BIPOLAR DISORDER

BIPOLAR DISORDER
Bipolar disorder is a common mood disorder. There is pathology

of mood, which it can be increase (mania) or decrease

(depression), that cant be controlled and cause marked
impairment in social and occupational function.
Bipolar disorder is also a chronic episodic illness that occur in

an alternating pattern, and are usually separated by an interval

of remission.

Definition
A. PPDGJ III :

Recurrent episodes ( at least two ) show mood disturbance

accompanied by marked impairment in activities, which in one
period of time shows increase of mood accompanied by
increase of energy and activities (hypomania/mania), while in
the other period of time shows decrease of mood
accompanied by decrease of energy and activities
(depression).

B. DSM IV TR :
Mood disorder consist of at least one manic, hypomanic or
mixed episode with history of one or more major depressive
episodes.

Classification
Bipolar I disorder :

Presence of major depressive episodes and manic or mixed

episode ( include single manic episode ).
Bipolar II disorder

Presence of major depressive and hypomanic episode. There

has never been a manic or mixed episode.,

 Cyclothymic disorder :

Presence of numerous periods with hypomanic symptoms, and

numerous period with depressive symptoms that do not meet
criteria for a major depressive episodes. For at least 2 years.
Bipolar disorder not otherwise specified:

Presence of manic symptoms, but criteria not meet for bipolar I,

bipolar II, or cyclothymic disorder, not required for diagnosis.

Epidemiology :
Bipolar I prevalence : 0,4% - 1,6%
Bipolar II prevalance : 0,5%
Men and women have the same prevalence
First episode usually between 15-24 years
In men the first symptom reported is usually mania, and women

tend to experience depression .

Bipolar I disorder : > in single or divorce

> in high level sosioeconomic

Etiology
Still not clear
Interaction between biologic, genetic, and psychososial factor .

a. Biologic factor :
interaction between neurotranmitter systems, involving NE,
dopamine & serotonine.

b. Genetic factor :
- Adoption child & twins research
- First degree relatives with bipolar I disorder : 8- 18x > experience
bipolar I compare to control group.
- 50% patients with bipolar I disorder have at least one of their
parents with mood disorder.
- If one of the parents with bipolar I disorder
25% of the children experience mood disorder

c. Psychosocial factor :
- Life events .
Many reports inform that first episode of Bipolar I Disorder
usually related to stressfull events.
- Family pathology influence remission,recurrence and adaptation
function.

Clinical Features
Manic
- Increase of mood : expansive or irritable.
- Inflated of self esteem or grandiosity.
- Decrease need for sleep.
- More talkactive than usual
- Flight of ideas
- Distractibility
- Increase in goaldirected activities ( social, occupational, sexual )
- Excessive involvement in pleasurable activities.
- With psychotic symptoms like delusion and halucination ( mood
congruent or mood incongruent )

Ghaemy :
Mania : increase of mood : euforia or irritable ( at least one week )
+ 7 cardinal symptoms (DIGFAST) :
D : Distractibility
I : Insomnia
G : Grandiosity
F : Flight of ideas
A : Activities
S : Speech
T : Thoughtlessness
Euforia + 3 CS ; Irritable + 4 CS

Depression
- Mood depression almost all day, almost every day.

- Loss of interest almost every activities.

- Decrease or increase of body weight ( >5 % ) not because of diet.
- Insomnia or hypersomnia
- Psychomotor agitation or retardation .
- Loss of energy.
- Feeling guilty >>
- Concentration difficulties.
- Repeated idea of suicide.
- With psychotic symtoms ( mood congruent or incongruent), usually bad
prognosis.

Ghaemy :

Depression : depressive mood ( at least two weeks ) + 8 neurovegetative symptoms ( SIGECAPS )

S : Sleep
I : Interest
G : Guilt
E : Energy
C : Concentration
A : Appetite
P : psychomotor changes
S : Suicide
Depressive mood + 4 NS ; Anhedonia mood + 4 NS

MULTIDIMENSION OF BIPOLAR
DISORDER
Mania

Subsyndromal
mania
(hypomania)

Subsyndrom
al
Depression

Recurrence
(mania)

Remissio
n
Depressi
on

 Hypomanic :

Milder than manic.

Rapid cycling :
4 mood episodes yearly
3 times women > men
Ultra rapid cycling :
4 episodes monthly
Mixed episodes :
Simultaneous symptoms of depression and mania.
Evidence up to 30 40% of all bipolar I patients.
Women > Men

Prognosis
Prognosis of Bipolar I disorder is worse than Major Depression
Around 40-50% persons get the second episodes after 2 years.
Bad prognosis :

- bad premorbid function

- alcohol dependen
- with psychotic features
- male.
7 % Bipolar Disorder has no relapse.
45% experience more than 1 episodes
40% become chronic
4% experience > 10 episodes

 In longterm treatment, it predicts 15% reach complete

remission, 45% reach complete remission with relapse/

recurrence, 30% partial remission,and 10% become chronic.
Recurrence rate lower in person who take prophylaxis
medicine routinly.
Good prognosis :
- Stable family
- No comorbidities with other psychiatric disorder
- Late onset

About 15-20 % patients that cant be cured, lasting with

suicide
Suicide risk mostly happen during depression, followed by
mixed episode, psychotic state and mania
Recurrence rate of bipolar high enough
It cause significant economic burden

Treatment
Consider :
Patients safety
Proper diagnostic evaluation
Therapy procedure not only in acute phase but long term.
1. Hospitalization :

If there is emergency condition ( suicide, homicide )

- Agitation condition
- Bad physical condition
- To make accurate diagnosis.

2. Pharmacotherapy :
- Mood stabilizers ( eg : lithium, carbamazepine, valproate )
- Atypical antipsychotics.
3. Psychotherapy :
- In order to support patients to overcome or adaptation to their
life problems, which the problems can become a precipitating
factor of relapse/recurrence.
- Cognitive behaviour therapy can be choosen.

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