Download bipolar disorder

BIPOLAR DISORDER
N.İREM ABDULHAYOĞLU
• Bipolar disorder, bipolar affective disorder, or manic-depressive
illness (MDI), is a common, severe, and persistent mental illness.
• Mental health condition that causes extreme mood swings that
include emotional highs (mania or hypomania) and lows
(depression).
Epidemiology
• The estimated lifetime prevalence of bipolar disorder among
adults worldwide is 1 to 3 percent.
• The mean age of onset for bipolar I disorder is 18 years and
for bipolar II disorder 20 years .
• The ratio of men to women who develop bipolar disorder is
approximately 1:1 .
• WHO estimated that bipolar disorder was the 46th greatest
cause of disability and mortality in the world, which placed
bipolar disorder ahead of breast cancer as well as Alzheimer’s
disease.
• Many bipolar patients never receive treatment .
Etiology
• The pathogenesis of bipolar disorder is not known.
• The etiology may involve biologic, psychologic, and
social factors.
Genetics: First-degree relatives of people with BPI are
approximately 7 times more likely to develop BPI than
the general population.
The lifetime risk of bipolar disorder for a
monozygotic co-twin is 40 to 70 percent.
With the involvement of
the ANK3,CACNA1C, and CLOCK genes.
Neurophysiologic factors:
• Decreased activation and diminution of gray matter in a
cortical-cognitive brain network, which has been associated
with the regulation of emotions in patients with bipolar
disorder.
• An increased activation in ventral limbic brain regions that
mediate the experience of emotions and generation of
emotional responses was also discovered.
Psychosocial factors:
• Advancing paternal age, which is associated with increased
genetic mutations during spermatogenesis, can increase the
risk of bipolar disorder in one’s offspring.
• Stressful life events such as childhood maltreatment may be
associated with onset of bipolar disorder and a more severe
course of illness. Pregnancy is a particular stress for women
with a manic-depressive illness history.
Biochemical factors: People with unipolar depression,
antidepressant treatment is associated with an increased risk
of subsequent mania/bipolar disorder.
• Increase in epinephrine and norepinephrine causes mania and
a decrease in epinephrine and norepinephrine causes
depression.
• Drugs used to treat depression and drugs of abuse (e.g.
cocaine) that increase levels of monoamines, including
serotonin, norepinephrine, or dopamine, can all potentially
trigger mania.
Types
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Bipolar I disorder
Bipolar II disorder
Cyclothymic disorder
Mixed features
Rapid-cycling
Clinical Presentation
• Mania, hypomania, major depression or mixed features
• The severity of these syndromes varies widely across patients
• Some symptomatic patients remit and become euthymic,
while other patients transition immediately from one type of
syndrome to another (eg, from major depression to mania)
without an intervening period of euthymia
• The mood episode at onset of bipolar disorder is usually major
depression.
• Prodromal signs and symptoms such as irritability, anxiety,
mood lability (“mood swings”), agitation, aggressiveness,
sleep disturbance, and hyperactivity may precede onset of
diagnosable bipolar disorder.
Mania
• Manic episodes involve clinically
significant changes in mood,
behavior, energy, sleep, and
cognition.
• Abnormally elevated, irritable,
and labile mood is a core
symptom required to diagnose
mania.
• Mood: Unusually good, euphoric, or high mood, which may be
accompanied by disinhibition (eg, wearing garish clothes or
disrobing in public), disregard for social boundaries,
expansiveness, and social activities (eg, acting flirtatious,
renewing old friendships, or lengthy telephone calls with
strangers). Mood often varies during the day.
• Behaviour: Persistently increased energy and goal-directed
activity. Increased planning and activity is typically marked by
impulsivity, poor judgement, and disregard for risks. Examples
include taking on new and foolish business ventures,
unaffordable spending sprees, numerous sexual encounters
with strangers, and driving recklessly. In addition, patients are
often unable to complete the many tasks or projects that are
started.
• Sleep: Decreased need for sleep. Manic patients may feel
well-rested after a few hours of sleep, or feel energetic
despite not sleeping for days.
• Appetite is increased.
• Libido: Sexual activity is often increased.
• Speech: Generally loud, pressured or accelerated, and difficult
to interrupt.
• Thinking: Patients generally have an exaggerated sense of
wellbeing and self-confidence, which may extend to
grandiosity of psychotic proportions .As an example, some
patients believe they have a special relationship with God or
celebrities.
• Cognition: Increased mental activity, racing thoughts,
distractibility, and difficulty distinguishing between relevant
and irrelevant thoughts; these symptoms result in flight of
ideas. Patients may not recall events that occur during manic
episodes.
• Hallucinations: also occur in severe cases.
• Insight: is invariably impaired.They seldom think themselves ill
or in need of treatment.
As a result, psychosocial functioning is markedly impaired, and
hospitalization is often required to protect manic patients and
prevent behavior leading to painful consequences (eg, financial
ruin, job loss, divorce, and assaulting others)
Hypomania
Hypomanic episodes are characterized by an elevated,
expansive, or irritable mood of at least 4 consecutive days
duration.
• Self-esteem may be inflated during hypomania, but never
reaches the point of delusional grandiosity that can occur
during mania.
• Although mental overactivity and flight of ideas can occur in
either hypomania or mania, thought form is more organized in
hypomania.
• Hypomanic speech can be loud and rapid, but typically is
easier to interrupt than manic speech.
• By definition, hypomania never necessitates hospitalization;
by contrast, mania frequently does.
Major depression
• Generally characterized by dysphoria, as well as slowing in the
pace of mental and physical activity (eg, speech is slow and
soft)
• Interest in pleasurable activities (eg, sex) is minimal,
energy is low, and memory and concentration are impaired.
• Appetite is typically diminished and accompanied by weight
loss.
• Sleep disturbances (insomnia or hypersomnia)
• Feelings of worthlessness and excessive guilt and suicidal
thoughts and behavior.
• Poor eye contact, poor hygiene
• Feelings of hopelessness and helplessness
• Somatic symptoms (eg, pain), and impaired psychosocial
functioning
Bipolar I
• %0.4-1.6, equal prevelance
among sexes
• In men, manic episodes are
seen more
• In women, depressive
episodes and rapid cycling
are seen more
• Recurrent
• For diagnosis:
At least 1 manic episode
lasting for 1 week
Bipolar II
• 0.5%, may be more
common in women than
men
• Men have more hypomanic
episodes than depressive
episodes
• Interval between episodes
decrease with age
• For diagnosis:
 Presence of one or
more depressive
episodes
 Presence of at least
one hypomanic
episode
 Mixed episode: Occasionally, manic and depressive symptoms
occur together, as a mixed mood state. For example, an
overactive and overtalkative patient may have profound
depressive thoughts including suicidal ideas.
 Rapid-cycling: Having four or more mood episodes within a
12-month period. Women appear more likely than men to
have rapid cycling. A rapid-cycling pattern increases risk
for severe depression and suicide attempts.
Antidepressants may sometimes be associated with triggering
or prolonging periods of rapid cycling.
 Cyclothymic disorder: milder form of bipolar disorder
Episodes of hypomania and mild depression for 2 years.
Diagnosis
• Often very complicated; it mimics many other disorders and
has comorbidity
• Careful history and examination
• It is important to first rule out the possibility of any other
organic diagnosis:
Epilepsy
 Thyroid disorder
 Multiple sclerosis
Medications(eg, antidepressants can propel a patient into
mania; other medications may include baclofen, bromide,
bromocriptine, captopril, cimetidine, corticosteroids,
cyclosporine, disulfiram, hydralazine, isoniazid, levodopa,
methylphenidate, metrizamide, procarbazine, procyclidine)
AIDS
Differential Diagnosis
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Major Depressive Disorder
Schizophrenia
Anxiety Disorders
Abuse of stimulant drugs
Posttraumatic Stress Disorder
Multiple Sclerosis
Neurosyphilis
Dementia
Endocrine Disorders
Comorbidity
Most bipolar patients have at least one comorbid psychiatric or
general medical illness.Patients with comorbidity have a worse
course of illness.
• Anxiety disorders
• Substance use disorders
• Attention deficit hyperactivity disorder (ADHD)
• Eating disorders
• Intermittent explosive disorder
• Personality disorders
Prognosis
• Significant morbidity and mortality rates.
• Approximately 25-50% of individuals with bipolar disorder
attempt suicide, and 11% successfully commit suicide.
• Factors suggesting a worse prognosis include the following:
Poor job history
Substance abuse
Psychotic features
Depressive features between periods of mania and depression
Male sex
• Factors suggesting a better prognosis include the following:
Length of manic phases (short duration)
Late age of onset
Treatment of Bipolar disorder
• The treatment of bipolar affective disorder is directly related
to the phase of the episode (ie, depression or mania) and the
severity of that phase, and it may involve a combination of
psychotherapy and medication.
• Acute care and crisis stabilization for psychosis ,suicidal or
homicidal ideas or other unstable or dangerous conditions.
• Movement toward full recovery from a depressed or manic
state
• Attainment and maintenance of euthymia
Pharmacotherapy
• Anxiolytics, Benzodiazepines ( lorazepam, clonazepam)
• Mood stabilizers (lithium carbonate;first-line agent for longterm prophylaxis)
• Anticonvulsants: effective in preventing mood swings
(carbamazepine, valproate sodium,valproic acid, divalproex
sodium, lamotrigine, topiramate)
• Antipsychotics, 2nd Generation or atypical:treatment of
both acute mania and mood stabilization (asenapine,
ziprasidone, quetiapine, risperidone, aripiprazole, olanzapine,
olanzapine and fluoxetine, clozapine, paliperidone)
• Antipsychotics, 1st Generation (inhaled loxapine,
haloperidol)
• Phenothiazine antipsychotics (chlorpromazine)
• Dopamine agonists (pramipexole)
• Antidepressant therapy
Non Pharmacological Therapy
• Psychotherapy:may help to decrease relapse rates, improve
quality of life, and/or increase functioning, or more favourable
symptom improvement.
• Electroconvulsive therapy (ECT): useful in a number of
patients with bipolar affective disorder,such as the following;
When rapid, definitive medical/psychiatric treatment is
needed
When the risks of ECT are less than that of other treatments
When the bipolar disorder is refractory to an adequate trial
with other treatment strategies
When the patient prefers this treatment modality
• proven to be highly effective in the treatment of acute mania
Indications for Inpatient
Management
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Danger to self
Danger to others
Delirium
Marked psychotic symptoms
Total inability to function
Total loss of control (excessive spending, undertaking a
dangerous trip)
• Medical conditions that warrant medication monitoring
(substance withdrawal/intoxication)
Dietary and Activity Measures
• Patients should be advised not to make significant changes in
their salt intake, because increased salt intake may lead to
reduced serum lithium levels and reduced intake may lead to
increased levels and toxicity.
• Patients in the depressed phase are encouraged to exercise.
• These individuals should try to develop a regular daily
schedule of major activities, especially times of going to bed
and waking up.
• Both the exercise and the regular schedule are keys to
surviving this illness.
Prevention and Long-Term
Monitoring
• Prevention is the key to the long-term treatment;
First, use medications such as lithium serve as mood
stabilizers
Second, psycho education is instituted for the patient and the
patient’s family; it is critical that the patient and the patient’s
family understand and recognize the importance of
medication compliance and the early signs of mania and
depression
THANK YOU..
References
• https://www.uptodate.com.lproxy.yeditepe.edu.tr/contents/bi
polar-disorder-in-adults-epidemiology-andpathogenesis?source=search_result&search=bipolar&selected
Title=6~150#H1
• https://www.uptodate.com.lproxy.yeditepe.edu.tr/contents/bi
polar-disorder-in-adults-clinical-features?source=see_link
• https://www.uptodate.com.lproxy.yeditepe.edu.tr/contents/bi
polar-disorder-in-adults-pharmacotherapy-for-acute-maniaand-hypomania?source=see_link
• http://emedicine.medscape.com/article/286342-treatment
• Kaplan and Sadock's Comprehensive Textbook of Psychiatry