Bipolar Disorder: Clinical Conundrums 1.

Abstract

Byline: M. Reddy, M. Vijay, Swetha. Reddy Introduction Bipolar disorder (BD) is a well-documented disorder with a high heritability.[sup][1] It was familiar to physicians from antiquity, but the clear description was provided in the mid-19[sup]th century. Over the next 150 years, the understanding, management and research of BD changed in significant ways. Mania may be the only disorder in the medical encyclopedia where patient “enjoys the sufferings” from active symptoms of his disorder! In this editorial, after charting a course of historical evolution, we make an attempt to examine the contemporary issues regarding diagnostic features from a clinical ground reality. Evolution of the Diagnostic Entity After initial observations of Areteaus of Cappadocia in AD 150, scientific delineation of BD was done by two French psychiatrists, Falret and Baillarger in the 1850s [sup][2] – “folie circulaire” and “folie a double forme.” Kahlbaum in 1863 tried categorizing psychiatric illnesses based on symptoms, course, outcome, and etiology to construct a natural disease entity. He differentiated between disorders with continuous but remitting course and those with continuous and progressive course. Taking cue from Kalhbaum, Kraepelin later proposed his dichotomy, which had enduring validity lasting till date. Emil Kraepelin in the early 20[sup]th century divided the psychotic illnesses based on disease course and outcome into two major groups – dementia praecox (schizophrenia) and manic-depressive insanity (MDI). Kraepelin's MDI included manic-depressive psychosis and recurrent depressive disorders, which got later teased out into bipolar and unipolar disorders, the core criterion being episodic nature with a good outcome. Recovery and recurrence as a rule still hold high validity for this group of mood disorders. The description in the classificatory systems, International Classification of Diseases and Diagnostic and Statistical Manual (DSM), is greatly influenced by this dichotomy. DSM-5 delineated mood disorders into bipolar spectrum and depressive spectrum disorders. Perspective from the Clinical Practice Described diagnostic criteria, specifiers, and concepts of spectrum disorders demand analytical evaluation from the perspective of the clinical practitioner. Course and Outcome BD remains a recurrent, episodic psychiatric disorder with recovery being the rule, in a significant majority of patients if not all. Many patients can be promised with significant improvement from the acute episode within a specific period, with good clinical and functional outcomes after the episode resolution. Historically, even in the case of patients who were admitted during the years of 1875–1924 in North West Wales Asylum, (United Kingdom) with a retrospective diagnosis of BD, “almost all patients went home well.”[sup][3] It is a common clinical observation that in the disease course of BD, some patients do remain in the state of euthymia for months, extending to years, without any pharmacological or psychological interventions. This also is the case with many patients diagnosed with unipolar/recurrent depressive disorder. This remains one significantly unique and characteristic phenomenon of the chronicity of mood disorders when compared to other psychological/medical chronic illnesses. Bipolar Disorder in Diagnostic and Statistical Manual 5 DSM-5 suffers from many a deficit in its delineation of the diagnostic criteria for BDs. The episodic course of the disorder (A “clinical biomarker” with high diagnostic utility value) is totally ignored. History of the illness with clear episodicity remains an important clinical indicator in the diagnostic process. For example, a patient with 3–4 past episodes with a limited duration followed by total recovery in the past, say, 10–15 years will be diagnosed as having the mood disorder irrespective of current clinical presentation. …