Diagnosing and treating bipolar spectrum disorders
Recently, Zara Adams included a piece on bipolar spectrum disorders in APA’s “Six Things Psychologists Are Talking About.” I was drawn to her piece because she begins by noting that, “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.”
After discussing the complexities of the disorder, which she indicates includes its earliest symptoms, longitudinal course, and the psychological factors that increase risk of recurrences, she defines the disorder and diagnosis as follows:
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.
She adds that 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.”
She examines the categories in the DSM-5, concluding that, “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.”
She then notes that bipolar spectrum disorders can look like any of a variety of other disorders, moving to examples of two girls, one 11 and one 18 years old, walking the reader through Youngstrom’s evidence-based assessment (EBA) model which “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. . . . 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.”
This article provides ample detail regarding treatment, beginning with antipsychotic drugs or mood stabilizers during an acute manic episode, adding that, “Increasingly, psychopharmacology research is offering alternatives, such as the new antipsychotic drug lurasidone . . . and the anesthetic ketamine, which has been proven effective for treatment-resistant depression. . . . 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”
She then turns to the treatment of depression since the individual typically more days being depressed than manic. She turns to therapy, including FFT and Interpersonal and social rhythm therapy (IPSRT), adding that improved nutrition and physical activity can be helpful. After addressing cognitive rehabilitation therapies, she concludes by emphasizing the importance of multidisciplinary teams.