM-IV-TR really describes what goes on in mania.

I will discuss tomorrow some options for treatment. Again I welcome any questions or comments.

Thought for the day

Without treatment bipolar disorder can be a devastating disease.

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