When people with bipolar disorder are no longer “bipolar” | Expert Perspective

As the disease progresses, some patients with bipolar disorder gradually lose The periodicity and polarity of the disease course manifests as a state of “four dissimilarities” with complex and diverse symptoms that are ubiquitous but do not meet the formal diagnostic criteria. In a recent article published in Bipolar Disord., the authors refer to this state as“bipolar vortex” span> (Bipolar maelstrom).

The author points out, combined with actual cases, that for these bipolar disorder in the later stage of the disease course Patients, using both classificationand dimensional perspectives can help improve diagnosis and reduce patient suffering.


Patient AG, male, 61 years old, married, suffering from bipolar I disorder for a long time, was referred to our clinic more than ten years ago .

Patient’s bipolar disorder began with a manic episode with psychotic symptoms in late adolescence and was hospitalized; diagnosed at age 35 Experienced Generalized Anxiety Disorder, with occasional panic attacks; diagnosed with OCD at age 50 . Before coming to my clinic, the patient had been hospitalized more than 20 times for manic or depressive episodes, but had also been free of mood episodes for 16 years and did not require hospitalization.

During the first five years of my visit, the patient was hospitalized for only 5 months; The frequency is getting higher and the hospital stay is getting longer. During the first five years, episodes of mania, hypomania, and depression were well-defined with complete remission between episodes; symptoms of comorbid psychotic disorders were largely confined to, and resolved or lessened during, episodes of mood. During the next five years, however, the characteristics of the patient’s disease course changed significantly, with shorter and shorter interictal periods, which eventually disappeared completely.

Specifically, although the severity and nature of symptoms and the degree of emotional distress varied over the next five years, patients had Consistently plagued by a wide variety of symptoms, including sadness, uncontrollable crying, hypervigilance, psychomotor agitation, unrelieved anxiety, rushing speech, panic attacks, insomnia, racing thoughts, intrusive painful memories, Difficulty concentrating, poor memory, obsessions, and suicidal ideation.

Patient had a previous suicide attempt, many years earlier, by overdose of prescription drugs; no history of alcohol and drug abuse. Within the past five years, the patient had undergone a comprehensive examination to rule out any medical causes that might have exacerbated psychiatric symptoms. The patient’s treatment compliance is good, and regular follow-up visits can be achieved. The patient’s husband and wife relationship is good, and his lover often accompanies the doctor and provides valuable information to the doctor.

Before the change in course characteristics, the patient’s mood continued to improve with lithium, lamotrigine, and olanzapine. However, within the past five years, the patient has tried valproic acid, carbamazepine, lurasidone, aripiprazole, epipiprazole, clozapine, and often in combination with other psychotropic medications; also prior to reinitiation Medications that work, but these become intolerable or ineffective. During one hospitalization, the patient was briefly treated with bupropion, which resulted in life-threatening delirium mania that required electroconvulsive therapy, which was not very effective.

Delirium mania can be fatal, this etiology needs to be considered | Classic case< /p>


Currently, the patient’s medication includes quetiapine 500mg/d, olanzapine 20mg/d, haloperidol 15mg/d, oxazepam 15mg/d, clonazepam 2mg /d, Topiramate 275mg/d; Another lorazepam 0.5mg/d is used as needed. Specifically:

Quetiapine was used to improve depression, but the patient developed restless legs, requiring the addition of clonazepam.

Olanzapine for mixed seizures, haloperidol for olanzapine in addition to haloperidol because higher doses of olanzapine were not effective in controlling agitation.

Oxazepam is used to treat anxiety during the day.

Topiramate is used because patients find it helpful Treat symptoms of obsessive-compulsive and post-traumatic stress, especially intrusive painful memories.

The patient has not been hospitalized for more than a year. Cognitive-behavioral therapy has benefited patients in the early years; today, however, formal psychotherapy is difficult for patients. At present, the patient is using a comprehensive treatment plan of drug therapy + psychoeducation + supportive treatment.


The Oxford Dictionary defines “maelstrom” (vortex) as a situation that: Overwhelmed by strong emotions or confusing events, difficult to control and fearful. This term nicely describes the subjective experience of this patient: complex symptoms, diffuse fear, and a sense of loss of control. In fact, this term also represents the confusion, frustration, and challenges faced by doctors in the face of such patients: the patient’s state is difficult to summarize in diagnostic terms, and the treatment lacks evidence-based protocols for reference.

This patient’s symptoms span multiple diagnoses, including bipolar disorder, anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and insomnia obstacle. However, these symptoms did not qualify for a formal taxonomic diagnosis due to insufficient entries, or insufficient duration. Two hallmarks of bipolar disorder in general, polarity and periodic span>, have disappeared in this patient, replaced by changing but widespread symptoms. Similarly, patients’ co-morbid psychiatric disorders and bipolar disorder, and between these comorbidities, have become less clear-cut. This state brings functional impairment across multiple dimensions, including understanding/communication, daily activities, and social participation.

The current clinical phase of this patient can be regarded as a persistent mixed state, characterized by a change in informed consent and a combination of other psychiatric disorders. series of symptoms. Historically, this mixed state has been considered “protracted and suboptimal”; according to Kaczynski et al., this patient was unable to live independently, with cognitive and functional impairments, and was classified as stage IV bipolar disorder. With regard to the diagnosis of mixed states, Kraepelin concluded: “If the mixed seizures occur in the context of a cycle of mood … then the diagnosis is not difficult; however, if the patient’s mixed state has no cause and effect, the diagnosis is quite difficult.”< /span>

In fact, the patient in this case belonged to the state of Kraepelin in the first half of the sentence in his early years, including distinct mood episodes and normal interictal mood; A taxonomic diagnostic perspective is sufficient to help us understand its course and to guide treatment. For now, however, a categorical perspective may not be enough. We also need to introduce a dimensional perspective, focusing on the patient’s subjective symptoms and pain, the characteristics of the past disease course, and past treatment experience (eg, avoiding antidepressants). guide the formulation of treatment plans. The specific methods are as follows:

▶ Follow-up follow-up consultations are planned in a structured manner, and the follow-up consultation time is intentionally shortened to reduce irritation to patients.

▶ Obtain valuable information from the patient’s spouse on a regular basis.

▶ Use individualized psychological education strategies, including helping patients identify and manage personal triggers, form daily routines, especially sleep- Awakening cycles, and further improvements in treatment compliance.

▶ With regard to pharmacotherapy, focus on identifying and managing those cross-diagnostic symptoms such as insomnia and anxiety.

This case also highlights the limitations of current guidelines for patients with an “atypical” clinical presentation. The patient in this case responded well to evidence-based drugs and psychotherapy in the early years, but thereafter the efficacy and tolerability of these treatments were not as good as before. The patient’s current regimen of three antipsychotics and three benzodiazepines met neither bipolar disorder nor anxiety guidelines; The burden of side effects is also severe. However, we are also worried that once the treatment plan is “moved”, the patient’s condition will fall into instability again. The current regimen should not be viewed as our treatment recommendation, but rather reflects the dilemma we face in this patient population.

Fig. 1 Mixed states of bipolar disorder may be included in the patient’s comorbidities; ID, insomnia disorder ; AD, anxiety disorder; OCD, obsessive-compulsive disorder; BD, bipolar disorder; PTSD, post-traumatic stress disorder

this case Patients also suggested the need for a conceptual reconstruction of the mixed state of bipolar disorder to include symptoms of co-morbid anxiety disorder, insomnia disorder, obsessive-compulsive disorder, and post-traumatic stress disorder, as shown in Figure 1. From a therapeutic perspective, it may be better to consider psychiatric comorbidities as part of the mixed state phenotype.

Bibliography: Sharma V, Brauen S. Bipolar maelstrom: Diagnostic uncertainties and treatment challenges. Bipolar Disord. 2022 Jun 2. doi: 10.1111/bdi.13238. Epub ahead of print. PMID: 35653372.

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