Cathy is a 22 year old college student. For the past five days, Cathy has had very little sleep, and has been almost ceaselessly active, sleeping poorly and expressing ideas that others find very odd. Cathy has experienced two previous episodes of similar behaviour, alternated with periods of intense depression.
Cathy is experiencing some of the symptoms that, according to the World Health Organization in the tenth edition of the International Classification of Diseases (ICD-10) (WHO, 1992), are likely to be found in people suffering from Bipolar Affective Disorder (BPAD, F31):
“A disorder characterized by two or more episodes in which the patient’s mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of an elevation of mood and increased energy and activity (hypomania or mania) and on others of a lowering of mood and decreased energy and activity (depression). Repeated episodes of hypomania or mania only are classified as bipolar” (WHO, 1992).
BPAD has an annual incidence of 7 new cases per 100.000, and its overall prevalence is about 3% in the population (Schmitt et al., 2014). A systematic review (Caetano Dell’Aglio Jr. et al., 2013) shows no significant differences between males and females, and the higher prevalences have been found in individuals without a partner and people with low-income. The first episode usually occurs in early adulthood, with the highest rate taking place between the ages of 15 and 19 years, but it can also occur later in life (Rihmer & Kiss, 2002).
The diagnosis of BPAD has developed from Emil Kraepelin’s explanation as “Manic Depressive Insanity” over 100 years ago (Kraepelin, 1907). According to NICE guidelines (National Institute for Health and Clinical Excellence Guidelines, 2006), features of both mania (or hypomania, a lesser level of mania) and depression must coexist for at least two weeks for formal diagnosis. Manic episodes usually begin unexpectedly and last between 2 weeks and 4–5 months, while depression tends to last longer (average of 6 months).
During a manic episode, grandiosity (exaggerated self-esteem, beliefs of special powers and unreal abilities) and delusions (thoughts that are unreal, also called false beliefs) can occur (Davies & Craig, 2009). In the case presented, for example, Cathy is probably having a manic episode, experiencing delusions and grandiosity: she believes that she has swapped minds with her local MP, developing five theories of government that could save the world from poverty. Even though no elections are scheduled, Cathy has begun to campaign for an elected position in government. Moreover, Cathy believes that has special powers and can give birth without having sex. On this evidence, Cathy is likely to be experiencing a manic episode with psychotic symptoms (F31.2, ICD-10) (WHO, 1992).
In order not to forget her ideas, Cathy has started to write notes to herself everywhere. Cathy’s family and friends, who have always known her to be tidy and organized, have been shocked to find her room in total disorder with frenzied and disjointed messages written all over the walls and furniture. A person that is experiencing a manic episode presents with a substantial and excessive change from their usual mood, activity and thought; behaviour is disinhibited, agitated, uncontainable and possibly risky (Davies & Craig, 2009).
Depressive episodes are similar to those in unipolar major depression (NICE, 2006). When Cathy was in the depressed state, she could not bring herself to go to her classes or to any other activities; she suffered from insomnia, poor appetite, and difficulty concentrating. At the lowest points of her depressive periods, Cathy contemplated suicide, speaking of plans to walk into the sea and drown herself, or to jump from the top of a building.
In BPAD, the depressive phase tends to develop slowly, and, if untreated, to have an average duration of six months. Risk of suicide is high: in a review, Pompili et al. (2013) have estimated ‘the risk of suicide in bipolar patients to be 20–30 times higher than that of the general population’.
In severe mania, a person can become hostile, suspicious and verbally or physically aggressive. In severe depression, a person may start to think of, or even plan, suicide. If, in the future, Cathy will seriously neglect herself by not (or over) eating or drinking, misusing substances, behaving in a way that places her or others at risk, actions under The Mental Health Act (1983) could be considered, after a Mental Health Act Assessment carried out by an Approved Mental Health Practitioner (AMHP) and two doctors (NICE, 2006).
While identifying BPAD, problems with Differential Diagnosis may occur. Many symptoms overlap with other psychiatric disorders, comorbidity is frequent and, mostly in manic and hypomanic states, patients often lack insight into their conditions (Bauer & Pfenning, 2005). An irritable and excited mood could show a similar pattern to that observed after a major traumatic event, while grandiose ideas, delusions, disordered thoughts and rapid speech may be confused with psychosis and schizophrenia (Davies & Craig, 2009). According with the National Manic-Depression Association (2001), initial symptoms in BPAD are manic or depressive episodes, whereas psychotic symptoms are not likely to appear at the onset of the illness. Moreover, there may be confusion with personality disorders, especially Borderline type, in which rapid changes of mood occur continually from early adolescence, but are more related with likely to be reactions to life-events rather than a switch in internal state (Piver, Yatham & Lam, 2002).
The exact mechanism underlying BPAD remains unclear, with a mix of biological, environmental and social factors playing a role (Barnett & Smoller, 2009).
Several studies (Barnett & Smoller, 2009; Nierenberg et al., 2013; Kerner, 2014) have indicated a strong genetic component: 60-80% of the risk of developing the disorder in the population is accounted by genetic influences. Compared with the general population, the risk of BPAD is about ten times higher in first degree-relatives of those with a diagnosis of BPAD (Barnett & Smoller, 2009). Perhaps in Cathy’s family there is a person with a history of BPAD, or similar psychiatric disorders.
Biochemical abnormalities could be one of the reasons for Cathy’s symptoms: these include imbalances in the serotonergic and dopaminergic systems, as well as disturbance of the thyroid hormone metabolism or cortisol (Bauer & Whybrow, 2001; Martini et al., 2004). Finally, BPAD could also be triggered or exacerbated by stressful life events such as traumatic experiences (i.e. abuse, bereavement, relationship or work breakdown), or social or physical conditions. Cathy is studying catering at college, and seems concerned about world poverty; maybe these pressures (stress for her exams, feelings of powerlessness in helping underprivileged people), as well as others that needs to be investigated and also her inability to deal with stress (as explained by the Stress Vulnerability Model) (Zubin and Spring, 1977), might exacerbate her conditions, and trigger some manic symptoms.
Considering Cathy’s case, the possibility of experiencing a future relapse is high: BPAD is a chronic and recurrent illness, where relapses occur in more than 30% of patients in the first year and 70% within five years (Gitlin et al., 1995). To reduce this risk and to improve the response to medication, early recognition and treatment of BPAD is essential (Berk et al., 2011). Treatment depends on the presenting phase of the illness. First-line treatments, that should be considered as a long-term care, are psychotherapy and mood stabilizers, such as lithium, anticonvulsants, and antipsychotics (NICE, 2006; Price & Marzani-Nissen, 2012).
As suggested by NICE Guidelines (2006), together with pharmacotherapy, Cathy would benefit from Cognitive Behaviour Therapy (CBT)to manage her mood swings and reduce possible future complications. Her support systems, such as family and friends, should be supported and educated about early signs of mood relapse and suicidal ideation, and also about the effectiveness of early intervention (Morriss et al., 2007). If Cathy wanted it, mental health services could be involved to help her: with a proper Care Programme Approach (CPA) and support from Community Mental Health Services, the possibility to stay out of hospital and having a life in the community is high and positive.
N.B. To create this case scenario, several and different cases have been mixed, to protect confidentiality and privacy of data. Therefore, Cathy does not represent a real person.
Mental Health Worker (NHS)
American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text revision. Washington, DC: American Psychiatric Association.
Barnett, J.H. and Smoller, J.W. (2009) ‘The genetics of bipolar disorder’. Neuroscience, 164(1), pp. 331–43.
Berk, M., Brnabic, A., Dodd, S., Kelin, K., Tohen, M., Malhi, G. S., Berk, L., Conus, P. and McGorry, P. D. (2011) ‘Does stage of illness impact treatment response in bipolar disorder? Empirical treatment data and their implication for the staging model and early intervention’. Bipolar Disorders, 13(1), pp. 87-98.
Caetano Dell’Aglio Jr., J., BassoII, L. A., Iracemade Lima Argimon, I., Arteche, A. (2013) ‘Systematic review of the prevalence of bipolar disorder and bipolar spectrum disorders in population-based studies’. Trends Psychiatry Psychotherapy, 35(2). Porto Alegre.
Craddock, N. and Sklar, P. (2013). ‘Genetics of bipolar disorder’. Lancet, 381(9878), pp. 1654–1662.
Davies, T. and Craig, T. (2009) ABC of Mental Health, 2nd edition. Blackwell Publishing.
Department of Health (1983) The Mental Health Act 1983. London: Stationery Office. Available at: http://www.legislation.gov.uk/ukpga/1983/20/contents
Department of Health (2001) The expert patient: A new approach to chronic disease management for the 21st century. DH, London.
Edvardsen, J., Torgersen, S., Røysamb, E., Lygren, S., Skre, I., Onstad, S. and Oien, P. A. (2008) ‘Heritability of bipolar spectrum disorders. Unity or heterogeneity?’. Journal of Affective Disorders, 106(3), pp. 229–240.
Gitlin, M. J., Swendsen, J., Heller, T. L. and Hammen, C. (1995) ‘Relapse and impairment in bipolar disorder’. American Journal of Psychiatry, 152(11), pp. 1635-1640.
Hayden, E. P. and Nurnberger, J. I. (2006) ‘Molecular genetics of bipolar disorder.’ Genes, Brain and Behaviour, 5(1), pp. 85-95.
Hirschfeld, R. M. A. (2005) Guideline watch: Practice guideline for the treatment of patients with bipolar disorder. American Psychiatric Association, Arlington, VA. Available at: http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm
Jones, S., Haywood, P. and Lam, D. (2002) Coping with bipolar disorder: A guide to living with manic depression. Oneworld Publications, Oxford.
Judd, L., Akiskal, H. S., Schettler, P. J., Endicott, J., Maser, J., Solomon, D. A., Leon, A. C., Rice, J. A. and Keller, M. B. (2002) ‘The long-term natural history of the weekly symptomatic status of bipolar I disorder’. Archives of General Psychiatry, 59(6), 530-537.
Kerner, B. (2014) ‘Genetics of bipolar disorder’. The Application of Clinical Genetics, 7, 33–42.
Kieseppä, T., Partonen, T., Haukka, J., Kaprio, J. and Lönnqvist, J. (2004) ‘High Concordance of Bipolar I Disorder in a Nationwide Sample of Twins’. American Journal of Psychiatry, 161(10), pp. 1814–1821.
Kraepelin, E. (1907) Clinical Psychiatry. MacMillan and Company, London.
McGuffin, P., Rijsdijk, F., Andrew, M., Sham, P., Katz, R. and Cardno, A. (2003) ‘The Heritability of Bipolar Affective Disorder and the Genetic Relationship to Unipolar Depression’. Archives of General Psychiatry, 60(5), pp. 497–502.
Morriss, R. K., Faizal, M. A., Jones, A. P., Williamson, P. R., Bolton, C. and McCarthy, J. P. (2007) ‘Interventions for helping people recognise early signs of recurrence in bipolar disorder’. Cochrane Database Systematic Review, 24(1), CD004854.
National Depressive and Manic-Depressive Association (2001) National DMDA Constituency Survey. Living with Bipolar Disorder: how far have we really come?. Available at: http://www.dbsalliance.org/pdfs/bphowfar1.pdf
National Institute for Health and Clinical Excellence (2006) Bipolar disorder: The management of bipolar disorder in adults, children and adolescents, in primary and secondary care. NICE guideline CG38. NICE, London. Available at: http://guidance.nice.org.uk/CG38/
Nierenberg, A. A, Kansky, C., Brennan, B. P., Shelton, R. C., Perlis, R., Losifescu, D. V. (2013) ‘Mitochondrial modulators for bipolar disorder: a pathophysiologically informed paradigm for new drug development’. The Australian and New Zealand Journal of Psychiatry, 47(1), pp. 26–42.
Perry, A., Tarrier, N., Morriss, R., McCarthy, E. and Limb, K. (1999) ‘Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment’. British Medical Journal, 318(7177), pp. 149–53.
Piver, A., Yatham, L. N. and Lam, R. W. (2002) ‘Bipolar spectrum disorders: new perspectives’. Canadian Family of Physician, 48, pp. 896–904.
Pompili, M., Gonda, X., Serafini, G., Innamorati, M., Sher, L., Amore, M., Rihmer, Z. and Girardet, P. (2013) ‘Epidemiology of suicide in bipolar disorders: a systematic review of the literature’. Bipolar Disorders, 15(5), pp. 457–490.
Price, A. L. and Marzani-Nissen, G. R. (2012) ‘Bipolar Disorders: A Review’. American Family Physician, 85(5), pp. 483-493.
Reich, T., Clayton, P. J. and Winokur, G. (1969) ‘Family history studies: V. The genetics of mania’. The American Journal of Psychiatry, 125(10), pp. 1358–1369.
Rihmer, Z. and Kiss, K. (2002) ‘Bipolar disorders and suicidal behaviour’. Bipolar Disorders, (suppl 1), pp. 21-25.
Shastry, B. S. (2005) ‘Bipolar disorder: an update’. Neurochemistry International, 46(4), pp. 273–279.
Schmitt, A., Malchow, B., Hasan, A. and Falkai, P. (2014) ‘The impact of environmental factors in severe psychiatric disorders’. Frontiers in Neuroscience, 8(19), doi: 10.3389/fnins.2014.00019.
Scott, A. I. F. ed. (2005) The ECT Handbook, 2nd edn. Council Report CR128, Royal College of Psychiatrists, London.
Young, A. H. and Hammond, J. M. (2007) ‘Lithium in mood disorders: increasing evidence base, declining use?’. British Journal of Psychiatrist, 191, pp. 474–476.
Zubin, J. and Spring, B. (1977) ‘Vulnerability: A New View on Schizophrenia’. Journal of Abnormal Psychology, 86, pp. 103-126.
World Health Organization (2010) ICD-10 Version: 2010. Available at: http://apps.who.int/classifications/icd10/browse/2010/en (Accessed: 30 May 2014).