By

Ekam Emefiele

Med. Student

BIPOLAR DISORDER

It is also known as manic-depressive disorder

Bipolar disorder is a serious mental illness that is

characterized by extreme mood swings from mania to

depression.

It affects about 0.6-0.9% of the general population,

and it occurs in males and females equally.

It can result in damaged relationships, poor job or

school performance and even suicide. But it can be

treated and people with the illness can lead full and

productive lives

People with BD are also at higher risk for thyroid

disease, migraine, heart diseases, diabetes, obesity

and other physical illnesses.

History Bipolar Disorder

•200 CE First reports

•1913 Emil Kraepelin

•Manic -Depressive

•1930’s ECT first used

•1949 Lithium first used

•1950 Chlorpromazine first used

•1952 Genetic link recognized

•1980 Bipolar Disorder term adopted

•1995 Depakote approved for BP

•2003 First atypical approved for BP

Main Distinction: unipolar or bipolar

Unipolar: only one end of the emotion spectrum

Major Depressive Episode

Manic Episode

Dysthymia: mild, chronic form of depression

Epidemiology

Peak age of onset is adolescence through early

20s.

• Onset of first manic episode after age 40 years is

a “red flag” to consider substance use or general

medical condition

Lifetime suicide rates range from 10-15%

Seasonal variation

• Depression is more common in fall, winter and

spring

• Mania is more common in summer

Causes

The exact cause of bipolar disorder is unknown.

Experts believe there are a number of factors that

work together to make a person more likely to

develop the condition.

Chemical imbalance in the brain e.g.

noradrenaline, serotonin and dopamine

Genetics: BD is frequently inherited, with genetic

factors accounting for about 80% of the cause of

this condition

Environmental factors e.g. stress, seasonal

changes, substance abuse, sleep deprivation,

medications (like antidepressants) etc.

EVIDENCE FOR HERITABILITY OF

BIPOLAR

Family Studies-First degree relatives are 8 to 18

times more likely to have Bipolar I

2 to 10 times to have MDD.

Risk is 25% if one parent has illness, and 50% to

75% with both parents affected

Twin Studies- Concordance rate in MZ twins is

33-90%, while in DZ is 5-25%

Symptoms of Manic episodeMood changes

A long period of feeling “high” or overly happy mood

Extreme irritability

Behavioral changes

Talking very fast, jumping from one idea to another

Having racing thoughts

Being easily distracted

Increasing activities such as taking a new projects

Sleeping little or not being tired

High sex drive

Symptoms of Depressive

episodeMood changes

An overly long period of feeling sad or hopeless

Loss of interest in activities once enjoyed, including sex

Behavioral changes

Feeling tired or “slowed down”.

Having problems concentrating, remembering and making decisions

Being restless and irritable

Changing eating or sleeping habits

Thinking of death or suicide or attempting suicide

Uncontrollable crying

Types

There are several types of BD, all involves

episodes of depression and mania to a degree.

They includes;

Bipolar I disorder

Bipolar II disorder

Bipolar disorder not otherwise specified (BD-

NOS)

Cyclothymia

Bipolar I disorder

This is defined by manic episode or mixed episode

that last at least 7 days or by mania symptoms that

are so severe that the person needs immediate

hospitalization.

Usually depressive episodes occurs as well,

typically lasting at least 2 weeks but not required for

diagnosis.

Bipolar II disorder• It is considered to be the milder form of BD

• According to American Psychiatric Association (APA), the diagnosis for Bipolar II disorder involves a minimum of one hypomanic episode lasting at least 4days and one or more episode of major depression.

• They usually suffer lower grade of hypomania, if not treated, it can lead to full mania

• The DSM lists school failure, occupational failure, and divorce as social problems associated with Bipolar II Disorder.

• Bipolar II symptoms tend to occur more frequently in women than men. When it does occur in males, the number of hypomanic episodes typically equals that of depressive episodes whereas depression tends to dominate in women.

Cyclothymic Disorder It is a milder form of BD

It is characterized by episodes of hypomania as well as mild depression for at least 2 years.

However, the symptoms do not meet the diagnostic requirements for any other type of BD

Individuals with Cyclothymia do not remain symptom-free for more than two months at a time

Substance abuse may be associated with Cyclothymia, as well as sleep disorders.

The condition typically has a slow, gradual, and progressive onset and a chronic course once established.

There is a 15-50% chance that cyclothymic individuals will go on to develop bipolar I or II disorders in later life.

Bipolar Disorder NOS It is a bipolar condition that does not neatly fit into the

symptomology of BD I, BD II or cyclothymia

If you are diagnosed with this disorder, you are likely to be re-evaluated for one of the other types of BD when you have another episode

Examples given by DSM to give diagnosis includes;

I. Having symptoms of mania and depression but the episodes are too short to qualify as an actual episode

II. Having many episodes of hypomania, but not had a depressive episode

III. Having a manic or mixed episode, but you were previously diagnosed with a psychotic disorder or schizophrenia

IV. Having symptoms of hypomania and depression, but they don’t last long enough to qualify as cyclothymia

V. It looks like you have a BD, but your doctor thinks your symptoms might be caused by drugs, alcohol or a general medical condition

Rapid-cycling BD

This is a severe form of BD

It occurs when a person has 4 or more episodes

of major depression, mania, hypomania or mixed

states all within a year

RC-BD seems to be more common in people who

had their first bipolar episode at a younger age

It affects more women than men

• BD may also be present in a mixed state in

which you might experience both mania and

depression at the same time.

• During a mixed state, you might feel very

agitated, have trouble sleeping, experience major

changes in appetite and have suicidal thoughts

• People in the mixed state may feel very sad or

hopeless while at the same time feel energized.

Sometimes a person with severe episodes of mania and depression has psychotic symptoms too such as hallucinations and delusions.

The psychotic symptoms tends to reflect the person’s extreme mood.

For example;

a) If you are having psychotic symptoms during manic episode, you may believe you are a famous person, have a lot of money or have special powers

b) If you are having psychotic symptoms during depression, you might believe you are ruined and penniless or have committed a crime

• As a result, people with BD who are having psychotic symptoms are sometimes misdiagnosed with schizophrenia

Patients with bipolar II disorder are more frequently

misdiagnosed with unipolar disorder for the

following reasons;

Often the patient feels remarkably well when

hypomanic and he/she is therefore unlikely to

spontaneously report these episodes and may

even deny them when directly questioned.

Patients with hypomania do not present with

psychotic symptoms and they are not

hospitalized, so there may be no indication or

records of a previous hypomanic episode

BD and Substance Abuse• Substance abuse is very common with people with BD, but

the reasons for this link is unclear.

• Some people with BD may try to treat their symptoms with alcohol or drugs.

• However, substance abuse may trigger or prolong bipolar symptoms and their behavioral control problems associated with mania can result in a person drinking too much.

• According to the most recent literature on substance abuse and bipolar disorder, these two problems occur together so frequently that all young people with a bipolar diagnosis should also be assessed for drug and alcohol problems.

• Those who experience mixed states or rapid cycling have the highest rate of danger from substance abuse — the discomfort a person feels in these moods is so great that he/she may be willing to do or take almost anything to make it stop.

Management

Bipolar disorder cannot be cured, but it can be

treated effectively over the long-term. Proper

treatment helps many people with BD—even those

with the most severe forms of the illness—gain

better control of their mood swings and related

symptoms. But because it is a lifelong illness, long-

term, continuous treatment is needed to control

symptoms. However, even with proper treatment,

mood changes can occur

Treatment is more effective if you work closely with

a doctor and talk openly about your concerns and

choices. An effective maintenance treatment plan

usually includes a combination of medication and

psychotherapy.

Medications This is the key in stabilizing BD

Initial treatment of mania consist of Lithium or Valproicacid (Depacote)

If the patient is psychotic, a neuroleptic medication (antipsychotics) is also given

Long-acting benzodiazepines may be used for treating agitation. However, it should be used with caution in patients with a history of substance abuse because of the addictive potential of these agents.

When the patient with BD becomes depressed, an SSRI or bupropion is recommended. The use of tricyclic antidepressants should be avoided because of the possibilities of inducing rapid-cycling of the symptoms.

Note that taking only an antidepressant can

increase your risk of switching to mania or

hypomania, or of developing rapid-cycling

symptoms. To prevent this switch, it is usually

required that the patient takes a mood-stabilizing

medication at the same time as an antidepressant.

PsychotherapyWhen done in combination with medication, psychotherapy can be an effective treatment for BD. It can provide support, education, and guidance to people with BD and their families. Some psychotherapy treatments used to treat BD include:

Cognitive behavioral therapy (CBT), which helps people with BD learn to change harmful or negative thought patterns and behaviors.

Family-focused therapy, which involves family members. It helps enhance family coping strategies, such as recognizing new episodes early and helping their loved one. This therapy also improves communication among family members, as well as problem-solving.

Interpersonal and social rhythm therapy, which

helps people with BD improve their relationships

with others and manage their daily routines.

Regular daily routines and sleep schedules may

help protect against manic episodes.

Psychoeducation, which teaches people with

BD about the illness and its treatment.

Psychoeducation can help you recognize signs of

an impending mood swing so you can seek

treatment early, before a full-blown episode

occurs. Usually done in a group, psychoeducation

may also be helpful for family members and

caregivers.

Electroconvulsive Therapy

(ECT)• For cases in which medication and psychotherapy do not work,

electroconvulsive therapy (ECT) may be useful. ECT, formerly known as "shock therapy," once had a bad reputation. But in recent years, it has greatly improved and can provide relief for people with severe bipolar disorder who have not been able to recover with other treatments.

• Before ECT is administered, a patient takes a muscle relaxant and is put under brief anesthesia. He or she does not consciously feel the electrical impulse administered in ECT. On average, ECT treatments last from 30–90 seconds. People who have ECT usually recover after 5–15 minutes and are able to go home the same day.

• Sometimes ECT is used for bipolar symptoms when other medical conditions, including pregnancy, make the use of medications too risky. ECT is a highly effective treatment for severely depressive, manic, or mixed episodes. But it is generally not used as a first-line treatment.

• ECT may cause some short-term side effects, including confusion, disorientation, and memory loss. People with bipolar disorder should discuss possible benefits and risks of ECT with an experienced doctor.

Thank you!