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Bipolar disorder
Bipolar disorder is characterized by recurrent episodes of mania and depression. It is classified into Bipolar I and II based on the severity of manic episodes. The exact causes are unknown but genetic and biochemical factors are thought to play a role. Clinical features include changes in mood, energy, sleep patterns, and risk-taking behavior. Treatment involves mood stabilizers like lithium, antipsychotics, and antidepressants to control symptoms and prevent future episodes. Prognosis depends on factors like comorbidities, stress levels, and medication compliance.
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Introduction to bipolar disorder characterized by mood episodes. Previously known as manic depressive psychosis.
Bipolar I features severe mania and depression, while Bipolar II has hypomania and severe depression.
Theories on the causes of bipolar disorder include genetic, biochemical, neuroendocrine, sleep patterns, and brain imaging studies.
Describes symptoms in the depressive and manic forms, illustrating key features of each clinical episode.
Discusses course duration of episodes, factors affecting prognosis, and distinctions between good and poor prognostic indicators.
Important considerations to rule out other conditions like organic causes, psychotic disorders, and adjustment disorders.
Treatment options include antidepressants, lithium, antipsychotics, and other mood stabilizers with specific doses mentioned.
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Bipolar disorder
- 1. Bipolar disorder Presented by Dr.Chandan N Intern, Department of Psychiatry, MIMS, Mandya
- 2. • Bipolar moodor affective disorder is characterized by recurrent episodes of mania and depression in the same patient at different times. • Earlier known as manic depressive psychosis (MDP)
- 3. Types • Bipolar I:Characterized by episodes of severe mania and severe depression. • Bipolar II: Characterized by episodes of hypomania (not requiring hospitalization) and severe depression.
- 4. Etiology • Etiology isnot known. • Theories: • Genetic hypothesis • Biochemical theories • Neuroendocrine theories • Sleep studies • Brain imaging
- 5. Genetic hypothesis • Thelife-time risk for the first degree relatives getting bipolar disorder is 25%. • Children with one parent having bipolar disorder has a risk of 27% of life time risk, children with both parents having bipolar disorder is 74%. • The risk in monozygotic twins is 65% and dizygotic twins is 20%.
- 6. Biochemical theories • Catecholamine'sabnormality (norepinephrine, dopamine and serotonin) in one or more sites at brain. • Acetyl choline and GABA may also play a role. • The effects of antidepressants and mood stabilizers also provide additional evidence.
- 7. Neuroendocrine theories • Moodsymptoms are prominently present in endocrine disorders like hypothyroidism, Cushing’s disease, and Addison’s disease.
- 8. Sleep studies • Indepression, decreased REM latency (i.e., the time between falling asleep and the first REM period is decreased). • Increased duration of the first REM period. • Delayed sleep onset.
- 9. Brain imaging • CTscan, MRI scan of brain, PET scan and SPECT have yielded inconsistent, but suggestive findings. • Findings include ventricular dilatation, white matter hyper-intensities, and changes in the blood flow and metabolism in prefrontal cortex, anterior cingulate cortex, and caudate.
- 10. Clinical features Depression Form: -constantly feeling sad or worthless - sleeping too much or too little - feeling tired and having little energy - appetite and weight changes - problems focusing - thoughts of suicide Manic Form: - increase in energy level - less need for sleep - easily distracted - nonstop talking - increased self confidence - focused on getting things done, but does not accomplish much - is involved in risky activities even though bad things may happen
- 11. Clinical features (Contd.) •A current episode can be • Hypomanic • Manic without psychotic symptoms • Manic with psychotic symptoms • Mild or moderate depression • Severe depression without psychotic symptoms • Severe depression psychotic symptoms • Mixed or • In remission
- 13. Course of thedisorder • Earlier age of onset • Average manic episodes last for 3-4 months, a depressive episode lasts for 4-6 months • With rapid institution of treatment symptoms of mania are controlled within 2 weeks and of depression within 6-8 weeks • Rapid cyclers • Ultra rapid cyclers • Increased mortality almost 2 times the normal population
- 14. Prognostic factors • Goodprognostic factors • Acute or abrupt onset • Typical clinical features • Severe depression • Well adjusted premorbid personality • Good response to treatment
- 15. • Poor prognosticfactors • Co-morbid medical disorders, personality disorders or alcohol dependence • Double depression • Catastrophic stress or chronic ongoing stress • Unfavourable early environment • Marked hypochondriacal features, or mood incongruent psychotic features • Poor drug compliance
- 16. Differential diagnosis • Ruleout organic causes (drug induced, dementia) • Rule out acute and transient psychotic disorders, schizo-affective disorders, and schizophrenia • Rule out delusional disorders • Rule out adjustment disorders with depressed mood, generalized anxiety disorder, normal grief reaction, and OCD (with or without secondary depression)
- 17. Management • Antidepressants • ECT •Lithium • Antipsychotics • Other mood stabilizers
- 18. Antidepressants Antidepressant Equivalent doseto 25mg imipramine Usual therapeutic range (mg/day) Imipramine 25 150-300 Amitryptyline 25 150-300 Nortryptyline 25 150-300 Clomipramine 25 75-250 Fluoxetine - 10-60 Paroxetine - 10-40 Sertraline - 50-200 Escitalopram - 10-20 Mirtazepine - 15-45
- 19. Lithium • Drug ofchoice for manic episode and preventing further episodes in bipolar disorder. • 1-2 week period lag before appreciable improvement. • Usual dose 900-1500mg of LiCO3 per day. • Low therapeutic index. • Plasma levels >2mEq/L is toxic and 2.5-3mEq/L may be lethal.
- 20. Lithium (Contd.) • Acutesymptoms of toxicity are muscle twitchings, drowsiness, delirium, coma and convulsions, vomiting, severe diarrhoea, albuminuria, hypotension, cardiac arrythmia. • Before starting lithium therapy CBC, ECG, urine routine, RFT, TFT should be done.
- 21. Antipsychotics • Risperidone, olanzepine,quetipine, haloperidol and chlorpromazine can be used. • Indications: • Acute manic episode • Delusional depression
- 22. Other mood stabilizers •Sodium valproate (1000-3000mg/day) • Carbamazepine (600-1600mg/day) and oxcarbazepine • Lorazepam and clonazepam • Topiramate • Lamotrigine • T3 and T4 as adjuncts in rapid cyclers.