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La "depresión maníaca" y los "trastornos bipolares" vuelven a dirigir aquí. Para la revista médica, consulte Trastornos bipolares (revista) . Para otros usos, consulte Depresión maníaca (desambiguación) .

Trastorno bipolar
Otros nombresTrastorno afectivo bipolar (TABP), [1] enfermedad bipolar, maníaco depresivo, trastorno maníaco depresivo, enfermedad maníaco-depresiva (histórica), [2] psicosis maníaco-depresiva, locura circular (histórica), [2] enfermedad bipolar [3]
P culture.svg
El trastorno bipolar se caracteriza por episodios de depresión y manía.
EspecialidadPsiquiatría
SíntomasPeríodos de depresión y estado de ánimo elevado [4] [5]
ComplicacionesSuicidio , autolesión [4]
Inicio habitual25 años [4]
TiposTrastorno bipolar I , trastorno bipolar II , otros [5]
CausasAmbiental y genético [4]
Factores de riesgoAntecedentes familiares, abuso infantil , estrés a largo plazo [4]
Diagnóstico diferencialTrastorno por déficit de atención con hiperactividad , trastornos de la personalidad , esquizofrenia , trastorno por consumo de sustancias [4]
TratamientoPsicoterapia , medicamentos [4]
MedicamentoLitio , antipsicóticos , anticonvulsivos [4]
Frecuencia1-3% [4] [6]

El trastorno bipolar , anteriormente conocido como depresión maníaca , es un trastorno mental caracterizado por períodos de depresión y períodos de estado de ánimo anormalmente elevado que duran de días a semanas cada uno. [4] [5] [7] Si el estado de ánimo elevado es severo o está asociado con psicosis , se llama manía ; si es menos grave, se llama hipomanía . [4] Durante la manía, un individuo se comporta o se siente anormalmente enérgico, feliz o irritable, [4] ya menudo toman decisiones impulsivas sin tener en cuenta las consecuencias. [5]Por lo general, también hay una menor necesidad de dormir durante las fases maníacas. [5] Durante los períodos de depresión, el individuo puede experimentar llanto y tener una perspectiva negativa de la vida y un contacto visual deficiente con los demás. [4] El riesgo de suicidio es alto; durante un período de 20 años, el 6% de las personas con trastorno bipolar murieron por suicidio, mientras que entre el 30 y el 40% se autolesionaron . [4] Otros problemas de salud mental, como los trastornos de ansiedad y los trastornos por uso de sustancias , se asocian comúnmente con el trastorno bipolar. [4]

Si bien no se comprenden claramente las causas del trastorno bipolar, se cree que influyen tanto los factores genéticos como los ambientales . [4] Muchos genes, cada uno con pequeños efectos, pueden contribuir al desarrollo del trastorno. [4] [8] Los factores genéticos representan alrededor del 70 al 90% del riesgo de desarrollar trastorno bipolar. [9] [10] Los factores de riesgo ambientales incluyen antecedentes de abuso infantil y estrés a largo plazo . [4] La afección se clasifica como trastorno bipolar I si ha habido al menos un episodio maníaco, con o sin episodios depresivos, y comotrastorno bipolar II si ha habido al menos un episodio hipomaníaco (pero no episodios maníacos completos) y un episodio depresivo mayor. [5] Si los síntomas se deben a medicamentos o problemas médicos, no se diagnostican como trastorno bipolar. [5] Otras afecciones que tienen síntomas superpuestos con el trastorno bipolar incluyen el trastorno por déficit de atención con hiperactividad , los trastornos de la personalidad , la esquizofrenia y el trastorno por uso de sustancias, así como muchas otras afecciones médicas. [4] No se requieren pruebas médicas para un diagnóstico , aunque análisis de sangre o imágenes médicaspuede descartar otros problemas. [11]

Los estabilizadores del estado de ánimo, el litio y ciertos anticonvulsivos como el valproato y la carbamazepina, son el pilar de la prevención de recaídas a largo plazo. [12] Los antipsicóticos se administran durante los episodios maníacos agudos, así como en los casos en que los estabilizadores del estado de ánimo se toleran mal o son ineficaces o cuando el cumplimiento es deficiente. [12] Existe alguna evidencia de que la psicoterapia mejora el curso de este trastorno. [13] El uso de antidepresivos en episodios depresivos es controvertido; pueden ser efectivos pero se han relacionado con el desencadenamiento de episodios maníacos. [14]El tratamiento de los episodios depresivos suele ser difícil. [12] La terapia electroconvulsiva (TEC) es eficaz en los episodios maníacos y depresivos agudos, especialmente con psicosis o catatonia . [a] [12] Es posible que se requiera la admisión a un hospital psiquiátrico si una persona representa un riesgo para sí misma o para otros; En ocasiones, es necesario un tratamiento involuntario si la persona afectada se niega al tratamiento. [4]

El trastorno bipolar se presenta en aproximadamente el 1% de la población mundial. [12] En los Estados Unidos, se estima que alrededor del 3% se ve afectado en algún momento de su vida; las tasas parecen ser similares en mujeres y hombres. [6] [16] La edad más común a la que comienzan los síntomas es a los 20 años; un inicio más temprano en la vida se asocia con un peor pronóstico. [17] Alrededor de un cuarto a un tercio de las personas con trastorno bipolar tienen problemas económicos, sociales o laborales debido a la enfermedad. [4] El trastorno bipolar se encuentra entre las 20 principales causas de discapacidad en todo el mundo y genera costos sustanciales para la sociedad. [18] Debido a las elecciones de estilo de vida y los efectos secundarios de los medicamentos, el riesgo de muerte por causas naturales comoLa enfermedad coronaria en personas con trastorno bipolar es el doble que en la población general. [4]

Signos y síntomas

Cambios de humor bipolares

La adolescencia tardía y la adultez temprana son años pico para la aparición del trastorno bipolar. [19] [20] La afección se caracteriza por episodios intermitentes de manía o depresión , con ausencia de síntomas intermedios. [21] Durante estos episodios, las personas con trastorno bipolar presentan alteraciones en el estado de ánimo normal , la actividad psicomotora (el nivel de actividad física que está influenciado por el estado de ánimo) (p. Ej., Inquietud constante con manía o movimientos lentos con depresión), ritmo circadiano y cognición . La manía puede presentarse con diversos niveles de alteración del estado de ánimo, que van desde la euforia asociada con la "manía clásica" hasta la disforia.e irritabilidad . [22] Los síntomas psicóticos como delirios o alucinaciones pueden ocurrir tanto en episodios maníacos como depresivos, su contenido y naturaleza son consistentes con el estado de ánimo predominante de la persona. [4]

De acuerdo con los criterios del DSM-5 , la manía se distingue de la hipomanía por la duración, ya que la hipomanía está presente si los síntomas del estado de ánimo elevado están presentes durante al menos cuatro días consecutivos y la manía está presente si dichos síntomas están presentes durante más de una semana. A diferencia de la manía, la hipomanía no siempre se asocia con un funcionamiento deficiente. [12] Los mecanismos biológicos responsables del cambio de un episodio maníaco o hipomaníaco a un episodio depresivo, o viceversa, siguen siendo poco conocidos. [23]

Episodios maníacos

Una litografía en color de 1892 que representa a una mujer diagnosticada con manía hilarante

También conocida como episodio maníaco, la manía es un período distinto de al menos una semana de estado de ánimo elevado o irritable, que puede variar desde la euforia hasta el delirio . El síntoma central de la manía implica un aumento de la energía de la actividad psicomotora . La manía también puede presentarse con aumento de la autoestima o grandiosidad , pensamientos acelerados , lenguaje presionado que es difícil de interrumpir, disminución de la necesidad de dormir, comportamiento social desinhibido, [22] aumento de las actividades orientadas a objetivos y deterioro del juicio: exhibición de comportamientos caracterizados como impulsivos. o de alto riesgo, como hipersexualidad o gasto excesivo. [24] [25][26] Para cumplir con la definición de episodio maníaco, estos comportamientos deben afectar la capacidad del individuo para socializar o trabajar. [24] [26] Si no se trata, un episodio maníaco suele durar de tres a seis meses. [27]

En los episodios maníacos graves, una persona puede experimentar síntomas psicóticos , en los que el contenido del pensamiento se ve afectado junto con el estado de ánimo. [26] Pueden sentirse imparables, o como si tuvieran una relación especial con Dios, una gran misión que cumplir u otras ideas grandiosas o delirantes. [28] Esto puede conducir a un comportamiento violento y, a veces, a la hospitalización en un hospital psiquiátrico . [25] [26] La gravedad de los síntomas maníacos se puede medir mediante escalas de calificación como la Young Mania Rating Scale , aunque quedan dudas sobre la confiabilidad de estas escalas. [29]

El inicio de un episodio maníaco o depresivo suele estar presagiado por una alteración del sueño . [30] Los cambios de humor, psicomotores y del apetito y un aumento de la ansiedad también pueden ocurrir hasta tres semanas antes de que se desarrolle un episodio maníaco. [ cita médica necesaria ] Los individuos maníacos a menudo tienen un historial de abuso de sustancias desarrollado durante años como una forma de "automedicación". [31]

Episodios hipomaníacos

Una litografía de 1858 titulada 'La melancolía se convierte en manía'

La hipomanía es la forma más leve de manía, definida como al menos cuatro días de los mismos criterios que la manía, [26] pero que no causa una disminución significativa en la capacidad del individuo para socializar o trabajar, carece de características psicóticas como delirios o alucinaciones , y no requiere hospitalización psiquiátrica. [24] El funcionamiento general en realidad puede aumentar durante los episodios de hipomanía y algunos creen que sirve como un mecanismo de defensa contra la depresión. [32] Los episodios hipomaníacos rara vez progresan a episodios maníacos en toda regla. [32] Algunas personas que experimentan hipomanía muestran una mayor creatividad [26] [33]mientras que otros están irritables o demuestran falta de juicio. [10]

La hipomanía puede sentirse bien para algunas personas que la experimentan, aunque la mayoría de las personas que experimentan hipomanía afirman que el estrés de la experiencia es muy doloroso. [26] Las personas bipolares que experimentan hipomanía tienden a olvidar los efectos de sus acciones en quienes les rodean. Incluso cuando la familia y los amigos reconocen los cambios de humor , la persona a menudo niega que algo esté mal. [34] Si no se acompañan de episodios depresivos, los episodios hipomaníacos a menudo no se consideran problemáticos, a menos que los cambios de humor sean incontrolables o volátiles. [32] Por lo general, los síntomas continúan durante unas pocas semanas a unos meses. [35]

Episodios depresivos

Artículo principal: trastorno depresivo mayor
'Melancolía' de William Bagg , según una fotografía de Hugh Welch Diamond

Los síntomas de la fase depresiva del trastorno bipolar incluyen sentimientos persistentes de tristeza , irritabilidad o ira, pérdida de interés en actividades que antes disfrutaba , excesiva o inapropiada culpabilidad , desesperanza , dormir demasiado o no lo suficiente , cambios en el apetito y / o peso, fatiga , problemas para concentrarse, autodesprecio o sentimientos de inutilidad, y pensamientos de muerte o suicidio . [36]Aunque los criterios del DSM-5 para diagnosticar episodios unipolares y bipolares son los mismos, algunas características clínicas son más comunes en estos últimos, como aumento del sueño, aparición repentina y resolución de síntomas, aumento o pérdida de peso significativo y episodios graves después del parto. [12]

Cuanto más temprana sea la edad de aparición, es más probable que los primeros episodios sean depresivos. [37] Para la mayoría de las personas con tipos bipolares 1 y 2, los episodios depresivos son mucho más prolongados que los episodios maníacos o hipomaníacos. [17] Puesto que un diagnóstico de trastorno bipolar requiere un episodio maníaco o hipomaníaco, muchos individuos afectados son inicialmente mal diagnosticados como teniendo la depresión mayor y tratados incorrectamente con antidepresivos prescritos. [38]

Episodios afectivos mixtos

Artículo principal: Estado afectivo mixto

En el trastorno bipolar, un estado mixto es un episodio durante el cual los síntomas de manía y depresión ocurren simultáneamente. [39] Las personas que experimentan un estado mixto pueden tener síntomas maníacos, como pensamientos grandiosos, mientras que simultáneamente experimentan síntomas depresivos como culpa excesiva o sentimientos suicidas. [39] Se considera que tienen un mayor riesgo de comportamiento suicida, ya que las emociones depresivas como la desesperanza a menudo se combinan con cambios de humor o dificultades con el control de los impulsos . [39] Los trastornos de ansiedad se presentan con mayor frecuencia como comorbilidad en los episodios bipolares mixtos que en la depresión bipolar no mixta o manía. [39]El abuso de sustancias (incluido el alcohol ) también sigue esta tendencia, por lo que parece representar los síntomas bipolares como una mera consecuencia del abuso de sustancias. [39]

Condiciones comórbidas

El diagnóstico de trastorno bipolar puede ser complicado por coexistentes ( comorbilidad ) trastornos psiquiátricos incluyendo el trastorno obsesivo-compulsivo , trastorno de consumo de sustancias , trastornos de la alimentación , trastorno de hiperactividad con déficit de atención , la fobia social , el síndrome premenstrual (incluyendo el trastorno disfórico premenstrual ), o trastorno de pánico . [31] [36] [40] [41] Un análisis longitudinal completo de los síntomas y episodios, asistido si es posible por discusiones con amigos y familiares, es crucial para establecer un plan de tratamiento donde existen estas comorbilidades.[42] Los hijos de padres con trastorno bipolar tienen con mayor frecuencia otros problemas de salud mental. [ necesita actualización ] [43]

Las personas con trastorno bipolar a menudo tienen otras afecciones psiquiátricas coexistentes, como ansiedad (presente en aproximadamente el 71% de las personas con trastorno bipolar), uso de sustancias (56%), trastornos de la personalidad (36%) y trastorno por déficit de atención con hiperactividad (10-20 %) que pueden aumentar la carga de la enfermedad y empeorar el pronóstico. [17] Ciertas afecciones médicas también son más comunes en personas con trastorno bipolar en comparación con la población general. Esto incluye mayores tasas de síndrome metabólico (presente en el 37% de las personas con trastorno bipolar), migrañas (35%), obesidad (21%) y diabetes tipo 2 (14%). [17]Esto contribuye a un riesgo de muerte que es dos veces mayor en las personas con trastorno bipolar en comparación con la población general. [17]

Causas

Es probable que las causas del trastorno bipolar varíen entre los individuos y el mecanismo exacto subyacente al trastorno sigue sin estar claro. [44] Se cree que las influencias genéticas representan entre el 73% y el 93% del riesgo de desarrollar el trastorno, lo que indica un fuerte componente hereditario. [10] La heredabilidad general del espectro bipolar se ha estimado en 0,71. [45] Los estudios de gemelos se han visto limitados por tamaños de muestra relativamente pequeños, pero han indicado una contribución genética sustancial, así como la influencia ambiental. Para el trastorno bipolar I, la tasa a la que los gemelos idénticos (mismos genes) tendrán ambos trastornos bipolares I (concordancia) es de alrededor del 40%, en comparación con alrededor del 5% engemelos fraternos . [24] [46] Una combinación de bipolar I, II y ciclotimia produjo tasas similares de 42% y 11% (gemelos idénticos y fraternos, respectivamente). [45] Las tasas de combinaciones bipolar II sin bipolar I son más bajas (bipolar II en 23 y 17%, y bipolar II combinado con ciclotimia en 33 y 14%), lo que puede reflejar una heterogeneidad genética relativamente más alta . [45]

La causa de los trastornos bipolares se superpone con el trastorno depresivo mayor. Al definir la concordancia como los co-gemelos que tienen trastorno bipolar o depresión mayor, la tasa de concordancia aumenta al 67% en gemelos idénticos y al 19% en gemelos fraternos. [47] La concordancia relativamente baja entre los gemelos fraternos criados juntos sugiere que los efectos ambientales familiares compartidos son limitados, aunque la capacidad de detectarlos se ha visto limitada por tamaños de muestra pequeños. [45]

Genético

Los estudios de genética conductual han sugerido que muchas regiones cromosómicas y genes candidatos están relacionados con la susceptibilidad al trastorno bipolar y cada gen ejerce un efecto de leve a moderado . [40] El riesgo de trastorno bipolar es casi diez veces mayor en los familiares de primer grado de personas con trastorno bipolar que en la población general; de manera similar, el riesgo de trastorno depresivo mayor es tres veces mayor en los familiares de las personas con trastorno bipolar que en la población general. [24]

Aunque el primer hallazgo de ligamiento genético para la manía fue en 1969, [48] los estudios de ligamiento no han sido consistentes. [24] Los hallazgos apuntan fuertemente a la heterogeneidad, con diferentes genes implicados en diferentes familias. [49] Asociaciones significativas robustas y replicables en todo el genoma mostraron que varios polimorfismos de un solo nucleótido (SNP) comunes están asociados con el trastorno bipolar, incluidas variantes dentro de los genes CACNA1C , ODZ4 y NCAN . [40] [50] El estudio de asociación de todo el genoma más grande y más recienteno logró encontrar ningún locus que ejerza un gran efecto, lo que refuerza la idea de que ningún gen es responsable del trastorno bipolar en la mayoría de los casos. [50] Los polimorfismos en BDNF , DRD4 , DAO y TPH1 se han asociado con frecuencia con el trastorno bipolar y se asociaron inicialmente en un metanálisis , pero esta asociación desapareció después de la corrección para múltiples pruebas . [51] Por otro lado, se identificaron dos polimorfismos en TPH2 asociados con el trastorno bipolar. [52]

Debido a los hallazgos inconsistentes en un estudio de asociación de todo el genoma , múltiples estudios han emprendido el enfoque de analizar SNP en vías biológicas. Vías de señalización tradicionalmente asociados con el trastorno bipolar que han sido apoyados por estos estudios incluyen la hormona liberadora de corticotropina señalización, cardíaco β-adrenérgicos de señalización, fosfolipasa C de señalización, glutamato de señalización del receptor, [53] de señalización hipertrofia cardiaca, la señalización de Wnt , la señalización de Notch , [54 ] y endotelina 1señalización. De los 16 genes identificados en estas vías, se encontró que tres estaban desregulados en la porción de la corteza prefrontal dorsolateral del cerebro en estudios post-mortem: CACNA1C , GNG2 e ITPR2 . [55]

El trastorno bipolar se asocia con una expresión reducida de enzimas reparadoras de ADN específicas y un aumento de los niveles de daños oxidativos del ADN . [56]

Ambiental

Los factores psicosociales juegan un papel importante en el desarrollo y curso del trastorno bipolar, y las variables psicosociales individuales pueden interactuar con las disposiciones genéticas. [57] Es probable que los acontecimientos vitales recientes y las relaciones interpersonales contribuyan al inicio y la recurrencia de los episodios bipolares del estado de ánimo, al igual que ocurre con la depresión unipolar. [58] En las encuestas, 30 a 50% de los adultos diagnosticados con trastorno bipolar informan experiencias traumáticas / abusivas en la infancia, que se asocian con un inicio más temprano, una tasa más alta de intentos de suicidio y más trastornos concurrentes como el estrés postraumático. desorden . [59]El número de eventos estresantes reportados en la niñez es mayor en aquellos con un diagnóstico de adulto de trastorno del espectro bipolar que en aquellos sin él, particularmente eventos derivados de un ambiente hostil más que del propio comportamiento del niño. [60] De manera aguda, la falta de sueño puede inducir manía en alrededor del 30% de las personas con trastorno bipolar. [61]

Neurológico

Con menos frecuencia, el trastorno bipolar o un trastorno similar al bipolar puede ocurrir como resultado o en asociación con una afección o lesión neurológica que incluye accidente cerebrovascular , lesión cerebral traumática , infección por VIH , esclerosis múltiple , porfiria y, en raras ocasiones, epilepsia del lóbulo temporal . [62]

Mecanismos propuestos

Más información: Biología del trastorno bipolar
Los estudios de imágenes cerebrales han revelado diferencias en el volumen de varias regiones del cerebro entre pacientes con trastorno bipolar y sujetos de control sanos.

Los mecanismos precisos que causan el trastorno bipolar no se comprenden bien. Se cree que el trastorno bipolar está asociado con anomalías en la estructura y función de ciertas áreas del cerebro responsables de las tareas cognitivas y el procesamiento de las emociones. [21] Un modelo neurológico para el trastorno bipolar propone que el circuito emocional del cerebro se puede dividir en dos partes principales. [21] El sistema ventral (regula la percepción emocional) incluye estructuras cerebrales como la amígdala , la ínsula , el estriado ventral, la corteza cingulada anterior ventral y la corteza prefrontal . [21]El sistema dorsal (responsable de la regulación emocional) incluye el hipocampo , la corteza cingulada anterior dorsal y otras partes de la corteza prefrontal. [21] El modelo plantea la hipótesis de que el trastorno bipolar puede ocurrir cuando el sistema ventral está sobreactivado y el sistema dorsal no está activo. [21] Otros modelos sugieren que la capacidad de regular las emociones está alterada en personas con trastorno bipolar y que la disfunción de la corteza prefrontal ventricular (vPFC) es crucial para esta alteración. [21]

Los metaanálisis de estructurales de MRI estudios han demostrado que ciertas regiones del cerebro (por ejemplo, la izquierda rostral anterior cingulate cortex , corteza fronto-insular , ventral prefrontal cortex, y Claustrum ) son más pequeños en personas con trastorno bipolar, mientras que otros son más grandes ( ventrículos laterales , globo pálido , cingulado anterior subgenual y amígdala). Además, estos metanálisis encontraron que las personas con trastorno bipolar tienen tasas más altas de hiperintensidades profundas de la materia blanca . [63] [64] [65] [66]

Los hallazgos de la resonancia magnética funcional sugieren que el vPFC regula el sistema límbico , especialmente la amígdala. [67] En las personas con trastorno bipolar, la disminución de la actividad de vPFC permite una actividad desregulada de la amígdala, lo que probablemente contribuye a un estado de ánimo lábil y una mala regulación emocional. [67] De acuerdo con esto, el tratamiento farmacológico de la manía devuelve la actividad de vPFC a los niveles en personas no maníacas, lo que sugiere que la actividad de vPFC es un indicador del estado de ánimo. Sin embargo, aunque el tratamiento farmacológico de la manía reduce la hiperactividad de la amígdala, permanece más activo que la amígdala de las personas sin trastorno bipolar, lo que sugiere que la actividad de la amígdala puede ser un marcador del trastorno en lugar del estado de ánimo actual. [68] Manic and depressive episodes tend to be characterized by dysfunction in different regions of the vPFC. Manic episodes appear to be associated with decreased activation of the right vPFC whereas depressive episodes are associated with decreased activation of the left vPFC.[67]

Las personas con trastorno bipolar que se encuentran en un estado de ánimo eutímico muestran una menor actividad en la circunvolución lingual en comparación con las personas sin trastorno bipolar. [21] Por el contrario, demuestran una disminución de la actividad en la corteza frontal inferior durante los episodios maníacos en comparación con las personas sin el trastorno. [21] Estudios similares que examinaron las diferencias en la actividad cerebral entre las personas con trastorno bipolar y las que no lo tenían no encontraron un área constante en el cerebro que fuera más o menos activa al comparar estos dos grupos. [21]Las personas con trastorno bipolar tienen una mayor activación de las áreas límbicas ventrales del hemisferio izquierdo, que median experiencias emocionales y la generación de respuestas emocionales, y una menor activación de las estructuras corticales del hemisferio derecho relacionadas con la cognición, estructuras asociadas con la regulación de las emociones. [69]

Los neurocientíficos han propuesto modelos adicionales para intentar explicar la causa del trastorno bipolar. Un modelo propuesto para el trastorno bipolar sugiere que la hipersensibilidad de los circuitos de recompensa que consisten en circuitos frontoestriatales causa manía y la disminución de la sensibilidad de estos circuitos causa depresión. [70] Según la hipótesis del "encendido", cuando las personas que están genéticamente predispuestas al trastorno bipolar experimentan eventos estresantes, el umbral de estrés en el que se producen los cambios de humor se reduce progresivamente, hasta que los episodios finalmente comienzan (y se repiten) espontáneamente. Existe evidencia que respalda una asociación entre el estrés de la vida temprana y la disfunción del eje hipotalámico-pituitario-suprarrenalque conduce a su sobreactivación, que puede desempeñar un papel en la patogénesis del trastorno bipolar. [71] [72] Otros componentes del cerebro que se ha propuesto que desempeñan un papel en el trastorno bipolar son las mitocondrias [44] y una bomba de ATPasa de sodio . [73] Los ritmos circadianos y la regulación de la hormona melatonina también parecen estar alterados. [74]

La dopamina , un neurotransmisor responsable del ciclo del estado de ánimo, ha aumentado la transmisión durante la fase maníaca. [23] [75] La hipótesis de la dopamina establece que el aumento de la dopamina da como resultado una regulación negativa homeostática secundaria de elementos clave del sistema y receptores, como una menor sensibilidad de los receptores dopaminérgicos. Esto da como resultado una disminución de la transmisión de dopamina característica de la fase depresiva. [23] La fase depresiva termina con una regulación positiva homeostática que potencialmente reinicia el ciclo nuevamente. [76] Glutamato is significantly increased within the left dorsolateral prefrontal cortex during the manic phase of bipolar disorder, and returns to normal levels once the phase is over.[77]

Los medicamentos utilizados para tratar el trastorno bipolar pueden ejercer su efecto modulando la señalización intracelular, como mediante la reducción de los niveles de mioinositol , la inhibición de la señalización del AMPc y la alteración de las subunidades de la proteína G asociada a la dopamina. [78] En consonancia con esto, se notificaron niveles elevados de G αi , G αs y G αq / 11 en muestras de cerebro y sangre, junto con una mayor expresión y sensibilidad de la proteína quinasa A (PKA); [79] normalmente, la PKA se activa como parte de la cascada de señalización intracelular aguas abajo del desprendimiento de G αs subunidad del complejo de proteína G.

Los niveles disminuidos de ácido 5-hidroxiindolacético , un subproducto de la serotonina , están presentes en el líquido cefalorraquídeo de las personas con trastorno bipolar durante las fases de depresión y manía. Se ha planteado la hipótesis de un aumento de la actividad dopaminérgica en los estados maníacos debido a la capacidad de los agonistas de la dopamina para estimular la manía en personas con trastorno bipolar. La disminución de la sensibilidad de los receptores adrenérgicos α 2 reguladores , así como el aumento de los recuentos de células en el locus coeruleus, indicaron un aumento de la actividad noradrenérgica en personas maníacas. Se han encontrado niveles bajos de GABA en plasma en ambos lados del espectro del estado de ánimo. [80]Una revisión no encontró diferencias en los niveles de monoamina, pero encontró un recambio anormal de noradrenalina en personas con trastorno bipolar. [81] Se descubrió que el agotamiento de la tirosina reduce los efectos de la metanfetamina en personas con trastorno bipolar, así como los síntomas de manía, lo que implica a la dopamina en la manía. Se encontró que la unión de VMAT2 aumentaba en un estudio de personas con manía bipolar. [82]

Diagnóstico

El trastorno bipolar se diagnostica comúnmente durante la adolescencia o la edad adulta temprana, pero el inicio puede ocurrir durante toda la vida. [5] [83] Su diagnóstico se basa en las experiencias autoinformadas del individuo, el comportamiento anormal informado por miembros de la familia, amigos o compañeros de trabajo, signos observables de enfermedad evaluados por un médico e idealmente un examen médico para descartar otras causas. Las escalas de calificación calificadas por los cuidadores, específicamente de la madre, han demostrado ser más precisas que los informes calificados por maestros y jóvenes para identificar a los jóvenes con trastorno bipolar. [84] La evaluación generalmente se realiza de forma ambulatoria; Se considera la admisión a un centro de internación si existe un riesgo para uno mismo o para los demás.

The most widely used criteria for diagnosing bipolar disorder are from the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the World Health Organization's (WHO) International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10). The ICD-10 criteria are used more often in clinical settings outside of the U.S. while the DSM criteria are used within the U.S. and are the prevailing criteria used internationally in research studies. The DSM-5, published in 2013, includes further and more accurate specifiers compared to its predecessor, the DSM-IV-TR.[85]Este trabajo ha influido en la próxima undécima revisión de la CIE, que incluye los diversos diagnósticos dentro del espectro bipolar del DSM-V. [86]

Several rating scales for the screening and evaluation of bipolar disorder exist,[87] including the Bipolar spectrum diagnostic scale, Mood Disorder Questionnaire, the General Behavior Inventory and the Hypomania Checklist.[88] The use of evaluation scales cannot substitute a full clinical interview but they serve to systematize the recollection of symptoms.[88] On the other hand, instruments for screening bipolar disorder tend to have lower sensitivity.[87]

Differential diagnosis

Mental disorders that can have symptoms similar to those seen in bipolar disorder include schizophrenia, major depressive disorder,[89] attention deficit hyperactivity disorder (ADHD), and certain personality disorders, such as borderline personality disorder.[90][91][92] A key difference between bipolar disorder and borderline personality disorder is the nature of the mood swings; in contrast to the sustained changes to mood over days to weeks or longer, those of the latter condition (more accurately called emotional dysregulation) are sudden and often short-lived, and secondary to social stressors.[93]

Although there are no biological tests that are diagnostic of bipolar disorder,[50] blood tests and/or imaging are carried out to investigate whether medical illnesses with clinical presentations similar to that of bipolar disorder are present before making a definitive diagnosis. Neurologic diseases such as multiple sclerosis, complex partial seizures, strokes, brain tumors, Wilson's disease, traumatic brain injury, Huntington's disease, and complex migraines can mimic features of bipolar disorder.[83] An EEG may be used to exclude neurological disorders such as epilepsy, and a CT scan or MRI of the head may be used to exclude brain lesions.[83] Additionally, disorders of the endocrine system such as hypothyroidism, hyperthyroidism, and Cushing's disease are in the differential as is the connective tissue disease systemic lupus erythematosus. Infectious causes of mania that may appear similar to bipolar mania include herpes encephalitis, HIV, influenza, or neurosyphilis.[83] Certain vitamin deficiencies such as pellagra (niacin deficiency), Vitamin B12 deficiency, folate deficiency, and Wernicke Korsakoff syndrome (thiamine deficiency) can also lead to mania.[83] Common medications that can cause manic symptoms include antidepressants, prednisone, Parkinson's disease medications, thyroid hormone, stimulants (including cocaine and methamphetamine), and certain antibiotics.[94]

Bipolar spectrum

Since Emil Kraepelin's distinction between bipolar disorder and schizophrenia in the 19th century, researchers have defined a spectrum of different types of bipolar disorder.

Bipolar spectrum disorders include: bipolar I disorder, bipolar II disorder, cyclothymic disorder and cases where subthreshold symptoms are found to cause clinically significant impairment or distress.[5][83][86] These disorders involve major depressive episodes that alternate with manic or hypomanic episodes, or with mixed episodes that feature symptoms of both mood states.[5] The concept of the bipolar spectrum is similar to that of Emil Kraepelin's original concept of manic depressive illness.[95] Bipolar II disorder was established as a diagnosis in 1994 within DSM IV; though debate continues over whether it is a distinct entity, part of a spectrum, or exists at all.[96]

Criteria and subtypes

Simplified graphical comparison of bipolar I, bipolar II and cyclothymia[97][98]:267

The DSM and the ICD characterize bipolar disorder as a spectrum of disorders occurring on a continuum. The DSM-5 and ICD-11 lists three specific subtypes:[5][86]

  • Bipolar I disorder: At least one manic episode is necessary to make the diagnosis;[99] depressive episodes are common in the vast majority of cases with bipolar disorder I, but are unnecessary for the diagnosis.[24] Specifiers such as "mild, moderate, moderate-severe, severe" and "with psychotic features" should be added as applicable to indicate the presentation and course of the disorder.[5]
  • Bipolar II disorder: No manic episodes and one or more hypomanic episodes and one or more major depressive episode.[99] Hypomanic episodes do not go to the full extremes of mania (i.e., do not usually cause severe social or occupational impairment, and are without psychosis), and this can make bipolar II more difficult to diagnose, since the hypomanic episodes may simply appear as periods of successful high productivity and are reported less frequently than a distressing, crippling depression.
  • Cyclothymia: A history of hypomanic episodes with periods of depression that do not meet criteria for major depressive episodes.[100]

When relevant, specifiers for peripartum onset and with rapid cycling should be used with any subtype. Individuals who have subthreshold symptoms that cause clinically significant distress or impairment, but do not meet full criteria for one of the three subtypes may be diagnosed with other specified or unspecified bipolar disorder. Other specified bipolar disorder is used when a clinician chooses to provide an explanation for why the full criteria were not met (e.g., hypomania without a prior major depressive episode).[5] If the condition is thought to have a non-psychiatric medical cause, the diagnosis of bipolar and related disorder due to another medical condition is made, while substance/medication-induced bipolar and related disorder is used if a medication is thought to have triggered the condition.[101]

Rapid cycling

Most people who meet criteria for bipolar disorder experience a number of episodes, on average 0.4 to 0.7 per year, lasting three to six months.[102] Rapid cycling, however, is a course specifier that may be applied to any bipolar subtype. It is defined as having four or more mood disturbance episodes within a one-year span. Rapid cycling is usually temporary but is common amongst people with bipolar disorder and affects between 25.8%–45.3% of them at some point in their life.[36][103] These episodes are separated from each other by a remission (partial or full) for at least two months or a switch in mood polarity (i.e., from a depressive episode to a manic episode or vice versa).[24] The definition of rapid cycling most frequently cited in the literature (including the DSM-V and ICD-11) is that of Dunner and Fieve: at least four major depressive, manic, hypomanic or mixed episodes during a 12-month period.[104] The literature examining the pharmacological treatment of rapid cycling is sparse and there is no clear consensus with respect to its optimal pharmacological management.[105]People with the rapid cycling or ultradian subtypes of bipolar disorder tend to be more difficult to treat and less responsive to medications than other people with bipolar disorder.[106]

Children

Main article: Bipolar disorder in children
Lithium is the only medication approved by the FDA for treating mania in children.

In the 1920s, Kraepelin noted that manic episodes are rare before puberty.[107] In general, bipolar disorder in children was not recognized in the first half of the twentieth century. This issue diminished with an increased following of the DSM criteria in the last part of the twentieth century.[107][108] The diagnosis of childhood bipolar disorder, while formerly controversial,[109] has gained greater acceptance among childhood and adolescent psychiatrists.[110] American children and adolescents diagnosed with bipolar disorder in community hospitals increased 4-fold reaching rates of up to 40% in 10 years around the beginning of the 21st century, while in outpatient clinics it doubled reaching 6%.[109] Studies using DSM criteria show that up to 1% of youth may have bipolar disorder.[107] The DSM-5 has established a diagnosis—disruptive mood dysregulation disorder—that covers children with long-term, persistent irritability that had at times been misdiagnosed as having bipolar disorder,[111] distinct from irritability in bipolar disorder that is restricted to discrete mood episodes.[110]

Elderly

Bipolar disorder is uncommon in older patients, with measured lifetime prevalence of 1% in over 60s and 12-month prevalence of 0.1 to 0.5% in people over 65. Despite this, it is overrepresented in psychiatric admissions, making up 4 to 8% of inpatient admission to aged care psychiatry units, and the incidence of mood disorders is increasing overall with the aging population. Depressive episodes more commonly present with sleep disturbance, fatigue, hopelessness about the future, slowed thinking, and poor concentration and memory; the last three symptoms are seen in what is known as pseudodementia. Clinical features also differ between those with late onset bipolar disorder and those who developed it early in life; the former group present with milder manic episodes, more prominent cognitive changes and have a background of worse psychosocial functioning, while the latter present more commonly with mixed affective episodes,[112] and have a stronger family history of illness.[113] Older people with bipolar disorder suffer cognitive changes, particularly in executive functions such as abstract thinking and switching cognitive sets, as well as concentrating for long periods and decision-making.[112]

Prevention

Attempts at prevention of bipolar disorder have focused on stress (such as childhood adversity or highly conflictual families) which, although not a diagnostically specific causal agent for bipolar, does place genetically and biologically vulnerable individuals at risk for a more severe course of illness.[114]

Management

Main article: Treatment of bipolar disorder

The aim of management is to treat acute episodes safely with medication and work with the patient in long-term maintenance to prevent further episodes and optimise function using a combination of pharmacological and psychotherapeutic techniques.[12] Hospitalization may be required especially with the manic episodes present in bipolar I. This can be voluntary or (local legislation permitting) involuntary. Long-term inpatient stays are now less common due to deinstitutionalization, although these can still occur.[115] Following (or in lieu of) a hospital admission, support services available can include drop-in centers, visits from members of a community mental health team or an Assertive Community Treatment team, supported employment, patient-led support groups, and intensive outpatient programs. These are sometimes referred to as partial-inpatient programs.[116]

Psychosocial

Psychotherapy aims to assist a person with bipolar disorder in accepting and understanding their diagnosis, coping with various types of stress, improving their interpersonal relationships, and recognizing prodromal symptoms before full-blown recurrence.[10] Cognitive behavioral therapy, family-focused therapy, and psychoeducation have the most evidence for efficacy in regard to relapse prevention, while interpersonal and social rhythm therapy and cognitive-behavioral therapy appear the most effective in regard to residual depressive symptoms. Most studies have been based only on bipolar I, however, and treatment during the acute phase can be a particular challenge.[117] Some clinicians emphasize the need to talk with individuals experiencing mania, to develop a therapeutic alliance in support of recovery.[118]

Medication

Lithium is often used to treat bipolar disorder and has the best evidence for reducing suicide.

Medications may differ depending on what episode is being treated.[12] The medication with the best overall evidence is lithium, which is an effective treatment for acute manic episodes, preventing relapses, and bipolar depression.[119][120] Lithium reduces the risk of suicide, self-harm, and death in people with bipolar disorder.[121] Antipsychotics and mood stabilizers used together are quicker and more effective at treating mania than either class of drug used alone. Some analyses indicate antipsychotics alone are also more effective at treating acute mania.[12] Mood stabilizers are used for long-term maintenance but have not demonstrated the ability to quickly treat acute bipolar depression.[106] It is unclear if ketamine (a common general dissociative anesthetic used in surgery) is useful in bipolar disorder.[122]

Mood stabilizers

Lithium and the anticonvulsants carbamazepine, lamotrigine, and valproic acid are classed as mood stabilizers due to their effect on the mood states in bipolar disorder.[106] Lithium is preferred for long-term mood stabilization,[58] although it erodes kidney and thyroid function over extended periods.[12] Valproate has become a commonly prescribed treatment and effectively treats manic episodes.[123] Carbamazepine is less effective in preventing relapse than lithium or valproate.[124][125] Lamotrigine has some efficacy in treating depression, and this benefit is greatest in more severe depression.[126] It has also been shown to have some benefit in preventing bipolar disorder relapses, though there are concerns about the studies done, and is of no benefit in rapid cycling subtype of bipolar disorder.[127] Valproate and carbamazepine are teratogenic and should be avoided as a treatment in women of childbearing age, but discontinuation of these medications during pregnancy is associated with a high risk of relapse.[17] The effectiveness of topiramate is unknown.[128]

Antipsychotics

Antipsychotic medications are effective for short-term treatment of bipolar manic episodes and appear to be superior to lithium and anticonvulsants for this purpose.[58] Atypical antipsychotics are also indicated for bipolar depression refractory to treatment with mood stabilizers.[106] Olanzapine is effective in preventing relapses, although the supporting evidence is weaker than the evidence for lithium.[129] A 2006 review found that haloperidol was an effective treatment for acute mania, limited data supported no difference in overall efficacy between haloperidol, olanzapine or risperidone, and that it could be less effective than aripiprazole.[130] Carbamazepine effectively treats manic episodes, with some evidence it has greater benefit in rapid-cycling bipolar disorder, or those with more psychotic symptoms or more symptoms similar to that of schizoaffective disorder.

Antidepressants

Antidepressants are not recommended for use alone in the treatment of bipolar disorder and have not been found to be of any benefit over mood stabilizers.[12][131] Atypical antipsychotic medications (e.g., aripiprazole) are preferred over antidepressants to augment the effects of mood stabilizers due to the lack of efficacy of antidepressants in bipolar disorder.[106] Treatment of bipolar disorder using antidepressants carries a risk of affective switches; where a person switches from depression to manic or hypomanic phases.[17] The risk of affective switches is higher in bipolar I depression; antidepressants are generally avoided in bipolar I disorder or only used with mood stabilizers when they are deemed necessary.[17] There is also a risk of accelerating cycling between phases when antidepressants are used in bipolar disorder.[17]

Other

Short courses of benzodiazepines are used in addition to other medications for calming effect until mood stabilizing become effective.[132] Electroconvulsive therapy (ECT) is an effective form of treatment for acute mood disturbances in those with bipolar disorder, especially when psychotic or catatonic features are displayed. ECT is also recommended for use in pregnant women with bipolar disorder.[12]

Children

Treating bipolar disorder in children involves medication and psychotherapy.[109] Unfortunately, the literature and research on the effects of psychosocial therapy on bipolar spectrum disorders are scarce, making it difficult to determine the efficacy of various therapies.[133] Mood stabilizers and atypical antipsychotics are commonly prescribed.[109] Among the former, lithium is the only compound approved by the FDA for children.[107] Psychological treatment combines normally education on the disease, group therapy, and cognitive behavioral therapy.[109] Long-term medication is often needed.[109]

Prognosis

A lifelong condition with periods of partial or full recovery in between recurrent episodes of relapse,[36][134] bipolar disorder is considered to be a major health problem worldwide because of the increased rates of disability and premature mortality.[134] It is also associated with co-occurring psychiatric and medical problems, higher rates of death from natural causes (e.g., cardiovascular disease), and high rates of initial under- or misdiagnosis, causing a delay in appropriate treatment and contributing to poorer prognoses.[4][37] When compared to the general population, people with bipolar disorder also have higher rates of other serious medical comorbidities including diabetes mellitus, respiratory diseases, HIV, and Hepatitis C virus infection.[135] After a diagnosis is made, it remains difficult to achieve complete remission of all symptoms with the currently available psychiatric medications and symptoms often become progressively more severe over time.[87][136]

Compliance with medications is one of the most significant factors that can decrease the rate and severity of relapse and have a positive impact on overall prognosis.[137] However, the types of medications used in treating BD commonly cause side effects[138] and more than 75% of individuals with BD inconsistently take their medications for various reasons.[137] Of the various types of the disorder, rapid cycling (four or more episodes in one year) is associated with the worst prognosis due to higher rates of self-harm and suicide.[36] Individuals diagnosed with bipolar who have a family history of bipolar disorder are at a greater risk for more frequent manic/hypomanic episodes.[139] Early onset and psychotic features are also associated with worse outcomes,[140][141] as well as subtypes that are nonresponsive to lithium.[136]

Early recognition and intervention also improve prognosis as the symptoms in earlier stages are less severe and more responsive to treatment.[136] Onset after adolescence is connected to better prognoses for both genders, and being male is a protective factor against higher levels of depression. For women, better social functioning before developing bipolar disorder and being a parent are protective towards suicide attempts.[139]

Functioning

Changes in cognitive processes and abilities are seen in mood disorders, with those of bipolar disorder being greater than those in major depressive disorder.[142] These include reduced attentional and executive capabilities and impaired memory.[143] People with bipolar disorder often experience a decline in cognitive functioning during (or possibly before) their first episode, after which a certain degree of cognitive dysfunction typically becomes permanent, with more severe impairment during acute phases and moderate impairment during periods of remission. As a result, two-thirds of people with BD continue to experience impaired psychosocial functioning in between episodes even when their mood symptoms are in full remission. A similar pattern is seen in both BD-I and BD-II, but people with BD-II experience a lesser degree of impairment.[138]

When bipolar disorder occurs in children, it severely and adversely affects their psychosocial development.[110] Children and adolescents with bipolar disorder have higher rates of significant difficulties with substance abuse, psychosis, academic difficulties, behavioral problems, social difficulties, and legal problems.[110] Cognitive deficits typically increase over the course of the illness. Higher degrees of impairment correlate with the number of previous manic episodes and hospitalizations, and with the presence of psychotic symptoms.[144] Early intervention can slow the progression of cognitive impairment, while treatment at later stages can help reduce distress and negative consequences related to cognitive dysfunction.[136]

Despite the overly ambitious goals that are frequently part of manic episodes, symptoms of mania undermine the ability to achieve these goals and often interfere with an individual's social and occupational functioning. One third of people with BD remain unemployed for one year following a hospitalization for mania.[145] Depressive symptoms during and between episodes, which occur much more frequently for most people than hypomanic or manic symptoms over the course of illness, are associated with lower functional recovery in between episodes, including unemployment or underemployment for both BD-I and BD-II.[5][146] However, the course of illness (duration, age of onset, number of hospitalizations, and presence or not of rapid cycling) and cognitive performance are the best predictors of employment outcomes in individuals with bipolar disorder, followed by symptoms of depression and years of education.[146]

Recovery and recurrence

A naturalistic study from first admission for mania or mixed episode (representing the hospitalized and therefore most severe cases) found that 50% achieved syndromal recovery (no longer meeting criteria for the diagnosis) within six weeks and 98% within two years. Within two years, 72% achieved symptomatic recovery (no symptoms at all) and 43% achieved functional recovery (regaining of prior occupational and residential status). However, 40% went on to experience a new episode of mania or depression within 2 years of syndromal recovery, and 19% switched phases without recovery.[147]

Symptoms preceding a relapse (prodromal), specially those related to mania, can be reliably identified by people with bipolar disorder.[148] There have been intents to teach patients coping strategies when noticing such symptoms with encouraging results.[149]

Suicide

Bipolar disorder can cause suicidal ideation that leads to suicide attempts. Individuals whose bipolar disorder begins with a depressive or mixed affective episode seem to have a poorer prognosis and an increased risk of suicide.[89] One out of two people with bipolar disorder attempt suicide at least once during their lifetime and many attempts are successfully completed.[40] The annual average suicide rate is 0.4%, which is 10–20 times that of the general population.[150] The number of deaths from suicide in bipolar disorder is between 18 and 25 times higher than would be expected in similarly aged people without bipolar disorder.[151] The lifetime risk of suicide has been estimated to be as high as 20% in those with bipolar disorder.[24]

Risk factors for suicide attempts and death from suicide in people with bipolar disorder include older age, prior suicide attempts, a depressive or mixed index episode (first episode), a manic index episode with psychotic symptoms, hopelessness or psychomotor agitation present during the episodes, co-existing anxiety disorder, a first degree relative with a mood disorder or suicide, interpersonal conflicts, occupational problems, bereavement or social isolation.[17]

Epidemiology

Burden of bipolar disorder around the world: disability-adjusted life years per 100,000 inhabitants in 2004.
  <180
  180–185
  185–190
  190–195
  195–200
  200–205
  205–210
  210–215
  215–220
  220–225
  225–230
  >230

Bipolar disorder is the sixth leading cause of disability worldwide and has a lifetime prevalence of about 1 to 3% in the general population.[6][152][153] However, a reanalysis of data from the National Epidemiological Catchment Area survey in the United States suggested that 0.8% of the population experience a manic episode at least once (the diagnostic threshold for bipolar I) and a further 0.5% have a hypomanic episode (the diagnostic threshold for bipolar II or cyclothymia). Including sub-threshold diagnostic criteria, such as one or two symptoms over a short time-period, an additional 5.1% of the population, adding up to a total of 6.4%, were classified as having a bipolar spectrum disorder.[154] A more recent analysis of data from a second US National Comorbidity Survey found that 1% met lifetime prevalence criteria for bipolar I, 1.1% for bipolar II, and 2.4% for subthreshold symptoms.[155] Estimates vary about how many children and young adults have bipolar disorder.[110] These estimates range from 0.6 to 15% depending on differing settings, methods, and referral settings, raising suspicions of overdiagnosis.[110] One meta-analysis of bipolar disorder in young people worldwide estimated that about 1.8% of people between the ages of seven and 21 have bipolar disorder.[110] Similar to adults, bipolar disorder in children and adolescents is thought to occur at a similar frequency in boys and girls.[110]

There are conceptual and methodological limitations and variations in the findings. Prevalence studies of bipolar disorder are typically carried out by lay interviewers who follow fully structured/fixed interview schemes; responses to single items from such interviews may suffer limited validity. In addition, diagnoses (and therefore estimates of prevalence) vary depending on whether a categorical or spectrum approach is used. This consideration has led to concerns about the potential for both underdiagnosis and overdiagnosis.[156]

The incidence of bipolar disorder is similar in men and women[157] as well as across different cultures and ethnic groups.[158] A 2000 study by the World Health Organization found that prevalence and incidence of bipolar disorder are very similar across the world. Age-standardized prevalence per 100,000 ranged from 421.0 in South Asia to 481.7 in Africa and Europe for men and from 450.3 in Africa and Europe to 491.6 in Oceania for women. However, severity may differ widely across the globe. Disability-adjusted life year rates, for example, appear to be higher in developing countries, where medical coverage may be poorer and medication less available.[159] Within the United States, Asian Americans have significantly lower rates than their African and European American counterparts.[160] In 2017, the Global Burden of Disease Study estimated there were 4.5 million new cases and a total of 45.5 million cases globally.[161]

History

Main article: History of bipolar disorder
German psychiatrist Emil Kraepelin first distinguished between manic–depressive illness and "dementia praecox" (now known as schizophrenia) in the late 19th century.

In the early 1800s, French psychiatrist Jean-Étienne Dominique Esquirol's lypemania, one of his affective monomanias, was the first elaboration on what was to become modern depression.[162] The basis of the current conceptualization of bipolar illness can be traced back to the 1850s. In 1850, Jean-Pierre Falret described "circular insanity" (la folie circulaire, French pronunciation: ​[la fɔli siʁ.ky.lɛʁ]); the lecture was summarized in 1851 in the "Gazette des hôpitaux" ("Hospital Gazette").[2] Three years later, in 1854, Jules-Gabriel-François Baillarger (1809–1890) described to the French Imperial Académie Nationale de Médecine a biphasic mental illness causing recurrent oscillations between mania and melancholia, which he termed folie à double forme (French pronunciation: ​[fɔli a dubl fɔʀm], "madness in double form").[2][163] Baillarger's original paper, "De la folie à double forme," appeared in the medical journal Annales médico-psychologiques (Medico-psychological annals) in 1854.[2]

These concepts were developed by the German psychiatrist Emil Kraepelin (1856–1926), who, using Kahlbaum's concept of cyclothymia,[164] categorized and studied the natural course of untreated bipolar patients. He coined the term manic depressive psychosis, after noting that periods of acute illness, manic or depressive, were generally punctuated by relatively symptom-free intervals where the patient was able to function normally.[165]

The term "manic–depressive reaction" appeared in the first version of the DSM in 1952, influenced by the legacy of Adolf Meyer.[166] Subtyping into "unipolar" depressive disorders and bipolar disorders has its origin in Karl Kleist's concept – since 1911 – of unipolar and bipolar affective disorders, which was used by Karl Leonhard in 1957 to differentiate between unipolar and bipolar disorder in depression.[167] These subtypes have been regarded as separate conditions since publication of the DSM-III. The subtypes bipolar II and rapid cycling have been included since the DSM-IV, based on work from the 1970s by David Dunner, Elliot Gershon, Frederick Goodwin, Ronald Fieve, and Joseph Fleiss.[168][169][170]

Society and culture

See also: List of people with bipolar disorder, Category:Books about bipolar disorder, and Category:Films about bipolar disorder
Singer Rosemary Clooney's public revelation of bipolar disorder made her an early celebrity spokesperson for mental illness.[171]

Cost

The United States spent approximately $202.1 billion on people diagnosed with bipolar disorder I (excluding other subtypes of bipolar disorder and undiagnosed people) in 2015.[135] One analysis estimated that the United Kingdom spent approximately £5.2 billion on the disorder in 2007.[172][173] In addition to the economic costs, bipolar disorder is a leading cause of disability and lost productivity worldwide.[18] People with bipolar disorder are generally more disabled, have a lower level of functioning, longer duration of illness, and increased rates of work absenteeism and decreased productivity when compared to people experiencing other mental health disorders.[174] The decrease in the productivity seen in those who care for people with bipolar disorder also significantly contributes to these costs.[175]

Advocacy

There are widespread issues with social stigma, stereotypes, and prejudice against individuals with a diagnosis of bipolar disorder.[176] In 2000, actress Carrie Fisher went public with her bipolar disorder diagnosis. She became one of the most well-recognized advocates for people with bipolar disorder in the public eye and fiercely advocated to eliminate the stigma surrounding mental illnesses, including bipolar disorder.[177] Stephen Fried, who has written extensively on the topic, noted that Fisher helped to draw attention to the disorder's chronicity, relapsing nature, and that bipolar disorder relapses do not indicate a lack of discipline or moral shortcomings.[177] Since being diagnosed at age 37, actor Stephen Fry has pushed to raise awareness of the condition, with his 2006 documentary Stephen Fry: The Secret Life of the Manic Depressive.[178][179] In an effort to ease the social stigma associated with bipolar disorder, the orchestra conductor Ronald Braunstein cofounded the ME/2 Orchestra with his wife Caroline Whiddon in 2011. Braunstein was diagnosed with bipolar disorder in 1985 and his concerts with the ME/2 Orchestra were conceived in order to create a welcoming performance environment for his musical colleagues, while also raising public awareness about mental illness.[180][181]

Notable cases

Numerous authors have written about bipolar disorder and many successful people have openly discussed their experience with it. Kay Redfield Jamison, a clinical psychologist and professor of psychiatry at the Johns Hopkins University School of Medicine, profiled her own bipolar disorder in her memoir An Unquiet Mind (1995).[182] Several celebrities have also publicly shared that they have bipolar disorder; in addition to Carrie Fisher and Stephen Fry these include Catherine Zeta-Jones, Mariah Carey, Jane Pauley, Demi Lovato,[177] and Selena Gomez.[183]

Media portrayals

Several dramatic works have portrayed characters with traits suggestive of the diagnosis which have been the subject of discussion by psychiatrists and film experts alike.

In Mr. Jones (1993), (Richard Gere) swings from a manic episode into a depressive phase and back again, spending time in a psychiatric hospital and displaying many of the features of the syndrome.[184] In The Mosquito Coast (1986), Allie Fox (Harrison Ford) displays some features including recklessness, grandiosity, increased goal-directed activity and mood lability, as well as some paranoia.[185] Psychiatrists have suggested that Willy Loman, the main character in Arthur Miller's classic play Death of a Salesman, has bipolar disorder.[186]

The 2009 drama 90210 featured a character, Silver, who was diagnosed with bipolar disorder.[187] Stacey Slater, a character from the BBC soap EastEnders, has been diagnosed with the disorder. The storyline was developed as part of the BBC's Headroom campaign.[188] The Channel 4 soap Brookside had earlier featured a story about bipolar disorder when the character Jimmy Corkhill was diagnosed with the condition.[189] 2011 Showtime's political thriller drama Homeland protagonist Carrie Mathison has bipolar disorder, which she has kept secret since her school days.[190] The 2014 ABC medical drama, Black Box, featured a world-renowned neuroscientist with bipolar disorder.[191] In the TV series Dave, the main character Dave, played by Lil Dicky who plays a fictionalized version of himself, is an aspiring rapper. Lil Dicky's real-life hype man GaTa plays himself. In an episode, after being off his medication and having an episode, GaTa tearfully confesses to having bipolar disorder and that was the reason for his episode. GaTa suffers from bipolar disorder in real life, but, as with his character in the show, is able to maintain it with medication.[192]

Creativity

Main article: Creativity and mental illness § Bipolar disorder

A link between mental illness and professional success or creativity has been suggested, including in accounts by Socrates, Seneca the Younger, and Cesare Lombroso. Despite prominence in popular culture, the link between creativity and bipolar has not been rigorously studied. This area of study also is likely affected by confirmation bias. Some evidence suggests that some heritable component of bipolar disorder overlaps with heritable components of creativity. Probands of people with bipolar disorder are more likely to be professionally successful, as well as to demonstrate temperamental traits similar to bipolar disorder. Furthermore, while studies of the frequency of bipolar disorder in creative population samples have been conflicting, full-blown bipolar disorder in creative samples is rare.[193]

Research

Research directions for bipolar disorder in children include optimizing treatments, increasing the knowledge of the genetic and neurobiological basis of the pediatric disorder and improving diagnostic criteria.[109] Some treatment research suggests that psychosocial interventions that involve the family, psychoeducation, and skills building (through therapies such as CBT, DBT, and IPSRT) can benefit in addition to pharmocotherapy.[133]

See also

  • Outline of bipolar disorder

Explanatory notes

  1. ^ Catatonia is a syndrome characterized by profound unresponsiveness or stupor with abnormal movements in a person who is otherwise awake.[15]

Citations

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  • Liddell HG, Scott R (1980). A Greek-English Lexicon (Abridged ed.). Oxford University Press. ISBN 978-0-19-910207-5.
  • Millon T (1996). Disorders of Personality: DSM-IV-TM and Beyond. New York: John Wiley and Sons. ISBN 978-0-471-01186-6.
  • Robinson DJ (2003). Reel Psychiatry: Movie Portrayals of Psychiatric Conditions. Port Huron, Michigan: Rapid Psychler Press. ISBN 978-1-894328-07-4.
  • Sadock BJ, Kaplan HI, Sadock VA (2007). Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (Tenth ed.). ISBN 978-0-7817-7327-0. Retrieved April 2, 2016.

Further reading

Library resources about
Bipolar disorder
  • Resources in your library
  • Resources in other libraries
  • Healy D (2011). Mania: A Short History of Bipolar Disorder. Baltimore: Johns Hopkins University Press. ISBN 978-1-4214-0397-7.
  • Mondimore FM (2014). Bipolar Disorder: A Guide for Patients and Families (3rd ed.). Baltimore: Johns Hopkins University Press. ISBN 978-1-4214-1206-1.
  • Yatham L (2010). Bipolar Disorder. New York: Wiley. ISBN 978-0-470-72198-8.

External links

  • International Society for Bipolar Disorders Task Force report on current knowledge in pediatric bipolar disorder and future directions
Classification
D
  • ICD-10: F31
  • ICD-9-CM: 296.0, 296.1, 296.4, 296.5, 296.6, 296.7, 296.8
  • OMIM: 125480 309200
  • MeSH: D001714
  • DiseasesDB: 7812
External resources
  • MedlinePlus: 000926
  • eMedicine: med/229
  • Patient UK: Bipolar disorder