精神病学3------Bipolar-Disorders

,Bipolardisorders,Yao-qiankun,Bipolardisorderisaprevalent,disabling,andrecurrentpsychiatricdisease,whichuntilrecentlywasequatedwithclassicmanicdepressiveillness(i.e.bipolardisorder).Majordepressivedisorderandbipolardisorderconstitutethetwomajormooddisordersinpsychiatry.,However,bipolardisorderencompassesamuchbroaderrangeofillnessesthanbipolardisorder.Thisrangeofillnessesisoftenreferedtoasbipolarspectrumdisordersandincludebipolardisorder,bipolardisorder,andotherformsofbipolardisorder.Ingeneral,bipolardisorderischaracterizedbyadysregulationofmoodandassociatedriskybehavior,impulsivity,andinterpersonalproblems.Bipolardisordercausessignificantimpairmentinsocial,occupational,orotherimportantareasoffunctioning,andmayleadtoprematuremortalitythroughsuicide.WHOidentifiedbipolardisorderasthesixthleadingcauseofdisability-adjustedlifeyears(DALYs)intheworldamongpeopleaged15-44years.,Tosumup,bipolardisorderisachronicmooddisorderthatplacesasignificantburdennotonlyonthepatients,butalsoontheirfamiliesandsocietyingeneral.,Epidemiology,Thelifetimeprevalencerateofbipolardisorderisabout1percentinwesterncountries,andthisistrueacrossalmostallsocialclasses,educationlevelsandraces.AccordingtoWMH-CIDI(WorldMentalHealth-CompositeInternationalDiagnosticInterview)surveys,inEastAsiaandPacificregionsthelifetimeprevalencerateofbipolardisorderis0.1%-0.7%.,InKorea,anation-wideepidemiologicalstudyconductedin2001showedthatthelifetimeprevalencerateofthismentalillnesswas0.4%and,intermsofthenumberofDALYscausedbyneuropsychaitricdisorders,bipolardisorderwasranked5th.However,ifthediagnosisofbipolardisorderandothersubtypes(mixedordepressed)isincludedinthiscalculation,muchhigherprevalenceratesofapproximately5percentareobtained.,Incontrasttounipolardepression,thegenderratioinbipolarisapproximately1:1.However,whenthedepression-maniacontinuumisconsideredasaspectrumofmooddisorders,adistincttrendisobserved,namelythatthehigherthedepressivecomponent,thehigherproportionofwomen.Currentevidenceindicatesthatthepeakageofonsetissituatedbetweenlateadolescenceandearlyadulthoodthatisaround20yearsofage.Onsetafterage60israre.,Likemajordepressivedisorder,bipolarillnessismoreprevalentamongdivorced,separated,orwidowedindividuals.Fromthegeneticpointofview,bipolarillnesshasahigherheritabilitythanunipolaraffectivedisorder.Theconcordancerateforbipolarillnessinmonozygotictwinsisreportedtobeasmuchas79%;indizygotictwinstherateisapproximately24%inprimarilyEuropeanandU.Spopulation.,SymptomsandSigns,Manicepisodes,Theessentialcriterionfordiagnosisofbipolardisorderisapastorpresenthistoryofoneormoremanicepisodes.Manicepisodesaredefinesasadistinctperiodduringwhichthereisanabnormallyandpersistentlyelevated,expansive,orirritablemood.Thisperiodofabnormalmoodmustlastforatleast1week.Inmanymanicepisodes,andparticularlyintheinitialstages,thepredominantmoodiseuphoria.Theeuphoriaexperiencedbythemanicpatienthasaninfectiousquality.,Theexpansivequalityofthemoodischaracterizedbyunceasingandindiscriminateenthusiasmforinterpersonal,sexual,oroccupationalinteractions.Althoughelevatedmoodconstitutesthecoresymptomofmanicepisodes,thepredominantmooddisturbancemayalsofrequentlyobserved,andthesubjectsmoodisoftenaccompaniedbyasenseofconvictionusuallyinvolvingaself-perceivedtalentorperceptionandoccasionallyresultinginamarkedsenseofamanicgrandiosityorevendelusions.,Oneoftheimportantearlysymptomsofamanicepisodeisthedecreasedneedforsleep,tothepointthatmanymanicpatientsmaynotsleepatallevenforseveraldays,withoutfeelinganytiredness.Manicspeechischaracteristicallyrapid,loud,anddifficulttointerrupt.Manicpatientsareeasilydistractibleandrespondtobothinternalandexternalstimuliinaself-referentialmanner.Insomecases,however,anxietyandfeelingofsuspicioncancausetheverbaloutputofsuchindividualstobemarkedlydecreased,withthesefindingsoccasionallyleadingtoamisdiagnosisofthismentalillness.Manicpatientsfrequentlyshowflightofideasasevidencedbyanearlycontinuousflowofacceleratedspeech,withabruptchangesfromonetopictoanother.,Diagnosticclassification,Insomebipolarpatients,onlyonemanicepisodemayoccurintheirlifetime.Therefore,ICD-10classifiesbipolardisorderintoasinglemanicepisodeandbipolaraffectivedisorder.InDSM-TR,fourbipolardisordercategoriesareincluded;bipolardisorder,bipolardisorder,cysclothymicdisorder,andbipolardisordernototherwisespecified.,Hypomaniaisacondition,whichisfrequentlyobservedintheearly,orrecoveryphaseofamanicepisode.Ahypomanicepisodeismuchlikeastandardmanicepisodeintermsofitssymptomsandsigns.Incontrasttoamanicepisode,however,ahypomanicepisodeisnotsevereenoughtocauseanymarkedimpairmentinsocialoroccupationalfunctioningortorequirehospitalisation,andtherearenopsychoticfeatures.,Bipolaraffectivedisorderischaracterizedbytwoormoreepisodes,inwhichthepatientsmoodandactivitylevelsaresignificantlydisturbed,withthisdisturbanceconsisting,onsomeoccasions,ofanelevationofmoodandincreasedenergyandactivity(hypomaniaormania)and,onotheroccasions,ofaloweringofmoodanddecreasedenergyandactivity(depression)，withcompleterecoveryoffunctionbeingobservedbetweenepisode，Repeatedepisodesofmaniaorhypomania,withnointerspersedepisodesofdepression,arerareandareclassifiedas“otherbipolaraffectivedisorders”inICD-10.,Foradiagnosisofbipolardependsonthepatientsmoodstateofthecurrentepisode(Table5.1).Whenthepatientisinastateofdepression,thediagnosisidssubdividedbytheseverityandclinicalfeaturesofthedepressedepisode.,Patientsexperiencingmixedepisodesexhibiteitheramixtureorarapidalterationofmanicanddepressivesymptoms.Theseepisodesarevariouslyreferredtoasmixedmaniaordysphoricmania.Mixedepisodeofbipolardisorderischaracterizedbydysphoricallyexcitedmoods,anger,irritability,panicattacks,agitation,suicidalideation,insomniaandgrandiosity,aswellasdepressedmoodinwhommaniaissuperimposedonadepressivetemperamentoradysthymicbaseline.Otherbipolaraffectivedisordersincludesbipolar(predominantlydepressionwithdiscretespontaneoushypomanicepisodes)asdefinedinDSM-andrecurrentmanicepisodesNOS.,F31.0bipolaraffectivedisorder,currentepisodehypomanicF31.1Bipolaraffectivedisorder,currentepisodemanicwithoutpsychoticsymptoms,F31.2Bipolaraffectivedisorder,currentepisodemanicwithpsychoticsymptoms,F31.3Bipolaraffectivedisorder,currentepisodemoderateormilddepression,F31.4Bipolaraffectivedisorder,currentepisodeseveredepressionwithpsychoticsymptoms,F31.5Bipolaraffectivedisorder,currentepisodeseveredepressionwithpsychoticsymptoms,F31.6Bipolaraffectivedisorder,currentepisodemixedF31.7Bipolaraffectivedisorder,currentepisoderemissionF31.8Bipolaraffectiveotherbipolaraffectivedisorders,F31.9Bipolaraffectivedisorder,unspecified,Management,Pharmacotherapy,Duringtheirseveremanicepisodes,patientsshouldbeadmitted,inordertoensurethattheyareinasafeenvironmentinwhichtheirmedicationcanbebegunandstabilized.Lithiumisthestandardtreatmentforabipolarpatientinmanicepisode.Afavourableresponsetolithiumisreportedinapproximately80%ofbipolarmanicpatients.Inaddition,Lithiumconstitutesaneffectivemaintenancetherapyagentforpreventingordiminishingtheintensityofsubsequentepisodesinbipolarpatientswithaclinicalhistoryofmania.,However,sincelithiumhasarelativelyslowonsetofaction,adjunctivetreatmentwithantipsychoticsand/orbenzodiazepineisoftennecessary.Theadverseeffectsassociatedwithlithiumtreatmenteffects(tremor,memoryloss,ataixa),dermatologicaleffects(acne,psoriasis,anddiverserashes),andthyroideffects(goiter,hypothyroidism,andmyxedema).However,thesecomplicationsarerelativelyinfrequent.,Anticonvulsantssuchasvalproateandcarbamazepinearealsousedinthetreatmentofbipolardisorder.Valproatehasasuperiortherapeuticindexandlesstoxicitycomparedtolithium.Valproatemayalsohaveawiderrangeofefficacyinthosesubtypesofbipolardisorderthatarelessresponsivetolithium,includingthosewithrapidcyclingandmixedstates.Althoughvalproatehasarelativelybenignsafetyprofile,itisnonethelessassociatedwithadverseeffectssuchasgastrointestinalsymptoms,tremor,hairloss,weightgain,andhepatotoxicity.,Carbamazepinehasmoodstabilizingproperties,butitislesspreferredbecauseofitscomplexpharmacokineticinteractionsandlowertherapeuticindex,whichmakeitsomewhatdifficulttouseincombinationwithothermedication.Themajorconcernwiththeclinicaluseofcarbamazepineisthepossibilityofthepatientdevelopingpotentiallyhethalconditionssuchasagranulocytosisoraplasticamenia,Therefore,bothvalproateandcarbamazepinerequireroutinebloodmonitoringforhepaticandhaematologicalfunctions.Thepossibleuseofnewanticonvulsants,suchasgabapentin,lamotrigineandtopiramate,andtheatypicalantipsychoticdrug,alanzapine,inthetreatmentofbipolardisorderhasrecentlybeenstudied.However,asyet,thenumberofstudiessupportingtheirutilityinthetreatmentofbipolardisorderremainsmuchsmallerthanthatoflithiumandvalproate.,Thepharmacotherapyofdepressiveepisodesindipolardisorderisverysimilartothatofmajordepressivedisorder,however,theuseofconventionalantidepressantsrequirescarefulconsideration,duetotheriskofinducingmaniaorrapidcycling.,Psychotherapy,Althoughpharmacotherapyisessentialtotheacuteandlong-termtreatmentofbipolardisorder,psychotherapyplaysanimportantadjunctiveroleinallphasesofthismentalillness.Therefore,psychosocialinterventionisalmostalwaysindicatedinthetreatmentofpatientssocialandoccupationalfunctioning,aswellashisorherbaselinecharacterandresponsetopharmacotherapy.Stressfullifeeventsareassociatedwithanincreaseintherelapserateofbipolarpatients.,Thus,psychosocialinterventionsshouldhelppatientstoreducethenumberandseverityofthestressorsintheirlives.Thetypesofpsychosocialinterventionscommonlyusedforbipolardisorderarecognitivebehaviouraltherapy,psychoeducation,Andfamilytherapy.Cognitivebehaviouraltherapyhelpspeoplewithbipolardisorderlearntochangeinappropriateornegativethoughtpatternsandbehavioursassociatedwiththeillness.,Psychoeducationinvolvesteachingpeoplewithbipolardisorderandtheirfamilyabouttheillnessanditstreatment,andhowtorecognizesignsofrelapsesothatearlyinterventioncanbesoughtbeforeafull-blownillnessepisodeoccurs.Familytherapyusesvariousstrategiestoalleviatethoseformsofdistresswithinthefamilythatmayeithercontributetoorresultfromtheillpersonssymptoms.,CourseandPrognosis,Bipolardisorderisanepisodic,recurrentdisease.Asthenumberofepisodesincreases,theintervalfromthestartofoneepisodetothestartofthenexttendstodecrease.Afteraboutfiveepisodes,theinterepisodeintervalfrequentlystabilizesat6to9months.Inmostcases,bipolardisorderstartswithdepression.However,asthedisorderprogresses,mostpatientsexperiencebothdepressiveandmanicepisodes.Themanicepisodesusuallyhavearapidonsetincontrasttothedepressiveepisodes.Anuntreatedmanicepisodesusuallylastsabout3months.Therefore,cliniciansshouldnotdiscontinuedrugsbeforethattime.,Genderdifferencesinthecourseofbipolarillnesshavebeenreported;Mentendtohaveanequalnumberofmanicanddepressiveepisodesovertheentirecourseoftheirillness,Womenaremoresusceptibletodepression.,Althoughthemajorityofindividualswithbipolardisorderreturntobeingfullyfunctionalbetweenepisodes,20%to30%ofpatientscontinuetodisplaymoodlabilityandinterpersonalandoccupationaldifficulties.Juddetal.recentlyreportedthatpatientswithbipolardisorderweresymptomaticallyill47.3%ofthetimeandthat,ofthisperiodofthetimeandthat,ofthisperiodofillness,depressivesymptoms