BPAD
Bipolar Affective Disorder (BPAD) (also known as Manic Depressive Psychosis in the past) is a disorder of mood.
Mood can be defined as a pervasive and sustained emotion or feeling tone that influences a person’s behavior and colours his or her perception of being in the world.
As the name suggests, in Bipolar disorder, the patient’s mood fluctuates between 2 mood extremes- Depression & Mania (Like North pole & South pole).
Symptoms of Depression
1. Depressed mood
2. Loss of interest and enjoyment
3. Reduced energy leading to increased fatiguability & diminished activity
4. Reduced concentration & attention
5. Reduced self-esteem & self confidence
6. Ideas of guilt and unworthiness
7. Bleak and pessimistic views of the future
8. Ideas or acts of self-harm or suicide
9. Disturbed sleep
10. Diminished appetite
Symptoms of Mania
1. Abnormally and persistently elevated, expansive or irritable mood
2. Abnormally and persistently increased goal directed activity or energy
3. Inflated self-esteem or grandiosity
4. Decreased need for sleep (feels rested even after only 3 hours of sleep)
5. More talkative than usual or pressure to keep talking
6. Flight of ideas or subjective experience that thoughts are racing
7. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
8. Increase in goal directed activity (socially, at work, or sexually) or psychomotor
agitation (i.e., purposeless non goal directed activity)
9. Excessive involvement in activities that have a high potential for painful consequences (eg: buying sprees, sexual indiscretions or foolish business investments).
10. Sometimes, if the episode is severe, there might also be psychotic symptoms likesuspiciousness, hearing voices etc.
Causes/ risk factors of BPAD
Biological factors
1. Neurotransmitters : Neurotransmitters are chemicals in the brain found between neurons & they help in the transmission of signals from one neuron to another. There are many neurotransmitters like Serotonin, Norepinephrine, Dopamine, GABA, Acetylcholine, Glutamate, glycine – the balance of which are found disturbed in mood disorders, thus altering the signal transmission & thereby the connectivity between different brain regions.
2. Receptors : Different Neurotransmitters bind to specific receptors on the neurons to transmit the signals. In mood disorders, these receptors may be upregulated or downregulated or hypo-functional or hyper-functional for specific neurotransmitters in specific brain regions.
3. Second Messengers and Intracellular Cascades : Each Neurotransmitter after binding to its specific receptor on the neuron, triggers the G Proteins & some enzymes causing the production of 2nd messengers such as cAMP & cGMP, which in turn regulate the function of neuronal membrane ion channels; thereby regulating the transmission of signals across neurons. In mood disorders, this complex machinery is found to be deranged.
4. Alterations of Hormonal Regulation : Various hormones like BDNF, Cortisol, Thyroid hormone, Growth hormone are found to be dysregulated in Mood disorders.
5. Alterations of Sleep Neurophysiology : Normal sleep has different stages like REM & NREM (I-IV) electro-physiologically. In mood disorders, its deranged or fragmented.
6. Immunological Disturbance : Impaired cellular immunity – decreased ability of the body to fight against germs, pathogens & diseases.
7. Structural and Functional Brain Imaging :
• CT & MRI Scans have shown that mood disorders damage different parts of the Brain, causing Neurodegenerative changes – Ventricular enlargement, cortical atrophy, sulcal widening & reduced hippocampal or caudate nucleus volumes.
• PET Scans have shown decreased brain metabolism, more on the left hemisphere of brain in depression & on the right hemisphere in mania. Evidence suggests that medications normalize these changes.
Genetic Factors
1. Family Studies : If one parent has a mood disorder, the child will have a risk of 10-25% for mood disorder. If both parents have mood disorder, this risk doubles. The more members of the family are affected, the greater the risk is to a child. The risk is greater if the affected family members are first-degree relatives rather than more distant relatives.
2. Twin Studies : If one Monozygotic (identical) twin has a mood disorder, there is 70 to 90 percent risk that the other twin will develop the same disorder. In the case of
Dizygotic (fraternal) twins, the risk is 16-35%.
Psychosocial Factors
1. Life Events and Environmental Stress : Stressful life events more often precede the development of mood disorders. Stress results in long-lasting changes in the brain’s biology- alter the Neurotransmitter balance, intraneuronal signalling systems & even loss of neurons and synaptic contacts. As a result, a person has a high risk of developing subsequent episodes of a mood disorder, even without an external stressor.
2. Personality Factors : Persons with certain personality disorders – OCD, histrionic, and borderline – may be at greater risk for depression than persons with antisocial or paranoid personality disorder.
Diagnosing BPAD
BPAD is diagnosed by conducting a –
1. Psychiatric interview- of the client (patient) & informants (relatives). A detailed history of the complaints & the present illness, past history of psychiatric illness, family history to see if there are any genetic predisposing causes, personal history to see if any marital/relationship problems or any substance use like alcohol or if there are any external stressors like job loss contributing to the present illness, general medical history to rule out any possibility of any physical illness causing a secondary depression/mania (like hypothyroidism/ vitD3 deficiency/parkinsonism/Dementia), assessment of personality to see if any personality traits or personality disorder is contributing to the current episode of illness.
2. Mental Status examination- General appearance & behaviour, Psychomotor activity, Talk, Thought, Mood, Affect, Perception, Cognitive functions- attention & concentration, memory, intelligence, abstractability, judgment & insight are assessed.
3. Physical Examination- to see if the patient has any undiagnosed medical condition like hypothyroidism, parkinsonism or any other neurological condition causing or contributing to the present psychiatric illness.
4. Neuro-Psychiatric assessment scales- depression rating scales & mania rating scales to have an objective measurement of depression/mania
Investigations
Blood levels of Thyroid hormones, Blood vitamin D3 levels, Blood sugar levels etc to see if any physical illness is contributing or causing the depression/mania
Treatment of BPAD
A. Pharmacotherapy – It’s the treatment by using medicines- Mood stabilizers, Antidepressants, Antipsychotics. Medicines correct the neurochemical imbalances, the receptor dysregulations, 2nd messenger & intracellular disarray, stops neuronal loss, increases neuronal dendritic spines and re-establishes neuronal synaptic connections and thus improves and normalises connectivity of different brain regions, thus improving the mood & cognitive symptoms of depression. CT, MRI, PET & FMRI studies have shown that treatment with drugs have a positive rebuilding effect on the brain. Mood stabilizers, Antidepressants & antipsychotics are safe, efficacious and are not addictive. Most of the antidepressants have no to minimal side effects. The duration of treatment depends on the duration of the illness, its severity, no of depressive episodes etc. It’s important to complete the full course of treatment and not to stop treatment after mere resolution of symptoms as premature termination of treatment can lead to illness recurrence. After each episode of depression/mania, the illness severity increases, frequency of the episodes increases and the response to treatment decreases and thus there will be more residual symptoms.
Mood stabilizers
1. Lithium
2. Sodium Valproate & Valproic acid
3. Carbamazepine & Oxcarbazepine
Mood stabilizing antipsychotics
1. Olanzapine
2. Risperidone
3. Aripiprazole
There are various classes of Antidepressants. They are –
1. SSRIs – Specific Serotonin Reuptake inhibitors. Eg: Fluoxetine, Escitalopram
2. SNRIs – Serotonin Norepinephrine Reuptake inhibitors. Eg: Venlafaxine
3. NASSA – Norepinephrine and Specific Serotonin Reuptake inhibitors. Eg: Mirtazapine
4. NDRI – Norepinephrine Dopamine Reuptake inhibitor. Eg: Bupropion
B. Psychotherapy – Psychotherapy is the treatment by psychological means to overcome the patient’s problem. There are 3 types of psychotherapy which are useful in depression.
1. Cognitive Therapy- Correcting cognitive distortions (-ve thoughts)
2. Interpersonal Therapy- focusses on the patient’s current interpersonal problems.
3. Behaviour Therapy- Focusses on maladaptive behaviour patterns.
Reference :
1. Oxford Textbook of Psychiatry
2. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry
3. The ICD-10: Classification of Mental and Behavioural Disorders
4. Diagnostic and Statistical Manual of Mental Disorders (DSM–5)
5. https://www.ncbi.nlm.nih.gov/pmc/
Self-Assessment
