Bipolar & Related Disorders

Department of Medicine / Division of Psychiatry Dr.
Noor Alhuda Adnan Al Ghuraibawi
Bipolar and Related Disorders
Bipolar I Disorder
Bipolar II Disorder
Cyclothymic Disorder
Fig. 1 Mood Disorders
Epidemiology
 The annual incidence of Bipolar Illness is considered generally less than 1%, but it is
difficult to estimate because milder forms of Bipolar Disorder are often missed.
 Bipolar I Disorder has an equal prevalence among men and women. Manic episodes
are more common in men & depressive episodes are more common in women.
Bipolar I Disorder:
For a diagnosis of bipolar I disorder, it is necessary to meet the criteria for a
manic episode. The manic episode may have been preceded by and may be followed by
hypomanic or major depressive episodes. Most patients experience both depressive and
manic episodes, although 10 to 20 % experience only manic episodes.
1
Department of Medicine / Division of Psychiatry Dr. Noor Alhuda Adnan Al Ghuraibawi
DSM 5 Criteria for Manic Episode:
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood
and abnormally and persistently increased goal-directed activity or energy, lasting
at least 1 week and present most of the day, nearly every day (or any duration if
hospitalization is necessary).
B. During the period of mood disturbance and increased energy or activity, 3 (or more)
of the following symptoms (4 if the mood is only irritable) are present to a significant
degree and represent a noticeable change from usual behavior :
1. Inflated self-esteem or grandiosity.
2.Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3.More talkative than usual or pressure to keep talking.
4.Flight of ideas or subjective experience that thoughts are racing.
5.Distractibility (i.e., attention too easily drawn to unimportant or irrelevant
external stimuli), as reported or observed.
6.Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation (i.e., purposeless, non-goal-directed activity).
7.Excessive involvement in activities that have a high potential for painful
consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions,
or foolish business investments).
C. The mood disturbance is sufficiently severe to cause marked impairment in social or
occupational functioning, or to necessitate hospitalization to prevent harm to self or
others, or there are psychotic features.
D. The episode is not attributable to the physiological effects of a substance (e.g a drug
of abuse, a medication, or other treatment)
2
Hypomanic Episode:
A. A distinct period of abnormally and persistently elevated, expansive, or irritable
mood and abnormally and persistently increased activity or energy, lasting at least 4
consecutive days and present most of the day, nearly every day.
B. During the period of mood disturbance and increased energy and activity, 3 (or more)
of the above symptoms (4 if the mood is only irritable) have persisted, represent
a noticeable change from usual behavior, and have been present to a significant
degree.
C. The episode is associated with an unequivocal change in functioning that is
uncharacteristic of the individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or
occupational functioning or to necessitate hospitalization. If there are psychotic
features, the episode is, by definition, manic.
F. The episode is not attributable to the physiological effects of a substance (e.g., a drug
of abuse, a medication, or other treatment)
Psychodynamic factors in Mania:
Most theories of mania view manic episodes as a defense against underlying depresseion.
The manic state may also result from tyrannical superego, which produces intolerable self-
criticism that is then replaced by euphoric self- satisfaction.
3
Bipolar II Disorder:
For a diagnosis of bipolar II disorder, it is necessary to meet the criteria for a
current or past hypomanic episode and the criteria for a current or past major depressive
episode. There has never been a manic episode in Bipolar II Disorder.
Manic episode with mixed features
If a person if simultaneously having both a manic and depressive episode, the diagnosis is
technically categorized as "manic episode with mixed features."
Treatment
 Treatment of Manic Episode
Patients with severe mania are best treated in the hospital where aggressive response can
be achieved within days or weeks. Treatment by Mood Stabilizers.
Mood Stabilizers:
Lithium Carbonate: is considered the prototypical Mood Stabilizer. The onset of antimanic
action can be slow, therefore, supplemented in the early phases of treatment by another
drugs.
Lithium has low therapeutic index. Therapeutic serum Lithium levels are between 0.6 and
1.2 mEq / L. Serum level more than 1.5 mEq / L can lead to toxicity: seizures, confusion,
cardiac arrhythmia and coma.
The acute use of Lithium has been limited in recent years because of the problematic side
effects and the need for frequent laboratory tests.
4
Valproate:Valproic acid (Depakene) or Divalproex sodium (Depakote) Can be used for
acute mania as well as prophylactic agent.
Typical dose levels of valproic acid are 750 – 2,500 mg per day.
Carbamazepine (Tegretol):
Mood – Stabilizing anticonvulsant. Typical dose to treat acute mania range between 600 –
1800 mg per day.
Clonazepam and Lorazepam:
High potency benzodiazepine , both may be effective for acute mania agitation, insomnia,
aggression and dysphoria.
Antipsychotics
Like Olanzapine, Risperidone, Quetiapine, Ziprasidone & Aripiprazole have demonstrated
antimanic efficacy.
 Treatment of Acute Bipolar Depression
The relative usefulness of standard antidepressants in bipolar depression remain
controversial because of their propensity to induce mania or hypomania.
Accordingly, antidepressant drugs are often enhanced by a mood stabilizer are used.
A fixed combination of Olanzapine and Fluoxtine (Symbyax) is available.
Prognosis
Studies of the course and the prognosis of mood disorders have generally concluded that
mood disorders tend to have long course and that patients tend to have relapses.
Cyclothymic Disorder
5
Cyclothymic Disorder is symptomatically a mild form of bipolar ll disorder, characterized .
by episodes of hypomania and mild depression for more than two years
In DSM-5, cyclothymic disorder id defined as " chronic, fluctuating mood disturbance", the
patient has never met the criteria for a major depressive episode and did not meet the
criteria for manic episode during the first 2 years of disturbance
Treatment:
Mood stabilizers and psychotherapy

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Department of Medicine / Division of Psychiatry Dr.

Noor Alhuda Adnan Al Ghuraibawi

Bipolar and Related Disorders

Fig. 1 Mood Disorders

For a diagnosis of bipolar I disorder, it is necessary to meet the criteria for a

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

DSM 5 Criteria for Manic Episode:

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood

and abnormally and persistently increased goal-directed activity or energy, lasting

degree and represent a noticeable change from usual behavior :

1. Inflated self-esteem or grandiosity.

3.More talkative than usual or pressure to keep talking.

4.Flight of ideas or subjective experience that thoughts are racing.

5.Distractibility (i.e., attention too easily drawn to unimportant or irrelevant

external stimuli), as reported or observed.

6.Increase in goal-directed activity (either socially, at work or school, or sexually) or

psychomotor agitation (i.e., purposeless, non-goal-directed activity).

7.Excessive involvement in activities that have a high potential for painful

consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions,

or foolish business investments).

C. The mood disturbance is sufficiently severe to cause marked impairment in social or

occupational functioning, or to necessitate hospitalization to prevent harm to self or

others, or there are psychotic features.

of abuse, a medication, or other treatment)

A. A distinct period of abnormally and persistently elevated, expansive, or irritable

C. The episode is associated with an unequivocal change in functioning that is

uncharacteristic of the individual when not symptomatic.

E. The episode is not severe enough to cause marked impairment in social or

occupational functioning or to necessitate hospitalization. If there are psychotic

features, the episode is, by definition, manic.

of abuse, a medication, or other treatment)

Psychodynamic factors in Mania:

criticism that is then replaced by euphoric self- satisfaction.

For a diagnosis of bipolar II disorder, it is necessary to meet the criteria for a

episode. There has never been a manic episode in Bipolar II Disorder.

Manic episode with mixed features

technically categorized as "manic episode with mixed features."

 Treatment of Manic Episode

be achieved within days or weeks. Treatment by Mood Stabilizers.

cardiac arrhythmia and coma.

effects and the need for frequent laboratory tests.

Valproate:Valproic acid (Depakene) or Divalproex sodium (Depakote) Can be used for

acute mania as well as prophylactic agent.

1800 mg per day.

Clonazepam and Lorazepam:

aggression and dysphoria.

Like Olanzapine, Risperidone, Quetiapine, Ziprasidone & Aripiprazole have demonstrated

 Treatment of Acute Bipolar Depression

The relative usefulness of standard antidepressants in bipolar depression remain

controversial because of their propensity to induce mania or hypomania.

A fixed combination of Olanzapine and Fluoxtine (Symbyax) is available.

Cyclothymic Disorder is symptomatically a mild form of bipolar ll disorder, characterized .

criteria for manic episode during the first 2 years of disturbance

Mood stabilizers and psychotherapy

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