"Bipolar affective disorder is a serious psychopathology that results in serious struggles and challenges throughout life" (Nisha, 2019).

It is a chronic and complex mood disorder, characterized by a combination of manic episodes (bipolar mania), hypomanic and depressive (bipolar depression), with sub-syndromic symptoms (symptoms that would not meet criteria to diagnose a depressive episode) substantially that commonly present between major mood episodes.

"It is one of the leading causes of disability worldwide." (Jain & Mitra, 2022).

Understanding Bipolar Affective Disorder

Bipolar 1 disorder has often been associated with severe medical and psychiatric comorbidities, early mortality, high levels of functional disability, and impaired quality of life. The necessary characteristic of Bipolar 1 disorder involves the occurrence of at least one manic episode in a lifetime, although depressive episodes are common.

Bipolar 2 disorder requires the occurrence of at least one hypomanic episode and one major depressive episode.

This article reviews the etiology, epidemiology, diagnosis, and treatment of bipolar affective disorder and highlights the role of the multidisciplinary team in the management and improvement of care for patients with this condition.

Etiology: the causes of bipolar affective disorder (BPD)

According to Jain and Mitra (2022), bipolar affective disorder (BAD) can be caused by a variety of factors. Among them:

Biological Factors of TAB

Genetic factors: The risk of bipolar disorder is 10-25% when one of the parents has a mood disorder. Twin studies have shown concordance rates of 70-90% in monozygotic twins. Chromosome 18q and 22q have the strongest evidence of a link to bipolar disorder. Bipolar 1 disorder has the highest genetic linkage of all psychiatric disorders.[5]

Neuroanatomy: the prefrontal cortex, the anterior cingulate cortex, the hippocampus, and the amygdala are important areas for emotional regulation, response conditioning and behavioral response to stimuli.

Structural and functional neuroimaging: Abnormal hyperdensities in subcortical regions, especially in the thalamus, basal ganglia and periventricular area in bipolar disorder, indicate recurrent episodes and show neurodegeneration. Patients with major depression or a family history of mood disorder have increased glucose metabolism in the limbic region with decreased metabolism in the anterior cerebral cortex.

Bipolar Affective Disorder and the Biogenic Amines factor

Biogenic amines: the dysregulation of neurotransmitters implicated in this disorder includes dopamine, serotonin, and norepinephrine; however, data has yet to converge to reveal a valid association.

Imbalance of hormonal regulation: adrenocortical hyperactivity is observed in mania. Chronic stress decreases brain-derived neurotrophic factor (BDNF), that impairs neurogenesis and neuroplasticity. Growth hormone is released upon stimulation by dopamine and norepinephrine, and its release is inhibited by somatostatin. Increased levels of somatostatin in the CSF are seen in mania.

Psychosocial Factors in Bipolar Affective Disorder

1. a significant life stressor can lead to neuronal changes, such as neurotransmitter levels, synaptic signaling changes, as well as neuronal loss. This is implicated in the first episode of the mood disorder, as well as in the recurrence of subsequent episodes.

Those with coexisting histrionic, obsessive compulsive, or borderline personality traits in the setting of BPD are more likely to precipitate depressive episodes.

Epidemiology of bipolar affective disorder (BAD)

In the general population, the lifetime prevalence of ABD is around 1% for type 1 and around 0.4% for type 2. Most studies suggest that TAB I has an equal prevalence in men and women.

The average age of onset of bipolar disorder is early adulthood - 18 to 20 years of age. Although Jain and Mitra (2022) state that there are recorded peaks of onset between the ages of 15 to 24 years and 45 to 54 years. Some authors believe that bipolar disorders usually begin in children and adolescents with an episode of major depression, chronic fluctuating abnormalities of mood hyperactivity, cognition, and conduct disturbances.

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In the early stage, the symptoms presented are nonspecific and not limited to the mood spectrum. For Gautam et al. (2019) bipolar affective disorder is "often associated with comorbid disorders, such as anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), Oppositional defiant disorder (ODD) and conduct disorders (CTs)".

Diagnosis of the disorder

Usually, diagnoses in children are difficult because of commonly associated comorbidities. Children present with atypical or mixed features, such as unstable mood, irritability, behavior problems and rapid cycles. The presentation in adolescence can be incongruous, bizarre, and/or paranoid moods, which can also make diagnosis difficult.

The 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) or the 10th edition of the International Classification of Diseases (ICD 10) are often used to aid in diagnosis.

Symptoms such as irritability, grandiosity, persistent sadness or low mood, loss of interests and/or pleasure, low energy, sleep and appetite disturbances, lack of concentration or indecisiveness, low self-confidence, suicidal thoughts and acts, guilt or self-blame and agitation or psychomotor retardation should be present for most of the day, It is also very important to make sure that the symptoms are not secondary to medications, illegal drugs, or other medical conditions.

Treatment of bipolar affective disorder (BAD)

The first step in managing BPD is to confirm the diagnosis of mania or hypomania and define the patient's mood state, because the treatment approach differs significantly for hypomania, mania, depression, and euthymia.

• Mild depression: usually does not require medication. will depend on the availability of psychological therapies, behavioral therapies, counseling services, and family therapy. in some settings, medication and psychosocial management are provided simultaneously.
• Moderate depression: a combination of antidepressant and psychotherapy is recommended.
• Severe depression: psychopharmacological treatment with cognitive behavioral therapy (CBT) and family therapy is advisable.
• Manic symptoms: treatment can be started with low-dose antipsychotic agents and mood stabilizers.

"The main objectives are to ensure the safety of patients and people close to them and achieve clinical and functional stabilization with as few adverse effects as possible. In addition, engagement in treatment and the development of a therapeutic alliance are important in any chronic illness that requires long-term adherence." (Jain & Mitra, 2022)

Bibliographic references:

Gautam, S., Jain, A., Gautam, M., Gautam, A., & Jagawat, T. (2019).Clinical practice guidelines for bipolar affective disorder (BPAD) in children and adolescents.Indian Journal of Psychiatry, 61(8), 294. //doi.org/10.4103/psychiatry.indianjpsychiatry_570_18

Jain, A., & Mitra, P. (2022). Bipolar Affective Disorder. In StatPearls. StatPearls Publishing.

Nisha, S., A. (2019).Stressful Life Events and Relapse in Bipolar Affective Disorder: A Cross-Sectional Study from a Tertiary Care Center of Southern India - Sivin P. Sam, A. Nisha, P. Joseph Varghese, 2019.Indian Journal of Psychological Medicine. //journals.sagepub.com/doi/abs/10.4103/IJPSYM.IJPSYM_113_18

This article about Bipolar Affective Disorder (BAD) was written by Jorge G. Castro do Valle Filho (Instagram: @jorge.vallefilho), MD, Radiologist, member of the Brazilian Medical Association and Colégio Brasileiro de Radiologia e Diagnóstico por Imagem. Specialist in Neuroscience and Neuroimaging from Johns Hopkins University - Maryland/USA. MBA in People Management from the University ofMaster's degree in Health Care Management from Miami University of Science and Technology (MUST University), Florida/USA. Training and Certification in Emotional Intelligence, High Performance Mindset and Emotion Management from Instituto Brasileiro de Coaching - IBC.

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