Individual Outline by Saumya Valookaran as a part of the Bipolar Disorder group Neurowiki

Bipolar disorder is a mood disorder that is characterized by recurrent periods of mania and depression. Symptoms can influence a variety of different aspects in a patient’s life, such as behaviour. In addition to experiencing episodes of mania and depression, which can have unpredictable time durations, many affected individuals experience disrupted sleep/wake cycles[1] . As a result of the variability associated with the symptoms of bipolar disorder, it is difficult to diagnose. Understanding the symptoms of this disorder is important because many affected individuals can be undiagnosed and may suffer the repercussions of the illness without receiving treatment. Some recent studies have also found differences in the duration and frequency of symptoms in regards to age and gender[2] .


Mania




Mania must be present alongside depression in individuals in order to be classifed as bipolar disorder[3]. When experiencing mania, individuals must display ill-tempered, ecstatic or outgoing moods for at minimum of one week, alongside at least 3 other symptoms[3]. There are several other dimensions accompanying mania. As table 1 displays, individuals encountering mania can also show unrealistically high self-esteem, reduced need for sleep, take more risks and be very distracted among other symptoms[3]. A manic patient can display delusional thoughts and hallucinations[3]. Also, mania has been associated with impulsive activities[3]. Symptoms of mania can occur separately or simultaneously with depressive symptoms. It has been found that in bipolar patients, 31.2% of patients did not have concomitant manic symptoms, while 54% had a few symptoms[3] . Of these symptoms, agitation, distraction and racing thoughts were the most common[4].

Recognizing symptoms of mania is important for early diagnosis because individuals can progress from unipolar depression to bipolar disorder. A study examined subthreshold hypomanic symptoms and its relation to start mania or hypomania[4] . Hypomania is a reduced intensity form of mania[3]. This study concluded that symptoms of hypomania were related to the progression to bipolar disorder[5].
bipolar-disorder-fig1_large.jpg
Fig 1. This figure demonstrates the range of emotions associated with bipolar disorder.

Table 1. Manic Symptoms

  • Ecstatic, ill-tempered or outgoing moods[3]
  • High self-esteem[3]
  • Reduced necessity for sleep[3]
  • Delusional thoughts or hallucinations[3]
  • High energy[3]
  • Pressured speech[4]
  • Racing thoughts[4]
  • Agitation[4]
  • High risk behaviours[4]
  • Intensified goal-directed endeavors[5]

Depression



Symptoms of depression can vary tremendously amongst bipolar patients. The depressive episode of bipolar disorder can impact individuals emotionally, behaviourally, cognitively and physiologically[3]. Sadness and low moods are emotional symptoms[3]. Additionally, some individuals lose interest activities they previously enjoyed[3]. Physiological and behavioural symptoms can include variation in eating patterns, sleep changes and/or changes in energy levels[3]. The variability of the symptoms causes depressive episodes in individuals hard to clearly define. Cognitively, symptoms include thoughts of suicide, feelings of worthlessness, etc.[3]. Hallucinations and delusions are also a common symptom of depression[3].

A study was conducted on the neurocognitive impairment caused by bipolar disorder[5] . The influence of the mood changes related to bipolar disorder was examined and it was found that depressive symptoms were associated with worse verbal skills[6]. Bipolar disorder can affect individual’s daily functioning by impeding their social life. Even when symptoms are scarce and it appears the individual is recovering, there can be residual symptoms and difficulties in cognitive functioning[6] . It has been shown that residual depressive symptoms can lead to impairment in psychosocial functioning[7].
bipolar-disorder-symptoms.jpg
Fig 2. This figure displays the various symptoms associated with the depressive and manic phases of bipolar disorder


Table 2. Depressive Symptoms

  • Sadness[3]
  • Depressed moods[3]
  • Anhedonia (reduction of pleasure from previously enjoyed activities)[3]
  • Impairments in sleep[3]
  • Low levels of energy[3]
  • Feelings of worthlessness[3]
  • Cognitive impairment (reduced attention and concentration)[3]
  • Suicidal thoughts[3]
  • Delusions and hallucinations[3]


Circadian Dysregulation



In bipolar disorder, one of the symptoms that was common to both depressive and manic episodes was sleep dysregulation. Changes in sleep ranged from hypersomnia to insomnia[3]. Incidences of both hypersomnia and insomnia vary considerably in bipolar patients[7] . Sleep disturbances can also occur between episodes of mania and depression[8]. Studies have found that bipolar individuals who experienced sleep disturbances, were more sensitive to light, had lower melatonin levels and in those experiencing mania, higher levels of cortisol during the night[8]. Circadian dysregulation has been causally linked to the irregular emotionality found in bipolar disorder[8] . In mania, a reduced need for sleep is usually seen, while in depression, a higher need for sleep can be observed[9]. It has been found that rapid eye movement (REM) sleep is important in regulation emotions and in individuals with bipolar disorder there is a reduced amount of REM sleep[9]. Sleep disturbances are one of the main aspects of bipolar disorder that directly affect daily life[9].

Previously, it was found that the individuals who encountered a greater amount of depressive episodes had sleep patterns that were more erratic[9] . This implicated that sleep pattern variation can be associated with the bipolar disorder illness course[10]. Specifically, this study hypothesized that during depressive episodes, disturbances in sleep can cause individuals to stay in bed longer and possibly that this time may have negative impacts on mood[10].



Symptom Variability in Bipolar Disorder




The symptoms involved in bipolar disorder are extremely variable and as a result make it difficult to diagnose. Symptoms are variable among adults and children and between males and females.


Symptoms in Children and Adolescents


Bipolar disorder can manifest in children and in adults/adolescents. Depression has been found to be the most recurrent episode for adolescents[10] . It has also been shown that adolescents with childhood onset bipolar disorder had the longest illness[11]. The study observed that the symptoms of mania and depression were more severe in adolescents[11]. Children displayed increased irritability, when compared to adolescents[11]. The severity of symptoms increased with age[11]. Amygdala dysfunction is a common symptom in both adults and children[11] . More specifically, it has been shown that the amygdala is important in face-emotion processing[12]. A recent study found that children with bipolar disorder have difficulties in identifying facial emotions[12]. Another study has found that in children, bipolar disorder is distinguished by less severe and less frequency symptoms with mainly depressive symptoms, but also rapid changes in mood[12] .


Symptoms in Males and Females


It has been found that females are more likely to be diagnosed with bipolar disorder than males[13] . Evidence also suggests that there is a difference in symptoms between males and females with bipolar disorder[14] . Depressive episodes in bipolar disorder are much more common amongst females[15] . Also, the study found that the depressive episodes are correlated with hormonal changes within the women[15]. Another study also found that women were more likely to experience depressive episodes, but this was correlated with differences in cycling and anxiety disorders[2]. They found that women had higher rates of rapid cycling and anxiety disorders, resulting in an increased frequency of depressive episodes[2].
  1. ^ Cardinali, D.P., Seithikurripu, R.P., & Brown, G.M. (2011). Sleep and circadian dysregulation in depressive illness. Pharmacological implications. Clinical Neuropsychiatry, 8(6), 321-338.
  2. ^ Altshuler, L.L., Kupka, R.W., Helleman, G., Frye, M.A., Sugar, C.A., McElroy, S.L., et al. (2010). Gender and depressive symptoms in 711 patients with bipolar disorder evaluated prospectively in the Stanley Foundation Bipolar Treatment Outcome Network. The American Journal of Psychiatry, 167 (6), 708-715.
  3. ^ Nolen-Hoeksema, S. (2011). Abnormal Psychology. (2nd ed.). Toronto: Mcgraw-Hill Ryerson Limited.
  4. ^ Goldberg, J.F., Perlis, R.H., Bowden, C.L., Thase, M.E., Miklowitz, D.J., Marangell, L.B., et al. (2009). Manic symptoms during depressive episodes in 1380 patients with bipolar disorder: findings from the STEP-BD. The American Journal of Psychiatry, 166 (2), 173-181.
  5. ^ Fiedorowicz, J.G., Endicott, J., Leon, A.C., Solomon, D.A., Keller, M.B., & Coryell, W.H. (2011). Subthreshold hypomanic symptoms in progression from unipolar major depression to bipolar disorder. American Journal of Psychiatry, 168 (1), 40-48.
  6. ^ Chaves, O.C., Lombardo, L.E., Bearden, C.E., Woolsey, M.D., Martinez, D.M., Barrett, J.A., et al. (2011). Association of clinical symptoms and neurocognitive performance in bipolar disorder: a longitudinal study. Bipolar Disorders, 13(1), 118-123.
  7. ^ Deckersbach, T., Nierenberg, A.A., Kessler, R., Lund, H.G., Ametrano, R.M., Sachs, G., et al. (2010). Cognitive rehabilitation for bipolar disorder: an open trial for employed patients with residual depressive symptoms. CNS Neuroscience & Therapeutics, 16(5), 298-307.
  8. ^ Harvey, A.G. (2008). Sleep and circadian rhythms in bipolar disorder: seeking synchrony, harmony and regulation. American Journal of Psychiatry, 165(7), 820-829.
  9. ^ Murray, G., & Harvey, A. (2010). Circadian rhythms and sleep in bipolar disorder. Bipolar Disorders, 12, 459-472.
  10. ^ Eidelman, P., Talbot, L.S., Gruber, J., & Harvey, A.G. (2011). Sleep, illness course, and concurrent symptoms in inter-episode bipolar disorder. Journal of Behavior Therapy and Experimental Psychiatry, 41(2), 145-149.
  11. ^ Birmaher, B., Axelson, D., Strober, M., Gill, M., Yang, M., Ryan, N., et al. (2009). Comparison of manic and depressive symptoms between children and adolescents with bipolar spectrum disorders. Bipolar Disorders, 11(1), 52-62.
  12. ^ Brotman, M.A., Rich, B.A., Guyer, A.E., Lunsford, J.R., Horsey, S.E., Reising, M.M., et al. (2011). Amygdala activation during emotion processing of neutral faces in children with severe mood dysregulation versus ADHD or bipolar disorder. American Journal of Psychiatry, 167 (1), 61-69.
  13. ^ Birmaher, B., Axelson, D., Goldstein, B., Strober, M., Gill, M. Hunt, J., et al. (2009). Four-year longitudinal course of children and adolescents with bipolar spectrum disorder. American Journal of Psychiatry, 166(7), 795-804.
  14. ^ Graae, L., Karlsson, R., & Paddock, S. (2012). Significant association of estrogen receptor binding site variation with bipolar disorder in females. ER DNA-Binding Variation in Mood Disorders, 7(2), 1-9.
  15. ^ Kriegshauser, K., Sajatovic, M., Jenkins, J.H., Cassidy, K.A., Muzina, D., Fattal, O., et al. (2010). Gender differences in subjective experience and treatment of bipolar disorder. Journal of Nervous & Mental Disease, 198(5), 370-372.