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Mania Neel Halder, Alpha Hospitals, Bury, UK Ó 2015 Elsevier Ltd. All rights reserved.
Abstract Bipolar disorder, previously known as manic depression, is a chronic episodic mental illness associated with behavioral disturbances. It is characterized by episodes of mania (or hypomania) and depression, and either one can occur first. A diagnosis of bipolar requires at least one depressive episode and at least one manic or hypomanic episode. This article explores the history, diagnosis, epidemiology, course and prognosis, etiology, and management of bipolar disorder. The management of the depressive phase is similar to unipolar depression, and is covered in the article Depression.
Introduction When I came out of the hospital . I fancied that I hadn’t had anything, only afterwards did I have the feeling that I’d been ill. What can you say, I have moments when I’m twisted by enthusiasm or madness or prophecy like a Greek oracle on her tripod. Vincent van Gogh, 3 February 1889, in a letter addressed to his brother Theo
Mania is a serious mental disorder characterized typically by elevated mood, a quickening of speech and thoughts, a feeling of having more energy, and need for less sleep, grandiosity, occasionally heightened sexuality and irritability. The Oxford Dictionary (2010) describes mania as a “mental illness marked by periods of great excitement or euphoria, delusions, and overactivity.” The word mania comes from the Greek word literally meaning ‘madness.’ Depression has been covered in the article ‘Depression’.
History of Bipolar In the first century BC, the Greek physicians suggested a connection between melancholia and mania. Just as they thought melancholia resulted from an excess of ‘black bile,’ mania was thought to result as an excess of ‘yellow bile.’ In the nineteenth century French doctors started thinking of mania and depression as being on the same continuum: ‘la folie double forme’ (Baillarger, 1854), and ‘folie circularie,’ a circular form of mania and depression (Falret, 1854). Although Falret (1854) had described mild forms of mania, Mendel (1881) was the first person to define ‘hypomania’ as a “form of mania which typically shows itself only in the mild stages, abortively, so to speak.” Kahlbaum (1882) described cyclothymia as milder changes in mood shifts but not enough to become depression or mania. It was around this time when van Gogh produced his paintings, and future historians would comment on how they could tell when he was in his more elated and more depressed stages of his illness from his paintings alone (see Figure 1). This is made easier due to the large number of letters written by van Gogh, all dated and many detailing his state of mind and health, and therefore making it possible to match the paintings to the letters. The painting shown was completed in what was described as the most productive
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period of his painting career, and the use of the vivid colors and the content of blossoming trees are in sharp contrast with the darker colors shown in the article ’Depression‘. Kraepelin (1921) then made the leap and separated mood disorders from others such as schizophrenia, introducing the term ‘manic depressive.’ Leonhard in 1957 used the word ‘bipolar’ to distinguish between people who experienced mania and depression, and ‘unipolar’ for those with depression only (Leonhard, 1957). Bipolar has now been adopted into modern psychiatric practice, and replaced the term ‘manic depression.’
Diagnosis There are two widely recognized contemporary classification systems in use worldwide for depression: the ICD-10 (WHO, 1992) and DSM-IV (APA, 1994), both of which have new versions due out in the near future. Operational definitions are provided for clinical and epidemiological research. Table 1 shows the similarities and differences between the two main classification systems. Both systems have categories for single and recurrent episodes, and both have a category
Figure 1 Vincent van Gogh. Orchard with blossoming apricot trees. Painting, Oil on Canvas. Arles: March 1888. In Van Gogh Museum, Amsterdam.
International Encyclopedia of the Social & Behavioral Sciences, 2nd edition, Volume 14
http://dx.doi.org/10.1016/B978-0-08-097086-8.27037-2
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Table 1
Classification of mania/bipolar disorder
ICD-10 Manic episode l Hypomania l Mania, without psychosis l Mania, with psychosis Bipolar affective psychosis l Currently hypomanic l Currently manic (with/without psychosis) l Currently depressed (mild, moderate, or severe) l Currently mixed l In remission Cyclothymia
DSM-IV Hypomanic episode Manic episode l Mild l Moderate l Severe l Severe with psychosis Bipolar I and II disorders l Current (or most recent episode) l Hypomanic l Manica l Depressed l Mixeda Cyclothymic disorder
a
Excludes bipolar II disorder.
A ‘mixed’ episode of bipolar disorder can occur where a depressed mood may be accompanied by days or weeks of overactivity and pressure of speech; or conversely, a manic mood to be accompanied by agitation, loss of energy, and libido. Sometimes depressive symptoms and hypomanic or manic symptoms may alternate day to day or even hour to hour. According to the ICD-10, a diagnosis of mixed bipolar disorder should be made if the two sets of symptoms are both prominent for the greater part of the current episode, which should last at least 2 weeks (DSM-IV requires the episode to be at least 1 week). Rapid cycling disorder can occur with both bipolar I and II disorders, and the diagnosis is made where there are at least four affective episodes (i.e., major depression, mania, hypomania, or mixed mood disorder) in the previous 12 months. Rapid cycling is more common in women, and unfortunately has a poorer response to treatment such as with lithium. Any assessment of bipolar disorder needs to include the following: l
for cyclothymia, as a persistent instability of mood involving periods of mild depression and mild elation, but neither being severe or prolonged enough to meet the criteria for bipolar. Also both systems divide mania into whether or not it features with psychotic symptoms. In the ICD-10 (WHO, 1992), the authors write that people with cyclothymia may not come to the attention of medics, as the elevated periods may well be enjoyable to the individual. Hypomania is more persistent (of at least 4 days) and more marked than the elation experienced in cyclothymia, but there are no hallucinations or delusions, and the symptoms do not tend to lead to a severe disruption of work or social rejection. This is in contrast to mania, where normal social inhibitions are lost, and there is marked distractibility. This is in addition to the usual core symptoms of elation, increased energy (resulting in overactivity), pressure of speech (characterized by uninterruptability), increased self-esteem and optimism, and decreased need for sleep. There is a tendency to embark on extravagant and dangerous schemes, spend money recklessly, and make some inappropriate amorous advances. The episode should last at least 1 week before a diagnosis is made. If psychosis is present, it usually takes the form of delusions of grandiosity (e.g., having superpowers, being extremely wealthy, or related to royalty). Persecutory or religious delusions can also be present. ‘Flight of ideas’ can be present, whereby the individual flits from topic to topic with a tenuous connection, often ending up on an answer far removed from the question asked. Sims (1995) describes an example of flight of ideas in his book, of a female patient saying: “They thought I was in the pantry at home . Peekaboo . there’s a magic box. Poor darling Catherine, you know, Catherine the Great, the fire grate, I’m always up the chimney. I want to scream with joy .. Hallelujah!” In severe cases, there may be a neglect of self-care, and of eating and drinking, and they may be placing themselves at risk from and to others. A diagnosis of bipolar requires at least one depressive episode and at least one manic or hypomanic episode. DSM-IV further separates bipolar into: l l
Bipolar I – where mania has occurred on one occasion Bipolar II – where hypomania has occurred (but not mania)
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l l l l l l
Detailed history of the episode (symptoms, presence of hallucinations or delusions, collateral history if possible) Any previous episodes of mania or depression Any suicidal or homicidal thoughts Any self-neglect Family history Substance misuse, smoking, and alcohol intake General physical health
In addition one needs to rule out the following that can present in similar ways to bipolar, but should not be misdiagnosed as such (Smith et al., 2011): l l l l l l
Hyperthyroidism or hypothyroidism Anorexia nervosa Cerebrovascular event Dementia Other psychiatric disorders, for example, schizophrenia Acute drug withdrawal or illicit drug ingestion
Sims (1995) describes in his book about how the manic patient “looks at his world with complete, unshakeable, and wholly unjustified optimism.” The person with mania frequently does not have insight into the illness, meaning that when others try and help slow things down, it often manifests in what Sims calls ‘manic irritability’, when “he feels all his brilliant ideas are frustrated by the lack of vision of everyone else” (Sims, 1995).
Epidemiology Males and females are equally affected in bipolar disorder (but not in rapid cycling), in contrast to depression, which is more common in women. The lifetime prevalence of bipolar disorder varies from 0.3% to 1.5%. The average age of onset in Western countries is around the mid-20s, although the most common age of onset is the late teenage years, 15–19 years (Joyce, 1984). The second most frequent age range of onset is 20–24 years. Late-onset bipolar disorder is rare but it does occur. Interesting Yutzy et al. (2012) report an increase in the prevalence bipolar affective disorders I and II, where from
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mid-1970s to 2000 it ranged from 0.4% to 1.6%, and by the late 1990s to the 2000s, it had climbed from approximately 5% to 7%.
Course and Prognosis Manic episodes last between 2 weeks and 4–5 months in bipolar disorder, although over the course of the disorder, there are many more episodes of depression than mania. Ninety percent of patients would experience more than one episode of mania. As patients become older, the time between episodes becomes shorter in duration. Unfortunately, only 20% achieve 5-year stability with good social and personal outcome (NICE, 2006). According to Abreu et al. (2009) 25–56% present at least one suicide attempt during their lifetime and 15–19% die from the attempt. Lithium has been shown to reduce the risk of suicide and number of suicide attempts in bipolar disorder, but is less effective in rapid cycling bipolar disorder, which has a poorer prognosis (Tondo and Baldessarini, 2009). There is an association between bipolar disorder and premature death. In a national cohort study of 6618 adults with bipolar disorder, Crump et al. (2013) found that those with bipolar disorder died about up to 9 years earlier on average than the rest of the population. They died prematurely from multiple causes, including cardiovascular disease, diabetes, chronic obstructive pulmonary disease, influenza or pneumonia, unintentional injuries, and suicide. Several factors have been reported to indicate a better or worse prognosis for bipolar (Soreff and Ahmed, 2014). Factors suggesting a worse prognosis include the following: l l l l l l
Poor job history Alcohol abuse Psychotic features Depressive features between periods of mania and depression Evidence of depression Male sex Factors suggesting a better prognosis include the following:
l l l l l
Shorter manic phases Late age of onset Few thoughts of suicide Few psychotic symptoms Few medical problems
a concordance of 33–90% for bipolar I in identical twins (Soreff and Ahmed, 2014). If genes were the only etiological factor, one would expect 100% concordance as they share 100% of their genes. Conversely, adoption studies show that environment alone is also not the only factor. Children whose biologic parents have either bipolar I or a major depressive disorder remain at increased risk of developing an affective disorder, even if they are reared in a home with adopted parents who are not affected (Soreff and Ahmed, 2014). A child of a parent with bipolar disorder has a 50% chance of having a major psychiatric disorder. First-degree relatives of people with bipolar I are approximately 7 times more likely to develop bipolar I than the general population (Soreff and Ahmed, 2014).
Biochemical Factors Certain drugs such as cocaine that increase the levels of monamines (dopamine, serotonin, norepinephrine) in the brain can precipitate mania. Some authors have implicated the neurotransmitter glutamate in the etiology of affective disorders, and postmortems looking at the frontal lobes of those with affective disorders have shown elevated levels of glutamate (Hashimoto et al., 2007). The hypothalamic–pituitary–adrenal (HPA) axis is a regulatory system that integrates neuronal and endocrine function, and manic and depressed bipolar individuals appear to have a dysregulated HPA axis. The HPA axis is linked to the serotonin system, sleep disturbance, and cortisol secretion. Exploring this further may give rise to other novel treatment strategies.
Neurophysiological Factors A decrease in gray matter, a decreased activation in certain brain regions, and an increased activation in other regions (such as the ventral limbic area that mediate and generate emotional responses) have been discovered (Houenou et al., 2011), although more research in this area is needed.
Psychodynamic Factors Melanie Klein proposed that mania was a defense against depression, and certain personality characteristics may be present in those with bipolar disorder (disturbances in neuroticism, extraversion, and openness) (Barnett et al., 2011). A dysregulation of self-esteem, childhood trauma, and abuse have been proposed as etiological factors for bipolar disorder (Leverich et al., 2002).
Etiology Genetic Factors
Environmental Factors
Bipolar disorder is one of the most heritable of all psychiatric disorders. There is a genetic component to bipolar disorder, and the literature suggests the involvement of the following genes: ANK3, CACNA1C, and CLOCK genes (Sklar et al., 2008; Ferreira et al., 2008). These genes are thought to make someone susceptible to bipolar disorder, but like many other psychiatric disorders, there are other environmental factors that come into play. Further evidence of the gene–environment hypothesis comes from twin studies, where there is
The gene–environment hypothesis dictates that the genes make an individual susceptible to the disorder, and the environment acts as an additive to cause the disease; different researchers have proposed differing amounts of interaction between the genes and the environment. A stressful circumstance can often act as a trigger for bipolar, and these could include relationship breakdown, abuse, death of a loved one, physical illness, prolonged sleep disturbance, or accumulative stress related to money, work, or relationships.
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Cultural Factors
Pharmacological Interventions
In the UK, Afro-Caribbean immigrants have been found to be at a greater risk of presenting as manic than their Caucasian counterparts (van Os et al., 1996), although this could be due to the stress of immigration or racial prejudice. In Figi, a condition called ‘matiruku’ has been reported, described as a ‘periodic insanity’ (Price and Karim, 1978). It is characterized by increased talkativeness, increased psychomotor activity, elated mood, a decreased need for sleep, and occasional violence. These episodes would occur at the same time every month, or every year, and would last about 2–7 days. Diagnoses could be influenced by the self-report of individuals belonging to certain communities, giving skewed data. For example, in Amish communities, overly inflated self-esteem is considered to be a grave sin. In both prospective and retrospective studies carried out in China and Israel in individuals with bipolar disorder, there has been a preponderance of recurrent manic episodes over depressive episodes. This is the opposite to what has been found in other areas across Europe and other Western countries. Some authors suggest that climactic factors may play a part in the course for bipolar disorder (Sanches and Jorge, 2004).
Treatment of Acute Manic or Hypomanic Symptoms The drug treatment of an acute manic or hypomanic episode depends on the severity of symptoms and clinicians should be guided by current medication doses and previous response (NICE, 2006). When the NICE (2006) guidelines were written only lithium, olanzapine, quetiapine, risperidone, and valproate semisodium were licensed for the treatment of acute mania in the UK. Lithium, olanzapine, or valproate should be considered for long-term treatment (2–5 years depending on risk factors) of bipolar disorder. Lithium requires monitoring of levels and monitoring of renal and thyroid function. Pharmacological agents approved by the FDA, however, for use in treating bipolar disorder are as follows (taken from Sorref and Ahmed, Medscape, updated 2014): l l l l l l l l
Treatment and Management The following is largely based on the current National Institute for Health and Clinical Excellence (NICE) guidelines in the UK for adults, children, or adolescents with bipolar disorder (NICE, 2006), and the Evidence-based guidelines for treating bipolar disorder: revised second edition from British Association for Psychopharmacology (Goodwin, 2009). NICE provides national guidance and advice to improve health and social care, and the recommendations are based on the best available evidence, also taking into account of cost–benefit ratio.
Non-pharmacological Treatment Of paramount importance is the need to establish a trusting therapeutic relationship between the individual with bipolar, and the carers and health-care professionals. The following are examples of non-pharmacological treatments that can help in bipolar (Patient.co.uk, 2012). l l l l l l l l l l
l l
Education regarding diagnosis, treatment, and side-effects Good communication Self-help groups Support groups Self-monitoring of symptoms, side-effects, and triggers Coping strategies Psychological therapy Encouragement of engagement in calming activities Telephone support Diet – adjunct use of omega-3 fatty acids could help bipolar depressive but not bipolar manic symptoms (Sarris et al., 2012) Regular exercise Psychological interventions such as cognitive behavioral therapy and supportive psychotherapy (Goodwin, 2009)
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l l l l
Valproate (manic) Carbamazepine, extended-release (manic, mixed) Lamotrigine (maintenance) Lithium (manic, maintenance) Aripiprazole (manic, mixed, maintenance) Ziprasidone (manic, mixed) Risperidone (manic, mixed) Asenapine (manic, mixed) Quetiapine (manic, depression) Chlorpromazine (manic) Olanzapine (manic, mixed, maintenance) Olanzapine–fluoxetine (depression)
Figure 2 shows the initial treatment plan for mania or mixed bipolar episode as devised by the British Association of Psychopharmacology (Goodwin, 2009).
Management of Depressive Symptoms This is the same as in the management in unipolar depression, and is included in the articles on depression and antidepressants, and hence has not been included here. Of note, however, there is a risk of switching to a manic episode with antidepressants, and thus caution is advised and careful monitoring is necessary. In bipolar, antidepressant may not be as effective, and a combination therapy (antidepressant with an antimanic agent) may be required.
Management of Acute Mixed Episodes NICE (2006) advises that antidepressants should be avoided, and prescribers should consider treating patients with an acute mixed episode as if they had an acute manic episode (see above). Patients should be monitored closely for risk of suicide.
Management of Rapid Cycling Previous treatments need to be reviewed, and the prescriber needs to check for compliance with medication. If they are on antidepressants, then this needs to be stopped. Thyroid function should be checked, and anti-manic therapy will need to be optimized. Lithium and valproate is used first line, but if this does not work, lithium can be trialed on its own (NICE, 2006). Lithium levels would need to be
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Diagnosis
Bipolar disorder manic
Assessment
ty, paƟent pa Safety, and family preferences and consider need for admission
CommunicaƟon
ain treatment tre Explain plan
Severity Severe
Mild
I.M. (if required)
Ora treatment tmen Oral
t Oral treatment
AnƟpsychoƟc or benzodiazepine
AnƟpsychoƟc or valproate
AnƟpsychoƟc or valproate or lithium (or carbamazepine
On anƟdepressant?
Taper and disconƟnue
Sleep deprived?
sider benzodiazepine b Consider short term
Already on long term treatment?
mize and conƟnue OpƟmize
i response Review
P Poor response
Good response
Figure 2
Evidence-based guidelines for treating manic or mixed bipolar episode. Goodwin, 2009.
checked, as both lithium withdrawal and lithium toxicity can cause rapid cycling. Psycho-education (in addition to keeping a ‘mood diary’ detailing aspects of their symptoms, when they occur and anything that helps) should be
encouraged. The focus should be on optimizing the longterm treatment instead of focusing on each individual episode. Medication trial should last for more than 6 months (NICE, 2006).
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Electroconvulsive Treatment in Bipolar Electroconvulsive treatment (ECT) should only be considered in severe cases, with the aim of obtaining short-term and quick resolution or improvement of the symptoms. ECT should be used only when pharmacological and psychological treatment has been tried and failed. ECT can also be used if the situation is thought to be life threatening in those with severe depression, catatonia, or a prolonged or severe manic episode (NICE, 2006). The effects of ECT are thought to be short-lived.
Summary In recent times, more people in the media and public eye are declaring their diagnoses of bipolar. This has undoubtedly increased the awareness of the condition, with a hoped decrease in stigma. Some have emphasized the positive aspects of having bipolar; for example there is evidence that it is strongly correlated to creativity and literacy (Santosa et al., 2007). Others who have experienced bipolar have commented on the enjoyable experience of having the increased energy and mood during the elated phase. This has even had the effect of a perceived increase in individuals coming to their health care specialists with a selfdiagnosis of bipolar, which could be due to the increased awareness, and decreased stigma, but may also be due to the “lay person’s aspirations for higher social status, as illustrated by the implicit association of bipolar disorder with celebrity status and creativity” (Chan and Sireling, 2010). The question arises about whether some of the successful people we see with bipolar would have been as talented if they did not have their illness. In one of his last letters van Gogh wrote: “If I could have worked without this accursed disease, what things I might have done.” The treatment available today was not present then, and we simply do not know if his brilliance as an artist was because of his mental illness or in spite of it. What we do know is that the world is undoubtedly better off for having his paintings.
See also: Antidepressant Drugs; Depression; Mental Disorders, Epidemiology of; Mentally III, Public Attitudes towards; Psychopharmacotherapy: Side Effects; Psychotherapy and Pharmacotherapy; Schizophrenia; Suicide.
Bibliography Abreu, L.N., Lafer, B., Baca-Garcia, E., Oqeundo, M.A., 2009. Suicidal ideation and suicide attempts in bipolar disorder type I: an update for the clinician. Revista Brasileira de Psiquiatria 31 (3), 271–280. American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders, fourth ed. (DSM-IV). APA, Washington, DC. Baillarger, J., 1854. Note sur un genre de folie. Bulletin de la Academie Imperiale de Medicine (Paris) 19, 340–352. Barnett, J.H., Huang, J., Perlis, R.H., Young, M.M., Rosenbaum, J.F., Nierenburg, A.A., Sachs, G., Nimgaonkar, V.L., Miklowitz, D.J., Smoller, J.W., 2011. Personality and bipolar disorder: dissecting state and trait associations between mood and personality. Psychological Medicine 41 (8), 1593–1604. Chan, D., Sireling, L., 2010. ‘I want to be bipolar’. a new phenomenon. The Psychiatrist Online 34, 103–105. Crump, C., Sundquist, K., Winkleby, M.A., Sundquist, J., 2013. Comorbidities and mortality in bipolar disorder: a Swedish national cohort study. JAMA Psychiatry 70 (9), 931–939. Falret, J., 1854. Mémoire sur la folie circulaire. Bulletin de I’Académie Imperiale de Médecin (Paris) 19, 382–400.
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Ferreira, M.A., O’Donovan, M.C., et al., 2008. Collaborative genome-wide association analysis supports a role for ANK3 and CACNA1C in bipolar disorder. Nature Genetics 40 (9), 1056–1058. Goodwin, G.M., 2009. Evidence-based guidelines for treating bipolar disorder: revised second edition- recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology 23 (4), 346–388. Hashimoto, K., Sawa, A., Iyo, M., 2007. Increased levels of glutamate in brains from patients with mood disorders. Biological Psychiatry 62 (11), 1310–1316. Houenou, J., Frommberger, J., Carde, S., Glasbrenner, M., Diener, C., Leboyer, M., Wessa, M., 2011. Neuroimaging-based markers of bipolar disorder: evidence from two meta-analyses. Journal of Affective Disorders 132 (3), 344–355. Joyce, P.R., 1984. Age of onset in bipolar affective disorder and misdiagnosis in schizophrenia. Psycholigical Medicine 14, 145–149. Kahlbaum, K.L., 1882. Uber cyclisches Irresein. Der Irrenfreund 10, 145–157. Kraepelin, E., 1921. Manic Depressive Insanity and Paranoia (R.E. Barclay, Trans., G.M. Robertson, Ed.). Livingstone, Edinburgh, UK. Leonhard, K., 1957. Aufteilung der endogenen Psychosen. Akademie. Leverich, G., McElroy, S.L., Suppes, T., Keck Jr., P.E., Denicoff, K.D., Nolen, W.A., Altshuler, L.L., Rush, A.J., Kupka, R., Frye, M.A., Autio, K.A., Post, R.M., 2002. Early physical and sexual abuse associated with an adverse course of bipolar illness. Biological Psychiatry 51, 288–297. Mendel, E., 1881. Die Manie. Urban and Schwazenburg, Vienna. NICE, 2006. The Management of Bipolar Disorder in Adults, Children and Adolescents, in Primary and Secondary Care. Available at: http://www.nice.org.uk/guidance/ cg38/chapter/guidance (last accessed 06.08.14.). van Os, J., Takei, N., Castle, D.J., Wessely, S., Der, G., MacDonald, A.M., Murray, R.M., 1996. The incidence of mania: time trends in relation to gender and ethnicity. Social Psychiatry and Psychiatric Epidemiology 31 (3–4), 129–136. Patient.co.uk, 2012. Bipolar Disorder. Available at: http://www.patient.co.uk/doctor/ bipolar-disorder#ref-2 (last accessed 08.05.14.). Price, J., Karim, I., 1978. Matiruku, a Fijian madness: an initial assessment. British Journal of Psychiatry 133, 228–230. Puri, B.K., Hall, A.D., 2004. Revision Notes in Psychiatry, second ed. Arnold, London. Sanches, M., Jorge, M.R., 2004. Transcultural aspects of bipolar disorder. Revista Brasileira de Psiquiatria 26 (Suppl. III), 54–56. Stevenson, Angus (Ed.), 2010. Oxford Dictionary of English, third ed. Oxford University Press. Santosa, C.M., Strong, C.M., Nowakowska, C., Wang, P.W., Rennicke, C.M., Ketter, T.A., 2007. Enhanced creativity in bipolar disorder patients: a controlled study. Journal of Affective Disorders 100, 31–39. Sarris, J., Mischoulon, D., Schweiter, I., 2012. Omega-3 for bipolar disorder: metaanalyses of use in mania and bipolar depression. Journal of Clinical Psychiatry 73 (1), 81–86. Sims, A., 1995. Symptoms in the Mind. An Introduction to Descriptive Psychopathology, second ed. W.B. Sauders Company Ltd, London. Sklar, P., Smoller, J.W., Fan, J., Ferreira, M.A., Perlis, R.H., Chambert, K., et al., 2008. Whole-genome association study of bipolar disorder. Molecular Psychiatry 13 (6), 558–569. Soreff, S., Ahmed, I., Updated 2014. Bipolar Affective Disorder. Medscape. Available on: http://emedicine.medscape.com/article/286342-overview (last accessed 06.08.14.). Smith, D.J., Griffiths, D.J., Kelly, M., Hood, K., Craddock, N., Simpson, S.A., 2011. Unrecognised bipolar disorder in primary care patients with depression. British Journal of Psychiatry 199, 49–56. Tondo, L., Baldessarini, R.J., 2009. Long-term lithium treatment in the prevention of suicidal behavior in bipolar. Epidemiologia e Psichiatria Sociale 18 (3), 179–183. World Health Organisation, 1992. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. WHO, Geneva. Yutzy, S.H., Woofter, C.R., Abbott, C.C., Melhem, I.M., Parish, B.S., 2012. The increasing frequency of mania and bipolar disorder: causes and potential negative impacts. Journal of Nervous and Mental Disease 200 (5), 380–387.
Relevant Websites www.dballiance.org – Depression and Bipolar Support Alliance. www.ibpf.org – International Bipolar Foundation. http://emedicine.medscape.com/article/286342-overview#showall – Medscape. www.NICE.org.uk – National Institute for Health and Clinical Excellence. http://www.patient.co.uk/doctor/bipolar-disorder#ref-2 – Patient.co.uk. Bipolar Disorder. http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/bipolardisorder.aspx – Royal College of Psychiatrists information on bipolar. http://bipolarhelpvideos.com/tedxterrytalks-laura-bain-living-with-bipolar-type-ii/ – TED Talks. Laura Bain – Living with Bipolar II.
Abstract Bipolar disorder, previously known as manic depression, is a chronic episodic mental illness associated with behavioral disturbances. It is characterized by episodes of mania (or hypomania) and depression, and either one can occur first. A diagnosis of bipolar requires at least one depressive episode and at least one manic or hypomanic episode. This article explores the history, diagnosis, epidemiology, course and prognosis, etiology, and management of bipolar disorder. The management of the depressive phase is similar to unipolar depression, and is covered in the article Depression.
Introduction When I came out of the hospital . I fancied that I hadn’t had anything, only afterwards did I have the feeling that I’d been ill. What can you say, I have moments when I’m twisted by enthusiasm or madness or prophecy like a Greek oracle on her tripod. Vincent van Gogh, 3 February 1889, in a letter addressed to his brother Theo
Mania is a serious mental disorder characterized typically by elevated mood, a quickening of speech and thoughts, a feeling of having more energy, and need for less sleep, grandiosity, occasionally heightened sexuality and irritability. The Oxford Dictionary (2010) describes mania as a “mental illness marked by periods of great excitement or euphoria, delusions, and overactivity.” The word mania comes from the Greek word literally meaning ‘madness.’ Depression has been covered in the article ‘Depression’.
History of Bipolar In the first century BC, the Greek physicians suggested a connection between melancholia and mania. Just as they thought melancholia resulted from an excess of ‘black bile,’ mania was thought to result as an excess of ‘yellow bile.’ In the nineteenth century French doctors started thinking of mania and depression as being on the same continuum: ‘la folie double forme’ (Baillarger, 1854), and ‘folie circularie,’ a circular form of mania and depression (Falret, 1854). Although Falret (1854) had described mild forms of mania, Mendel (1881) was the first person to define ‘hypomania’ as a “form of mania which typically shows itself only in the mild stages, abortively, so to speak.” Kahlbaum (1882) described cyclothymia as milder changes in mood shifts but not enough to become depression or mania. It was around this time when van Gogh produced his paintings, and future historians would comment on how they could tell when he was in his more elated and more depressed stages of his illness from his paintings alone (see Figure 1). This is made easier due to the large number of letters written by van Gogh, all dated and many detailing his state of mind and health, and therefore making it possible to match the paintings to the letters. The painting shown was completed in what was described as the most productive
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period of his painting career, and the use of the vivid colors and the content of blossoming trees are in sharp contrast with the darker colors shown in the article ’Depression‘. Kraepelin (1921) then made the leap and separated mood disorders from others such as schizophrenia, introducing the term ‘manic depressive.’ Leonhard in 1957 used the word ‘bipolar’ to distinguish between people who experienced mania and depression, and ‘unipolar’ for those with depression only (Leonhard, 1957). Bipolar has now been adopted into modern psychiatric practice, and replaced the term ‘manic depression.’
Diagnosis There are two widely recognized contemporary classification systems in use worldwide for depression: the ICD-10 (WHO, 1992) and DSM-IV (APA, 1994), both of which have new versions due out in the near future. Operational definitions are provided for clinical and epidemiological research. Table 1 shows the similarities and differences between the two main classification systems. Both systems have categories for single and recurrent episodes, and both have a category
Figure 1 Vincent van Gogh. Orchard with blossoming apricot trees. Painting, Oil on Canvas. Arles: March 1888. In Van Gogh Museum, Amsterdam.
International Encyclopedia of the Social & Behavioral Sciences, 2nd edition, Volume 14
http://dx.doi.org/10.1016/B978-0-08-097086-8.27037-2
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Table 1
Classification of mania/bipolar disorder
ICD-10 Manic episode l Hypomania l Mania, without psychosis l Mania, with psychosis Bipolar affective psychosis l Currently hypomanic l Currently manic (with/without psychosis) l Currently depressed (mild, moderate, or severe) l Currently mixed l In remission Cyclothymia
DSM-IV Hypomanic episode Manic episode l Mild l Moderate l Severe l Severe with psychosis Bipolar I and II disorders l Current (or most recent episode) l Hypomanic l Manica l Depressed l Mixeda Cyclothymic disorder
a
Excludes bipolar II disorder.
A ‘mixed’ episode of bipolar disorder can occur where a depressed mood may be accompanied by days or weeks of overactivity and pressure of speech; or conversely, a manic mood to be accompanied by agitation, loss of energy, and libido. Sometimes depressive symptoms and hypomanic or manic symptoms may alternate day to day or even hour to hour. According to the ICD-10, a diagnosis of mixed bipolar disorder should be made if the two sets of symptoms are both prominent for the greater part of the current episode, which should last at least 2 weeks (DSM-IV requires the episode to be at least 1 week). Rapid cycling disorder can occur with both bipolar I and II disorders, and the diagnosis is made where there are at least four affective episodes (i.e., major depression, mania, hypomania, or mixed mood disorder) in the previous 12 months. Rapid cycling is more common in women, and unfortunately has a poorer response to treatment such as with lithium. Any assessment of bipolar disorder needs to include the following: l
for cyclothymia, as a persistent instability of mood involving periods of mild depression and mild elation, but neither being severe or prolonged enough to meet the criteria for bipolar. Also both systems divide mania into whether or not it features with psychotic symptoms. In the ICD-10 (WHO, 1992), the authors write that people with cyclothymia may not come to the attention of medics, as the elevated periods may well be enjoyable to the individual. Hypomania is more persistent (of at least 4 days) and more marked than the elation experienced in cyclothymia, but there are no hallucinations or delusions, and the symptoms do not tend to lead to a severe disruption of work or social rejection. This is in contrast to mania, where normal social inhibitions are lost, and there is marked distractibility. This is in addition to the usual core symptoms of elation, increased energy (resulting in overactivity), pressure of speech (characterized by uninterruptability), increased self-esteem and optimism, and decreased need for sleep. There is a tendency to embark on extravagant and dangerous schemes, spend money recklessly, and make some inappropriate amorous advances. The episode should last at least 1 week before a diagnosis is made. If psychosis is present, it usually takes the form of delusions of grandiosity (e.g., having superpowers, being extremely wealthy, or related to royalty). Persecutory or religious delusions can also be present. ‘Flight of ideas’ can be present, whereby the individual flits from topic to topic with a tenuous connection, often ending up on an answer far removed from the question asked. Sims (1995) describes an example of flight of ideas in his book, of a female patient saying: “They thought I was in the pantry at home . Peekaboo . there’s a magic box. Poor darling Catherine, you know, Catherine the Great, the fire grate, I’m always up the chimney. I want to scream with joy .. Hallelujah!” In severe cases, there may be a neglect of self-care, and of eating and drinking, and they may be placing themselves at risk from and to others. A diagnosis of bipolar requires at least one depressive episode and at least one manic or hypomanic episode. DSM-IV further separates bipolar into: l l
Bipolar I – where mania has occurred on one occasion Bipolar II – where hypomania has occurred (but not mania)
485
l l l l l l
Detailed history of the episode (symptoms, presence of hallucinations or delusions, collateral history if possible) Any previous episodes of mania or depression Any suicidal or homicidal thoughts Any self-neglect Family history Substance misuse, smoking, and alcohol intake General physical health
In addition one needs to rule out the following that can present in similar ways to bipolar, but should not be misdiagnosed as such (Smith et al., 2011): l l l l l l
Hyperthyroidism or hypothyroidism Anorexia nervosa Cerebrovascular event Dementia Other psychiatric disorders, for example, schizophrenia Acute drug withdrawal or illicit drug ingestion
Sims (1995) describes in his book about how the manic patient “looks at his world with complete, unshakeable, and wholly unjustified optimism.” The person with mania frequently does not have insight into the illness, meaning that when others try and help slow things down, it often manifests in what Sims calls ‘manic irritability’, when “he feels all his brilliant ideas are frustrated by the lack of vision of everyone else” (Sims, 1995).
Epidemiology Males and females are equally affected in bipolar disorder (but not in rapid cycling), in contrast to depression, which is more common in women. The lifetime prevalence of bipolar disorder varies from 0.3% to 1.5%. The average age of onset in Western countries is around the mid-20s, although the most common age of onset is the late teenage years, 15–19 years (Joyce, 1984). The second most frequent age range of onset is 20–24 years. Late-onset bipolar disorder is rare but it does occur. Interesting Yutzy et al. (2012) report an increase in the prevalence bipolar affective disorders I and II, where from
486
Mania
mid-1970s to 2000 it ranged from 0.4% to 1.6%, and by the late 1990s to the 2000s, it had climbed from approximately 5% to 7%.
Course and Prognosis Manic episodes last between 2 weeks and 4–5 months in bipolar disorder, although over the course of the disorder, there are many more episodes of depression than mania. Ninety percent of patients would experience more than one episode of mania. As patients become older, the time between episodes becomes shorter in duration. Unfortunately, only 20% achieve 5-year stability with good social and personal outcome (NICE, 2006). According to Abreu et al. (2009) 25–56% present at least one suicide attempt during their lifetime and 15–19% die from the attempt. Lithium has been shown to reduce the risk of suicide and number of suicide attempts in bipolar disorder, but is less effective in rapid cycling bipolar disorder, which has a poorer prognosis (Tondo and Baldessarini, 2009). There is an association between bipolar disorder and premature death. In a national cohort study of 6618 adults with bipolar disorder, Crump et al. (2013) found that those with bipolar disorder died about up to 9 years earlier on average than the rest of the population. They died prematurely from multiple causes, including cardiovascular disease, diabetes, chronic obstructive pulmonary disease, influenza or pneumonia, unintentional injuries, and suicide. Several factors have been reported to indicate a better or worse prognosis for bipolar (Soreff and Ahmed, 2014). Factors suggesting a worse prognosis include the following: l l l l l l
Poor job history Alcohol abuse Psychotic features Depressive features between periods of mania and depression Evidence of depression Male sex Factors suggesting a better prognosis include the following:
l l l l l
Shorter manic phases Late age of onset Few thoughts of suicide Few psychotic symptoms Few medical problems
a concordance of 33–90% for bipolar I in identical twins (Soreff and Ahmed, 2014). If genes were the only etiological factor, one would expect 100% concordance as they share 100% of their genes. Conversely, adoption studies show that environment alone is also not the only factor. Children whose biologic parents have either bipolar I or a major depressive disorder remain at increased risk of developing an affective disorder, even if they are reared in a home with adopted parents who are not affected (Soreff and Ahmed, 2014). A child of a parent with bipolar disorder has a 50% chance of having a major psychiatric disorder. First-degree relatives of people with bipolar I are approximately 7 times more likely to develop bipolar I than the general population (Soreff and Ahmed, 2014).
Biochemical Factors Certain drugs such as cocaine that increase the levels of monamines (dopamine, serotonin, norepinephrine) in the brain can precipitate mania. Some authors have implicated the neurotransmitter glutamate in the etiology of affective disorders, and postmortems looking at the frontal lobes of those with affective disorders have shown elevated levels of glutamate (Hashimoto et al., 2007). The hypothalamic–pituitary–adrenal (HPA) axis is a regulatory system that integrates neuronal and endocrine function, and manic and depressed bipolar individuals appear to have a dysregulated HPA axis. The HPA axis is linked to the serotonin system, sleep disturbance, and cortisol secretion. Exploring this further may give rise to other novel treatment strategies.
Neurophysiological Factors A decrease in gray matter, a decreased activation in certain brain regions, and an increased activation in other regions (such as the ventral limbic area that mediate and generate emotional responses) have been discovered (Houenou et al., 2011), although more research in this area is needed.
Psychodynamic Factors Melanie Klein proposed that mania was a defense against depression, and certain personality characteristics may be present in those with bipolar disorder (disturbances in neuroticism, extraversion, and openness) (Barnett et al., 2011). A dysregulation of self-esteem, childhood trauma, and abuse have been proposed as etiological factors for bipolar disorder (Leverich et al., 2002).
Etiology Genetic Factors
Environmental Factors
Bipolar disorder is one of the most heritable of all psychiatric disorders. There is a genetic component to bipolar disorder, and the literature suggests the involvement of the following genes: ANK3, CACNA1C, and CLOCK genes (Sklar et al., 2008; Ferreira et al., 2008). These genes are thought to make someone susceptible to bipolar disorder, but like many other psychiatric disorders, there are other environmental factors that come into play. Further evidence of the gene–environment hypothesis comes from twin studies, where there is
The gene–environment hypothesis dictates that the genes make an individual susceptible to the disorder, and the environment acts as an additive to cause the disease; different researchers have proposed differing amounts of interaction between the genes and the environment. A stressful circumstance can often act as a trigger for bipolar, and these could include relationship breakdown, abuse, death of a loved one, physical illness, prolonged sleep disturbance, or accumulative stress related to money, work, or relationships.
Mania
Cultural Factors
Pharmacological Interventions
In the UK, Afro-Caribbean immigrants have been found to be at a greater risk of presenting as manic than their Caucasian counterparts (van Os et al., 1996), although this could be due to the stress of immigration or racial prejudice. In Figi, a condition called ‘matiruku’ has been reported, described as a ‘periodic insanity’ (Price and Karim, 1978). It is characterized by increased talkativeness, increased psychomotor activity, elated mood, a decreased need for sleep, and occasional violence. These episodes would occur at the same time every month, or every year, and would last about 2–7 days. Diagnoses could be influenced by the self-report of individuals belonging to certain communities, giving skewed data. For example, in Amish communities, overly inflated self-esteem is considered to be a grave sin. In both prospective and retrospective studies carried out in China and Israel in individuals with bipolar disorder, there has been a preponderance of recurrent manic episodes over depressive episodes. This is the opposite to what has been found in other areas across Europe and other Western countries. Some authors suggest that climactic factors may play a part in the course for bipolar disorder (Sanches and Jorge, 2004).
Treatment of Acute Manic or Hypomanic Symptoms The drug treatment of an acute manic or hypomanic episode depends on the severity of symptoms and clinicians should be guided by current medication doses and previous response (NICE, 2006). When the NICE (2006) guidelines were written only lithium, olanzapine, quetiapine, risperidone, and valproate semisodium were licensed for the treatment of acute mania in the UK. Lithium, olanzapine, or valproate should be considered for long-term treatment (2–5 years depending on risk factors) of bipolar disorder. Lithium requires monitoring of levels and monitoring of renal and thyroid function. Pharmacological agents approved by the FDA, however, for use in treating bipolar disorder are as follows (taken from Sorref and Ahmed, Medscape, updated 2014): l l l l l l l l
Treatment and Management The following is largely based on the current National Institute for Health and Clinical Excellence (NICE) guidelines in the UK for adults, children, or adolescents with bipolar disorder (NICE, 2006), and the Evidence-based guidelines for treating bipolar disorder: revised second edition from British Association for Psychopharmacology (Goodwin, 2009). NICE provides national guidance and advice to improve health and social care, and the recommendations are based on the best available evidence, also taking into account of cost–benefit ratio.
Non-pharmacological Treatment Of paramount importance is the need to establish a trusting therapeutic relationship between the individual with bipolar, and the carers and health-care professionals. The following are examples of non-pharmacological treatments that can help in bipolar (Patient.co.uk, 2012). l l l l l l l l l l
l l
Education regarding diagnosis, treatment, and side-effects Good communication Self-help groups Support groups Self-monitoring of symptoms, side-effects, and triggers Coping strategies Psychological therapy Encouragement of engagement in calming activities Telephone support Diet – adjunct use of omega-3 fatty acids could help bipolar depressive but not bipolar manic symptoms (Sarris et al., 2012) Regular exercise Psychological interventions such as cognitive behavioral therapy and supportive psychotherapy (Goodwin, 2009)
487
l l l l
Valproate (manic) Carbamazepine, extended-release (manic, mixed) Lamotrigine (maintenance) Lithium (manic, maintenance) Aripiprazole (manic, mixed, maintenance) Ziprasidone (manic, mixed) Risperidone (manic, mixed) Asenapine (manic, mixed) Quetiapine (manic, depression) Chlorpromazine (manic) Olanzapine (manic, mixed, maintenance) Olanzapine–fluoxetine (depression)
Figure 2 shows the initial treatment plan for mania or mixed bipolar episode as devised by the British Association of Psychopharmacology (Goodwin, 2009).
Management of Depressive Symptoms This is the same as in the management in unipolar depression, and is included in the articles on depression and antidepressants, and hence has not been included here. Of note, however, there is a risk of switching to a manic episode with antidepressants, and thus caution is advised and careful monitoring is necessary. In bipolar, antidepressant may not be as effective, and a combination therapy (antidepressant with an antimanic agent) may be required.
Management of Acute Mixed Episodes NICE (2006) advises that antidepressants should be avoided, and prescribers should consider treating patients with an acute mixed episode as if they had an acute manic episode (see above). Patients should be monitored closely for risk of suicide.
Management of Rapid Cycling Previous treatments need to be reviewed, and the prescriber needs to check for compliance with medication. If they are on antidepressants, then this needs to be stopped. Thyroid function should be checked, and anti-manic therapy will need to be optimized. Lithium and valproate is used first line, but if this does not work, lithium can be trialed on its own (NICE, 2006). Lithium levels would need to be
488
Mania
Diagnosis
Bipolar disorder manic
Assessment
ty, paƟent pa Safety, and family preferences and consider need for admission
CommunicaƟon
ain treatment tre Explain plan
Severity Severe
Mild
I.M. (if required)
Ora treatment tmen Oral
t Oral treatment
AnƟpsychoƟc or benzodiazepine
AnƟpsychoƟc or valproate
AnƟpsychoƟc or valproate or lithium (or carbamazepine
On anƟdepressant?
Taper and disconƟnue
Sleep deprived?
sider benzodiazepine b Consider short term
Already on long term treatment?
mize and conƟnue OpƟmize
i response Review
P Poor response
Good response
Figure 2
Evidence-based guidelines for treating manic or mixed bipolar episode. Goodwin, 2009.
checked, as both lithium withdrawal and lithium toxicity can cause rapid cycling. Psycho-education (in addition to keeping a ‘mood diary’ detailing aspects of their symptoms, when they occur and anything that helps) should be
encouraged. The focus should be on optimizing the longterm treatment instead of focusing on each individual episode. Medication trial should last for more than 6 months (NICE, 2006).
Mania
Electroconvulsive Treatment in Bipolar Electroconvulsive treatment (ECT) should only be considered in severe cases, with the aim of obtaining short-term and quick resolution or improvement of the symptoms. ECT should be used only when pharmacological and psychological treatment has been tried and failed. ECT can also be used if the situation is thought to be life threatening in those with severe depression, catatonia, or a prolonged or severe manic episode (NICE, 2006). The effects of ECT are thought to be short-lived.
Summary In recent times, more people in the media and public eye are declaring their diagnoses of bipolar. This has undoubtedly increased the awareness of the condition, with a hoped decrease in stigma. Some have emphasized the positive aspects of having bipolar; for example there is evidence that it is strongly correlated to creativity and literacy (Santosa et al., 2007). Others who have experienced bipolar have commented on the enjoyable experience of having the increased energy and mood during the elated phase. This has even had the effect of a perceived increase in individuals coming to their health care specialists with a selfdiagnosis of bipolar, which could be due to the increased awareness, and decreased stigma, but may also be due to the “lay person’s aspirations for higher social status, as illustrated by the implicit association of bipolar disorder with celebrity status and creativity” (Chan and Sireling, 2010). The question arises about whether some of the successful people we see with bipolar would have been as talented if they did not have their illness. In one of his last letters van Gogh wrote: “If I could have worked without this accursed disease, what things I might have done.” The treatment available today was not present then, and we simply do not know if his brilliance as an artist was because of his mental illness or in spite of it. What we do know is that the world is undoubtedly better off for having his paintings.
See also: Antidepressant Drugs; Depression; Mental Disorders, Epidemiology of; Mentally III, Public Attitudes towards; Psychopharmacotherapy: Side Effects; Psychotherapy and Pharmacotherapy; Schizophrenia; Suicide.
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Relevant Websites www.dballiance.org – Depression and Bipolar Support Alliance. www.ibpf.org – International Bipolar Foundation. http://emedicine.medscape.com/article/286342-overview#showall – Medscape. www.NICE.org.uk – National Institute for Health and Clinical Excellence. http://www.patient.co.uk/doctor/bipolar-disorder#ref-2 – Patient.co.uk. Bipolar Disorder. http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/bipolardisorder.aspx – Royal College of Psychiatrists information on bipolar. http://bipolarhelpvideos.com/tedxterrytalks-laura-bain-living-with-bipolar-type-ii/ – TED Talks. Laura Bain – Living with Bipolar II.