a case study of bipolar disorder

Patient Case: 30-Year-Old Male With Bipolar Disorder

Nidal Moukaddam, MD, PhD, presents the case of a 30-year-old male diagnosed with bipolar 1 disorder and shares her initial impressions on diagnosis.

EP: 1 . Patient Case: 30-Year-Old Male With Bipolar Disorder

Ep: 2 . approaching the treatment of bipolar disorder, ep: 3 . treatment selection for bipolar disorder, ep: 4 . takeaways for bipolar disorder management.

Nidal Moukaddam, MD, PhD: Today, we’re going to talk about a new case. A 30-year-old man has taken short-term disability leave from work due to the progression of a depressive episode. He received a diagnosis of bipolar I disorder about 10 years ago. He had his first episode of mania at the age of 20 and 2 subsequent episodes of mania between the ages of 21 and 29. He was treated with lithium, which was highly effective, but he experienced excessive thirst and developed hyperthyroidism. His lithium level at the time was in the therapeutic range of 0.8 mEq/L. He was switched to valproate; however, valproate lacked the efficacy of lithium and caused adverse effects of sedation and weight gain. During his third manic episode, he started on olanzapine but experienced excessive weight gain. He was then cross-titrated to quetiapine, which improved his manic symptoms. However, weight gain again became an adverse effect, and he also complained of sedation. The patient reported sleeplessness and made unnecessary online purchases when unable to sleep, but the quetiapine sleepiness was unacceptable. Despite these adverse effects, he continued taking] quetiapine until he decompensated into his third depressive episode. The quetiapine was then augmented with lamotrigine, which was titrated up to 300 mg per day but demonstrated no efficacy. At the time of presentation, the patient was adhering to the medications. He did not have a substance use disorder, which was confirmed by a negative toxicology screen. His TSH [thyroid-stimulating hormone] level was in the middle of the normal range, and he had no suicidal ideations or psychotic symptoms.

I think the most important thing to do when somebody comes to you, even if they tell you they have a diagnosis, is to confirm the diagnosis. You want to start by making up your own mind, and sometimes the patient is not a good source of information. But in the case of bipolar disorder without psychosis, you expect the patient to be able to give you a solid history. Typically, the part of the history that’s hardest to nail down is mania. When people experience mania, they have excessive energy and excessive activation that creates the need for sleep, and sometimes they like it. They feel that this is the way it should be, so they don’t point it out as pathological. Now, the DSM-5 [ Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ] criteria tell us that mania that leads to hospitalization or some negative consequence like incarceration is problematic no matter what the duration is. Assuming the patient did not end up in the hospital or in prison, we want to verify the story of mania. In the current case presentation, I can see many of my colleagues saying, “Hey, you’re not giving us enough symptoms of mania. He’s a bit sleepless. He makes frivolous purchases. That’s bipolar disorder but not bipolar I; maybe it’s bipolar II.”

Thus, my first step would be to explain that this patient had at least a week without sleep. During that week, he was spacing, had pressured speech, and was talking fast to the point that others around him commented about it. He became more impulsive, and buying things was the tip of the iceberg. He also became more sexual to the point where it got him in trouble in his relationships, he spent more money than he had planned, etc. These examples of impulsivity often nail down the diagnosis of bipolar disorder. Of course, these symptoms change with the time that we live in. For example, before unlimited plans on cell phones, you would have been taught to ask: “Do you get a very high bill on your phone when you’re manic?” Because patients with mania talk a lot, and the bills would be higher when they call across state lines or internationally. First, I would recommend verifying the diagnosis. My impression of the patient is that this is somebody with a set diagnosis of bipolar I. Three manic episodes is a lot. He has impairment because of it, and it’s affected his job. Thus, my first step is confirming the diagnosis. My second would be a lot of psychoeducation; make sure that the patient understands what he’s up against and why he needs treatment.

Transcript Edited for Clarity

Evaluating the Efficacy of Lumateperone for MDD and Bipolar Depression With Mixed Features

Blue Light Blockers: A Behavior Therapy for Mania

Efficacy of Modafinil for Treatment of Neurocognitive Impairment in Bipolar Disorder

Blue Light, Depression, and Bipolar Disorder

Securing the Future of Lithium Research

An Update on Early Intervention in Psychotic Disorders

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Real Life Bipolar Disorder: A Case Study of Susan

Bipolar disorder is a complex and often misunderstood mental health condition that affects millions of individuals worldwide. For those living with bipolar disorder, the highs and lows of life can be dizzying, as they navigate through periods of intense mania and debilitating depression. To truly grasp the impact of this disorder, it’s crucial to explore real-life experiences and the stories of those who have dealt firsthand with its challenges.

In this article, we delve into the fascinating case study of Susan, a woman whose life has been profoundly shaped by her bipolar disorder diagnosis. By examining Susan’s journey, we aim to shed light on the realities of living with this condition and the strategies employed to manage and treat it effectively.

But before we plunge deeper into Susan’s story, let’s first gain a comprehensive understanding of bipolar disorder itself. We’ll explore the formal definition, the prevalence of the condition, and its impact on both individuals and society as a whole. This groundwork will set the stage for a more insightful exploration of Susan’s experience and provide valuable context for the subsequent sections of this article.

Bipolar disorder is more than just mood swings; it is a condition that can significantly disrupt an individual’s life, relationships, and overall well-being. By studying a real-life case like Susan’s, we can gain a personal insight into the multifaceted challenges faced by those with bipolar disorder and the importance of effective treatment and support systems. In doing so, we hope to foster empathy, inspire early diagnosis, and contribute to the advancement of knowledge about bipolar disorder’s complexities.

The Case of Susan: A Real Life Experience with Bipolar Disorder

Susan’s story provides a compelling illustration of the impact that bipolar disorder can have on an individual’s life. Understanding her background, symptoms, and the effects of the disorder on her daily life can provide valuable insights into the challenges faced by those with bipolar disorder.

Background Information on Susan

Susan, a thirty-eight-year-old woman, was diagnosed with bipolar disorder at the age of twenty-five. Her early experiences with the disorder were characterized by periods of extreme highs and lows, often resulting in strained relationships and an inability to maintain steady employment. Susan’s episodes of mania frequently led to impulsive decision-making, excessive spending sprees, and risky behaviors. On the other hand, her depressive episodes left her feeling hopeless, fatigued, and unmotivated.

Symptoms and Diagnosis of Bipolar Disorder in Susan

To receive an accurate diagnosis, Susan underwent a thorough examination by mental health professionals. The criteria for diagnosing bipolar disorder include significant and persistent mood swings, alternating between periods of mania and depression. Susan exhibited classic symptoms of bipolar disorder, such as elevated mood, increased energy, racing thoughts, decreased need for sleep, and reckless behavior during her manic episodes. These episodes were interspersed with periods of deep sadness, loss of interest in activities, and changes in appetite and sleep patterns during depressive phases.

Effects of Bipolar Disorder on Susan’s Daily Life

Living with bipolar disorder presents unique challenges for Susan. The unpredictable shifts in her mood and energy levels significantly impact her ability to function in both personal and professional spheres. During manic phases, Susan experiences heightened productivity, creativity, and confidence, often leading her to take on excessive responsibilities and projects. However, these periods are eventually followed by crashes into depressive episodes, leaving her unable to complete tasks, maintain relationships, or even perform routine self-care. The constant fluctuations in her emotional state make it difficult for Susan to establish a sense of stability and predictability in her life.

Susan’s struggle with bipolar disorder is not uncommon. Many individuals with this condition face similar obstacles in their daily lives, attempting to manage the debilitating highs and lows while striving for a sense of normalcy. By understanding the real-life implications of bipolar disorder, we can more effectively tailor our support systems and treatment options to address the needs of individuals like Susan. In the next section, we will explore the various approaches to treating and managing bipolar disorder, providing potential strategies for improving the quality of life for those living with this condition.

Treatment and Management of Bipolar Disorder in Susan

Managing bipolar disorder requires a multifaceted approach that combines psychopharmacological interventions, psychotherapy, counseling, and lifestyle modifications. Susan’s journey towards finding effective treatment and management strategies highlights the importance of a comprehensive and tailored approach.

Psychopharmacological Interventions

Pharmacological interventions play a crucial role in stabilizing mood and managing symptoms associated with bipolar disorder. Susan’s treatment plan involved medications such as mood stabilizers, antipsychotics, and antidepressants. These medications aim to regulate the neurotransmitters in the brain associated with mood regulation. Susan and her healthcare provider closely monitored her medication regimen and made adjustments as needed to achieve symptom control.

Psychotherapy and Counseling

Psychotherapy and counseling provide individuals with bipolar disorder a safe space to explore their thoughts, emotions, and behaviors. Susan engaged in cognitive-behavioral therapy (CBT), which helped her identify and challenge negative thought patterns and develop healthy coping mechanisms. Additionally, psychoeducation in the form of group therapy or support groups allowed Susan to connect with others facing similar challenges, fostering a sense of community and reducing feelings of isolation.

Lifestyle Modifications and Self-Care Strategies

In addition to medical interventions and therapy, lifestyle modifications and self-care strategies play a vital role in managing bipolar disorder. Susan found that maintaining a stable routine, including regular sleep patterns, exercise, and a balanced diet, helped regulate her mood. Avoiding excessive stressors and implementing stress management techniques, such as mindfulness meditation or relaxation exercises, also supported her overall well-being. Engaging in activities she enjoyed, nurturing her social connections, and setting realistic goals further enhanced her quality of life.

Striving for stability and managing bipolar disorder is an ongoing process. What works for one individual may not be effective for another. It is crucial for individuals with bipolar disorder to work closely with their healthcare providers and engage in open communication about treatment options and progress. Fine-tuning the combination of psychopharmacological interventions, therapy, and self-care strategies is essential to optimize symptom control and maintain stability.

Understanding the complexity of treatment and management helps foster empathy for individuals like Susan, who face the daily challenges associated with bipolar disorder. It underscores the importance of early diagnosis, accessible mental health care, and ongoing support systems to enhance the lives of individuals living with this condition. In the following section, we will explore the various support systems available to individuals with bipolar disorder, including family support, peer support groups, and the professional resources that contribute to their well-being.

Support Systems for Individuals with Bipolar Disorder

Navigating the challenges of bipolar disorder requires a strong support system that encompasses various sources of assistance. From family support to peer support groups and professional resources, these networks play a significant role in helping individuals manage their condition effectively.

Family Support

Family support is vital for individuals with bipolar disorder. Understanding and empathetic family members can provide emotional support, monitor medication adherence, and help identify potential triggers or warning signs of relapse. In Susan’s case, her family played a crucial role in her recovery journey, providing a stable and nurturing environment. Education about bipolar disorder within the family helps foster empathy, reduces stigma, and promotes open communication.

Peer Support Groups

Peer support groups provide individuals with bipolar disorder an opportunity to connect with others who share similar experiences. Sharing personal stories, strategies for coping, and offering mutual support can be empowering and validating. In these groups, individuals like Susan can find solace in knowing that they are not alone in their struggles. Peer support groups may meet in-person or virtually, allowing for easier access to support regardless of physical proximity.

Professional Support and Resources

Professional support is crucial in the management of bipolar disorder. Mental health professionals, such as psychiatrists, psychologists, and therapists, provide expertise and guidance in developing comprehensive treatment plans. Regular therapy sessions allow individuals like Susan to explore emotional challenges and develop healthy coping mechanisms. Psychiatrists closely monitor medication effectiveness and make necessary adjustments. Additionally, case managers or social workers can assist with navigating the healthcare system, accessing resources, and connect individuals with other community services.

Beyond direct professional support, there are resources and organizations dedicated to bipolar disorder education, advocacy, and support. Online forums, websites, and helplines provide information, guidance, and a sense of community. These platforms allow individuals to access information at any time and connect with others who understand their unique experiences.

Support systems for bipolar disorder are crucial in empowering individuals and enabling them to lead fulfilling lives. They contribute to reducing stigma, providing emotional support, and ensuring access to resources and education. Through these support systems, individuals with bipolar disorder can gain self-confidence, develop effective coping strategies, and improve their overall well-being.

In the next section, we explore the significance of case studies in understanding bipolar disorder and how they contribute to advancing research and knowledge in the field. Specifically, we will examine how Susan’s case study serves as a valuable contribution to furthering our understanding of this complex disorder.

The Importance of Case Studies in Understanding Bipolar Disorder

Case studies play a vital role in advancing our understanding of bipolar disorder and its complexities. They offer valuable insights into individual experiences, treatment outcomes, and the overall impact of the condition on individuals and society. Susan’s case study, in particular, provides a unique perspective that contributes to broader research and knowledge in the field.

How Case Studies Contribute to Research

Case studies provide an in-depth examination of specific individuals and their experiences with bipolar disorder. They allow researchers and healthcare professionals to observe patterns, identify commonalities, and gain valuable insights into the factors that influence symptom presentation, treatment response, and prognosis. By analyzing various case studies, researchers can generate hypotheses and refine treatment approaches to optimize outcomes for individuals with bipolar disorder.

Case studies are particularly helpful in documenting rare or atypical presentations of bipolar disorder. They shed light on lesser-known subtypes, such as rapid-cycling bipolar disorder or mixed episodes, contributing to a more comprehensive understanding of the condition. Case studies also provide opportunities for clinicians and researchers to discuss unique challenges and discover innovative interventions to improve treatment outcomes.

Susan’s Case Study in the Context of ATI Bipolar Disorder

Susan’s case study is an example of how individual experiences can inform the development of Assessment Technologies Institute (ATI) for bipolar disorder. By examining her journey, researchers can analyze treatment approaches, evaluate the effectiveness of various interventions, and develop evidence-based guidelines for managing bipolar disorder.

Susan’s case study provides rich information about the impact of medication, psychotherapy, and lifestyle modifications on symptom control and overall well-being. It offers valuable insights into the benefits and limitations of specific interventions, highlighting the importance of personalized treatment plans tailored to individual needs. Additionally, Susan’s case study can contribute to ongoing discussions about the role of support systems and the integration of peer support groups in managing and enhancing the lives of individuals with bipolar disorder.

The detailed documentation of Susan’s experiences serves as a powerful tool for healthcare providers, researchers, and individuals living with bipolar disorder. It highlights the complexities and challenges associated with the condition while fostering empathy and understanding among various stakeholders.

Case studies, such as Susan’s, play a crucial role in enhancing our understanding of bipolar disorder. They provide insights into individual experiences, treatment approaches, and the impact of the condition on individuals and society. Through these case studies, we can cultivate empathy for individuals with bipolar disorder, advocate for early diagnosis and effective treatment, and contribute to advancements in research and knowledge.

By illuminating the realities of living with bipolar disorder, we acknowledge the need for accessible mental health care, support systems, and evidence-based interventions. Susan’s case study exemplifies the importance of a comprehensive approach to managing bipolar disorder, integrating psychopharmacological interventions, psychotherapy, counseling, and lifestyle modifications.

Moving forward, it is essential to continue studying cases like Susan’s and explore the diverse experiences within the bipolar disorder population. By doing so, we can foster empathy, encourage early intervention and personalized treatment, and contribute to advancements in understanding bipolar disorder, ultimately improving the lives of individuals affected by this complex condition.

Empathy and Understanding for Individuals with Bipolar Disorder

Developing empathy and understanding for individuals with bipolar disorder is crucial in fostering a supportive and inclusive society. By recognizing the unique challenges they face and the complexity of their experiences, we can better advocate for their needs and provide the necessary resources and support.

It is important to understand that bipolar disorder is not simply a matter of mood swings or being “moody.” It is a chronic and often debilitating mental health condition that affects individuals in profound ways. The extreme highs of mania and the lows of depression can disrupt relationships, employment, and overall quality of life. Developing empathy means acknowledging that these struggles are real and offering support and understanding to those navigating them.

Encouraging Early Diagnosis and Effective Treatment

Early diagnosis and effective treatment are key factors in managing bipolar disorder and reducing the impact of its symptoms. Encouraging individuals to seek help and reducing the stigma associated with mental illness are crucial steps toward achieving early diagnosis. Increased awareness campaigns and education can empower individuals to recognize the signs and symptoms of bipolar disorder in themselves or their loved ones, facilitating timely intervention.

Once diagnosed, providing access to quality mental health care and ensuring individuals receive appropriate treatment is essential. Bipolar disorder often requires a combination of pharmacological interventions, psychotherapy, and lifestyle modifications. By advocating for comprehensive treatment plans and promoting ongoing care, we can help individuals with bipolar disorder achieve symptom control and improve their overall well-being.

The Role of Case Studies in Advancing Knowledge about Bipolar Disorder

Case studies, like Susan’s, play a significant role in advancing knowledge about bipolar disorder. They provide unique insights into individual experiences, treatment outcomes, and the wider impact of the condition. Researchers and healthcare providers can learn from these individual cases, developing evidence-based guidelines and refining treatment approaches.

Additionally, case studies contribute to reducing stigma by providing personal narratives that humanize the disorder. They showcase the challenges faced by individuals with bipolar disorder and highlight the importance of support systems, empathy, and understanding. By sharing these stories, we can help dispel misconceptions and promote a more compassionate approach toward mental health as a whole.

In conclusion, developing empathy and understanding for individuals with bipolar disorder is essential. By recognizing the complexity of their experiences, advocating for early diagnosis and effective treatment, and valuing the insights provided by case studies, we can create a society that supports and uplifts those with bipolar disorder. It is through empathy and education that we can reduce stigma, promote accessible mental health care, and improve the lives of those affected by this condition.In conclusion, gaining a comprehensive understanding of bipolar disorder is crucial in order to support individuals affected by this complex mental health condition. Through the real-life case study of Susan, we have explored the numerous facets of bipolar disorder, including its background, symptoms, and effects on daily life. Susan’s journey serves as a powerful reminder of the challenges individuals face in managing the highs and lows of bipolar disorder and emphasizes the importance of effective treatment and support systems.

We have examined the various approaches to treating and managing bipolar disorder, including psychopharmacological interventions, psychotherapy, and lifestyle modifications. Understanding the role of these treatments and the need for personalized care can significantly improve the quality of life for individuals like Susan.

Support systems also play a crucial role in helping those with bipolar disorder navigate the complexities of the condition. From family support to peer support groups and access to professional resources, fostering a strong network of assistance can provide the necessary emotional support, education, and guidance needed for individuals to effectively manage their symptoms.

Furthermore, case studies, such as Susan’s, contribute to advancing our knowledge about bipolar disorder. By delving into individual experiences, researchers gain valuable insights into treatment outcomes, prognosis, and the impact of the condition on individuals and society as a whole. These case studies foster empathy, reduce stigma, and contribute to the development of evidence-based guidelines and interventions that can improve the lives of individuals with bipolar disorder.

In fostering empathy and promoting early diagnosis, effective treatment, and ongoing support, we create a society that actively embraces and supports individuals with bipolar disorder. By encouraging understanding, reducing stigma, and prioritizing mental health care, we can ensure that those affected by bipolar disorder receive the support and resources necessary to lead fulfilling and meaningful lives. Through empathy, education, and continued research, we can work towards a future where individuals with bipolar disorder are understood, valued, and empowered to thrive.

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• Open access
• Published: 06 November 2018

The challenges of living with bipolar disorder: a qualitative study of the implications for health care and research

• Eva F. Maassen   ORCID: orcid.org/0000-0003-0211-0994 1 , 2 ,
• Barbara J. Regeer 1 ,
• Eline J. Regeer 2 ,
• Joske F. G. Bunders 1 &
• Ralph W. Kupka 2 , 3  

International Journal of Bipolar Disorders volume  6 , Article number:  23 ( 2018 ) Cite this article

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In mental health care, clinical practice is often based on the best available research evidence. However, research findings are difficult to apply to clinical practice, resulting in an implementation gap. To bridge the gap between research and clinical practice, patients’ perspectives should be used in health care and research. This study aimed to understand the challenges people with bipolar disorder (BD) experience and examine what these challenges imply for health care and research needs.

Two qualitative studies were used, one to formulate research needs and another to formulate healthcare needs. In both studies focus group discussions were conducted with patients to explore their challenges in living with BD and associated needs, focusing on the themes diagnosis, treatment and recovery.

Patients’ needs are clustered in ‘disorder-specific’ and ‘generic’ needs. Specific needs concern preventing late or incorrect diagnosis, support in search for individualized treatment and supporting clinical, functional, social and personal recovery. Generic needs concern health professionals, communication and the healthcare system.

Patients with BD address disorder-specific and generic healthcare and research needs. This indicates that disorder-specific treatment guidelines address only in part the needs of patients in everyday clinical practice.

Bipolar disorder (BD) is a major mood disorder characterized by recurrent episodes of depression and (hypo)mania (Goodwin and Jamison 2007 ). According to the Diagnostic and Statistical Manual 5 (DSM-5), the two main subtypes are BD-I (manic episodes, often combined with depression) and BD-II (hypomanic episodes, combined with depression) (APA 2014 ). The estimated lifetime prevalence of BD is 1.3% in the Dutch adult population (de Graaf et al. 2012 ), and BD is associated with high direct (health expenditure) and indirect (e.g. unemployment) costs (Fajutrao et al. 2009 ; Michalak et al. 2012 ), making it an important public health issue. In addition to the economic impact on society, BD has a tremendous impact on patients and their caregivers (Granek et al. 2016 ; Rusner et al. 2009 ). Even between mood episodes, BD is often associated with functional impairment (Van Der Voort et al. 2015 ; Strejilevich et al. 2013 ), such as occupational or psychosocial impairment (Huxley and Baldessarini 2007 ; MacQueen et al. 2001 ; Yasuyama et al. 2017 ). Apart from symptomatic recovery, treatment can help to overcome these impairments and so improve the person’s quality of life (IsHak et al. 2012 ).

Evidence Based Medicine (EBM), introduced in the early 1990s, is a prominent paradigm in modern (mental) health care. It strives to deliver health care based on the best available research evidence, integrated with individual clinical expertise (Sackett et al. 1996 ). EBM was introduced as a new paradigm to ‘de - emphasize intuition’ and ‘ unsystematic clinical experience’ (Guyatt et al. 1992 ) (p. 2420). Despite its popularity in principle (Barratt 2008 ), EBM has also been criticized. One such criticism is the ignorance of patients’ preferences and healthcare needs (Bensing 2000 ). A second criticism relates to the difficulty of adopting evidence-based treatment options in clinical practice (Bensing 2000 ), due to the fact that research outcomes measured in ‘the gold standard’ randomized-controlled trials (RCTs) seldom correspond to the outcomes clinical practice seeks and are not responsive to patients’ needs (Newnham and Page 2010 ). Moreover, EBM provides an overview on population level instead of individual level (Darlenski et al. 2010 ). Thus, adopting research evidence in clinical practice entails difficulties, resulting in an implementation gap.

To bridge the gap between research and clinical practice, it is argued that patients’ perspectives should be used in both health care and research. Patients have experiential knowledge about their illness, living with it in their personal context and their care needs (Tait 2005 ). This is valuable for both clinical practice and research as their knowledge complements that of health professionals and researchers (Tait 2005 ; Broerse et al. 2010 ; Caron-Flinterman et al. 2005 ). This source of knowledge can be used in the process of translating evidence into clinical practice (Schrevel 2015 ). Moreover, patient participation can enhance the clinical relevance of and support for research and the outcomes in practice (Abma and Broerse 2010 ). Hence, it is argued that these perspectives should be explicated and integrated into clinical guidelines, clinical practice, and research (Misak 2010 ; Rycroft-Malone et al. 2004 ).

Given the advantages of including patients’ perspectives, patients are increasingly involved in healthcare services (Bagchus et al. 2014 ; Larsson et al. 2007 ), healthcare quality (e.g. guideline development) (Pittens et al. 2013 ) and health-related research (e.g. agenda setting, research design) (Broerse et al. 2010 ; Boote et al. 2010 ; Elberse et al. 2012 ; Teunissen et al. 2011 ). However, patients’ perspectives on health care and on research are often studied separately. We argue that to be able to provide care focused on the patients and their needs, care and research must closely interact.

We hypothesize that the challenges BD patients experience and the associated care and research needs are interwoven, and that combining them would provide a more comprehensive understanding. We hypothesize that this more comprehensive understanding would help to close the gap between clinical practice and research. For this reason, this study aims to understand the challenges people with BD experience and examine what these challenges imply for healthcare and research needs.

To understand the challenges and needs of people with BD, we undertook two qualitative studies. The first aimed to formulate a research agenda for BD from a patient’s perspective, by gaining insights into their challenges and research needs. A second study yielded an understanding of the care needs from a patient’s perspective. In this article, the results of these two studies are combined in order to investigate the relationship between research needs and care needs. Challenges are defined as ‘difficulties patients face, due to having BD’. Care needs are defined as that what patients ‘desire to receive from healthcare services to improve overall health’ (Asadi-Lari et al. 2004 ) (p. 2). Research needs are defined as that what patients ‘desire to receive from research to improve overall health’.

Study on research needs

In this study, mixed-methods were used to formulate research needs from a patient’s perspective. First six focus group discussions (FGDs) with 35 patients were conducted to formulate challenges in living with BD and hopes for the future, and to formulate research needs arising from these difficulties and aspirations. These research needs were validated in a larger sample (n = 219) by means of a questionnaire. We have reported this study in detail elsewhere (Maassen et al. 2018 ).

Study on care needs

This study was part of a nationwide Dutch project to generate a practical guideline for BD: a translation of the existing clinical guideline to clinical practice, resulting in a standard of care that patients with BD could expect. The practical guideline (Netwerk Kwaliteitsontwikkeling GGZ 2017 ) was written by a taskforce comprising health professionals, patients. In addition to the involvement of three BD patients in the taskforce, a systematic qualitative study was conducted to gain insight into the needs of a broader group of patients.

Participants and data collection

To formulate the care needs of people with BD, seven FGDs were conducted, with a total of 56 participants, including patients (n = 49) and caregivers (n = 9); some participants were both patient and caregiver. The inclusion criteria for patients were having been diagnosed with BD, aged 18 years or older and euthymic at time of the FGDs. Inclusion criteria for caregivers were caring for someone with BD and aged 18 years or older. To recruit participants, a maximum variation sampling strategy was used to collect a broad range of care needs (Kuper et al. 2008 ). First, all outpatient clinics specialized in BD affiliated with the Dutch Foundation for Bipolar Disorder (Dutch: Kenniscentrum Bipolaire Stoornissen) were contacted by means of an announcement at regular meetings and by email if they were interested to participate. From these outpatient clinics, patients were recruited by means of flyers and posters. Second, patients were recruited at a quarterly meeting of the Dutch patient and caregiver association for bipolar disorder. The FGDs were conducted between March and May 2016.

The FGDs were designed to address challenges experienced in BD health care and areas of improvement for health care for people with BD. The FGDs were structured by means of a guide and each session was facilitated by two moderators. The leading moderator was either BJR or EFM, having both extensive experience with FGD’s from previous studies. The first FGD explored a broad range of needs. The subsequent six FGDs aimed to gain a deeper understanding of these care needs, and were structured according to the outline of the practical guideline (Netwerk Kwaliteitsontwikkeling GGZ 2017 ). Three chapters were of particular interest: diagnosis, treatment and recovery. These themes were discussed in the FGDs, two in each session, all themes three times in total. Moreover, questions on specific aspects of care formulated by the members of the workgroup were posed. The sessions took 90–120 min. The FGDs were audiotaped and transcribed verbatim. A summary of the FGDs was sent to the participants for a member check.

Data analysis

To analyze the data on challenges and needs, a framework for thematic analysis to identify, analyze and report patterns (themes) in qualitative data sets by Braun and Clarke ( 2006 ) was used. First, we familiarized ourselves with the data by carefully reading the transcripts. Second, open coding was used to derive initial codes from the data. These codes were provided to quotes that reflected a certain challenge or care need. Third, we searched for patterns within the codes reflecting challenges and within those reflecting needs. For both challenges and needs, similar or overlapping codes were clustered into themes. Subsequently, all needs were categorized as ‘specific’ or ‘generic’. The former are specific to BD and the latter are relevant for a broad range of psychiatric illnesses. Finally, a causal analysis provided a clear understanding of how challenges related to each other and how they related to the described needs.

To analyze the data on needs regarding recovery, four domains were distinguished, namely clinical, functional, social and personal recovery (Lloyd et al. 2008 ; van der Stel 2015 ). Clinical recovery refers to symptomatic remission; functional recovery concerns recovery of functioning that is impaired due to the disorder, particularly in the domain of executive functions; social recovery concerns the improvement of the patient’s position in society; personal recovery concerns the ability of the patient to give meaning to what had happened and to get a grip on their own life. The analyses were discussed between BR and EM. The qualitative software program MAX QDA 11.1.2 was used (MaxQDA).

Ethical considerations

According to the Medical Ethical Committee of VU University Medical Center, the Medical Research Involving Human Subjects Act does not apply to the current study. All participants gave written or verbal informed consent regarding the aim of the study and for audiotaping and its use for analysis and scientific publications. Participation was voluntary and participants could withdraw from the study at any time. Anonymity was ensured.

This section is in three parts. The first presents the participants’ characteristics. The second presents the challenges BD patients face, derived from both studies, and the disorder-specific care and research needs associated with these challenges. The third part describes the generic care needs that patients formulated.

Characteristics of the participants

In the study on care needs, 56 patients and caregivers participated. The mean age of the participants was 52 years (24–75), of whom 67.8% were women. The groups varied from four to sixteen participants, and all groups included men and women. Of all participants 87.5% was diagnosed with BD, of whom 48.9% was diagnosed with BD I. 3.5% was both caregivers and diagnosed with BD. Of 4 patients the age was missing, and from 6 patients the bipolar subtype.

Despite the fact that participants acknowledge the inevitable diagnostic difficulties of a complex disorder like BD, in both studies they describe a range of challenges in different phases of the diagnostic process (Fig.  1 ). Patients explained that the general practitioner (GP) and society in general did not recognize early-warning signs and mood swings were not well interpreted, resulting in late or incorrect diagnosis. Patients formulated a need for more research on what early-warning signs could be and on how to improve GPs’ knowledge about BD. Formulated care needs were associated with GPs using this knowledge to recognize early-warning signs in individual patients. One participant explained that certain symptoms must be noticed and placed in the right context:

Challenges with diagnosis (squares) including relating research needs (white circles) and care needs (grey circles). (1): mentioned in study on research needs; (2): mentioned in study on care needs. Dotted lines: division of challenges into sub challenges. Arrows: causal relation between challenges

I call it, ‘testing overflow of ideas’. [….] When it happens for the first time you yourself do not recognize it. Someone else close to you or the health professional, who is often not involved yet, must signal it. (FG6)

Moreover, these challenges are associated with the need to pay attention to family history and to use a multidisciplinary approach to diagnosis to benefit from multiple perspectives. The untimely recognition of early symptoms also results in another challenge: inadequate referral to the right specialized health professional. After referral, people often face a waiting list, again causing delay in the diagnostic process. These challenges result in the need for research on optimal referral systems and the care need for timely referral. One participant described her process after the GP decided to refer her:

But, yes, at that moment the communication wasn’t good at all. Because the general practitioner said: ‘she urgently has to be seen by someone’. Subsequently, three weeks went by, until I finally arrived at depression [department]. And at that department they said: ‘well, you are in the wrong place, you need to go to bipolar [department ]’. (FG1)

The challenge of being misdiagnosed is associated with the need to be able to ask for a second opinion and to have a timely and thorough diagnosis. On the one hand, it is important for patients that health professionals quickly understand what is going on, on the other hand that health professionals take the time to thoroughly investigate the symptoms by making several appointments.

From both studies, two main challenges related to the treatment of BD were derived (Fig.  2 ). The first is finding appropriate and satisfactory treatment. Participants explained that it is difficult to find the right medication and dosage that is effective and has acceptable side-effects. One participant illustrates:

Challenges with treatment (squares) including relating research needs (white circles) and care needs (grey circles). (1): mentioned in study on research needs; (2): mentioned in study on care needs. Dotted lines: division of challenges into sub challenges. Arrows: causal relation between challenges

I think, at one point, we have to choose, either overweight or depressed. (FG1)

Some participants said that they struggle with having to use medication indefinitely, including the associated medical checks. The difficult search for the right pharmacological treatment results in the need for research on long-term side-effects, on the mechanism of action of medicine and on the development of better targeted medication with fewer adverse side-effects. In care, patients would appreciate all the known information on the side-effects and intended effects. One participant explained the importance of being properly informed about medication:

I don’t read anything [about medication], because then I wouldn’t dare taking it. But I do think, when you explain it well, the advantages, the disadvantages, the treatment, the idea behind it, that would help a lot in compliance. (FG1)

A second aspect is the challenge of finding non-pharmacological therapies that fit patients’ needs. They said they and the health professionals often do not know which non-pharmacological therapies are available and effective:

But we found the carefarm ourselves Footnote 1 [….]. You have to search for yourself completely. Yes, I actually hoped that that would be presented to you, like: ‘this would be something for you’. (FG3)

Participants mentioned a variety of non-pharmacological therapies they found useful, namely cognitive behavior therapy (CBT), EMDR, running therapy, social-rhythm training, light therapy, mindfulness, psychotherapy, psychoeducation, and training in living with mood swings. They formulated the care need to receive an overview of all available treatment options in order to find a treatment best suited to their needs. They would appreciate research on the effectiveness of non-pharmacological treatments.

A third aspect within this challenge is finding the right balance between non-pharmacological and pharmacological treatment. Participants differed in their opinion about the need for medication. Whereas some participants stated that they need medication to function, others pointed out that they found non-pharmacological treatments effective, resulting in less or no medication use. They explained that the preferred balance can also change over time, depending on their mood. However, they experience a dominant focus on pharmacological treatment by the health professionals. To address this challenge, patients need support in searching for an appropriate balance.

Next to the challenge of finding appropriate and satisfactory treatment, a second treatment-related challenge is hospitalization. Participants often had a traumatic experience, due to seclusion, the authoritarian attitudes of clinical staff, and not involving their family. Patients therefore found it important to try preventing being hospitalized, for example by means of home treatment, which some participants experienced positively. Despite the challenges relating to hospitalization, participants did acknowledge that in some cases it cannot be avoided, in which case they urged for close family involvement, open communication and being treated by their own psychiatrist. Still, in the study on research needs, hospitalization did not emerge as an important research theme.

In both studies, participants described challenges in all four domains of recovery: clinical, functional, social and personal (Fig.  3 ). In relation to clinical recovery, participants struggled with the symptoms of mood episodes, the psychosis and the fear of a future episode. In contrast, some participants mentioned that they sometimes miss the hypomanic state they had experienced previously due to effective medical treatment. In the domain of functional recovery, participants contended with having to function below their educational level due to residual symptoms, such as cognitive problems, due to the importance of preventing stress in order to reduce the risk of a new episode, and because of low energy levels. This leads to the care need that health professionals should pay attention to the level of functioning of their patients.

Challenges with recovery (squares) including relating research needs (white circles) and care needs (grey circles). (1): mentioned in study on research needs; (2): mentioned in study on care needs. Dotted lines: division of challenges into sub challenges. Arrows: causal relation between challenges

In the domain of social recovery, participants described challenges with maintaining friendships, due to stigma, being unpredictable and with deciding when to disclose the disorder. The latter resulted in the care need for tips on disclosure. Moreover, patients experienced challenges with reintegration to work, due to colleagues’ lack of understanding, problems with functioning during an episode, the complicating policy of the (Dutch) Employee Insurance Agency Footnote 2 in relation to the fluctuating course of BD and the negative impact of stress. These challenges are associated with the care need that health professionals should pay attention to work and the need for research on how to improve the Social Security Agency’s policy.

For their personal recovery, participants struggled with acceptance of the disorder, due to shame, stigma, having to live by structured rules and disciplines, and the chronic nature of BD. This results in care needs for grief counselling and attention to acceptance and the need for research on the impact of being diagnosed with BD. Limited understanding within society also causes problems with acceptance, corresponding with the care need for education for caregivers and for research on how to increase social acceptance. Another challenge in personal recovery was discovering what recovery means and what constitute meaningful daily activities. Patients appreciated the support of health professionals in this area. One participant described the difficult search for the meaning of recovery:

I have been looking to recover towards the situation [before diagnosis] for a long time; that I could do what I always did and what I liked. But then I was confronted with the fact that I shouldn’t expect that to happen, or only with a lot of effort. (…) Then you start thinking, now what? A compromise. I don’t want to call that recovery, but it is a recovered, partly accepted, situation. But it is not recovery as I expected it to be. (FG5)

In general, participants considered frequent contact with a nurse or psychiatrist supportive, to help them monitor their mood and help them find (efficient) self-management strategies. Most participants appreciated the involvement of caregivers in the treatment and contact with peers.

Generic care needs

We have described BD-specific needs, but patients mentioned also mentioned several generic care needs. The latter are clustered into three categories. The first concerns the health professionals . Participants stressed the importance of a good health professional, who carefully listens, takes time, and makes them feel understood, resulting in a sense of connection. Furthermore, a good health professional treats beyond the guideline, and focuses on the needs of the individual patient. When there is no sense of connection, it should be possible to change to another health professional. The second category concerns communication between the patient and the health professional . Health professionals should communicate in an open, honest and clear way both in the early diagnostic phase and during treatment. Open communication facilitates individualized care, in which the patient is involved in decision making. In addition, participants wanted to be treated as a person, not as a patient, and according to a strength-based approach. The third category concerns needs at the level of the healthcare system . Participants struggled with the availability of the health professionals and preferred access to good care 24/7 and being able to contact their health professional quickly when necessary. Currently, according to the participants, the care system is not geared to the mood swings of BD, because patients often faced waiting lists before they could see a health professional.

Is adequate treatment also having a number from a mental health institution you can always call when you are in need, that you can go there? And not that you can go in three weeks, but on a really short notice. So at least a phone call. (FG3)

Participants were often frustrated by the limited collaboration between health professionals, within their own team, between departments of the organization, and between different organizations, including complementary health professionals. They would appreciate being able to merge their conventional and complementary treatment, with greater collaboration among the different health professionals. Furthermore, they would like continuity of health professionals as this improves both the diagnostic phase and treatment, and because that health professional gets to know the patient.

We hypothesized that research and care needs of patients are closely intertwined and that understanding these, by explicating patients’ perspectives, could contribute to closing the gap between research and care. Therefore, this study aimed to understand the challenges patients with BD face and examine what these imply for both healthcare and research. In the study on needs for research and in the study on care needs, patients formulated challenges relating to receiving the correct diagnosis, finding the right treatment, including the proper balance between non-pharmacological and pharmacological treatment, and to their individual search for clinical, functional, social and personal recovery. The formulated needs in both studies clearly reflected these challenges, leading to closely corresponding needs. Another important finding of our study is that patients not only formulate disorder-specific needs, but also many generic needs.

The needs found in our study are in line with the current literature on the needs of patients with BD, namely for more non-pharmacological treatment (Malmström et al. 2016 ; Nestsiarovich et al. 2017 ), timely recognition of early-warning signs and self-management strategies to prevent a new episode (Goossens et al. 2014 ), better information on treatment and treatment alternatives (Malmström et al. 2016 ; Neogi et al. 2016 ) and coping with grief (Goossens et al. 2014 ). Moreover, the need for frequent contact with health professionals, being listened to, receiving enough time, shared decision-making on pharmacological treatment, involving caregivers (Malmström et al. 2016 ; Fisher et al. 2017 ; Skelly et al. 2013 ), and the urge for better access to health care and continuity of health professionals (Nestsiarovich et al. 2017 ; Skelly et al. 2013 ) are confirmed by the literature. Our study added to this set of literature by providing insights in patients’ needs in the diagnostic process and illustrating the interrelation between research needs and care needs from a patient’s perspective.

The generic healthcare needs patients addressed in this study are clustered into three categories: the health professional , communication between the patient and the health professional and the health system. These categories all fit in a model of patient-centered care (PCC) by Maassen et al. ( 2016 ) In their review, patients’ perspectives on good care are compared with academic perspectives of PCC and a model of PCC is created comprising four dimensions: patient, health professional, patient – professional interaction and healthcare organization. All the generic needs formulated in this study fit into these four dimensions. The need to be treated as a person with strengths fits the dimension ‘patient’, and the need for a good health professional who carefully listens, takes time and makes them feel understood, resulting in a good connection with the professional, fits the dimension ‘health professional’ of this model. Furthermore, patients in this study stressed the importance of open communication in order to provide individualized care, which fits the dimension of ‘patient–professional interaction’. The urge for better access to health care, geared to patients’ mood swings and the need for better collaboration between health professionals and continuity of health professionals fits the dimension of ‘health care organization’ of the model. This study confirms the findings from the review and contributes to the literature stressing the importance of a patient-centered care approach (Mills et al. 2014 ; Scholl et al. 2014 ).

In the prevailing healthcare paradigm, EBM, the best available evidence should guide treatment of patients (Sackett et al. 1996 ; Darlenski et al. 2010 ). This evidence is translated into clinical and practical guidelines, which thus facilitate EBM and could be used as a decision-making tool in clinical practice (Skelly et al. 2013 ). For many psychiatric disorders, treatment is based on such disorder - specific clinical and practical guidelines. However, this disease-focused healthcare system has contributed to its fragmented nature Stange ( 2009 ) argues that this fragmented care system has expanded without the corresponding ability to integrate and personalize accordingly. We argue that acknowledging that disorder - specific clinical and practical guidelines address only parts of the care needs is of major importance, since otherwise important aspects of the patients’ needs will be ignored. Because there is an increasing acknowledgement that health care should be responsive to the needs of patients and should change from being disease-focused towards being patient-focused (Mead and Bower 2000 ; Sidani and Fox 2014 ), currently in the Netherlands generic practical guidelines are written on specific care themes (e.g. co-morbidity, side-effects, daily activity and participation). These generic practical guidelines address some of the generic needs formulated by the patients in our study. We argue that in addition to disorder-specific guidelines, these generic practical guidelines should increasingly be integrated into clinical practice, while health professionals should continuously be sensitive to other emerging needs. We believe that an integration of a disorder-centered and a patient-centered focus is essential to address all needs a patient.

Strengths, limitations and future research

This study has several strengths. First, it contributes to the literature on the challenges and needs of patients with BD. Second, the study is conducted from a patient’s perspective. Moreover, addressing this aim by conducting two separate studies enabled us to triangulate the data.

This study also has several limitations. First, this study reflects the challenges, care needs and research needs of Dutch patient with BD and caregivers. Despite the fact that a maximum variation sampling strategy was used to derive a broad range of challenges and needs throughout the Netherlands, the Dutch setting of the study may limit the transferability to other countries. To understand the overlap and differences between countries, similar research should be conducted in other contexts. Second, given the design of the study, we could not differentiate between patients and caregivers since they participated together in the FGDs. More patients than caregivers participated in the study. For a more in-depth understanding of the challenges and needs faced by caregivers, in future research separate FGDs should be conducted. Third, due to the fixed outline of the practical guideline used to conduct the FGDs, only the healthcare needs for diagnosis, treatment and recovery of BD are studied. Despite the fact that these themes might cover a broad range of health care, it could have resulted in overlooking certain needs in related areas of well-being. Therefore, future research should focus on needs outside of these themes in order to provide a complete set of healthcare needs.

Patients and their caregivers face many challenges in living with BD. Our study contributes to the literature on care and research needs from a patient perspective. Needs specific for BD are preventing late or incorrect diagnosis, support in search for individualized treatment, and supporting clinical, functional, social and personal recovery. Generic healthcare needs concern health professionals, communication and the healthcare system. This explication of both disorder-specific and generic needs indicates that clinical practice guidelines should address and integrate both in order to be responsive to the needs of patients and their caregivers.

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Authors’ contributions

EFM designed the study, contributed to the data collection, managed the analysis and wrote the first draft of the manuscript. BJR designed the study and contributed to the data collection, data analysis, and writing of the manuscript. JFGB contributed to the study design and critical revision of the manuscript. EJR contributed to the study conception and critical revision of the manuscript. RWK contributed to the study design, acquisition of data, and critical revision of the manuscript. All authors contributed to the final manuscript. All authors read and approved the final manuscript.

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Maassen, E.F., Regeer, B.J., Regeer, E.J. et al. The challenges of living with bipolar disorder: a qualitative study of the implications for health care and research. Int J Bipolar Disord 6 , 23 (2018). https://doi.org/10.1186/s40345-018-0131-y

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5 Psychiatric Treatment of Bipolar Disorder: The Case of Janice

• Published: February 2013
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Chapter 5 covers the psychiatric treatment of bipolar disorder, including a case history, key principles, assessment strategy, differential diagnosis, case formulation, treatment planning, nonspecific factors in treatment, potential treatment obstacles, ethical considerations, common mistakes to avoid in treatment, and relapse prevention.

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Diagnosing and treating bipolar spectrum disorders

Patients with bipolar disorder cycle between two or more mood states, such as mania, hypomania, or depression

Vol. 53 No. 1 Print version: page 36

• Bipolar Disorder

CE credits: 1

Learning objectives: After reading this article, CE candidates will be able to:

• Discuss how psychologists’ understanding of bipolar disorder has changed over the past 3 decades.
• Describe mood states, symptoms, and diagnostic criteria for the four bipolar spectrum disorders.
• List front-line pharmacological and psychological treatments for bipolar disorder.

For more information on earning CE credit for this article, go to CE Corner .

In the 1990s, bipolar disorder was seen as a severe, rare, incurable condition found only in adults. Medication, primarily lithium, was the sole treatment offered to most patients. Today, experts are learning that the disorder is more common—affecting about 4% of U.S. children and adults—and presents along a diverse continuum. More than half of patients have their first mood symptoms in childhood or adolescence, a full range of treatments exist, and people with the condition can survive and thrive (Moreira, A. L., et al., The Journal of Clinical Psychiatry , Vol. 78, No. 9, 2017; Van Meter, A., et al., The Journal of Clinical Psychiatry , Vol. 80, No. 3, 2019).

“The more we study bipolar disorder, the more we appreciate its complexity, especially around the onset of symptoms and in the underserved,” said Manpreet K. Singh, MD, an associate professor of psychiatry and behavioral sciences at Stanford University. “There isn’t going to be a single genetic marker, research tool, or treatment plan that resolves this complexity.”

Psychologists and psychiatrists studying bipolar disorder are characterizing complexities of the condition, including its earliest symptoms, longitudinal course, and the psychological factors that increase risk of recurrences. They are also applying new approaches (such as studying vascular contributions to the condition) and technologies (including using wearable devices) to obtain rich new data.

All of this is driving two major shifts that are already proving life-changing for patients: earlier and more accurate diagnosis and increasingly personalized treatments.

“For a long time, there has been so much stigma, so much confusion, and so much uncertainty about this illness,” said Eric A. Youngstrom, PhD, a professor of psychology, neuroscience, and psychiatry at the University of North Carolina at Chapel Hill who studies bipolar disorder. “We now have a revolutionary new view for diagnosing and treating bipolar disorder that I’m positive can make a difference in people’s lives.”

Complex diagnosis

Bipolar disorder is an episodic condition in which patients cycle between two or more mood states. Diagnosis is typically a two-step process: Clinicians first diagnose mood episodes—such as mania, hypomania, or depression—and then they diagnose the disorder itself.

Mania is a distinct period of an elevated or irritable mood, along with persistent goal-directed behavior or energy, that lasts at least 1 week and potentially up to a few months and causes marked impairment, according to the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). Common symptoms include grandiosity, a decreased need for sleep, and excessive risky activity. A hypomanic episode is less severe: It lasts at least 4 days but does not cause marked impairment.

A depressive episode—which includes symptoms such as loss of interest, weight loss or gain, and thoughts of suicide—lasts 2 or more weeks and causes both impairment and distress. Mixed states, which are some of the hardest to treat, consist of phases with both manic and depressive symptoms. People with mixed states often have extreme irritability, volatility, and a high risk for suicide.

Euthymia, defined as mood functioning within normal limits, is crucial in diagnosing bipolar disorder because it helps clinicians find the beginning of a mood episode such as mania or hypomania. A patient who rapidly cycles between manic and depressive symptoms without a clear euthymia, for example, may be experiencing anxiety or attention-deficit/hyperactivity disorder (ADHD) rather than a mood disorder.

The DSM-5 lists four major categories of bipolar spectrum disorders, as well as versions of the illness induced by substances and other medical conditions, such as stroke or traumatic brain injury.

Bipolar I disorder is characterized by manic or mixed episodes, with or without depression, while bipolar II disorder involves episodes of hypomania and depression. Cyclothymic disorder involves depressive and hypomanic symptoms that cause impairment but do not meet the severity or duration criteria for bipolar I or II. The clinical picture of these disorders, including symptoms, prognosis, and comorbidities, typically looks similar in children and adults.

A fourth category, known as “other specified bipolar and related disorder,” describes patients with episodic mood symptoms who do not meet the criteria for the other three disorders—for example, a patient with recurrent manic symptoms that cause impairment but last less than 1 week. This disorder is more common than bipolar I or II, especially in children and adolescents, and carries a similar risk for co-occurring psychiatric conditions, suicide attempts, and family history of bipolar disorder. Research also suggests that in patients with a family history of the illness, about half go on to develop bipolar I or II (Axelson, D. A., et al., Journal of the American Academy of Child & Adolescent Psychiatry , Vol. 50, No. 10, 2011).

Experts argue that this points to the importance of providing support early on, even if it is not yet clear whether a patient will develop more severe mood symptoms (Singh, M. K., et al., Bipolar Disorders , Vol. 22, No. 7, 2020).

“The field needs to move toward something similar to what we see in heart disease, where we don’t wait for the full manifestation of the illness before acting,” said Benjamin Goldstein, MD, PhD, a professor of psychiatry and pharmacology at the University of Toronto and director of the Centre for Addiction and Mental Health’s Centre for Youth Bipolar Disorder in Toronto.

Earlier identification

Unfortunately, psychology and psychiatry have a poor record when it comes to the timely and accurate diagnosis of bipolar disorder, with a high rate of missed diagnoses and an average lag time of 5 or more years between the onset of mood symptoms and a diagnosis of bipolar disorder (Jensen-Doss, A., et al., Journal of Consulting and Clinical Psychology , Vol. 82, No. 6, 2014; Marchand, W. R., et al., Journal of Psychiatric Practice , Vol. 12, No. 2, 2006).

Part of the problem is that with their diverse range of states and symptoms, bipolar spectrum disorders can look like major depression, anxiety, psychosis, substance use disorders, autism spectrum disorders, ADHD, personality disorders, or conduct disorders.

Consider two patients who visited a mental health clinic. Tamika, an 11-year-old girl, came in with her mother, who reported that her daughter had sudden increases in anger, aggression, and trouble sleeping. At home, Tamika threw toys and broke dishes; at school, she was loud and disruptive. Lea, an 18-year-old in her senior year of high school, came in by herself, reporting problems with attention and anxiety about graduation and going to college. She thought she had ADHD. Could either of these patients have bipolar disorder?

To simplify the process of assessment and cut down on diagnostic errors when patients like Tamika or Lea come into a clinic, Youngstrom and his colleagues advocate that clinicians use a probability-based approach to diagnosis—akin to counting cards in blackjack—and they have created and tested a freely available model for doing so.

Youngstrom’s evidence-based assessment (EBA) model relies on an algorithm that makes risk calculations using the clinical evidence base. For example, compared with someone with no family history of mood disorders, a person’s chance of having bipolar disorder is 5 times higher if a parent or sibling has it, but only 2.5 times higher if a grandparent, aunt, or uncle does. The EBA model walks clinicians through a step-by-step evaluation that includes benchmark rates of various disorders, recommendations for high-quality clinical questionnaires, and reminders to ask about mitigating factors such as substance use, trauma, and bereavement ( Cognitive and Behavioral Practice , Vol. 22, No. 1, 2015). Unlike machine-learning approaches, the EBA method keeps the clinician in the driver’s seat, choosing whether to obtain more information and when and how to begin treatment.

Using the EBA model, a clinician diagnosed Lea with bipolar II disorder. By looking at screening questionnaires, gathering family history, and asking focused questions during the clinical interview, her provider found evidence that built the case for bipolar. Lea often slept less than usual yet had more energy. During such periods, she was more likely to fight with her mother and friends. And her father, who no longer lived at home, had bipolar disorder. Tamika, on the other hand, did not meet the criteria for any bipolar spectrum disorder. Instead, her clinical interview uncovered a recent sexual assault, leading to a diagnosis of post-traumatic stress disorder.

In some cases, a clinician may not reach 100% certainty that a patient has bipolar disorder, but early psychosocial and lifestyle interventions can improve long-term prospects, Goldstein said, especially in youth. “The more we can support young brains in developing healthy executive functioning, the better youth will be able to manage the illness if it strikes them,” he said.

Family-focused therapy (FFT), an intervention that teaches patients and family members about bipolar disorder and helps them communicate and solve problems related to mood episodes, can reduce depression and suicidal ideation in youth at risk for bipolar disorder (Miklowitz, D. J., et al., JAMA Psychiatry , Vol. 77, No. 5, 2020).

“When kids are showing early warning signs of bipolar disorder, the stress faced by families can be overwhelming, but how parents deal with these early signs can make a huge difference in kids’ outcomes,” said psychologist David Miklowitz, PhD, a professor of psychiatry at the University of California, Los Angeles.

Long-term treatment

Front-line treatment for most patients with bipolar disorder typically still includes medication, but there is also a growing recognition among many clinicians that drugs alone are not sufficient.

“We’re now realizing we can’t just treat everyone with medications,” said Miklowitz. “Psychoeducational treatment is very important in helping people learn how to cope with the disorder.”

Before starting psychotherapy, most patients who seek help during an acute episode of mania or depression receive an antipsychotic drug or mood stabilizer. Lithium is still considered the gold standard for both youth and adults, but it tends to work best for patients with bipolar I and a family history of the disorder (Grof, P., Neuropsychobiology , Vol. 62, No. 1, 2010). Long-term use of lithium, however, can lead to chronic kidney or thyroid problems, so providers and patients should carefully monitor side effects and seek the support of a physician when necessary (Forlenza, O. V., et al., The British Journal of Psychiatry , Vol. 215, No. 5, 2019).

Another issue is that patients may stop taking lithium once they feel stable, which puts them at high risk for additional mood episodes, hospitalization, and suicide (Prajapati, A. R., et al., Psychological Medicine , Vol. 51, No. 7, 2021). For that reason, experts say it is particularly important to combine medications with psychotherapy.

Increasingly, psychopharmacology research is offering alternatives, such as the new antipsychotic drug lurasidone (Pikalov, A., et al., International Journal of Bipolar Disorders , Vol. 5, No. 9, 2017) and the anesthetic ketamine, which has been proven effective for treatment-resistant depression (Kryst, J., et al., Pharmacological Reports , Vol. 72, 2020). Rapid transcranial magnetic stimulation, which involves electrical activation of the frontal cortex, is also showing promise for depression and may help patients with bipolar disorder, Miklowitz said, but more research is needed (Nguyen, T. D., et al., Journal of Affective Disorders , Vol. 279, 2021).

“Many people who live with bipolar disorder spend more days depressed than they do manic,” said Singh. “Researchers are now putting some muscle and grease into understanding how we treat bipolar depression over the long term.”

Once a patient is stable, psychotherapy can help them learn to navigate life with bipolar disorder. FFT, which Miklowitz developed, educates patients and their families about the disorder, including how to recognize early warning signs of a mood episode, such as altered sleep patterns. Typically delivered after a person’s first or second mood episode and lasting up to 9 months, FFT helps families create a relapse prevention plan and learn how to communicate effectively ( Family Process , Vol. 55, No. 3, 2016).

“With this disorder, psychotherapy is typically time-limited,” Miklowitz said. “Research has shown that 3-, 6-, or 9-month treatments focused on education and skill-building are effective in preventing recurrences and improving overall functioning.”

Psychosocial interventions such as FFT can be modified to help patients manage the symptoms of bipolar disorder across the life span. In adults, the sessions often include a spouse and cover additional concerns, such as physical intimacy. For older adults, sessions may include an adult child who is a caretaker. Clinicians may also incorporate neuropsychological testing to determine whether a patient is also experiencing dementia.

Interpersonal and social rhythm therapy (IPSRT), developed by psychologist Ellen Frank, PhD, a professor of psychiatry and psychology at the University of Pittsburgh School of Medicine, and her colleagues, also delivers psychoeducation and helps patients regulate their daily routines, including work, social interactions, and sleep-wake cycles. IPSRT has been shown to reduce manic and depressive symptoms and to improve overall functioning in people with bipolar spectrum disorders (Steardo, L., et al., Annals of General Psychiatry , Vol. 19, No. 15, 2020). Cognitive behavioral therapy, dialectical behavior therapy, and group therapy—which offers the added benefit of peer support—are similarly effective (Novick, D. M., & Swartz, H. A., Focus , Vol. 17, No. 3, 2019; Goldstein, T. R., et al., Journal of Child and Adolescent Psychopharmacology , Vol. 25, No. 2, 2015).

IPSRT works partly by stabilizing mood through establishing regular sleep-wake cycles. Another inexpensive, low-risk way to regulate sleep is with blue light-blocking glasses, which help trigger melatonin production. Indeed, early evidence indicates that wearing blue light–blocking glasses before bedtime can help stabilize manic symptoms (Hester, L., et al., Chronobiology International , Vol. 38, No. 10, 2021).

Growing evidence also supports lifestyle changes in nutrition and physical activity. Eating and exercising in accordance with U.S. Department of Health and Human Services guidelines can improve emotional well-being, Goldstein said, and it can also boost cardiovascular health, which is implicated in bipolar disorder. Research by Goldstein and others shows that chronic inflammation harms brain health and may predict worse treatment outcomes in bipolar disorder ( Bipolar Disorders , Vol. 22, No. 5, 2020).

For older patients, cognitive rehabilitation therapies, which are currently still in early trials, may become increasingly important, Miklowitz said. Research suggests that memory and other cognitive functions can deteriorate over time with successive mood episodes, and such therapies may help patients regain functioning (Solé, B., et al., International Journal of Neuropsychopharmacology , Vol. 20, No. 8, 2017).

To fully support patients with bipolar disorder, a coordinated effort between psychologists, who excel at developing and delivering psychosocial interventions, and psychiatrists, who have a sophisticated understanding of how medications can help, is crucial—and can even ameliorate depressive symptoms (Van der Voort, T. Y. G., et al., The British Journal of Psychiatry , Vol. 206, No. 5, 2018).

“It takes a village to treat bipolar disorder,” said Singh. “When patients, caregivers, psychiatrists, and allied mental health professionals work collaboratively, outcomes may be better than treatment by either a psychologist or psychiatrist alone.”

Opportunities for research

Even with these major strides in diagnosing and treating bipolar disorder, challenges remain. For one, interventions for bipolar depression are still less effective than those used for unipolar depression, and clinicians urgently need better options for their patients, said Goldstein. Some mood episodes, such as mixed states, and certain symptoms, such as irritability, attention problems, and anhedonia—or lack of motivation—also remain tough to treat, said Singh, and may ultimately require a multipronged approach. “Our patients are hungry for it. Usually, it’s those symptoms that linger that bring them to see us,” she said.

More attention is also needed to the longitudinal course of the illness, researchers say, which can continue to help delineate tailored treatment options. Clinicians hope to increasingly make personalized recommendations for medication and psychotherapy based on a patient’s symptom presentation, genetic risk, family history, recent environmental stressors, lifestyle factors, and more. For example, providers may soon be able to better predict which patients will do well with a 6-month course of psychotherapy and which will require regular check-ins with a provider.

Researchers are also further exploring how wearable devices and smartphone apps can help patients track and manage mood symptoms. Miklowitz is testing a version of FFT that includes app-based mood tracking and communication skill-building tasks in an effort to improve patient engagement and outcomes ( Journal of Affective Disorders , Vol. 281, 2021).

While research continues to home in on effective treatments, Youngstrom has directed his focus toward improving early recognition. That work involves comparing different questionnaires and rating scales, making them as short and convenient as possible without compromising accuracy, and improving accessibility for a variety of mental health providers and even patients.

“We’re reaching a point where we can deliver shortcuts that allow clinicians to work faster, be more accurate, and deliver better outcomes for their patients,” he said. “The science really does make this possible.”

Diagnosing bipolar disorders

Mood episodes.

• Elevated or irritable mood and persistent goal-directed behavior or energy
• Lasts at least 1 week
• Causes marked impairment
• Lasts at least 4 days
• Does not cause marked impairment
• Depressed mood or loss of interest in life
• Lasts at least 2 weeks
• Causes impairment and distress
• Episode includes both manic and depressive symptoms
• “Mixed mania” lasts at least 1 week or triggers hospitalization
• “Mixed hypomania” lasts at least 4 days with both depressed and hypomanic symptoms
• “Mixed depression” lasts at least 2 weeks with additional manic symptoms

Bipolar disorders

• Manic or mixed-manic episodes required for diagnosis
• Can diagnose with or without depressive episodes
• No history of manic or mixed episodes
• Diagnosis requires combination of hypomania and depression

Cyclothymia

• Combination of depresive and hypomanic episodes, but patients do not meet criteria for bipolar II

Other specified bipolar and related disorder

• Manic symptoms that do not fit into the other diagnostic categories
• Common diagnosis for children and adolescents

Further reading

Evidence-based assessment Youngstrom, E. A., et al., Wikiversity, 2021

Expanding bipolar outreach during college Singh, M. K., et al., Journal of Affective Disorders , 2021

The bipolar disorder survival guide (3rd ed.) Miklowitz, D. J., Guilford Press, 2019

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Recommended Reading

• New research reveals that bipolar spectrum disorders are more prevalent, treatable, and complex than experts once thought.
• More than half of patients have their first mood symptoms in childhood or adolescence, and accurate assessment is crucial for early intervention.
• Front-line treatment typically involves a combination of medication and psychotherapy.

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A Case Study on Bipolar Affective Disorder Current Episode Manic Without Psychotic Symptoms

• International Journal of Clinical Case Reports and Reviews

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Case Report | DOI: https://doi.org/10.31579/2690-4861/290

• Bhadra Sharma E 1
• Sannet Thomas 2*

1 MSc. Psychology Student, Parumala Mar Gregorios College, Valanjavattom, Tiruvalla, Kerala, India.

2 Doctoral Research Scholar, Department of Applied Psychology, Veer Bahadur Singh Purvanchal University, Jaunpur, Uttar Pradesh, India.

*Corresponding Author: Sannet Thomas, Doctoral Research Scholar, Department of Applied Psychology, Veer Bahadur Singh Purvanchal University, Jaunpur, Uttar Pradesh, India.

Citation: Bhadra Sharma E., Thomas S., (2023), A Case Study on Bipolar Affective Disorder Current Episode Manic Without Psychotic Symptoms, International Journal of Clinical Case Reports and Reviews. 13(1); DOI: 10.31579/2690-4861/290

Copyright: © 2023 Sannet Thomas, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Received: 16 January 2023 | Accepted: 19 January 2023 | Published: 30 January 2023

Keywords: mood disorders; bipolar affective disorder; mania; depression

Mood disorders are the second most common condition and can repeat for a variety of reasons. Bipolar mood disorders can cause severe manic and depressed episodes that, if not adequately treated, can result in substantial social and personal problems. This study used a single case study approach and was qualitative in nature. A patient with bipolar affective disorder without psychotic symptoms participated in the trial. A case history form and a mental state assessment instrument were used to gather the data, which was then analysed using the content analysis approach. A 27-year-old lady who has been diagnosed with bipolar affective disorder and is now experiencing a manic episode without psychotic symptoms served as the study's sample. The patient was a resident of a private mental health facility in Kerala. This study discovered that pharmacotherapy, family therapy, in-patient rehabilitation, out-patient rehabilitation, and cognitive behavioural therapy can all help manage bipolar affective disorder, current episode manic without psychotic symptoms. The outcome of the current study comprises a thorough analysis of the sample's history and present conditions, along with interventions and management techniques.

A mood disorder, formerly known as an affective disorder, is an emotional condition that primarily affects our state of mind. A clinically significant disturbance in how a person feels in connection to their surroundings, which results in unhelpful behavior, characterizes a set of mental illnesses known as mood disorders. (Claudio & Andrea, 2022). The primary issue with these diseases is a shift in mood or affect, typically toward melancholy or elation. (ICD-10). Seasonal affective disorder (SAD), major depressive disorder (MDD), and bipolar disorder (BD) are a few examples of mood disorders. These conditions can also be further classified according to the severity, timing, or suspected cause of the illness. (APA, 2013). Patients with mood disorders have bodily and cognitive abnormalities that impair their ability to function. One such change is the disruption of the sleep–wake cycle, which shows up both physiologically and behaviourally. (Claudio & Andrea, 2022).

Mood disorder patients exhibit two key moods: mania and depression. The extreme sorrow and hopelessness that characterize depression (Hooley et al., 2016). People during depressive episodes will have a persistent depressed mood and may lose interest in previously pleasurable activities along with significant changes in sleep pattern and appetite for at least two weeks. According to the diagnostic criteria of DSM-5, symptoms of a depressive episode include depressed mood, significant changes in sleep patterns and appetite, psychomotor agitation or retardation, diminished ability to think and concentrate, and recurrent thoughts of death. 60percentage to 90percentage of major depressive disorder patients experience sleep difficulties, with insomnia and hypersomnia being the most prevalent disorders. This varies depending on how severe the depression is. (Abad & Guilleminault, 2005).

Mania is the other major mood. The extreme and irrational enthusiasm and exhilaration that characterizes mania. When experiencing a manic episode, a person's mood is noticeably heightened and expansive, perhaps being interrupted by intensely irritable outbursts. (Hooley et al., 2016). For a precise diagnosis, these significant mood swings must last for at least a week. The existence of an abnormally high, expansive, and irritable mood for at least four weeks is the hallmark of the milder variant known as a hypomanic episode. Considering its difficult clinical presentations and long-term view, a patient with mania must be provided with a personalized treatment for functional recovery. Psychoeducational strategies are also used for the maintenance of treatment results (Pacchiarotti et al., 2020).

There are two main classifications of mood disorders. Both unipolar and bipolar mood disorders exist. Unipolar mood disorders are characterized by the recurrent occurrence of full-blown depressive episodes. For a clear diagnosis, the person must show the symptoms of a depressive episode for longer than two weeks. If a person suffers from the occurrence of depressive episodes for about two years, then the person can be diagnosed as having persistent depressive disorder (PDD) or formerly known dysthymia. Here the symptoms are commonly found as half-blown (Hooley et al., 2016).

Bipolar mood disorders are characterized by the presence of both key moods, that is, Depression and mania. A person with bipolar disorder may alternatively experience both depressive and manic episodes (Hooley et al., 2016). Bipolar I disorder and bipolar II disorder are subtypes of bipolar disorders. Among these, the occurrence of mixed episodes—which are characterized by symptoms of both full-blown manic and severe depressive episodes lasting at least one week—signals the existence of bipolar I disorder. When a person has significant depressive periods and hypomanic episodes, bipolar II disorder is identified. When a full-blown manic episode is lacking in a patient with bipolar II disorder, this condition is known as cyclothymia. When someone exhibits half-blown bipolar mood disorder symptoms for at least two years, it is diagnosed. (World Health Organization, 1992).

Suicide and mood problems are related. Compared to the non-clinical population, the clinical group has a much greater prevalence of suicidal conduct. (Shah et al., 2022). Mood disorders can occur with or without psychotic symptoms and they can be seen as associated with somatic symptoms (World Health Organization, 1992). It was shown that kids with social anxiety disorder were more likely to also have a mood problem. It was discovered that those kids had more significant anxiety issues prior to therapy. Recent research says that the treatment of mood disorders was related to anxiety reduction (Baartmans et al., 2022).

Causal factors of mood disorders focus on biological, psychological, and socio-cultural factors. Family studies and twin studies have indicated that the prevalence of mood disorders is around two to three times greater among blood relatives due to biological variables. (Akdemir&Gokler, 2008). This shows the genetic influence in increasing the vulnerability towards the development of unipolar mood disorders. Neurochemical factors and hormonal regulatory and immune system abnormalities can also contribute to mood disorder development. psychological root causes Consider stressful life situations as key causative variables. Numerous studies have demonstrated that extremely stressful life situations might serve as precursors for mood disorders. Numerous studies have shown that this illness has an impact on patients' whole families and may reduce their fortitude and adaptability.

Treatment and management of mood disorders include pharmacotherapy, psychotherapy, and alternative biological treatments. Pharmacological methods cannot be avoided in the treatment of mood disorders. Anti-depressants, anti-psychotics, and mood-stabilizing drugs are found to be commonly used in treating mood disorders. Monoamine oxidase inhibitors (MAOs) and selective serotonin reuptake inhibitors are examples of antidepressants (SSRIs). Patients with mood disorders are treated with lithium as a mood stabilizer. Several forms of psychotherapy are used widely for treating mood disturbances [Datta et al., 2021].

It is common to employ therapies including behavior activation therapy, family and marital therapy, interpersonal therapy, and cognitive behavioral therapy (CBT). In addition to these pharmacological methods and psychotherapies, several biological approaches include electroconvulsive therapy (ECT), bright light therapy, and deep brain stimulation.

When a person has bipolar affective disorder, the present episode is manic without psychotic symptoms (ICD F30.1) and they have previously experienced at least one prior affective episode (hypomanic, manic, depressed, or mixed). (ICD 10) Mania is defined by an elevated mood that is discordant with the patient's condition and lacks psychotic symptoms. It can range from thoughtless merriment to practically uncontrollable excitement. Increased energy that comes with elation causes overactivity, pressure in speaking, and a reduced desire for sleep. There is a lack of continuous attention, and distractions are frequently obvious. Overconfidence and lofty ideals can inflate one's sense of self-worth. Loss of typical social inhibitions can lead to actions that are careless, foolish, or out of character for the situation. (ICD 10).

Relevance Of the Study:

Mood disorders are the second most prevalent type of disorder in psychopathology. Mood disorders are commonly seen with relapses and recurrences. So, a continuation of medication and follow-up sessions are necessary. However, at least half of the people are never receiving adequate treatment. So, this particular study can help in reducing stigma and human rights violations towards the affected people. And, through this particular study, people can have more awareness about mood disorders, Specifically the bipolar affective disorder, current episode manic without psychotic symptoms.

Review Of Literature:

Shah, K., Trivedi, C., Kamrai, D., Srinivas, S., & Mansuri, Z. (2022) conducted a study on suicide in adolescents with mood disorders. The study's goals were to examine the relationship between youth suicide and mood disorders as well as the influence of comorbid conditions in disruptive mood dysregulation disorder on adolescent suicidal thoughts. The National Inpatient Sample dataset was utilized in the study to select individuals with mood disorders, and the Chi-square test was employed to compare groups. According to the study, teenagers with mood disorders who do not have disruptive mood dysregulation disorder had approximately double the chance of having suicidal thoughts or actually attempting suicide.

Baartmans, J. M. D., van Steensel, F. J. A., Klein, A. M., & Bögels, S. M. (2022) conducted a study on The Role of Comorbid Mood Disorders in Cognitive Behavioral Therapy for Childhood Social Anxiety. The study aimed to determine the degree of occurrence of mood disorders as the result of cognitive behavioral therapies in children with social anxiety. The sample of the study consisted of 152 children who were clinically diagnosed as having social anxiety or any other anxiety disorder. The findings imply that children with social anxiety are more likely than those with other anxiety disorders to also have comorbidity with a mood condition.

Rashid, M. H., Ahmed, A. U., & Khan, M. Z. R.  (2019) conducted a study on substance abuse among bipolar mood disorder patients. Determine the prevalence of drug use among patients with bipolar mood disorder was the goal of this descriptive cross-sectional investigation. 115 bipolar patients made up the sample; both males and females, inpatients and outpatients, were taken into account. Data collection was done using a standardized questionnaire. According to the survey, 23.8percentage of the respondents engaged in drug misuse.

Deepika, K. (2019). conducted a study on a case report on bipolar affective disorder: Mania with psychotic symptoms. The study adopted the method of a case study which aims to find the key characteristics and implications of mania with psychotic symptoms.

Akdemir, D., & Gokler, B. (2017) conducted a study on psychopathology in the children of parents with a bipolar mood disorder. The purpose of the study was to determine how frequently offspring of parents with bipolar mood disorder experience mental illnesses. 33 children of 28 control parents and 36 children of 28 parents with bipolar I illness made up the sample. The SADS-L (Schedule for Affective Disorders and Schizophrenia-Lifetime Version) and the SADS-L for School-Aged Children (Present and Lifetime Version) are screening tools (K-SADS-L). According to the study, children of parents with bipolar illness had a greater prevalence of psychopathology than children of the control group.

A case study can be defined as a record of research that consists of information about the development of a particular individual, group, or situation over time. It is a systematic investigation of a single individual or group of individuals which uses several statistical and psychological tools (McCombes, 2022)

The present study adopted the case study method. It is consisted with combined form of exploratory, cumulative and critical instance case studies. As a case study is an in-depth investigation of a person, a group of individuals, or a unit with the intention of generalizing it on several occasions. it allows us to explore the characteristics, meanings, and implications of the particular case. Exploratory case study involves detailed research of the subject aimed at providing an in-depth understanding of the study. Cumulative case study involves generalizing a phenomenon after collecting information from different sources. Critical instance case study aims in determining the cause and consequences of an event.

In this case study, case history and mental status examination have been taken from the client and informants. Information collected was cross-checked and reversed twice, and reliability and adequacy were also assured.

Sample Description:

A 27-year-old female inpatient with the bipolar affective disorder, current episode manic without psychotic symptoms. The patient was a married woman from a middle-class family who has been taking treatment for the past 10 years. The case was taken from one of the private mental health establishments in Kerala to which the patient was admitted. The patient was admitted to the hospital for 20 days, from there the data were collected by the researcher.

The present study uses Mental Status Examination (MSE) and case history. An MSE is an inevitable part of the clinical assessment which helps find the current state of the client, under the domains of general appearance, mood, affect, speech, thought process, perception, cognition, insight, and judgment.

A case history includes an in-depth analysis of a person or group. It mainly has detailed information relating to the patient’s psychological and medical conditions. A case history is used to get a client’s test results, and professional, sociological, occupational, and educational data. The data collected in a case history includes socio-demographic data, presenting complaints and their duration, nature of the illness, history of present illness, negative history, treatment history, family history, personal history, and pre-morbid personality.

Data Analysis:

The Present study uses the tool content analysis for analyzing data. Content analysis is a research tool that helps analyze the presence, meaning, and relationship of certain words or concepts. Content analysis is also helpful in quantifying the collected information.

Ethical Concerns:

Full consent from the participant was obtained. The confidentiality of the data collected from the participant was ensured. The participant is not harmed in any way. The anonymity of individuals and the privacy of the participant is ensured.

Case History:

Socio-demographic data:  The patient named J.O.V., is a 27-year-old female, hailing from a middle-class family who has been educated up to plus two and is presently unemployed. She was a married woman and mother of a 2-year-old child. The informants were the patient, her husband, and her sibling. The collected information was adequate and reliable.

Presenting complaints and their duration: Reported by the patient- The patient has reported that she was suffering from a decreased need for sleep and tended to throw objects when got angry, for the last seven months. For the past four months, she an increased craving for food and a feeling that people are avoiding her complained and also complains that her family is cursing that she is not attending to her child properly. 

Reported by the informant:   The informant has complained of lack of sleep (not sleeping for about 48 hours), not giving proper attention to the child, suicidal tendency, increased talk, getting raised easily, and throwing objects when got raised for the past seven months. They also complained about spending a lot of money on buying mobile phones, ornaments, and gadgets, and, overuse of mobile phones for the past four months.

Nature of illness:  The onset of illness was found to be gradual. The course was episodic and stable progress has been identified. Precipitating factors were not elicited.

History of present illness:  The patient was maintaining normal till seven months back. Then she started getting raised quickly without any reason and experienced a decreased need for sleep. She felt that everyone around her is trying to avoid her. When having such feelings, she preferred to be alone and isolated herself. At times she lost her interest in everything, so she will not do anything and simply sit alone without doing anything. After that, the patient started spending a lot of money buying ornaments, mobile phones, and gadgets. She experienced an increased craving for food. She had the wish to eat all time a day. Before four months her mood suddenly changed to an extraordinary sadness and continued lack of sleep. Then she started to elicit highly irritable behavior with increased talk. Her symptoms caused impairments in her personal and social life, as she became more irritable with decreased sleep and a situation of missing from the house. As she began not to attend even her child properly, her family brought the patient to one of the private hospitals in Kerala for treatment and getting In-patient care.

Negative history:  The patient has no history of head injury, trauma, epilepsy, headache, and vomiting. There is no history of psychoactive substance use. The patient shows no history of seeing or hearing things that others cannot see or hear. There is no history of the patient having repeated ideas, thoughts, or images coming to her mind. The patient has no history of irrational fear towards objects, events, or situations.

Treatment history:  The patient had taken treatment with in-patient care previously from another private hospital in Kerala. Then she took treatment from one of the Government medical colleges, Kerala In-Patient care for 20 days. In 2017, treatment was taken from another private hospital, in Kerala for 20 days. Then she took treatment from another Government medical college, several times.

History:  When the patient was 17 years old, the family identified behavioral changes such as increased talk, decreased need for sleep, and irritability. The patient was complaining that these changes occurred as a result of losing her friendship and love. But the family is not giving assurance for her complaint. Then she was taken to a private mental health centre, in Kerala for treatment and In-Patient care. There found an improvement with the treatment. She got married at the age of 21 years. After marriage, she started to show her symptoms including irritable behavior and increased talk. Due to this, the relationship got divorced 3 months after the marriage. After the divorce, she attempted suicide by jumping into a well. So, she was taken to one among the Government medical college hospital in Kerala, and was admitted for about 20 days (2015). The patient showed improvement with the treatment. Approximately 1 year later her symptoms started to reappear, and she went to another hospital alone for gaining treatment (according to the client). But the family brought her back and took treatment at a private mental health centre as in-patient for 20 days (2017). She showed improvement with the treatment. After that the client showed similar symptoms and has been getting medical care as in-patient several times from Government medical college, Kerala. 4 years later, she got married again. The relationship happily continued and she gave birth to a child. 7 months back she got hit by the current episode. 

Family history:  Consanguinity is absent. The patient belongs to a middle-class family, where her husband and brother are the earning members. The patient’s father is the family decision-maker. The patient maintained a good relationship with the family. General interaction within the family is good. There is a history of the psychiatric problem in her family. There found a history of wandering and missing out(grandfather). In the mother’s family, there is a history of suicide(grandfather) and mental illness(grandmother). The information about the illness is not known adequately. Her mother shows a history of bipolar affective disorder and her elder sister has a history of suicidal attempts and thyroid. There is no history of substance abuse in the family. The family is aware of the patient’s illness. Several members of the patient’s family show mental and behavioral dysfunctions and there are interpersonal conflicts in the family. So, family dynamics are dysfunctional.

Personal history:  The birth and development of the patient were appropriate. There are no complications during delivery. The delivery was full-term and normal at the hospital. There are no significant abnormalities in the pre-natal and post-natal development. The development milestones were age appropriate. The patient was brought up by their mother. There is no maternal deprivation observed. There is no history of neurotic traits such as nail biting, body rocking, night terrors, phobias, and stammering. Education history started education at 5 years. She belongs to an average student. The medium was Malayalam. She had many friends but the relationships were not well maintained. She discontinued her degree (BA Literature) during her first year due to illness. Relationships with teachers were not good. Occupation history:  The patient started an occupational career at the age of 25. She worked as a sales girl in a gold shop for about 2 months and left the job due to the pandemic situation. 

Marital history:  The patient got married at 21. The marriage was an arranged one with the consent of the family but got divorced after a relationship of only 3 months. Her disorder was the primary reason for the divorce. After 4 years, when she was 25 years old, she married again. The marriage was also an arranged one with the consent of the family. The husband is supportive. Currently, the client and her husband are satisfied with the relationship. Sexual history: the mode of gaining sexual knowledge is from friends. No history of sexual abuse is found. Marital sexual life is also satisfied. Menstrual history: menstrual cycle(menarche) begins at the age of 14 years. There are no significant abnormalities in the response to menarche noted. Then after the menstruation is regular till now. There were no mood swings during the menstrual cycle, but the client complained about back pain during menstruation. Substance use history, the patient has no history of any psychoactive substance use.

Pre-morbid personality:  Attitude towards self, she was a confident personality but was not able to make decisions. And she maintains an average level of self-esteem. Attitude towards others: she was an extrovert who quickly feels empathetic towards others. She doesn’t have many intimate friends. She always kept a good relationship with her family. She was not much talkative in the family except with her mother. The predominant mood was happy. Moral standards, she is a religious person who keeps religious rituals always. Stress reaction, she was able to tolerate and deal effectively with stress. Habit, the sleep pattern was normal, and had no habit of doing exercises. Fantasy life, dream with the content of ‘falling into the water. Other personality traits, there is no presence of personality traits such as OCD, ADHD, ODD, emotionally unstable personality, impulsivity, and narcissistic personality

Mental status examination (MSE)

General appearance and behavior:  The patient was alert, attentive, and conscious during the session. The patient’s dressing was appropriate. Eye contact was established and maintained. A good rapport was made. The patient’s attitude toward the examiner was cooperative. Reality contact was present. Tics/mannerisms and catatonic phenomena were absent.

Psychomotor activity: Increased psychomotor activity by walking during the session and drinking a lot of water.

Speech:  The speech was relevant and coherent. Reaction time was normal. Volume and tone were normal and she maintained the prosody of speech. 

Mood and affect:  The mood were sad and her affect was shallow which was inappropriate to the situation and congruent to the thought content.

Thought: The patient doesn’t show any abnormalities in the stream, form, possession, and content of thought. That is., there is no presence of flight of ideas, circumstantiality, tangentiality, obsessions, compulsions, etc.

Perception:  There is no presence of hallucinations and illusions. Other psychotic phenomena such as somatic passivity and made phenomena are absent. Other phenomena like depersonalization and derealization are also found to be absent.

Cognitive functions: Attention and concentration, the digit span test, and serial subtraction were given. In forward, the digit span is 4 and in backward the digit span is 3. In the serial subtraction test, the patient completed the task in 115 seconds. This shows that the patient’s attention was aroused and maintained. Orientation, the client was asked questions of time, place, and person, and found that the patient’s orientations were intact. Memory, the patient’s immediate memory was tested by conducting a recall test. The patient was able to recall what the examiner has said. The recent memory of the patient was tested by asking her questions regarding the past 24 hours and it is found that the patient’s recent memory was intact. Remote memory was tested by asking questions about personal details such as to say her date of birth. From this, it can be concluded that the patient’s memory was intact.

Intelligence:  General information, the patient was asked questions for testing general knowledge. The responses of the patient indicate that general information is adequate. Comprehension, the patient’s comprehension is assessed by asking some situational questions and is found adequate. Arithmetic ability, after comprehension, the arithmetic ability of the patient is assessed by asking some simple arithmetic questions and is found adequate. Abstract ability, the patient’s abstract ability is assessed by giving tests to find similarities and dissimilarities of objects the examiner is saying. Proverbs are given to the patient and asked to explain them. The assessments of general information, comprehension, arithmetic ability, and abstract ability indicate that the patient has an average intellectual capacity.

Judgment:  The patient's personal, social, and test judgment is found to be intact.

Insight:  The patient has a level five insight. Since she is accepting all her minor and major symptoms and is also aware of the need for treatment.

Provisional diagnosis:  F31.1 (ICD-10 CLASSIFICATION) Bipolar affective disorder, current episode manic without psychotic symptoms.

Diagnostic guidelines:  For a definite diagnosis

• The present episode has to meet the requirements for mania without psychotic symptoms. and
• There must have been at least one prior affective episode in the past, whether it was mixed, hypomanic, manic, or depressed.

Diagnostic criteria for mania:  The episode must last at least a week and be severe enough to substantially interfere with daily tasks and social interactions. Energy levels should rise along with a few of the symptoms listed below when the mood changes.

• Decreased need for sleep
• Grandiosity
• Excessive optimism
• Particularly pressure of speech

The patient has had such emotional episodes in the past and has recently had greater energy, decreased sleepiness, and excessive optimism. Given that this fits the aforementioned requirements, we can provisory classify the patient's present manic episode as having bipolar affective disorder.

Interventions And Management Plan:

A medical doctor or trained clinical psychologist determines an intervention and management plan for any mental disturbance. Since Bipolar affective disorder is a long-term condition, continuous and prolonged treatment is needed. Professionals suggest several management strategies for bipolar affective disorder treatment. This often includes:

Hospitalization- Doctors often prefer hospitalization if the patient seems to be more dangerous and has suicidal ideas. Psychiatric hospital care helps stabilize the patient’s mood, and, maintains a safe and calm atmosphere.

Medications - Several medications are used in treating bipolar disorders. Taking medication helps balance your moods in the right way. The types and doses of medicines are determined by the doctor. Commonly prescribed medications in the treatment of bipolar affective disorder include:

• Mood stabilizers- This includes lithium, valproic acid, equator, etc.
• Antipsychotics- Olanzapine, risperidone, aripiprazole. This comprises commonly prescribed antipsychotics. 
• Antidepressants- Antidepressants are given to manage depression. But these are prescribed along with mood stabilizers or antipsychotics since antidepressants trigger mania.
• Anti-anxiety medications- This has benzodiazepine in it. This provides better sleep and also helps with dealing with anxiety.

Psychotherapy- bipolar disorder treatment includes psychotherapy on a regular basis. Numerous therapies may be beneficial. A family, a group, or an individual may get therapy. 

Treatments provided include:

• Cognitive Behaviour Therapy (CBT)- The goal of this treatment is to discover unhealthy ideas and behaviors and replace them with constructive ones.
• Psychoeducation- Learning about bipolar illness can help patients better comprehend their current situation, prevent relapses, and adhere to therapy.
• Family-focused therapy- Family therapy helps make the family of the patient aware of the disorder and warning signs of bipolar episodes.

If the patient doesn't improve with antidepressants, further therapeutic options include electroconvulsive therapy (ECT) and occasionally transcranial magnetic stimulation.

This study discusses a case of bipolar affective disorder, current episode manic without psychotic symptoms. Here the study concentrates on the characteristics, symptoms and features of bipolar affective disorder, current episode manic without psychotic symptoms and also the interventions used for this case.  For those who suffer from bipolar affective disorder, the present episode is manic without psychotic symptoms, and the patient has previously had at least one prior affective episode (hypomanic, manic, depressed, or mixed). (ICD 10) Mania is defined by an elevated mood that is out of proportion to the patient's circumstances and can vary from casual merriment to almost uncontrollable excitement. Mania is characterized by the absence of psychotic symptoms. Overactivity, difficulty speaking, and a diminished need for sleep are all symptoms of the increased energy that comes with joy. Continuous concentration is lacking, and distractions are usually evident. An exaggerated feeling of self-worth can result from overconfidence and ambitious ambitions. Losing one's normal social inhibitions might cause one to act carelessly, foolishly, or inappropriately given the circumstances.                                                     

Limitations:

The study adopted a single case study method, the result cannot be generalized to larger populations.

Declarations:

This article's completion was not supported by any money.

Conflicts of interest/Competing interests

The authors have no financial or non-financial interests to report.

Data Availability Statement

Only datasets produced during and/or analyzed during the current investigation are available upon reasonable request from the corresponding author.

Authors' contributions

the two writers have each made a meaningful contribution and agree that they should both be given authorship credit.

Ethics approval

The Departmental Research Committee granted ethical approval.

Consent to participate

Informed consent was taken from the informant and also from the institution 

Consent for publication

All authors of this research Study consent to the work being used for publication.

Acknowledgments

The article, A case study on bipolar affective disorder, current episode without psychotic symptoms (ICD F 31.1), is a record of original research effort, we therefore declare. We attest to the work's originality and the absence of any instances of plagiarism across the whole manuscript.      

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Manic episode in patient with bipolar disorder and recent multiple sclerosis diagnosis

A case report.

Editor(s): Saranathan., Maya

a University of Minnesota Medical School

b Department of Psychiatry, University of Minnesota, Minneapolis, MN.

∗Correspondence: Simon Yang, University of Minnesota, 420 Delaware St. SE, Minneapolis MN 55455 (e-mail: [email protected] ).

Abbreviations: BD = bipolar disorder, MS = multiple sclerosis.

How to cite this article: Yang S, Wichser L. Manic episode in patient with bipolar disorder and recent multiple sclerosis diagnosis: a case report. Medicine . 2020;99:42(e22823).

Patient information was de-identified. Received written consent to use patient information as well.

The authors have no conflicts of interest to disclose.

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0

Introduction/Rationale: 

Multiple sclerosis (MS) is associated with a higher prevalence of mood and psychiatric disorders, such as bipolar disorder (BD). While mania is most often associated with BD, MS can also induce manic symptoms. However, it is crucial to distinguish which condition is causing mania since medical management is different based on its etiology. Herein, we report a case of a manic episode in a middle-aged female with a prolonged history of BD who received a recent diagnosis of MS 1 year ago.

Patient Concerns: 

A 56-year-old female presented with an episode of mania and psychosis while receiving a phenobarbital taper for chronic lorazepam use. She had a prolonged history of bipolar type 1 disorder and depression. She showed optic neuritis and was diagnosed with MS a year prior.

Diagnoses: 

The patient was diagnosed with BD-induced mania based on the absence of increased demyelination compared to previous MRI and lack of new focal or lateralizing neurologic findings of MS.

Interventions: 

Lithium was given for mood stabilization and decreased dosage of prior antidepressant medication. Risperidone was given for ongoing delusions.

Outcomes: 

After 8 days of hospitalization, patient's mania improved but demonstrated atypical features and ongoing delusions. She was discharged at her request to continue treatment in an outpatient setting.

Conclusion/Lesson: 

In BD patients with an episode of mania, MS should be included in the differential, since both conditions can cause manic symptoms. The origin of mania should be delineated through a detailed neurological exam, neuroimaging, and thorough patient-family psychiatric history for appropriate clinical treatment.

1 Introduction

Multiple sclerosis (MS) is an inflammatory autoimmune disease that focally damages the white matter in the brain and spinal cord. [1] It affects 1 in 1000 people and is the most common central nervous system disease for young adults in the Western world. [2] Initially, neurological symptoms are transient due to remyelination, but repeated demyelination progressively leads to diffuse and chronic neurodegeneration. Furthermore, previous studies have shown increased psychiatric symptoms and higher prevalence of psychiatric and mood disorders. [3]

Bipolar disorder (BD) is a mood disorder characterized by extreme mood fluctuations with episodes of mania or hypomania and depression. Mania, a hallmark of BD, is when the patient is in a state of elevated mood and energy, during which the patient reports symptoms such as euphoria or irritable mood, racing thoughts, overactivity, and reduced need for sleep. BD affects more than 1 in 100 people worldwide. [4]

The prevalence of BD in MS patients has been reported to be twice than that of the general population. [5] For patients diagnosed with BD and MS, there is no clear method to distinguish whether mania was induced from BD or from a MS flare-up. However, it is important to discern the cause of manic episode since management is different for BD-induced mania vs MS-induced mania. Herein, we describe a patient diagnosed with BD that later developed MS who presented to us during a manic episode. Through this case, we aim to examine the BD versus MS origins of manic episodes and discuss relevant literature.

2 Case Presentation

The patient was a 56-year-old female who came to us during an episode of mania and psychosis while receiving treatment at an addiction treatment center where she was taking a phenobarbital taper for chronic lorazepam use. She displayed symptoms of aggressive posturing, verbal abuse to staff, delayed response, and racing thoughts. She did not describe suicidal thoughts. She had 4 prior psychiatric hospitalizations. At age 33, she exhibited depression, anxiety, and paranoia that lead to her first hospitalization. At age 44, she attempted suicide via acetaminophen overdose. Her first reported manic episode was at age 45, during which bipolar type 1 disorder was considered as her differential and subsequently diagnosed. Her symptoms accompanied delusions during this episode, without suicidal ideation. Her most recent hospitalization was at age 49 for depression and paranoia with delusions of being wiretapped and people reading her mind. At age 55, the patient presented with optic neuritis and diagnosed with MS after a lumbar puncture showed oligoclonal bands.

Family history revealed depression in father and alcohol use disorder in mother. Past medical history described an acute onset dizziness when moving eyes left to right or vice versa and when standing up from a lying position.

Neurology consult found no focal or lateralizing findings. MRI analysis showed greater than 15 foci of T2 hyperintensity within white matter where some lesions were within periventricular and juxtacortical white matter of both cerebral hemispheres, consistent with a demyelinating disease. A single focus of enhancement in the posterior corona radiata was suggestive of active demyelination. No demyelinating signs were seen in the thoracic spine. However, no significant difference was seen compared to previous MRI.

During the present hospitalization, patient's prior bupropion was reduced due to concern for further mania activation. Lithium 600 mg twice a day was prescribed for mood stabilization. Risperidone 0.5 mg at bedtime was prescribed for ongoing delusions. Patient was not taking scheduled steroids prior to admission. After 8 days of hospitalization, patient's mania improved but demonstrated atypical features, such as absence of pressured speech, grandiosity, risk taking or sleep pattern changes. Per a family member's report, patient stated that she was in a movie and that everyone else was acting around her. Patient requested discharge to continue treatment in an outpatient setting.

3 Discussion

Although neurological symptoms of MS have been extensively studied, the psychiatric effects of MS are relatively less elucidated, despite the fact that the association of MS and psychiatric symptoms observed as early as 1872 by Jean-Martin Charcot. [6] In 1986, Schiffer et al suggested an association between BD and MS after identifying 10 patients with both BD and MS, out of more than 700,000 individuals, when epidemiologic data expected to find only 5.4 patients. [7] Co-occurrences of BD and MS have been reported infrequently through case studies. Recently, Carta et al conducted a case control study with 201 MS patients that examined the risk of BD in MS patients and reported OR of 44.4 for bipolar spectrum disorders. Specifically, bipolar type 2 diagnoses (7.5%) was more frequent than bipolar type 1 diagnoses (0.99%). [8]

The exact underlying mechanism and pathophysiology of BD and MS co-presentation is yet to be established. It is unknown whether BD is an early manifestation of MS or if both diseases share a common underlying cause presenting at similar timelines. More recent studies have shown genetic associations between BD and MS in human leukocyte antigen (HLA) DR2 gene and mitochondrial transcriptomes. [9,10] Further understanding of the etiology of this association may elucidate whether there are synergistic effects or crosstalk between MS and BD therapeutics.

While mania is a hallmark symptom of BD, MS can also exhibit a range of psychiatric symptoms including mania, euphoria, depression, hallucinations, and episodes of pathologic laughing and weeping, which is coined as ‘pseudobulbar effects.’ [11] Focal neuronal demyelination in MS patients may interfere with communication between frontal lobe brain regions responsible for emotion and manifests as emotional lability and exaggerated emotions, common symptoms in a manic or depressive episode. [12] Features of MS flare-up mania are no different than those of non-MS mania. However, the incidence of psychosis has been reported to be less common in MS. [13]

Differentiating the cause of the manic episode is of clinical significance as the treatment plan differs between a MS flare-up and a BD manic episode. For instance, while lithium and sodium valproate have been shown to be effective in treating mania in BD, no controlled trials of its efficacy in mania in MS patient has been published. [14] Additionally, manic episodes due to medications cannot be precluded. Steroid treatment in MS patient may often cause a moderate degree of mania. [15] Patients with a family history of alcohol use disorder or other affective disorder are more vulnerable to this cause. [15] Other medications, such as tizanidine, baclofen, and dantrolene, can also cause hypomania following their use. [16] Manic symptoms due to medications are often dose-dependent and manifest soon after initiating the medication. [16]

Detailed neurologic tests or neuroimaging can often help differentiate the cause of a manic episode. MS flare-ups often manifest with increased focal neurological symptoms including visual loss, fatigue, urinary incontinence, and cognitive impairment, in addition to any of the afore-mentioned mood symptoms. Additionally, MS flare-ups may show an increased degree of demyelination on MRI compared to prior images.

Both MS and BD-onset mania have been reported to show white matter changes on MRI by Young et al. [17,18] Especially, MS patients with mania and psychotic symptoms were shown to have plaques located in the bilateral temporal horn areas. [14] Neuroimaging of BD patients without MS has been more complex. Several studies proposed increased white matter and periventricular hyperintensities in these patients. [19,20] McDonald et al reported increased subcortical hyperintensities in T2 weighted MRI in late-onset BD patients. [19,21] Dupont et al reported increased white matter hyperintensities in early-onset BD patients. [19,22] Altshuler et al reported no significant difference white matter hyperintensities, but increased periventricular hyperintensity in BD type 1 patients. [19,23]

In our case, the absence of aforementioned focal or lateralizing finding in MS during the neurological exam, absence of increased demyelination compared to previous MRI, and family history of psychiatric disorders decreased the likelihood of her current symptoms representing a MS flare-up and was more consistent with BD-induced mania. Additionally, patient was not taking mania-inducing medications such as steroids, tizanidine, baclofen, or dantrolene. Patient's symptoms improved with lithium treatment. The patient's MRI showed increased white matter and periventricular T2 hyperintensity. However, no plaques at bilateral temporal horn areas were identified. Considering that her symptom onset was during a phenobarbital taper for chronic benzodiazepine use, her mania may have been a BD manic episode triggered by her benzodiazepine withdrawal directly or exacerbated from withdrawal symptoms, such as poor sleep and increased anxiety.

The ages at which this patient's illnesses presented - BD type I onset at age 45 preceding MS onset at age 55, is of particular note in relation to previous case reports. Marangoni et al identified case reports of 26 patients who had BD onset clearly preceding MS, via a PubMed search from inception to 2014. [24] The study showed an average of 5 years difference between BD and MS onset. The majority of these patients were found to have BD type I, where 25 patients had BD type I and 1 patient had BD type II with rapid cycling. Three cases reported family history of MS and 6 cases reported psychiatric family history. The study also noticed increased white matter lesions in periventricular and subcortical white matter – which was consistent with our case - as well as in the centrum semiovale, frontal, parietal, and temporal lobes. However, it did not identify association between certain BD type to MS types nor association between certain BD types with patterns of white matter lesions.

While the study had insufficient data to formulate a valid hypothesis, the study found that BD-preceded-MS had a higher age of both BD and MS onset compared to the age of onset of the combined pool of patients with BD and MS regardless of onset order. The study also suggested that later onset of MS may be associated with co-occurrence with BD. This case report, where the patient was diagnosed with BD and MS relatively later than the common age of onset of 20s or 30s, substantiates these trends found in previous case reports by Marangoni et al and speculates that late onset of BD or MS may be associated with BD-MS comorbidity. Past reports showed cases where acute psychotic symptoms led to MS diagnosis, which were coined as “inaugural manifestations” to MS. [25] Future research into the timing of onset can elucidate whether late diagnosis of mood or psychotic disorders can be early signs of comorbidity with MS.

4 Conclusion

In patients with co-occurrence of BD and MS, there is currently no clear guideline to discern the origin of manic episodes. However, it is important to attempt to discern the predominant cause of the manic episode through detailed patient history, neurologic exam, and neuroimaging, as it can affect treatment plans. Additionally, the presented case, along with previous cases of BD-preceding-MS correlating with generally later age of onset of BD and MS, may be a future direction for further investigation.

Author contributions

Conceptualization: Simon Yang.

Supervision: Lora Wichser.

Writing – original draft: Simon Yang.

Writing – review & editing: Simon Yang, Lora Wichser.

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Unmasking bipolar disorder: a patient’s journey and expert insights.

• August 30, 2024

Bipolar disorder is more than mere “mood swings”; it’s a complex, often misdiagnosed condition that requires deep understanding and careful management. This article delves into the intricacies of bipolar disorder through the lens of a patient’s experience and expert insights, shedding light into this condition.

Understanding Bipolar Disorder: Beyond Mood Swings

Bipolar disorder, also known as  manic-depressive illness , is characterized by dramatic shifts in mood, energy, and activity levels. These episodes range from depressive lows to manic highs, impacting a person’s ability to carry out daily tasks. According to  Dr. Amelia Kelley,  a therapist and researcher with the  Traumatic Stress Research Consortium  at the Kinsey Institute.

“It is important to understand that bipolar can appear differently in different people. It’s often confused with symptoms of other disorders, including ADHD and PTSD, but this diagnosis has many biological markers—so many that there are actual blood tests to test for bipolar.”

The distinction between bipolar disorder and other mood or cognitive conditions lies in the severity and duration of these mood swings. Unlike typical mood changes that many experience, bipolar disorder involves prolonged and extreme episodes that can last for days or months. The depressive phases can lead to suicidal thoughts and a complete lack of energy, while manic episodes often involve impulsive behaviors, such as hypersexuality or extravagant spending.

The Importance of Proper Diagnosis and Treatment

Accurate diagnosis is crucial for effective treatment. Dr. Kelley emphasizes the importance of seeking help from qualified mental health professionals.

“Many who leave bipolar untreated can make detrimental life choices, end up in dangerous relationships or circumstances, lose things that are important to them, and also become self-harming as the lows of depressive episodes dramatically increase the likelihood of suicidal thoughts,” she says.

A Personal Journey: Breana Grayson’s Story

Early Signs and Misunderstandings

Breana’s struggle with bipolar disorder began in her teenage years, though she did not recognize it at the time. Her mood swings affected her relationships and decision-making.

“On my good days, I felt like I could conquer the world, but on my bad days, I felt like a total failure,” she recalls.

These extreme highs and lows disrupted her life, making it difficult to hold a job, maintain relationships, or complete her education.

Hitting Rock Bottom

In 2017, Breana reached a breaking point. After moving to Florida on a whim, she found herself alone and unemployed. Her depressive episodes deepened, leading to an attempted suicide. Fortunately, she survived and recognized the need for a significant change. With her mother’s support, she sought help and began the journey toward diagnosis and treatment.

Receiving a Diagnosis

Breana’s path to diagnosis involved several steps, including therapy, group sessions, and consultations with a psychiatrist. When she was finally diagnosed with bipolar disorder, she felt a sense of relief.

“I wasn’t broken! I had a diagnosis!” she says.

Understanding that her condition was a medical issue, not a personal failing, was a turning point.

Managing Bipolar Disorder: Treatment and Lifestyle Changes

Effective management of bipolar disorder involves a combination of medication, therapy, and lifestyle adjustments. Breana’s treatment included antipsychotics and mood stabilizers, which required careful adjustment to find the right balance. Alongside medication, she adopted several lifestyle changes to maintain stability.

Medication and Therapy

Breana’s treatment plan included weekly talk therapy and regular psychiatric checkups. This consistent support helped her manage her symptoms and understand her condition better.

“Finding the right mix of medicines took some trial and error, but once we did, I began to see a huge difference,” she notes.

Lifestyle Adjustments

Breana also made significant lifestyle changes to support her mental health. She emphasizes the importance of a healthy diet, regular sleep, and exercise.

“Lack of sleep is one of my top triggers for manic episodes,” she explains.

Journaling, creative outlets, and maintaining strong social connections have also been crucial in her recovery.

The Ongoing Journey: Living with Bipolar Disorder

Living with bipolar disorder is an ongoing process of maintenance rather than a one-time cure. Breana acknowledges that she still faces challenges but has learned to manage them effectively.

“For every five good days, I’ll have one when I fantasize about not being alive. Thankfully, I can recover faster these days, and the mood swings aren’t as debilitating,” she says.

Breaking the Stigma

One of the hardest parts of living with bipolar disorder is dealing with the stigma and misunderstanding surrounding mental illness. Breana has found that being open about her condition with her loved ones has made a significant difference. She encourages others to do the same, emphasizing that bipolar disorder is not a personal failure but a medical condition that can be managed.

Expert Insights: Understanding and Supporting Patients with Bipolar Disorder

Dr. Kelley offers valuable insights for healthcare professionals on diagnosing and supporting patients with bipolar disorder. She stresses the importance of comprehensive assessments considering the patient’s medical and psychological history.

“Bipolar disorder requires a nuanced approach to diagnosis and treatment. It’s essential to differentiate it from other conditions and to understand the patient’s unique experiences,” she advises.

The Role of Medication

Medications play a critical role in managing bipolar disorder. Dr. Kelley notes that finding the right combination of drugs can be challenging but is essential for stabilizing mood swings. She advocates for ongoing monitoring and adjustments to ensure the best patient outcomes.

Psychotherapy and Support

Conclusion: Hope and Healing for Bipolar Disorder

Breana Grayson’s story and Dr. Amelia Kelley’s expertise highlight the complexities of bipolar disorder and the importance of proper diagnosis and treatment. While the journey can be challenging, there is hope for those living with bipolar disorder. Individuals can lead fulfilling lives and achieve their goals with the right combination of medication, therapy, and lifestyle changes.

Breana’s message to others facing similar challenges is clear: “You are not broken. Taking the steps and being responsible for managing your condition proves you have it together. There is no cure for bipolar disorder, but there is hope your life can get better.”

Through understanding, compassion, and ongoing support, healthcare professionals can make a significant difference in the lives of those affected by bipolar disorder. By sharing stories like Breana’s and continuing to educate ourselves and others, we can help reduce the stigma and provide the necessary tools for managing this complex condition.

Disclaimer : The content provided on this platform is intended for informational purposes only and does not replace professional medical advice, diagnosis, or treatment. Some materials may originate from third-party sources, and the views expressed are solely those of the respective authors or entities, not Docquity. Docquity does not warrant the accuracy, reliability, or completeness of the content and disclaims any responsibility for it. Users are advised to independently verify all information before acting upon it. 

“Here’s How I Knew I Had Bipolar Disorder”: A Patient’s Story with a Doctor’s Insights [Internet]. Accessed on August 08, 2024. Available at:  https://www.thehealthy.com/mental-health/how-i-knew-i-had-bipolar-disorder-patient-story/

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Cognitive impairment and risk of depressive episodes from a bipolar spectrum perspective: a case-control study in older adults during the covid-19 lockdown.

1. Introduction

2. materials and methods, 2.1. design and study sample, 2.2. instruments, 2.3. data analysis section, 2.4. ethical aspect, 4. discussion, 4.1. strengths of the study.

• there is an association between pre-existing mild cognitive impairment and increased risk of depression during the lockdown in older adults highlights interesting aspects;
• the study identifies a potentially vulnerable subgroup of the elderly population that requires targeted interventions and support during stressful events;
• this study underscores the need for further research on the mechanisms linking cognitive decline and depression in older adults, particularly those with a possible predisposition to BSD.

4.2. Limitations

• the small sample size limits the generalizability of the results;
• the use of secondary analyses reduces the robustness of the conclusions;
• due to the sample and analysis limitations, the results cannot be widely generalized to the entire elderly population.
• Using statistical analyses such as ANOVA in a case-control study can introduce potential biases. However, due to the inclusion of continuous variables, we found this type of statistical analysis to be more appropriate.

5. Conclusions

Author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Share and Cite

Primavera, D.; Bert, F.; Romano, F.; La Torre, G.; Gonzalez, C.I.A.; Perra, A.; Fragoso-Castilla, P.J.; Guerra Muñoz, M.E.; Tramontano, E.; Machado, S.; et al. Cognitive Impairment and Risk of Depressive Episodes from a Bipolar Spectrum Perspective: A Case-Control Study in Older Adults during the COVID-19 Lockdown. Psychiatry Int. 2024 , 5 , 482-491. https://doi.org/10.3390/psychiatryint5030034

Primavera D, Bert F, Romano F, La Torre G, Gonzalez CIA, Perra A, Fragoso-Castilla PJ, Guerra Muñoz ME, Tramontano E, Machado S, et al. Cognitive Impairment and Risk of Depressive Episodes from a Bipolar Spectrum Perspective: A Case-Control Study in Older Adults during the COVID-19 Lockdown. Psychiatry International . 2024; 5(3):482-491. https://doi.org/10.3390/psychiatryint5030034

Primavera, Diego, Fabrizio Bert, Ferdinando Romano, Giuseppe La Torre, Cesar Ivan Aviles Gonzalez, Alessandra Perra, Pedro José Fragoso-Castilla, Martha Esther Guerra Muñoz, Enzo Tramontano, Sergio Machado, and et al. 2024. "Cognitive Impairment and Risk of Depressive Episodes from a Bipolar Spectrum Perspective: A Case-Control Study in Older Adults during the COVID-19 Lockdown" Psychiatry International 5, no. 3: 482-491. https://doi.org/10.3390/psychiatryint5030034

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Polygenic Risk Scores and Twin Concordance for Schizophrenia and Bipolar Disorder

Affiliations.

• 1 Mental Health Center and West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China.
• 2 Med-X Center for Informatics, Sichuan University, Chengdu, China.
• 3 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
• 4 Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden.
• 5 College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada.
• 6 Department of Psychology, Yale University, New Haven, Connecticut.
• 7 Departments of Genetics and Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill.
• PMID: 39196586
• PMCID: PMC11359115 (available on 2025-08-28 )
• DOI: 10.1001/jamapsychiatry.2024.2406

Importance: Schizophrenia and bipolar disorder are highly heritable psychiatric disorders with strong genetic and phenotypic overlap. Twin and molecular methods can be leveraged to predict the shared genetic liability to these disorders.

Objective: To investigate whether twin concordance for psychosis depends on the level of polygenic risk score (PRS) for psychosis and zygosity and compare PRS from cases and controls from several large samples and estimate the twin heritability of psychosis.

Design, setting, and participants: In this case-control study, psychosis PRS were generated from a genome-wide association study (GWAS) combining schizophrenia and bipolar disorder into a single psychosis phenotype and compared between cases and controls from the Schizophrenia and Bipolar Twin Study in Sweden (STAR) project. Further tests were conducted to ascertain if twin concordance for psychosis depended on the mean PRS for psychosis. Structural equation modeling was used to estimate heritability. This study constituted an analysis of existing clinical and population datasets with genotype and/or twin data. Included were twins from the STAR cohort and from the Swedish Twin Registry. Data were collected during the 2006 to 2013 period and analyzed from March 2023 to June 2024.

Exposures: PRS for psychosis based on the most recent GWAS of combined schizophrenia/bipolar disorder.

Main outcomes and measures: Psychosis case status was assessed by clinical interviews and/or Swedish National Register data.

Results: The final cohort comprised 87 pairs of twins with 1 or both affected and 59 unaffected pairs from the STAR project (for a total of 292 twins) as well as 443 pairs with 1 or both affected and 20 913 unaffected pairs from the Swedish Twin Registry. Among the 292 twins (mean [SD] birth year, 1960 [10.8] years; 158 female [54.1%]; 134 male [45.9%]), 134 were monozygotic twins, and 158 were dyzygotic twins. PRS for psychosis was higher in cases than in controls and associated with twin concordance for psychosis (1-SD increase in PRS, odds ratio [OR], 2.12; 95% CI, 1.23-3.87 on case status in monozygotic twins and OR, 2.74; 95% CI, 1.56-5.30 in dizygotic twins). The association between PRS for psychosis and concordance was not modified by zygosity. The twin heritability was estimated at 0.73 (95% CI, 0.30-1.00), which overlapped with the estimate in the full Swedish Twin Registry (0.69; 95% CI, 0.43-0.85).

Conclusions and relevance: In this case-control study, using the natural experiment of twins, results suggest that twins with greater inherited liability for psychosis were more likely to have an affected co-twin. Results from twin and molecular designs largely aligned. Even as illness vulnerability is not solely genetic, PRS carried predictive power for psychosis even in a modest sample size.

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A Case Report of Mania and Psychosis Five Months after Traumatic Brain Injury Successfully Treated Using Olanzapine

Giordano f. cittolin-santos.

1 Faculty of Medicine, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil

Jesse C. Fredeen

2 Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA

Robert O. Cotes

There are few published pharmacologic trials for the treatment of acute mania following traumatic brain injury (TBI). To our knowledge, we present the first case report of an individual being treated and stabilized with olanzapine monotherapy for this condition.

Case Presentation

We describe the case of a 53-year-old African American male admitted to an inpatient psychiatric hospital with one month of behavioral changes including irritability, decreased need for sleep, hyperverbal speech, hypergraphia, and paranoia five months after TBI. Using Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria, he was diagnosed with bipolar disorder due to traumatic brain injury, with manic features. He was serially evaluated with clinical rating scales to measure symptom severity. The Young Mania Rating Scale (YMRS) score upon admission was 31, and the Clinician-Rated Dimensions of Psychosis Symptom Severity (CRDPSS) score was initially 9. After eight days of milieu treatment and gradual titration of olanzapine to 15 mg nightly, his symptoms completely abated, with YMRS and CRDPSS scores at zero on the day of discharge.

Olanzapine was effective and well tolerated for the treatment of mania following TBI.

1. Introduction

Mania develops in 1.9–9% of individuals after experiencing traumatic brain injury (TBI) [ 1 , 2 ]. Yet, there is a dearth of literature on pharmacologic treatment options for mania following TBI. The guidelines for the pharmacologic treatment of neurobehavioral sequelae of traumatic brain injury, published in 2006, concluded there was insufficient evidence to support the development of standards or guidelines in the treatment of TBI related mania [ 3 ]. Four studies were included in the review, including three case series (each with two patients) and one case report. Treatments successful in treating mania included clonidine [ 4 ], thioridazine/amitriptyline [ 5 ], electroconvulsive therapy [ 5 ], lithium [ 6 ], and valproate [ 6 ]. In addition to the studies presented in the 2006 guidelines, successful trials have been published with carbamazepine/lithium [ 7 ], lithium/thioridazine [ 8 ], lithium monotherapy [ 9 – 11 ], valproate/olanzapine [ 12 – 14 ], valproate monotherapy [ 15 ], carbamazepine/chlorpromazine [ 16 , 17 ], haloperidol [ 16 ], haloperidol/chlorpromazine [ 18 ], haloperidol/clonazepam [ 19 ], and quetiapine [ 20 ]. Here, we present the first case report of successful treatment with olanzapine monotherapy for mania after a traumatic brain injury.

2. Case Presentation

A 53-year-old African American male was brought by Emergency Medical Services (EMS) to the Emergency Room (ER) of an urban, public teaching hospital, due to threatening behavior, irritability, and an inability to care for himself. During the initial psychiatric consultation in the ER, the patient was hyperverbal with pressured speech and a tangential thought process. His mood was elevated, and his affect was labile with sudden and inappropriate bouts of tearfulness. He endorsed decreased need for sleep over the past few days and paranoid and persecutory delusions regarding strange noises around his apartment and his brother stealing money from his father. Per the EMS report, the patient was also emailing and texting neighbors paranoid and threatening messages, which resulted in multiple crisis hotline calls and the patient being brought to the hospital.

His past medical history was significant for a depressive episode treated successfully 25 years ago with sertraline and TBI five months prior to presentation. After the injury, he was followed by an outpatient neurologist for postconcussive syndrome. A brain MRI was ordered three months after TBI, which showed signs of mild white matter small vessel ischemic changes, but no other significant findings. The initial ER workup included a urinalysis, urine drug screen, complete metabolic panel, and thyroid function, all of which were unremarkable. A noncontrast CT scan of the brain was obtained and was unremarkable. He was admitted for inpatient psychiatric hospitalization. Using Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria [ 21 ], he was diagnosed with bipolar disorder due to traumatic brain injury, with manic features.

The patient was started on olanzapine 2.5 mg by mouth at bedtime upon admission. Manic features remained prominent, as he continued to demonstrate decreased need for sleep (three to five hours per night), pressured speech, irritability, emotional dysregulation, and labile affect. He often arose early in the morning and spent multiple hours writing questions for his treatment team. He refused valproate and lithium despite the team's suggestions. Olanzapine was gradually titrated and reached 15 mg on hospital day (HD) 6. Aside from one instance of refusal on HD 5, he was adherent with olanzapine throughout the hospitalization. Olanzapine was well tolerated. He was evaluated with serial clinical rating scales which included the Young Mania Rating Scale (YMRS) and the Clinician-Rated Dimensions of Psychosis Symptom Severity (CRDPSS). On HD 1, the YMRS score was 31 and CRDSS was 9. On HD 6, the YMRS score decreased to 30 and CRDPSS decreased to 7. On HD 7, he displayed significant clinical improvement. He slept throughout the night and on interview no longer had pressured speech. His thought process was logical, linear, and goal-directed, and the psychotic symptoms had also fully abated. On HD 8, the YMRS and CRDPSS scores were 0. He was subsequently discharged from hospital with appropriate outpatient follow-up.

3. Discussion

Mania due to TBI is a challenging diagnosis to make with confidence, and this can make the limited research challenging to interpret. TBI may be an independent risk factor for the development of bipolar disorder [ 1 , 22 – 24 ] and the DSM-5 does not report a definitive time course for which the diagnosis of TBI must take place and symptoms must emerge in order for the disorder to be characterized as mania due to TBI [ 21 ]. As in our case, the majority of individuals who ultimately develop bipolar disorder report a depressive episode first [ 25 ], but the later age of onset of manic symptoms and temporal relationship to TBI lends credence to the TBI's primary role in the development of manic symptoms. In the case presented here, the patient exhibited a combination of manic and psychotic symptoms, but manic symptoms were predominant. The duration of the manic episode (likely around 2 months) was within range of other manic episodes reported after TBI. In study of six patients following head injury who experienced mania, the duration of the episode was 2 months, and the mean estimated duration of elevated mood was 5.7 months [ 2 ].

Olanzapine is a second-generation antipsychotic medication effective for the treatment of acute bipolar mania [ 26 ] and recommended for acute mania by various guidelines across the world [ 27 – 29 ]. However, few pharmacologic (and no randomized) trials exist for the treatment of mania following TBI. Olanzapine has been used for acute mania following TBI in several reported cases. Grenne et al. [ 30 ] described a case of a 13-year-old boy treated with olanzapine 10 mg daily and zonisamide who had improvement of auditory hallucinations but continued mania and delusions. A 60-year-old man was treated with an unspecified dose of olanzapine and 2500 mg of valproate five months after a head injury [ 12 ]. A 42-year-old man was treated with olanzapine 15 mg daily and valproate 1000 mg daily for mania emerging three years after a head trauma [ 13 ]. A 69-year-old man eighteen months after TBI was treated with 7.5 mg of olanzapine and 250 mg of valproate three times daily [ 14 ]. In each of these cases, olanzapine was combined with another medication, and of note, valproate alone has been effective in treating mania secondary to TBI [ 15 ], making it challenging to know if the patient improved related to olanzapine or valproate. Furthermore, olanzapine monotherapy has been shown to be effective in treating psychotic symptoms following traumatic brain injury in two case reports [ 31 , 32 ]. In the case presented here, the patient was not agreeable to other pharmacologic treatments despite being offered lithium and valproate augmentation. In a 2014 review article, Jorge and Arciniegas recommended valproate or quetiapine as first-line therapies for bipolar disorder due to TBI [ 33 ]. We conclude that olanzapine could also be considered for this population, as it was effective and well tolerated in this case.

Conflicts of Interest

Dr. Robert O. Cotes has accepted research funding, consultation fees, and/or honoraria from Alkermes, Janssen, and Otsuka Pharmaceuticals. Drs. Giordano F. Cittolin-Santos and Jesse C. Fredeen have nothing to disclose.