What is manic-depressive psychosis or also bipolar affective disorder?

In the Middle Ages, people with mental disorders were cruelly ostracized from society. They were routinely imprisoned. Not as punishment, but because people were afraid of them, thought they were possessed by demons and witches. They wanted to protect themselves by imprisoning them.

Later on, mentally ill people were sent to convents where they were cared for by nuns. Later on, they were also sent to asylums, which more and more resembled hospitals.

Psychiatry as a medical discipline began to take shape at the end of the 18th century. Among the first psychiatrists were P. Pinel and J. E. D. Esquirol.

In the 19th century, the different types of disorders began to be classified and categorised. E. Kraepelin first coined the terms 'dementia praecox' and 'manic-depressive insanity'.

Dementia praecox was later renamed schizophrenia by E. Bleuler. Manic-depressive insanity first became cyclophrenic, then manic-depressive psychosis, which changed to the current name of bipolar affective disorder.

Bipolar affective disorder is a serious mental illness characterized by the patient's blurred perception of himself and his environment.

It is caused by chronic mood swings (affective lability). It alternates between periods of mania, periods of hypomania and periods of depression.

The disease affects more than 1% of the world's population, regardless of nationality, ethnicity or socio-economic status.

Bipolar disorder is one of the leading causes of disability among young people.

Mood swings are common in life, e.g. when faced with stressful events. If mood swings are prominent, persistent and accompanied by episodes of anxiety, it may be the basis of an affective disorder.

Affective disorders can be unipolar, where only one 'mood extreme' is present, i.e. depression. The other type is bipolar disorder, where mood swings from depression to mania.

Affected patients are characterised by a high incidence of co-existing psychiatric and physical illnesses, which impairs the overall experience of the illness and the patient's participation in normal social life.

This is one of the reasons why the disease causes increased mortality among young people, especially death by suicide.

Accurate diagnosis of bipolar disorder is difficult in clinical practice. It most often begins as a depressive episode that looks very similar to unipolar depression (depression without mania).

In addition, there are currently no known biomarkers that can detect this disorder in the laboratory. Therefore, the clinical assessment by a psychiatrist plays a key role in the diagnosis.

Like any other illness, whether psychological or physical, it has its causes. In the case of manic-depressive illnesses, these causes are most often genetic and environmental factors.

In fact, manic-depressive disorders present two opposing poles. One is the unhappy and anxious depression, the other the spectacular mania.

Just such illnesses, with a wide range of manifestations, can be strongly influenced by genetic and environmental factors.

Environmental factors

It is environmental factors that can have a major influence on the formation of the personality of the sufferer of manic-depressive disorders.

The term 'environmental influence' refers in particular to the use of alcoholic or psychotropic substances. Drugs and alcohol are responsible for the subsequent destabilisation of the patient's psyche.

Such destabilisation contributes significantly to the onset of a disease to which the individual may be genetically predisposed.

External environmental factors undoubtedly include so-called psychopathological influences.

These are events associated with family dysfunction, an inharmonious childhood and the associated upbringing, psychological stress, the experience of long-term oppression, aggression or bullying.

Chronic somatic illness and ill health, particularly associated with pain and fear for life, can also have a significant impact on the development of psychoses.

Bipolar disorders occur in people especially in early adulthood or adolescence as a result of possible environmental influences experienced especially during childhood.

Many patients have an earlier manifestation of manic-depressive disorders related to childhood sexual abuse.

Similarly, problems with the working sphere of life are greatly affected by the illness. The course of the illness is worsened, and there is an increased susceptibility to suicide attempts or suicidal thoughts.

There is a poorer response to pharmacological treatment in adulthood.

Another environmental trigger of manic-depressive psychosis is psychological stress.

Stress is the body's response to stressful stimuli (stressors). The body responds with defense mechanisms and its goal is to maintain body balance and prevent damage or death to the body.

Each person is subject to stressful situations individually. However, if too many stressful situations accumulate, the organism cannot cope with them. Often, it is unmanageable stress that leads to psychological destabilisation, which can lead to serious psychiatric illnesses such as bipolar affective psychosis.

Genetic factors

Genetic factors are currently the most commonly studied causes of manic-depressive disorders.

There is a certain genetic predisposition that is highly influential in the acquisition of manic-depressive disorders.

If at least one parent has the disorder, the child has a 15-30% probability of developing manic-depressive disorder. If two close relatives have the disorder, the risk is as high as 75%.

In identical twins, the probability of developing manic-depressive disorder is approximately 70% for both children.

Serotonin

Serotonin is one of the main and very important substances responsible for neurotransmission in the brain, the so-called neurotransmitters. It is involved in the regulation of many physiological processes such as emotions, cognition and the regulation of daily rhythms, the so-called internal clock.

Pathological levels of serotonin due to genetic predisposition or caused by external factors are the cause of mood swings in psychiatric disorders.

Serotonin is, however, a very well-studied molecule and its precise action is well known. Therefore, it could become the basis for the therapy of these disorders. It is the serotonin receptors that are the sites of action of drugs in many neurological and psychiatric diseases.

The bipolar patient suffers from very noticeable mood swings, which in the manic phase are manifested by exaggerated optimism, a sense of self-importance, great self-confidence, physical and mental expressiveness with a rapid rate of speech. He does not experience exhaustion despite a reduced need for sleep.

At the same time, he is aggressive, acts impulsively, without thinking through his actions, has impaired judgement and reduced concentration. He is quickly irritable, often behaves inappropriately, makes hasty decisions.

Conversely, when he becomes depressed, he experiences prolonged sadness. He has marked changes in appetite and sleep disturbances.

He has periods of crying, is pessimistic to apathetic, suffering from feelings of guilt and insignificance. He has unexplained pain and often thinks of death or suicide.

There are several types of bipolar and related disorders. They can include mania (or hypomania) and depression. Symptoms cause unpredictable changes in mood and behaviour, resulting in considerable distress and difficulty in life.

Classification of bipolar affective disorders:

• Bipolar I disorder involves the occurrence of at least one manic episode, which may be preceded or followed by a hypomanic or major depressive episode. In some cases, mania can cause the patient to become detached from reality, called psychosis, which is an acute condition in psychiatry.
• Bipolar II disorder is characterised by at least one major depressive episode and at least one hypomanic episode, but no manic episode.
• Cyclothymic disorder is a condition in which there are several consecutive periods of hypomanic symptoms and periods of depressive symptoms (although less severe than major depression) for at least two years (or one year in children and adolescents).
• Other types include bipolar and related disorders triggered by certain drugs or alcohol or as a result of ill health, such as Cushing's disease, multiple sclerosis or stroke.

Bipolar II disorder is not a milder form of bipolar I disorder, but a separate diagnosis.

Manic episodes of bipolar I disorder can be severe and dangerous. However, individuals with bipolar II disorder are depressed for longer periods of time, which is riskier in terms of self-harm.

Depression

Everyone has suffered from short-term depression during their lifetime due to stress, work difficulties, the death of a loved one, a breakup, school problems, or traumatic experiences.

Most of the time, however, all these symptoms disappear over time and the person gets back to mental and physical well-being.

However, if a person suffering from depressive states is not able to emerge from their influence in the longer term, he or she may be considered to have a depressive disorder.

Classical depression, however, is caused by pathological changes in addition to the environmental influences to which people are exposed on a daily basis.

Depression is classified in professional circles as a mood disorder, although it does not only alter the mood of the sufferer.

Depression engulfs the whole person, starting with the person's body and spirit and ending with an absolute change in his or her personality and relationship with the people around him or her.

It is therefore essential to correctly and timely identify the symptoms of this serious psychiatric illness at its earliest stages and to ensure its appropriate diagnosis and subsequent treatment.

The symptoms of depression can be very complex and vary from patient to patient. For depressed people, there is a general rule of symptom expression. These include feelings of sadness, hopelessness and loss of interest in things.

The symptoms are long lasting and often affect a person's intimate sphere, whether social, family or work.

The most common symptoms of clinical depression include:

• Depressed mood - Affected patients experience depressed mood on a daily basis or appear depressed in their behavior to others. They often feel helplessness and hopelessness, which culminates in distressed states of crying. Some have feelings of guilt and lowered self-esteem.
• Weight change - Patients with depression have increased or decreased appetite. They gain or lose approximately 5% of their weight every four weeks. Patients with milder depression tend to get fatter, while those with more severe depression tend to lose weight significantly.
• Loss of interest in daily activities - Affected patients absolutely lose interest in any activities and things that they used to do or enjoy regularly. Some patients lose pleasure in things that used to bring them pleasure.
• Loss of hygiene habits - In severe forms of depression, affected patients lose basic hygiene habits and neglect their hygiene.
• Fatigue - Depressed people usually complain of loss of energy and fatigue.
• Sleep disturbances - The accompanying sign of depressive disorders is often insomnia or just the opposite, which is characterized by depressed patients needing too much sleep.
• Depression or psychomotor hyperactivity - Depressed patients are extremely agitated, easily irritable. Others, on the other hand, are extremely calm, slow in speech and movement.
• Difficulties with concentration, memory and thinking - Depressed patients have noticeable memory problems, lose the ability to concentrate or solve problems rationally. They are unable to make independent decisions and their outlook on life increasingly declines towards negative tendencies.
• Feelings of guilt, worthlessness, or helplessness - Patients usually suffer from constant feelings of guilt and brooding over the past. They ruminate on past missteps and their irreversible correction. They experience feelings of helplessness and worthlessness. The patient loses the ability to fight with himself and often has self-destructive thoughts.
• Thoughts of death - Those who lose the desire to fight with themselves often have suicidal thoughts. They increasingly think more about death than about redemption from the difficulties they are experiencing. Some have suicidal thoughts, others have attempts. Some have planned in advance and act according to a plan, others have no plan and act impulsively.

A guided conversation between the therapist and the patient and his/her relatives is essential for a correct diagnosis of bipolar disorder.

By asking detailed and predetermined questions, the therapist distinguishes which psychological disorder the patient is presenting with and what stage he or she is currently in.

Such a psychiatric assessment involves, in addition to talking about thoughts, feelings and patterns of behaviour, the completion of a psychological self-assessment or questionnaire.

So-called mood mapping is a method in which the patient keeps a daily record of his or her moods, sleep patterns, or other factors that might help in making a diagnosis and finding the right treatment.

However, only twenty percent of bipolar disorder patients with a depressive episode are diagnosed with bipolar disorder in the first year of treatment.

This is due to the fact that the manic phase of the disorder can be delayed. Sometimes it is not recognized at the time of diagnosis by the patient or those close to the patient, who provide the physician with additional and more objective information about the patient's behavior in everyday life.

In addition, there is a time lag of up to 5-10 years between the onset of the first symptoms of the disease and the diagnosis of the disease.

The so-called diagnostic criteria for bipolar disorder are used to objectively assess the disorder.

The psychiatrist compares the patient's symptoms with the criteria for bipolar and related disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published by the American Psychiatric Association.

Examination of neurophysiological markers as a genetic risk for bipolar depression is now possible using neuroimaging techniques.

Neuroimaging is a new medical technique that uses a variety of methods to directly or indirectly image brain structure and function.

The most common differential diagnoses that are important to distinguish are other psychiatric diagnoses such as schizophrenia, anxiety disorders, substance abuse, and personality disorder (psychopathy).

Diagnosis in children

Diagnosis of children and teenagers with bipolar disorder involves the same criteria used for adults. However, the symptoms of children and teenagers often have different patterns and may not fit neatly into diagnostic categories.

In children, bipolar disorder can be confused with attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder.

Sometimes, however, these illnesses are combined, in which case the diagnosis is much more challenging.

Bipolar affective disorder is an illness that accompanies a person throughout his or her life. Therefore, periods of mania and depression also occur cyclically throughout life.

In between these episodes of extreme mood swings, most patients are asymptomatic. A small percentage of individuals have chronic symptoms, regardless of the effectiveness of treatment.

If bipolar disorder is diagnosed early and then treated correctly and over the long term, patients have a chance to live productive lives.

Without treatment, however, the symptoms gradually worsen and become unmanageable. Patients often lapse into substance abuse or resort to self-harm with suicidal thoughts and attempts.