I. Concept of bipolar disorder
Bipolar disorder, also known as bipolar disorder, refers to a type of mental disorder with manic or hypomanic episodes and depressive episodes. Bipolar disorder generally has an episodic course, manic episodes need to last more than one week, depressive episodes need to last more than two weeks, mania and depression often repeatedly cycle or alternate, or can also exist in a mixed manner. After each episode, the patient enters an intermittent remission period with normal mental status. Most patients have a tendency to have recurrent episodes, and some of them may have residual symptoms or become chronic.
In severe cases, psychotic symptoms such as hallucinations, delusions or catatonic symptoms may occur at the peak of the attack. Each episode often lasts for a considerable period of time and has a negative impact on daily life and social functioning.
Second, the damage of bipolar disorder on the brain
1, structural imaging studies: most CT studies found that the ventricles of the brain in patients with bipolar disorder are larger than those of normal controls. The incidence of ventricular enlargement is 12.5%~42%. Some patients had partial gray matter degeneration and volume reduction in some brain regions.
2. Functional imaging studies: Some depressed patients were found to have reduced local blood flow in the left frontal lobe and reduced blood flow in the left anterior cingulate gyrus, and the degree of reduction was positively correlated with the severity of depression.
III. Clinical manifestations
(A) Manic episode: The typical clinical symptoms are high emotion, running thoughts and increased activities.
1, emotional high: patients feel particularly happy, feel good about themselves, relaxed, carefree, smiling, cheerful, no difficult things, some people show a temper tantrum (irritable) because of a small matter.
2. Thinking is easy: the association of thinking is accelerated, words are increased, and the speech is incessant, rich, witty and humorous, and the patient himself feels that his brain has become very sensitive, intelligent and responsive. They feel good about themselves, exaggerate their own ability, wealth and status, think they have the ability to do great things and earn big money.
3. Increased activity: Patients are more active, good at socializing, good at minding their own business, and want to do big things and do many things. Energetic, sleep needs to be reduced, do not know tired. Do things without end, easy to divert attention, hasty behavior, regardless of the consequences. Good at spending money and seeking pleasure. Easily conflict with the surrounding area, increased sexual desire and rash sexual behavior.
When the manic state is severe, it may show incoordination symptoms, speech and behavior disorder, hallucinations, delusions and other psychotic symptoms. Often have no ability to recognize their condition and do not think they have a disease.
(ii) Depressive episodes.
1, depressed mood: patients lack of interest, no sense of cheerfulness, happy, fatigue and weakness, decreased energy, daytime anxiety, depression, sadness, long sighs, feeling no confidence in the future, lazy life, passive behavior. In more severe cases, there may be hallucinations, delusions and other symptoms, pessimism and despair, anorexia. This is often accompanied by anxiety symptoms such as worry, nervousness, irritability, and somatic discomfort.
2. Delayed thinking: Patients’ speech is reduced, their voice is low, their reaction is slow, their thinking is closed, and they feel that “their brain is like a rusty machine” or “their brain is not working like a paste”, and their ability is reduced.
3. Decreased volitional activity: slow behavior, passive and lazy life, not wanting to do anything, bedridden, not wanting to go to work, not wanting to go out, avoiding social life. In severe cases, even eating, drinking and personal hygiene are disregarded.
4, somatic symptoms: very common, there are serious insomnia, appetite disorders, lack of energy, decreased sexual function, weight loss, general irregular pain, amenorrhea and many other somatic discomfort, the symptoms are aggravated in the morning.
Fourth, bipolar disorder disease characteristics.
1, is a complex can recurrence of the disorder.
2, early age of onset: peak age of onset 15-24 years.
3. Gender: Bipolar I disorder is equally prevalent in men and women, while bipolar II disorder is common in women.
4. Difficult to diagnose: It usually takes 5-10 years before the diagnosis is confirmed.
5. High risk of suicide: 1/3 have attempted suicide and 10%-20% eventually die by suicide.
6, High relapse rate of bipolar disorder, worse prognosis for those with recurrent episodes.
7.High risk of physical disease: increased risk of cardiovascular disease and cancer.
8.Mental episodes: mania, hypomania, depression, mixed episodes and other forms.
9.Multiple co-morbidities.
10.Although bipolar disorder can remit on its own, untreated will prolong the course of the disease and increase relapse.
11.Long-term recurrent episodes can lead to personality changes and impaired social function, and 10% turn into chronic symptoms.
Five, bipolar disorder disease burden and harm
1, bipolar disorder disease burden is very heavy, in the 15 ~ 44 years old age group disability-adjusted life year reduction in the top 10 mental illness, bipolar disorder ranked third, China’s various disease burden bipolar disorder ranked 13th.
2, the relapse rate of bipolar disorder is high, and the prognosis is worse for repeated episodes.
Six, depression has the following characteristics to pay high attention to the emergence of potential bipolar disorder
1, early onset;
2, depression frequent episodes, and short episodes;
3, bipolar disorder first-degree relatives family history;
4, pre-morbid with affective exuberance and (or) cyclic temperament and (or) borderline personality disorder;
5, seasonal mood changes;
6, poor efficacy of previous antidepressant treatment and/or rapid change in mood after treatment and/or induced mania or hypomania;
7, excessive sleep and/or daytime sleepiness;
8. Bulimia or weight gain;
9.Psychomotor retardation;
10, with psychotic symptoms;
11, with postpartum depression.
VII. Principles of long-term treatment of bipolar disorder
1, the principle of comprehensive treatment: should take a combination of medication, physical therapy, psychotherapy (including family therapy) and crisis intervention measures, the purpose is to improve the efficacy, improve compliance, relapse and suicide, improve social function and better improve the quality of life of patients.
2, long-term treatment principles: bipolar disorder almost lifelong recurrent episodes in a cyclic manner, the frequency of its episodes is much higher than that of depressive disorders, often in a chronic process, therefore, should adhere to the principle of long-term treatment to interrupt recurrent episodes, long-term treatment includes three phases: acute treatment, consolidation phase treatment, maintenance phase treatment.
Eight, the reasons for the poor prognosis of bipolar disorder
1, high relapse rate: more than 90% of recurrent episodes;
2, high suicide rate: 25% to 50% of suicide attempts, 11% to 19% of suicide deaths;
3, high co-morbidity rate: 46% with alcohol dependence, 60% with drug dependence;
4, high disease burden.
Nine, bipolar disorder early identification of the top ten clues
1, early age of onset (age of first depressive episode <25 years).
2, episodic instability: refers to the state of mind fluctuates greatly, depression, anxiety, euphoria, irritability, tension, irritability, impulsivity, anger and other pathological moods in brief episodes, lasting several hours or 1~2 days.
3. Depressive episodes with atypical features: including hyperphagia, weight gain, excessive sleep, lead-like limb paralysis, brief euphoric episodes, with psychotic features, with various types of anxiety such as fear, obsessive-compulsive, panic attacks, with premenstrual irritability disorder, dysthymia-like irritability, depressive episodes with seasonality, etc.
4. Frequent depressive episodes, more than 4 depressive episodes in a year;
5.Antidepressant treatment causes transient mania.
6, Positive family history of bipolar disorder;
7, pre-morbid affective temperament;
8.Borderline personality disorder.
9.Mild manic episodes maintained for 2~3 days.
10.Boredom mania: its main manifestations are: irritability, anxiety, frustration, easy to provoke, impulsiveness, decreased self-control, lack of reason, increased activity, overactive thinking, etc. These manifestations can be interspersed or alternated in the middle of the depressive phase.
X. Factors affecting the maintenance of treatment adherence
1.Disease factors: substance abuse, previous hospitalization, psychotic symptoms, and decreased disease insight.
2, medication factors: adverse drug reactions, insignificant daily benefit, high daily dose and frequency of medication.
3. Patient’s attitude: not considering medication necessary, negative attitude toward medication, feeling significant changes in appearance, feeling interference with life goals.
XI. Predictors of increased risk of relapse in bipolar disorder
1.Recent history of substance abuse disorder;
2. Early history of verbal abuse;
3.Female;
4. Late onset of first depressive episode;
5. Atypical features (e.g., compulsions, psychotic symptoms inconsistent with state of mind);
6. Residual symptoms between episodes;
7, rapid cycling, non-working or social impairment;
8, unsupervised medication taking.
Twelve, the prevention of relapse of the six major recipes
1, medication needs to be adhered to;
2, family care is indispensable;
3, psychotherapy to reduce stress;
4.Improve the patient’s coping power;
5.Regular follow-up should be kept in mind;
6, early identification of recurrence symptoms.