7 Bipolar Disorder

7/28/2019 7 Bipolar Disorder

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Dr. Luh Nyoman Alit Aryani SpKJ

Dr. Nyoman Hanati SpKJ (K)


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Bipolar disorder, formerly known as manicdepressive illness, is not a new illness.

Bipolar I and Bipolar II disorder each affectmales and females equally, approximately 1%of the population.

Bipolar disorder is a chronic episodic illnessand up to 15% of patients commit suicide. It

emerges early in life, typically below the ageof 20 years


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Bipolar disorder is characterized by recurrentepisodes of mania and depression.

Severity disturb the quality of live as a resultof behavioral problems during manic

episodes and difficulty in continuing workduring depressive episodes, and threatens lifeby suicide.

Four bipolar disorder catagories are included

in DSM IV TR : bipolar I disorder, bipolar IIdisorder, cyclothymic disorder, and bipolardisorder not otherwise spesific.


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Enviromental factors can contributes to the onsetand development of mood episodes.

Research suggest that psychosocial events orpsychosocial stressors may contribute both

directly and via interactions with genetic factors. Structural and functional brain changes along

with neuroendocrine and neurocognitive changeshave been identified in bipolar disorder. Bipolar

disorder has a neurobiological basis but itsdetailed pathophysiology is unknown.


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Konas Bipolar I, Surabaya 090312

Environmental

Psychodynamic

Biochemical

Genetic


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A distinc period that represents a break frompremorbid functioning

A duration of at least 1 week.

An elevated or irritable mood At least three to four classic manic signs and

symptoms

The absence of any physical factors that

could account for the clinical picture


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F31 Bipolar affective disorder F31.0 Bipolar affective disorder, current episode hypomanic F31.1 Bipolar affective disorder, current episode manic without

psychotic symptoms F31.2 Bipolar affective disorder, current episode manic with psychotic

symptoms F31.3 Bipolar affective disorder, current episode mild or moderate

depression F31.4 Bipolar affective disorder, current episode severe depression

without psychotic symptoms F31.5 Bipolar affective disorder, current episode severe depression with

psychotic symptoms F31.6 Bipolar affective disorder, current episode mixed F31.7 Bipolar affective disorder, current ly in remission F31.8 Other bipolar affective disorders F31.9 Bipolar affective disorder, unspecified


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Mood Symptoms

Elated, euphoric mood

Irritable mood

Grandiosity

Cognitive (Thinking) Symptoms

Feelings of heightened

concentration

Distractibility, flight of idea

Accelerated thinking

(racing thoughts)

Bodily Symptoms

High risk behavior

Increased energy level

Decreased need for sleep

Erratic appetite

Increased libido

psychomotor agitation

Symptoms of Psychosis

Grandiose delusion

Hallucinations


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A milder form of mania where only some ofthe symptoms of mania occur.

The individual does not have hallucinations ordelutions.

The symptoms may alter functioning butoverall functioning is not significantlyimpaired and hence hospitalization notusually required for the treatment of

hypomania


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In practice hypomania can be difficult todiagnose because the symptoms can besubtle or fall to register as problematic.

However, hypomania can be a precursor tomania and is important to detect as it canalter the diagnosis from mayor depression tothat Bipolar II disorder.

A duration ofat least for 4 days


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Mood Symptoms

Depressed mood

Dysphoric mood

Diurnal variation of mood(early-morning depression,mood improving as day goes

on) Guilty feelings

Loss of ability to feel pleasure(anhedonia)

Social withdrawal Suicidal thoughts

Cognitive (Thinking) Symptoms

Poor concentration

Poor memory

Bodily Symptoms Sleep disturbance:

Insomnia hypersomnia

Appetite disturbance: weight loss weight gain

Loss of interest in sex Fatigue Constipation Headaches Worsening of painful

conditions

Symptoms of Psychosis Delusional thinking Hallucinations Catatonic states


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Cyclothymic disorder is characterized in DSM

IV TR by frequent short cycle ofsubsyndromal depression and hypomania.

The course of cyclothymia is continous ofintermittent, with infrequent periods of

euthymia.


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Shifts in mood often lack adequateprecipitants. Circadian factors may accountfor some of the extremes of emotionallability, such as the person,s going to sleep in

good spirits and waking up early with suicidalidea.

Mood swings in these ambulatory patientsare overshadowed by the chaos that theswings produce in their personal lives.


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Two to four depressive symptoms from thelist of depressed mood, or both in the settingof manic syndrome appear to suffice for the

diagnosis of mixed manic states, which occurin 50 percent of patients with bipolardisorder.

The duration of symptom at least for 1 week


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Mixed states occur predominantly in womenin whom mania is superimposed on adepressive temperament or a disthymicbaseline.

These consideration suggest that the DSM IV-TR concept of mixed episode as a cross-sectional mixture of mania and depression


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Bipolar II Disorder exist an overlappinggroup of intermediary forms characterized byreccurent mayor depressive episodes andhypomania.

It was described as soft bipolarity. It is actually more prevalent than bipolar I

disorder, and it appears to be true in theoutpatient setting, in which average 50

percent of person with mayor depressivedisorder


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Bipolar I Mania + Mayor Depressive Disorder Bipolar II Hypomania + Mayor Depressive Disorder Bipolar III Cyclothimia Disorder Bipolar IV Hipomania can be induced by Anti Depresan Bipolar V Reccurent Mayor Depressive Disorder with bipolar

disorder in family history Bipolar VI Mania Unipolar


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Physical examination,

Observation

Psychiatric interview

Full medical history (substance abuse, familyhistory of cardiovascular and cerebrovascular

disease, pregnancy and contraception) Laboratory evaluation prior to commencement of

pharmacotherapy.

Patients with depressive symptoms must be

screened for a diagnosis of bipolar disorder byroutinely asking for symptoms of mania/hypomania.


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Bipolar disorder usually underdiagnosis Misdiagnosis as mayor depressive disorder,

Consequences of misdiagnosis let tomismanagement,

Prognosis become worse,

Rapid cycling,

Increase suicidal rate

Higher cost management.


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Early detection, Control of symptoms

Prophylaxis,

Prevent relapse Reduce suicide risk, reduce cycling frequency

or milder degrees of mood instability,

Improve overall function.


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Mood stabilizers such as lithium anddivalproex (depakote) are the first choice ofdrugs used for bipolar disorder but secondgeneration antipsychotic such as olanzapine

are also used. Carbamazepine is also a well established

treatment.

Lamotrigine is used in the maintenance phase

of bipolar disorder. Topiramate is another anticonvulsant used in

bipolar disorder.


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ECT is highly effective in all phase of bipolardisorders.

Carbamazepine, Divalproex and valproic acidmay be more effective than lithium in thetreatment of mixed or dysphoric mania, rapidcycling, and psychotic mania and thetreatment of patients with a history ofmultiple manic episodes or comorbidsubstance abuse.


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Recommendations for pharmacologicaltreatment of acute mania bipolarFirst Line Lithium, divalproex, olanzapine, risperidone, quetiapine,

aripiprazole, ziprasidone, lithium or divalproex +quetiapine, lithium or divalproex + olanzapine

Second Line Carbamazepine, oxcarbazepine, ECT, lithium +

divalproex

Third Line Haloperidol, chlorpromazine, lithium or divalproex +haloperidol, lithium + carbamazepine, clozapine

Not Recommended Monotherapy with gabapentin, topiramate,lamotrigine, verapamil, tiagabine,risperidone + carbamazepine


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First Line Lithium, lamotrigine, lithium or divalproex + SSRI,olanzapine + SSRI, lithium + divalproex, quetiapinemonotherapy

Second Line Quetiapine + SSRI, lithium or divalproex + lamotrigine

Third Line Carbamazepine, olanzapine, divalproex, lithium +carbamazepine, lithium + pramipexole, lithium ordivalproex + venlafaxine, ECT, lithium or divalproex orAAP + TCA, lithium or divalproex or carbamazepine +SSRI + lamotrigineb, adjunctive EPA, adjunctive

topiramate

Not Recommended Monotherapy with gabapentin


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Psychological treatments are used mainly asadjuncts to pharmacotherapy.

Psychotherapy in conjunction with antimanicdrugs is more effective than either treatmentalone.

Psychotherapy is not indicated when a patientis experiencing a manic episode. In this

situation the safety of patient and the othersmust be paramount.


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Cognitive : in relation to increasingcompliance with mood stabilizer therapy

Behavioral : Help to set limits on impulsive orinapropriate behavior through techniques as

positive and negative reinforcement Psychoanalytically oriented : if patients is

capable of and desires insightinto underlyingconflicts that may triger manic episodes


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Relapses occur in most patients with bipolardisease and can be life-threatening.

Thus, multiple treatment guidelinesrecommend maintenance pharmacotherapyfor every patient



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7 Bipolar Disorder