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Typical Bipolar affective disorder

Recognition of a typical Bipolar affective disorder is fairly straightforward . The patient, who may have no previous history of mood disorder, presents with a signifi cant change in mood, activity and thought, which, although it might have been triggered by an identifiable life event, is clearly excessive and disproportionate. Changes may occur abruptly or escalate over a few days. Normal patterns of daily living (notably sleep and appetite) are disrupted, and behaviour is disinhibited, excited, uncontrollable and potentially risky.

A rapid flow of grandiose ideas gives rise to pressured and uninterruptible speech. Attempts to calm or contain the patient may be perceived as hostile, and the patient may react with uncharacteristic aggression. Delusions, disordered thought and unintelligible speech may be confused with schizophrenia, while excited and irritable mood may resemble the intense distress and agitation following a major traumatic event. Hypomania lies on the continuum from normal happiness to abnormal elation, and its diagnosis is less clear-cut. This state lacks psychotic features or significant social impairment, and many patients welcome its increased energy, creativity and sense of well-being. Its presence should alert the doctor to the possibility of bipolar II disorder (depression with hypomania) or ‘switching’ (onset of mania due to treatment of depression).

The depressive phase tends to develop more slowly, although rapid onset of a subjective sense of depression is a common complaint of patients being treated for mania, and may occur while other manic symptoms (especially excess energy) persist. In most respects, the depressive phase resembles a typical episode of unipolar depression and diagnosis depends on similar criteria.

Untreated depressive episodes have a median duration of six months. Recent studies have found subclinical depression (i.e. persistent depressive symptoms insuffi cient for diagnosis of a depressive episode) to be present for up to 50% of the time between major episodes. Risk of suicide is greater in bipolar than unipolar depression.

Mixed affective states are particularly unpleasant for the patient, and pose diagnostic difficulties. They are more prolonged than switching or the transition from one mood state to another: features of both mania and depression must coexist for at least two weeks for formal diagnosis. They may be misdiagnosed as personality disorder, especially the emotionally unstable type in which ‘mood swings’ from day to day occur repetitively from early adolescence. In schizoaffective disorder, clear schizophrenic and affective (usually manic) features are present simultaneously.

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