MOOD DISORDERSMOOD DISORDERS22

Dr Nesif J. Al-HemiaryDr Nesif J. Al-Hemiary

MBChB - FICMS(Psych)MBChB - FICMS(Psych)

International Associate of the International Associate of the RCPsych.(UK)RCPsych.(UK)

Bipolar disorderBipolar disorder

These disorders include Bipolar I, Bipolar II, and These disorders include Bipolar I, Bipolar II, and cyclothymia.cyclothymia.

Bipolar I disorder is a syndrome characterized by a Bipolar I disorder is a syndrome characterized by a complete set of manic symptoms (manic complete set of manic symptoms (manic episodes) occurs during the course of the disorder episodes) occurs during the course of the disorder and major depressive episodes, while in bipolar II and major depressive episodes, while in bipolar II disorder hypomanic symptoms occur instead of disorder hypomanic symptoms occur instead of mania.mania.

Cyclothymia is a chronic disorder in which there Cyclothymia is a chronic disorder in which there are episodes of hypomanic symptoms and mild are episodes of hypomanic symptoms and mild depressive symptoms. depressive symptoms.

Bipolar I DisorderBipolar I Disorder

Bipolar I disorder is less common than major depressive Bipolar I disorder is less common than major depressive disorder ,with a lifetime prevalence of 1% similar to the disorder ,with a lifetime prevalence of 1% similar to the figure of schizophrenia, while the lifetime prevalence of figure of schizophrenia, while the lifetime prevalence of bipolar II disorder is about 0.5%.bipolar II disorder is about 0.5%.

It has an equal prevalence for men and women.It has an equal prevalence for men and women. The onset is generally earlier than that of major depressive The onset is generally earlier than that of major depressive

disorder.disorder. The age of onset of BP I disorder ranges from childhood as The age of onset of BP I disorder ranges from childhood as

early as age of 5 or 6 to 50 years or even older ,with a early as age of 5 or 6 to 50 years or even older ,with a mean age of 30 years.mean age of 30 years.

It may be more common in divorced and single people than It may be more common in divorced and single people than among married people, but the difference may reflect an among married people, but the difference may reflect an early onset and the resulting marital discord characteristics early onset and the resulting marital discord characteristics of the disorder.of the disorder.

Clinical featuresClinical features The bipolar I & II disorders include the occurrence of recurrent The bipolar I & II disorders include the occurrence of recurrent

episodes of mania (bipolar I) or hypomania (bipolar II) and episodes of mania (bipolar I) or hypomania (bipolar II) and major depressive episodes.major depressive episodes.

The first episode can be any of them.The first episode can be any of them. Manic episodeManic episode::

1.1. An elevated ,expansive or irritable mood is the hallmark of a An elevated ,expansive or irritable mood is the hallmark of a manic episode.manic episode.

2.2. The elevated mood is euphoric and often infectious .The elevated mood is euphoric and often infectious .3.3. Patients are also disinhibited , and become angry when their Patients are also disinhibited , and become angry when their

freedom is restricted.freedom is restricted.4.4. They feel energetic ,sleep only few hours, become They feel energetic ,sleep only few hours, become

hyperactive ,hypersexual and spend a lot of money.hyperactive ,hypersexual and spend a lot of money.5.5. They may be preoccupied with religious, political, They may be preoccupied with religious, political,

financial ,sexual or persecutory ideas that can evolve into financial ,sexual or persecutory ideas that can evolve into complex delusional systems.complex delusional systems.

Hypomanic episode: characterized by symptoms which may Hypomanic episode: characterized by symptoms which may be similar to those of mania but they are less severe so that be similar to those of mania but they are less severe so that there is an equivocal change of functioning ( no marked there is an equivocal change of functioning ( no marked impairment of functioning).impairment of functioning).

Course and prognosisCourse and prognosis The natural history of bipolar I disorder is usually start The natural history of bipolar I disorder is usually start

with depression and is usually a recurring disorder.with depression and is usually a recurring disorder. Most patients experience both depressive and manic Most patients experience both depressive and manic

episodes , although 10-20% experience only manic episodes , although 10-20% experience only manic episodes.episodes.

The manic episodes typically have a rapid onset (hours The manic episodes typically have a rapid onset (hours to days) but may evolve over few weeks. An untreated to days) but may evolve over few weeks. An untreated manic episode lasts about three months; therefore manic episode lasts about three months; therefore drugs must not be discontinued before that time.drugs must not be discontinued before that time.

As the disorder progresses ,the time between episodes As the disorder progresses ,the time between episodes often decreases.often decreases.

After about five episodes ,however, the inter-episode After about five episodes ,however, the inter-episode interval often stabilizes at 6-9 months.interval often stabilizes at 6-9 months.

Some patients have rapidly cycling episodes.Some patients have rapidly cycling episodes. Prognosis of patients with bipolar I disorder have a Prognosis of patients with bipolar I disorder have a

poorer prognosis than do patients with major poorer prognosis than do patients with major depressive disorder. About 40-50% may have second depressive disorder. About 40-50% may have second episode within two years. episode within two years.

Differential diagnosisDifferential diagnosis

1.1. Schizophrenia.Schizophrenia.

2.2. Schizoaffective disorder.Schizoaffective disorder.

3.3. Medical disorders.Medical disorders.

4.4. Substance-related mood disorders.Substance-related mood disorders.

TreatmentTreatment Treatment of bipolar I disorder include:Treatment of bipolar I disorder include:1.1. Treatment of the episode whether depressive or manic.Treatment of the episode whether depressive or manic.2.2. Prophylactic treatment if indicated( maintenance) to Prophylactic treatment if indicated( maintenance) to

prevent or decrease the recurrence and severity of the prevent or decrease the recurrence and severity of the episodes.episodes.

Treatment of manic episodes:Treatment of manic episodes: drugs used for this purpose include basically mood drugs used for this purpose include basically mood

stabilizing drugs like lithium, carbamazepine , stabilizing drugs like lithium, carbamazepine , valproate, gabapentin, toperamate, clonazepam and valproate, gabapentin, toperamate, clonazepam and antipsychotic drugs. Treatment should not be stopped antipsychotic drugs. Treatment should not be stopped before three months to avoid relapse.before three months to avoid relapse.

Maintenance treatment:Maintenance treatment: the decision to maintain a patient on lithium or other the decision to maintain a patient on lithium or other

mood stabilizing drugs is based on the severity of the mood stabilizing drugs is based on the severity of the patientpatient’’s disorder, the risk of the adverse effects from s disorder, the risk of the adverse effects from these drugs and the quality of the patientthese drugs and the quality of the patient’’s support s support system.system.

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