Bipolar Type 1 Disorder Clinical Overview
I. The "On-Call" Snapshot
Clinical Significance in Malaysia: This is a common reason for acute psychiatric admissions, often presenting as aggression, psychosis, or significant self-neglect that brings them to the Emergency Department.
High-Yield Definition: Bipolar I Disorder is a chronic mental health condition defined by the lifetime occurrence of at least one manic episode. This manic episode may be preceded or followed by hypomanic or major depressive episodes. (Adapted from DSM-5-TR and Malaysian CPG for Management of Bipolar Disorder, 2nd Ed.).
Clinical One-Liner: Basically, it's a severe mood disorder where the patient has experienced at least one "high" (mania) that was severe enough to cause major functional impairment or require hospitalisation.
II. Etiology & Risk Factors
Etiology: The exact cause is unknown, but it's understood to be multifactorial. There's a strong genetic component. If a first-degree relative has it, the risk is about 10 times higher. This is thought to create a biological vulnerability that can be triggered by environmental factors.
Risk Factors:
Non-modifiable:
Family history (the single biggest risk factor).
Modifiable / Environmental Triggers:
Substance use (cannabis, stimulants).
Major life stressors or traumatic events.
Disruption of circadian rhythms (e.g., shift work, sleep deprivation).
Postpartum period.
III. Quick Pathophysiology
Think of it as a dysregulation of key neurotransmitters. In mania, there's an excess of excitatory neurotransmitters like dopamine and norepinephrine, leading to high energy, grandiosity, and impulsivity. In depression, there's a relative deficiency. Serotonin is also involved in mood regulation across both poles. Structural and functional brain changes are seen, but for your level, understanding the neurotransmitter imbalance is enough to grasp why our medications work—we are trying to stabilise this system.
IV. Clinical Assessment
Red Flags & Immediate Actions:
Imminent risk of harm to self or others (suicidal/homicidal ideation, severe aggression): → Alert senior immediately. Consider need for physical restraint and rapid tranquillisation. Initiate one-to-one nursing observation.
Psychotic features (delusions, hallucinations): → Alert senior. This indicates a severe episode and requires antipsychotic medication.
Total inability to care for self (not eating/drinking, severe neglect): → Alert senior. Patient may require admission for stabilisation, possibly involuntarily under the Mental Health Act 2001 if insight is impaired.
Signs of physical exhaustion or dehydration in mania: → Secure IV access, send bloods, and start hydration.
History: Always get a collateral history from family; the patient may lack insight, especially during a manic episode.
Mania Symptoms (Use the "DIGFAST" mnemonic):
Distractibility
Indiscretion/Impulsivity (spending sprees, sexual indiscretions)
Grandiosity (inflated self-esteem)
Flight of ideas (subjective racing thoughts)
Activity increase (psychomotor agitation)
Sleep deficit (decreased need for sleep)
Talkativeness (pressured speech)
Depression Symptoms: Standard questions for Major Depressive Disorder (low mood, anhedonia, changes in sleep/appetite, low energy, guilt, poor concentration, suicidal thoughts).
Pertinent Negatives: Ask about substance use to rule out a substance-induced cause. Ask about periods of normal mood (euthymia) in between episodes.
Physical Examination:
Mainly a mental state examination (MSE).
Appearance & Behaviour: Look for flamboyant or bizarre clothing, psychomotor agitation (pacing, restlessness) in mania, or psychomotor retardation and poor self-care in depression.
Speech: Pressured, loud, and rapid in mania. Slow, soft, and monotonous in depression.
Mood & Affect: Elated, euphoric, or irritable mood in mania. Depressed mood in a depressive episode. Affect will be congruent.
Thought: Flight of ideas, grandiose or persecutory delusions in mania. Ruminating, negative thoughts, and nihilistic delusions in depression.
Cognition: Assess for insight and judgment – often severely impaired in mania.
Clinical Pearl: Don't get distracted by the content of their grandiose delusions. Focus on the form of the thought. The key diagnostic feature is the flight of ideas and pressured speech, not whether they believe they are the Prime Minister.
V. Diagnostic Workflow
Differential Diagnosis:
Schizoaffective Disorder:
Points For: Presence of both mood episodes and psychotic symptoms.
Points Against: In Bipolar I, psychosis occurs during the mood episode. In schizoaffective disorder, there must be a period of at least 2 weeks of delusions or hallucinations in the absence of a major mood episode.
How to Differentiate: A careful timeline of symptoms is crucial. When did the psychosis start and stop relative to the mood changes?
Substance/Medication-Induced Bipolar Disorder:
Points For: Manic symptoms that appear after starting a new substance or medication (e.g., stimulants, corticosteroids, antidepressants).
Points Against: Symptoms persist long after the substance is stopped; clear episodes existed before substance use began.
How to Differentiate: Urine toxicology screen (UDS) and a thorough substance use history.
Borderline Personality Disorder (BPD):
Points For: Mood instability, impulsivity.
Points Against: Mood shifts in BPD are rapid, often triggered by interpersonal events, and last hours to a day. Manic episodes in Bipolar I are sustained for at least one week and represent a distinct change from baseline.
How to Differentiate: Look for a sustained, distinct episode versus a long-term pattern of interpersonal chaos and emotional dysregulation.
Investigations Plan:
Bedside / Initial:
Urine Drug Screen (UDS): Essential to rule out substance-induced mania (e.g., amphetamines, cannabis).
Urine FEME / Pregnancy Test (UPT): Mandatory for all female patients of childbearing age, as mood stabilisers like Sodium Valproate are highly teratogenic.
First-Line Labs & Imaging:
Full Blood Count (FBC), Renal Profile (RP), Liver Function Test (LFT), Thyroid Function Test (TFT): Rule out organic causes (e.g., hyperthyroidism mimicking mania) and establish a baseline before starting medications like Lithium (requires renal and thyroid monitoring) or Sodium Valproate (requires LFT monitoring).
CT Brain: Only indicated for first episodes with atypical presentation, neurological signs, or in the elderly to rule out intracranial pathology (e.g., frontal lobe tumour, stroke).
VI. Staging & Severity Assessment
We stage based on the current episode and its severity.
Identify the Current Episode:
Manic Episode: Meets full DIGFAST criteria for ≥1 week with severe functional impairment.
Hypomanic Episode: Similar symptoms but less severe, no psychosis, no hospitalisation required, lasting ≥4 days.
Major Depressive Episode: Standard criteria for depression.
Mixed Features: Meets criteria for a manic or depressive episode, but also has at least three symptoms from the opposite pole (e.g., manic with tearfulness and suicidal thoughts).
Assess Severity & Specifiers (from DSM-5):
With Psychotic Features: Presence of delusions or hallucinations. This automatically makes the episode severe and requires an antipsychotic.
With Anxious Distress: High levels of anxiety, tension, and worry.
Rapid Cycling: Four or more mood episodes (mania, hypomania, or depression) within one year. This indicates a more difficult-to-treat course.
The assessment directly impacts management. A severe manic episode with psychosis requires immediate hospitalisation and combination therapy. A depressive episode may be managed as an outpatient if suicide risk is low.
VII. Management Plan
Follow the Malaysian CPG on the Management of Bipolar Disorder (Second Edition).
Immediate Stabilisation (The ED Plan for Acute Mania/Agitation):
A/B/C: Usually not compromised unless there is extreme physical exhaustion.
D/E (De-escalation & Environment):
Verbal de-escalation in a calm, low-stimulus environment.
Rapid Tranquillisation (IM): If agitated and a danger to self/others.
First-line: IM Lorazepam 2-4mg OR IM Haloperidol 5-10mg. Can be combined if severe.
Consider IM Aripiprazole or Olanzapine as alternatives.
Definitive Treatment (The Ward Round Plan):
Acute Mania:
First-Line Monotherapy: Mood stabiliser (Sodium Valproate, Lithium) OR an atypical antipsychotic (Risperidone, Olanzapine, Quetiapine, Aripiprazole).
First-Line Combination Therapy (for severe mania): Mood stabiliser + Atypical Antipsychotic.
Acute Bipolar Depression:
First-Line: Quetiapine or Olanzapine.
Important: Avoid antidepressant monotherapy. It can precipitate mania. If used, it must be with a mood stabiliser.
Maintenance Treatment (To prevent relapse):
This is long-term, often lifelong.
First-Line: Lithium is the gold standard for long-term prophylaxis, especially in preventing suicide. Quetiapine is also a good option.
Other options include Sodium Valproate, Lamotrigine (better for preventing depressive relapse), and long-acting injectable (LAI) antipsychotics for patients with poor adherence.
Long-Term & Discharge Plan:
Psychoeducation: Crucial for patient and family to understand the illness, identify relapse signatures, and the importance of compliance.
Medication Adherence: Emphasise that stopping medication will lead to relapse.
Lifestyle: Advise on sleep hygiene, stress management, and avoiding illicit substances.
Follow-up: Regular psychiatric clinic follow-up for medication monitoring (e.g., Lithium levels, renal/thyroid function) and psychosocial support.
VIII. Complications
Immediate (During acute episode):
Mania: Dehydration, physical injury, financial ruin, sexually transmitted infections, legal issues. Management: Hospitalisation and stabilisation.
Depression: Suicide. Management: Close observation, crisis intervention.
Short-Term (Treatment-related):
Medication Side Effects: Weight gain/metabolic syndrome (Olanzapine, Quetiapine), extrapyramidal symptoms (Risperidone, Haloperidol), renal/thyroid dysfunction (Lithium). Management: Regular monitoring and choice of agent based on side effect profile.
Long-Term (Disease-related):
Suicide: Risk is up to 15-20% over a lifetime. Management: Long-term mood stabilisation, preferably with Lithium.
Cognitive Impairment: Repeated episodes can lead to decline in memory and executive function. Management: Prevent relapse with maintenance therapy.
Co-morbid Substance Use Disorder: Very common. Management: Integrated treatment approach.
IX. Prognosis
Bipolar I Disorder is a chronic, lifelong illness with a high rate of recurrence.
With effective long-term treatment, many can achieve significant periods of remission and lead functional lives.
Poor prognostic factors: Early age of onset, presence of psychotic features, rapid cycling, and co-morbid substance use.
X. How to Present to Your Senior
"Dr., for review please. This is [Patient Name/Bed], a [Age]-year-old [man/woman] with no known psychiatric history, who was brought to ED for [chief complaint, e.g., aggressive behaviour and talking nonsense for 1 week].
On examination, he is agitated with pressured speech and flight of ideas. He claims to be a multi-billionaire. My main differential is Bipolar I Disorder, current episode manic with psychotic features.
I have already sent off the baseline bloods including a UDS. My plan is to start treatment as per the CPG, likely with an antipsychotic like IM Haloperidol for immediate sedation and then start oral Sodium Valproate. I would like your opinion on the choice of mood stabiliser."
XI. Summary & Further Reading
Top 3 Takeaways:
The diagnosis of Bipolar I Disorder requires at least one manic episode.
Always rule out organic and substance-induced causes for a first presentation of mania.
NEVER prescribe antidepressant monotherapy; it can trigger a switch to mania. Always use it with a mood stabiliser if necessary.
Key Resources:
Primary Guideline: Management of Bipolar Disorder (Second Edition), Malaysian Ministry of Health
For Quick Review: UpToDate - "Bipolar I disorder: Clinical features, diagnosis, and course"
For In-depth Study: Amboss - "Bipolar and Related Disorders"
