Uncovering the mystery of "bipolar disorder"

Unveiling the mystery of "bipolar disorder"

Internet writer Nanpai Sanshu revealed his cheating on Weibo, causing heated discussions among netizens. The third uncle from Nanpai claimed that his ten-year marriage was coming to an end and the responsibility lay entirely with him. In addition, the third uncle from Nanpai also claimed to be a "scum" and felt sorry for the friends who loved him. The wife of Third Uncle Nanpai wrote in a post that she and Uncle Nanpai were not divorced, but that he was suffering from "bipolar disorder" and had an affair. Subsequently, the third uncle repeatedly updated Weibo to denounce the incident as a "farce" and said that the incident should end as soon as possible. Later, the third uncle updated his Weibo: "Okay, it's time to end the farce and move on with life." This incident made it public that the third uncle suffered from "bipolar disorder."

On June 20, 2013, according to the "Los Angeles Times" report, the Los Angeles autopsy department announced that the Chinese-Canadian girl Lan Kerr died of "accidental drowning" and that she also suffered from "bipolar disorder" ".

On August 9 of the same year, the media reported that Eason Chan, who had just finished his concert tour, had performed 25 shows in just two months. In the 11th show, Eason Chan revealed that he suffered from "bipolar disorder" and got angry at the fans during the final performance. He was obviously in poor mental condition.

In recent years, a survey in the United States showed that among the overall life outcomes of bipolar disorder, 7.8% committed suicide, 15.9% showed chronicity, 27% had recurrent attacks, 7.8% had incomplete remission, and 25.5% had remission. %, recovery 16%.

It can be said that bipolar disorder is a difficult mental health problem to solve. Patients have symptoms at least half of their illness. Even during asymptomatic periods, manifestations that impair social functioning may occur.

In addition, the lack of understanding of bipolar disorder also affects the help-seeking patterns of patients and their families.

Some large-scale international studies in my country have confirmed that 60% of patients with bipolar disorder symptoms have not received treatment within 6 months of the initial episode. 35% of people with bipolar disorder do not seek treatment within 10 years of first symptoms.

Let’s uncover the mystery of “bipolar disorder” together!

Bipolar disorder (also known as pendulum disease) is a type of mood disorder that includes both manic and depressive episodes.

It is worth noting that bipolar depression has not attracted enough attention from clinicians. It is reported that 37% of patients with bipolar depression were misdiagnosed as unipolar depression and were treated with antidepressants for a long time, thus inducing mania, Rapidly cycling attacks, increasing the frequency of attacks.

Bipolar affective disorder is a type of mood (affective) disorder, also known as bipolar mood (affective) disorder. It generally refers to episodes of mania or hypomania as well as Depressive episode is a type of mood disorder that adversely affects the patient's daily life and social functions.

After the onset of bipolar disorder, there are both manic or hypomanic episodes and depressive episodes. A manic episode needs to last for more than a week, and a depressive episode needs to last for more than two weeks. Mania and depression appear alternately or in cycles, or they can occur at the same time in a mixed manner. It generally has an episodic course, and each episode enters an intermittent remission period with normal mental status. Most patients have a tendency to have recurring attacks, and some may have residual symptoms or become chronic.

The patient has two or more episodes of marked disturbances in mood and activity levels, with at least one episode characterized by elevated mood, energy, and activity, and another episode characterized by depressed mood, decreased energy, and Reduced activity.

1. Symptom characteristics

Emotional high, irritable or depressed, or bipolar.

People with depressed mood range from mild pessimism to strong feelings of guilt.

Difficulty thinking, lack of decision-making, and lack of interest.

Headache, sleep disturbance, lack of energy.

Anxiety, severe cases may have motor retardation, agitation, hypochondriasis or persecutory delusions, anorexia, and insomnia.

2. Clinical manifestations

The clinical manifestations of bipolar disorder can be divided into depressive episodes, manic episodes or mixed episodes according to the characteristics of the episodes.

1. Depressive episode

The clinical symptoms and biological abnormalities of bipolar depression and unipolar depression are similar and difficult to distinguish. Bipolar depression is often ignored because of its atypical manifestations. Correct diagnosis of bipolar depressive disorder is a prerequisite for reasonable treatment. There are obvious differences in the treatment plans and prognosis of the two. The differences between the two are mainly reflected in:

(1) Demographic characteristics

①Gender: Women with unipolar depression suffer from it The rate is almost twice that of men, but the gender difference is not obvious among patients with bipolar disorder;

②Age: The average age of onset of bipolar disorder is 30 years old, and that of unipolar depression is 40 years old. The former is obvious The first episode of depression earlier than the latter, especially before the age of 25, is an important predictor of bipolar depression;

③Family history: Family surveys and twin studies have confirmed the familial aggregation of bipolar disorder. , compared with unipolar depression, the family transmission of patients with bipolar disorder (especially bipolar I type) is more closely related to genetic factors.

(2) Characteristics of depressive episodes

①Characteristics: Compared with unipolar depression, bipolar depression has a more rapid onset, shorter course, and more frequent recurrences;

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②Symptom characteristics: The symptom characteristics of bipolar depression that are different from unipolar depression include emotional instability, irritability, psychomotor agitation, thinking competition/crowding, increased sleep, obesity/weight gain, attention Lack of concentration, more suicidal ideation and depression anxiety and substance abuse (tobacco, alcohol, drugs, etc.).

2. Manic episode

(1) Elevated mood: feeling good about oneself, being cheerful, elated, smiling broadly all day long, having a certain contagiousness, and often winning the support of people around him ** Ming, causing bursts of laughter. Although some patients are in a high mood, their mood is unstable and unpredictable. Sometimes they are happy and joyful, and sometimes they are excited and angry. Some patients are characterized by anger, irritability, hostility, and may even engage in destructive and aggressive behaviors, but they often quickly turn from anger to joy or immediately apologize.

(2) Running thoughts: quick response, turbulent thoughts, many plans and goals, feeling that your tongue is racing with your thoughts, words cannot keep up with the speed of thinking, more words, endless eloquence, and eloquence , dancing and dancing, even if the mouth is dry and the voice is hoarse, they still have to talk non-stop, talk nonsense, the content is unrealistic, and often change the subject; they are arrogant, pretentious, arrogant, and arrogant.

(3) Increased activities: energetic, tireless, wide-ranging interests, quick movements, busy, nosy, but often ends in anticlimactic, achieves nothing, follows one's will, regardless of consequences, often spends extravagantly, is generous , over-grooming oneself in order to attract attention, being sensational, domineering, likes to teach others, likes to boss others around, behaves frivolously, often goes to entertainment venues, and attracts bees and butterflies.

(4) Physical symptoms: ruddy complexion, bright eyes, accelerated heart rate, and dilated pupils. Reduced need for sleep, difficulty falling asleep, early awakening, sleep rhythm disorder; hyperphagia, overeating, irregular eating due to being too busy, and weight loss caused by excessive consumption; increased interest in the opposite sex, hypersexuality, and ineffective sexual life control.

(5) Other symptoms: Inability to concentrate for a long time, easily affected by the external environment; memory enhanced, disordered and changeable; when the attack is extremely severe, the patient will be extremely excited and agitated, which may be short-lived, Fragments of auditory hallucinations, disordered behavior with no purpose, and impulsive behavior; disorders of consciousness, delusions, hallucinations, incoherent thinking and other symptoms may also occur, which is called delirium mania. Most patients lose insight in the early stages of the disease.

(6) Hypomanic episode: A manic episode with mild clinical manifestations is called hypomania. The patient may have an elevated mood, energetic, increased activity, and significant self-esteem that lasts for at least several days. Feeling good, difficulty concentrating and sustaining, mild splurging, increased social activities, increased libido, reduced need for sleep. Sometimes it manifests as irritability, arrogance, and reckless behavior, but it is not accompanied by hallucinations, delusions and other psychotic symptoms. It has a mild impact on the patient's social functions, and some patients sometimes do not have an impact on their social functions. It is often difficult for ordinary people to notice.

3. Mixed episode

Refers to the simultaneous occurrence of manic and depressive symptoms in one episode, which is clinically rare. It usually occurs during a rapid transition between mania and depression. For example, a patient experiencing a manic episode suddenly becomes depressed and then returns to mania a few hours later, giving a "mixed" impression. However, this mixed state generally lasts for a short time, and most of them quickly turn into a manic or depressive phase. During mixed episodes, both manic and depressive symptoms are atypical and can easily be misdiagnosed as schizoaffective disorder or schizophrenia.

3. Examination

Exclude bipolar disorder that may be caused by physical disease or substance dependence through physical examination (including neurological examination). Some patients with bipolar disorder (especially women) may have hypothyroidism and should have thyroid function tests done. People who are overly excited and do not eat well should pay attention to their understanding of water and salt metabolism and acid-base balance. The results of auxiliary examinations such as psychological tests, neurobiochemistry, neuroelectrophysiology and brain imaging are available for reference. Drug blood concentrations are measured during treatment to ensure efficacy, monitor side effects and treatment compliance.

IV. Pathogenesis factors

1. Biological factors

Neurobiochemical, psychopharmacological and neurotransmitter metabolism studies have confirmed that patients have central neurotransmitters. Metabolism abnormalities and corresponding changes in receptor function, abnormal content of 5-hydroxytryptamine and other neurotransmitters in the synaptic cleft of the brain;

Lack of functional activity of 5-hydroxytryptamine (5-HT) may be the basis of bipolar disorder , is a sign of susceptibility to bipolar disorder;

Reduced norepinephrine (NE) functional activity may be related to depressive episodes, and increased norepinephrine functional activity may be related to manic episodes;

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Reduced dopamine (DA) functional activity may be related to depressive episodes;

γ-aminobutyric acid (GABA) is an inhibitory neurotransmitter in the central nervous system. Studies have found that patients with bipolar disorder Reduced levels in plasma and cerebrospinal fluid;

Disordered balance of second messengers, which are indispensable mediators between extracellular information and intracellular effects;

Neuroendocrine function Disorders, mainly dysfunction of the hypothalamus-pituitary-adrenocortical axis and the hypothalamus-pituitary-thyroid axis.

2. Genetic factors

Surveys have found that the incidence of bipolar disorder among first-degree relatives of bipolar I disorder probands is higher than that among first-degree relatives of normal persons. The incidence rate is several times higher, and the closer the blood relationship is, the higher the incidence rate. In terms of molecular genetics, many scholars have explored marker genes that may be related to bipolar disorder, but there are no definite and reproducible results. The susceptibility genes of bipolar disorder require further research. Currently, the inheritance pattern of bipolar disorder tends to be polygenic.

3. Psychosocial factors

Adverse life events and environmental stress events can induce the onset of emotional disorders, such as unemployment, lovelorn, poor family relationships, and long-term high tension. Living status, etc. Genetic factors may lead to a susceptibility to affective disorders, and people with this susceptibility may develop the disease under certain environmental factors.

In general, the cause of the disease is not very clear. It is believed that both genetic and environmental factors play an important role in the pathogenesis, and the influence of genetic factors may be more prominent.

5. Age of onset

According to statistics, about half of patients with bipolar disorder develop their symptoms in adolescence. Only by early detection can the condition be best controlled.

If both parents have a history of the disease, the risk of the child being affected is 50%. If one parent has a history of the disease, the risk of the child being affected is about 15% to 20%. Those with a family history must be particularly vigilant.

Generally speaking, the age of onset of mania is about 20 to 25 years old, and the age of onset of depression is about 30 to 35 years old. The duration of manic and depressive episodes is also different. Generally, if left untreated, the symptoms of mania may last three to six months, and the symptoms of depression may last six to nine months.

6. Diagnostic criteria

A. Manic episode

(1) Symptomatic criteria

1. Symptoms are characterized by elevated mood and/or irritability and are relatively persistent.

2. The mood disorder of the first episode has lasted for at least 2 weeks (if the symptoms are severe enough to require hospitalization or those who have had a manic or depressive episode that definitely meets the criteria in the past are not subject to this restriction).

3. Have at least four of the following symptoms (if the mood is only irritability, then five are required):

a. Speech more than usual, or talk incessantly. ;

b, wandering thoughts and running thoughts;

c, inattention, shifting with the situation;

d, arrogance, overestimation of self;

e, feeling good about oneself: feeling mentally alert, physically strong or energetic;

f, needing less sleep;

g, increasing activity (Including work, daily activities, social interaction and sexual behavior);

h, rash and willful, regardless of the consequences.

(2) Severity standards

Clinical symptoms must reach one of the following severity levels:

a, unable to have effective conversations;

< p> b. Social abilities (referring to work, study, social or housework abilities) are significantly impaired;

c. Immediate treatment or hospitalization is required;

d. Psychotic symptoms are present.

(3) Exclusion criteria

1. When the emotional symptoms subside, the following symptoms continue to exist:

a. Delusions and hallucinations that are inconsistent with the mood.

b. Weird behavior.

c, "First-level symptoms".

d. Stress symptom cluster.

2. Emotional symptoms are appended to other diseases such as schizophrenia.

3. Emotional symptoms are caused by drugs, poisoning or other organic causes.

B, depressive episode

(1) Symptomatic criteria

1. Symptoms are mainly characterized by depressed mood; they are relatively long-lasting, but may have rhythmic changes within a day that are heavier in the morning and lighter in the evening.

2. For those who have had the first episode, the mood disorder has lasted for at least 2 weeks (if the symptoms are severe and require immediate treatment or hospitalization, or those who have had a definite manic or depressive episode in the past are not subject to this restriction).

3. Have at least four of the following symptoms:

a. Loss of interest or pleasure in daily activities, loss of sexual desire.

b. Significantly weakened energy, unexplained fatigue, weakness.

c. Recurrent thoughts of death, or suicide attempts or behaviors.

d. Feeling of self-blame or guilt.

e, decreased thinking ability or concentration.

f, psychomotor retardation or agitation.

g, insomnia, early awakening or excessive sleep.

h, loss of appetite and significant weight loss.

(2) Severity standard

Clinical symptoms must reach one of the following severity levels:

a. Social ability is significantly impaired;

b, requires immediate treatment or hospitalization;

c, has psychotic symptoms.

(3) Exclusion criteria

Same as item (3) in the manic episode criteria.

(4) Diagnostic criteria

Meet one of the following two items:

a. A person who had a manic episode in the past and is now experiencing a depressive episode ;

b. He had a depressive episode in the past and this time he showed a manic episode.

7. Disease Identification

Due to the complex and diverse clinical manifestations of bipolar disorder, it is easy to be misdiagnosed as unipolar depression, anxiety, schizophrenia, personality disorder, substance dependence, etc.

(1) Schizophrenia

1. Adolescent onset of schizophrenia can be distinguished from manic episode. The former also starts in adolescence and is characterized by excitement, talkativeness, and activity. many. But the main characteristics are disordered speech, weird, disorganized, stupid, childish and other weird behaviors, uncoordinated thinking, emotion and behavior, and uncoordinated psychomotor excitement. A manic episode is a coordinated psychomotor excitement based on an emotional upsurge. The mood is pleasant, elevated, and contagious.

2. Depressive symptoms may appear during the course of schizophrenia, while bipolar disorder may be accompanied by psychotic symptoms, so attention should be paid to the identification. Bipolar disorder is characterized by affective disorder as the dominant symptom and lasts throughout the entire course of the disease. The mood is high or low, accompanied by changes in thinking and behavior, and the inter-episode periods are normal. The main manifestations of schizophrenia are hallucinations, delusions, and logical thinking disorders, which are inconsistent with inner experience and the surrounding environment. There are often residual social functional impairments of varying degrees in the inter-episode period.

(2) Secondary affective disorders

Affective disorders can be caused by organic brain diseases, physical diseases, certain drugs and psychoactive substances (such as alcohol, methamphetamine, etc.). The points of identification between the two are as follows:

Secondary affective disorders should have a clear history of organic brain diseases, physical diseases, and a history of drug and psychoactive substance use; physical examination and laboratory examinations should have corresponding Changes in consciousness, memory, and intelligence may cause problems; emotional symptoms will improve as the condition of the primary disease improves, and worsen as the condition of the primary disease worsens.

(3) Identification of unipolar and bipolar depression

Unipolar depression and bipolar depression should be differentiated due to different treatment principles. Bipolar depression has the following characteristics: early age of onset, premorbid personality with exuberant and cyclic temperament, mood changes related to seasons, poor efficacy of previous antidepressants, or rapid changes in mood after treatment and induction of mania and hypomania. , accompanied by psychotic symptoms, increased sleep, weight gain, and increased eating. The condition changes obviously throughout the day, with symptoms being severe in the morning and gradually lessening in the afternoon and evening.

(4) Personality disorders

Is emotional change a personality problem or a disease? Pay attention to personality as a person’s consistent emotional and behavioral patterns, while bipolar disorder has an obvious onset time. Pathological emotions need to last for a certain period of time.

8. Treatment measures

Bipolar disorder is a cyclic relapsing disease that cannot yet be cured. However, through early diagnosis and long-term treatment, patients can completely control the condition and reduce recurrences. , to avoid deterioration.

(1) Principles of drug treatment

1. First use the safest and most effective drugs, mainly mood stabilizers.

2. Use drugs in combination in a timely manner according to the needs of the condition. The method of drug combination includes two mood stabilizers, a mood stabilizer plus an antipsychotic or a benzodiazepine plus a mood stabilizer. Antidepressants. When coadministering drugs, it is important to understand drug interactions resulting from induction or inhibition of metabolic enzymes.

3. Regularly monitor blood drug concentration and evaluate efficacy and adverse reactions. Since the therapeutic index of lithium salt is low and the therapeutic dose is close to the toxic dose, blood lithium concentration should be dynamically monitored. Treatment of mania with carbamazepine or valproate should also achieve antiepileptic plasma concentrations. The blood collection time should be 12 hours after the last dose (such as the next morning), and the trough blood drug concentration should be measured as the standard.

4. If one drug is not effective, another drug can be substituted or added. To judge that a mood stabilizer is ineffective, factors such as poor compliance and low blood drug concentration should be ruled out, and The medication time should be longer than 3 weeks. If the above factors are still ineffective, another mood stabilizer can be used instead or added.

(2) Therapeutic drugs

1. Commonly used mood stabilizers: (1) lithium carbonate; (2) valproate; (3) carbamazepine.

2. Candidate mood stabilizers: (1) lamotrigine; (2) topiramate; (3) gabapentin; (4) second-generation antipsychotics: clozapine, risperidone , olanzapine and quetiapine.

3. Benzodiazepines: lorazepam

4. First-generation antipsychotics: for acute patients with excitement, agitation, aggression or psychotic symptoms For patients with mania or mixed episodes, and depression associated with psychotic symptoms, the author can also use a short-term combination of mood stabilizers and first-generation antipsychotic drugs in the early stages of treatment.

5. Application of synergists and combined treatment with drugs. For patients with refractory bipolar disorder, especially those with refractory rapid cycling episodes, candidate mood stabilizers and calcium channel antagonists (differentiated drugs) Bodine 80-120mg/d, 2/d, nimodipine 40-90mg/d, 2-3/d) Thyroid hormone (T325-50ug/d, T480-200ug/d for 4-6 weeks), 5- HT1A receptor antagonists (such as buspirone, propranolol) can be considered as synergists in combination with classic mood stabilizers.

6. Problems with the use of antidepressants in bipolar disorder. In the treatment of bipolar disorder, the use of antidepressants may induce manic or hypomanic episodes, or increase cycle frequency. Or it may promote rapid cycling attacks and make treatment more difficult. Therefore, antidepressants should be used with caution during depressive episodes in bipolar disorder. If the depressive symptoms are very severe and last for more than 4 weeks, and depression has been the main clinical phase in previous episodes, antidepressants can be combined with full use of mood stabilizers. Generally, the first choice is acetaminophen, which has little anti-anxiety effect, followed by 5-HT reuptake inhibitors, and try not to choose TCAs with strong anti-anxiety effect.

(3) Psychological treatment

In addition to drug treatment, psychological treatment must also be carried out. During this process, doctors should pay close attention to the patient's emotional changes and soothe the patient's emotions so that the patient can relax, get rid of the troubles of bad emotions, and return to a peaceful and peaceful mood.

9. Patient care

(1) Respect, understand, accept, care, support, and help patients;

(2) Correctly understand the disease and support patients Active treatment and early treatment. Those with recurring attacks should establish the concept of long-term treatment, conduct regular outpatient reviews, communicate with doctors, monitor the condition and drug side effects, maintain stable condition, and prevent recurrence;

(3) Unstable condition When doing so, pay attention to prevent self-injury, suicide, impulsive injury, seek medical treatment as soon as possible, and provide psychological counseling. Let patients see hope and feel care and support when they are depressed, avoid conflicts and irritate patients when they are in a state of agitation or severe mania;

(4) Learn disease knowledge and treatment knowledge, and help patients observe their condition , respond to changes in the condition in a timely manner, adopt correct coping strategies, and avoid causing harm to yourself and others;

(5) Pay attention to helping patients develop good personalities, correct bad cognitive and behavioral patterns, and learn Methods of psychological adjustment;

(6) Promote patients to actively participate in social activities in order to reduce or prevent the occurrence of disability. During this process, the patient should be given more encouragement and affirmation, and practical goals should be set with the patient based on the patient's ability. Do not act too hastily.

Ding Jungui

June 18, 2018