1

Bipolar Disorder
- Dysregulation of mood.
- Diagnosis at least 2 episodes of mood disorder, at least one is
hypomania, mania or mixed.
- Single episode of mania or hypomania manic episode
- Mixed episode diagnostic criteria met for both manic and depressive
episodes
- Rapid cycling 4 or more episodes within 12 months
Hypomania Lesser degree of mania.
-Psychotic features (delusions, hallucinations) are not present
-Persistent mild elevation of mood for several days
-Increased activity and feeling of wellbeing
-Increased sociability, talkativeness, overfamiliarity, sexual energy
-Decreased need for sleep.
Mania Elevated mood out of keeping with the individuals circumstances
-Increased energy, over activity, pressure of speech, uncontrollable
excitement, flight of ideas
-Decreased need for sleep
-Loss of social inhibitions increased sociability, overfamiliarity, talkativeness,
irritable
-Attention cannot be sustained, marked distractibility
-Inflated self-esteem grandiose, overoptimistic ideas
-Behavior change spend money recklessly, aggressive, sexual disinhibition,
aggressive, embark on extravagant and impractical schemes
-ICD-10 criteria episode should last for at least 1 week and disrupt
ordinary work
-Mania with psychotic symptoms Grandiose delusions, Persecutory
delusions, auditory hallucinations
Depression Collection of symptoms indicating low mood, present for at
least 2 weeks
-Looking down, dull clothing, poor self-care, slow/hesitant/soft speech.
-ICD-10 criteria for diagnosing depression
Typical symptoms
Depressed mood
Loss of interest and enjoyment in usually pleasurable activities
Decreased energy and increased fatigability
Other symptoms
Reduced concentration and attention
Reduced self-esteem and self confidence
Ideas of guilt and unworthiness
Bleak and pessimistic views of the future

A Project by Dahaya A/L 2010 Batch

Ideas or acts of self-harm or suicide

Disturbed sleep
Diminished appetite

Epidemiology and Etiology

-Lifetime prevalence 0.3-1.5%
-Males & Females affected equally
-Etiology multifactorial (biological, psychological, social)
-Genetic 50-80% concordance in monozygotic twins, 5-10 times higher risk
in first degree relatives
-Endocrine disorders (Cushings syndrome), medication (antidepressants,
corticosteroids)
-Adverse life events, substance abuse
DDs of mania
Schizophrenia or Schizoaffective disorder
Intoxication with alcohol and other psychoactive substances
(amphetamines, hallucinogens)
Organic mood disorders SLE, multiple sclerosis, frontal lobe tumors
Mood disorder precipitated by medication (corticosteroids,
antidepressants)
Elderly Fronto-temporal dementia
Establishing the diagnosis
Mania
Elevated mood is prominent,
episodic illness
Delusions are mood congruent
(grandiose delusions, persecutory
delusions, auditory hallucinations)
Thought insertion, withdrawal,
broadcasting, passivity are rare
Past history of depressive or manic
episodes
Family history of depressive or
bipolar illness

Schizophrenia
Psychotic symptoms are prominent
Mood incongruent, bizarre delusions
can occur
3rd person auditory hallucinations or
running commentary
Thought insertion, withdrawal,
broadcasting, passivity can occur
Past history of psychotic episodes
Family history of schizophrenia

Intoxication or mania? Intoxication with alcohol causes positive

breathalyzer test, slurred speech and ataxia. Positive urine drug screen
for amphetamines and cannabis.
Dementia or mania? Dementia causes memory loss and cognitive
dysfunction. CT/MRI show cerebral atrophy.

A Project by Dahaya A/L 2010 Batch

Unipolar depression or bipolar disorder? In bipolar disease,

depressive episodes are shorter and less responsive to antidepressants
alone.

Risk Assessment
- Overspending investing money in grand schemes, ill planned
business ventures, heavy debts, selling off assets
- Socially disinhibited and overfamiliar social cost, stigma
- Sexual disinhibition, increased libido risk of STDs, pregnancy and
embarrassment
- Persecutory ideas, irritability aggression and violence, problems with
the law
- Depressive episodes risk of suicide or deliberate self-harm
Reasons for relapse
- Not being on mood stabilizers after the previous episode
- Inadequate dose
- Poor drug compliance
- Comorbid substance use
- Stressful life events or other mental trauma
Identifying social support
- Family and coworkers should understand the nature of the illness
- During depressive episodes support for their daily activities
- Caregivers can ensure good drug compliance
- Early identification of relapses
Management Plan
Goals of treatment Treat the acute episodes
- Minimize relapses
- Ensure optimal functioning
Treatment setting admit to hospital during a manic episode
- Depressive episode admit only if severe depression with high risk of
suicide
- If patients refuse involuntary admission under the mental health act
Supportive environment sometimes require sedation
- Minimize confrontation with other patients
Minimizing harm Restrict access to money
- Availability of rapid tranquilization
Educating patient and family multifactorial aetiology
- Long term mood stabilizers reduce relapses, importance of compliance
- Side effects, drug interactions, monitoring of Lithium treatment
- Lifestyle modifications (rest, substance use)
- Identifying relapses early

A Project by Dahaya A/L 2010 Batch

Pharmacological treatment
Acute manic episode
Antipsychotics Act rapidly to control behavioral disturbances
- Both typical and atypical antipsychotics are useful
- Tailed off once acute symptoms are resolved
- Atypical antipsychotics are effective mood stabilizers

Mood stabilizers Lithium and Sodium valproate

Slow onset of action. Therefore used in combination with
antipsychotics.
Serum lithium level maintained at a higher level during an acute
episode (1-2 mmol/L)
Benzodiazepines effective for behavioral disturbances
Not effective by themselves in treating mania
Used in combination with either mod stabilizers or antipsychotics

Severe manic episode combination of antipsychotic, mood stabilizer and

benzodiazepine
Resistant patients combination of 2 mood stabilizers, clozapine or ECT
Depressive episode Treatment is different from treating unipolar
depression
- Antidepressants must be used with caution. Should not be used alone
as it can precipitate a manic episode or cause rapid cycling.
- Antidepressants are used in combination with a mood stabilizer
- SSRIs are less likely to cause switching than TCAs
- Tailed off once symptoms are relieved
- Atypical antipsychotics are useful (quetiapine, olanzapine)
Maintenance treatment reduces risk of relapse
- Single mood stabilizer or a combination of 2 mood stabilizers if several
relapses occurred while on single mood stabilizer
- Duration of maintenance variable. Continued for at least 2 years after
a single episode.
- Selection of mood stabilizers lithium is effective in preventing both
manic and depressive episodes. Should not be used in renal failure
patients and in pregnancy and breast feeding.
- Sodium valproate should be avoided in women of childbearing age
as it can cause polycystic ovarian syndrome
- Carbamazepine less effective than lithium. High drug interaction
profile
- Lamotrigine 2nd line mood stabilizer. Risk of Steven- Johnson
syndrome
- Atypical antipsychotics

A Project by Dahaya A/L 2010 Batch

Electroconvulsive therapy effective in severe manic episodes and

severe depression.
- Rarely used for maintenance therapy

A Project by Dahaya A/L 2010 Batch