BIPOLAR DISORDERSPresented by:

Chris Miller, 4th Year Medical Student (USESOM),

Psychiatry Rotation

For: Dr. D. Martinez

TOPICS COVEREDBipolar I Disorder

Bipolar II Disorder

Cyclothymic Disorder

The epidemiology, etiology, clinical manifestations, and management of each disorder will also be covered.

BIPOLAR I DISORDERMost serious of all bipolar disorders

Diagnosed after at least one episode of mania.

Patients also may experience major depressive episodes in the course of their lives.

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DIAGNOSTIC CRITERIA FOR MANIC EPISODES

THREE TO FOUR OF THE FOLLOWING CRITERIA ARE REQUIRED DURING THE ELEVATED MOOD PERIOD

Highly inflated or grandiose self-esteem

Decreased need for sleep, or rested after only a few hours of sleep

Pressured speech

Racing thoughts and flight of ideas

Easy distractibility, failure to keep attention

Increased goal-directed activity

High excess involvement in pleasurable activities (sex, travel, spending money)General criteria for a manic episode require a period of

elevated, expansive, or irritable mood that lasts 1 week or requires hospitalization. A general medical condition and substance abuse must be ruled out before these symptoms are considered mania.

DIFFERENTIAL DIAGNOSIS OF MANIA

May be induced by:Antidepressant medications

Psychostimulants

Electroconvulsive therapy

Phototherapy

If the above occurs, the patient is diagnosed with substance-induced mood disorder

EPIDEMIOLOGY OF BIPOLAR I DISORDER

The lifetime prevalence is 0.4% to 1.6%

The ratio of males to females affected is equal

There are no racial variations in incidence

ETIOLOGY OF BIPOLAR I DISORDER

Genetic studies indicate that bipolar I disorder is associated with increased bipolar I, bipolar II, and major depressive episodes in first-degree relatives.

X-linkage has been shown in some studies but is still controversial.

Mania can be precipitated by:

Psychosocial stressorsSleep/wake cycle changes

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CLINICAL MANIFESTATIONS OF BIPOLAR I DISORDERDefined by the occurrence of a manic episode

A single manic episode is sufficient enough to meet diagnostic criteria but most patients have recurrent manic episodes mixed with depressive episodes

The 1st episode of mania usually occurs in the early 20s

Lifetime suicide rates range from 10% to 15%

CLINICAL MANIFESTATIONS OF BIPOLAR I DISORDER (CONT.)

Children can also present with bipolar disorder that resembles the adult type but differs according to their age and developmental level.

Very young children may present with uncontrollable giggling.

School-age children may try to teach their grammar class in the presence of their teacher.

Adolescents may present with severe anger outbursts and agitation.

Most children with bipolar disorder have more than one relative with the same condition.

MANAGEMENT OF BIPOLAR I DISORDER

The following medications can be used:Antipsychotics

Benzodiazepines

Mood stabilizers (valproic acid, lithium)

Combination therapy is more effective than monotherapy

Some atypical antipsychotics such as clozapine, quetiapine, olanzapine, and aripiprazole can be used for maintenance

Electroconvulsive therapy can also be used for refractory cases and patients intolerant to medications.

BIPOLAR II DISORDERBipolar II disorder is similar to bipolar I disorder except that mania is absent in bipolar II disorder.

Hypomania is the essential diagnostic finding.

Hypomania is a milder form of elevated mood than mania.

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BIPOLAR II DISORDEREPIDEMIOLOGY ETIOLOGY

The lifetime prevalence of bipolar II disorder is about

0.5%

Same factors as bipolar I disorder

More common in women

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CLINICAL MANIFESTATIONS OF BIPOLAR II DISORDERCharacterized by the occurrence of hypomania and episodes of major depression in an individual who has never met criteria for mania or a mixed state.

Hypomania is determined by the same symptom complex as mania, but the symptoms are less severe, cause less impairment, and usually do not require hospitalization.

Bipolar II is cyclic

Suicide occurs in 10% to 15% of patients (same as bipolar I)

MANAGEMENT OF BIPOLAR II DISORDER

The treatment is the same as for bipolar I disorder

Hypomanic episodes do not require as aggressive a treatment as mania.

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CYCLOTHYMIC DISORDER

Cyclothymic disorder is a recurrent, chronic, mild form of bipolar disorder in which mood typically oscillates between hypomania and dysthymia.

If a manic episode or depressive episode is experienced, cyclothymic disorder is not diagnosed.

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CYCLOTHYMIC DISORDER

EPIDEMIOLOGY ETIOLOGY

The lifetime prevalence of cyclothymic disorder is 0.4%

to 1%.

Genetic and familial studies reveal an association with

other mood disorders

The rate appears equal in men and women, although women are usually more likely to seek treatment

CLINICAL MANIFESTATIONS OF CYCLOTHYMIC

DISORDERCyclothymic disorder is a milder form of bipolar disorder consisting of recurrent mood disturbances between hypomania and dysthymic mood.

A single episode of hypomania is sufficient enough to diagnose cyclothymic disorder, although most individuals also have dysthymic periods.

• Cyclothymic disorder is never diagnosed when there is a history of mania, major depressive episode, or mixed episode.

MANAGEMENT OF CYCLOTHYMIC DISORDER

• Cyclothymic disorder can be treated with:– Psychotherapy– Mood stabilizers– Antidepressants

• Patients with cyclothymic disorder may never seek medical attention for their mood symptoms

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CONCLUSION• Bipolar I disorder

– Diagnosed by at least one manic episode and usually experiences depressive episodes

• Bipolar II disorder– Hypomania with

depressive episodes

• Cyclothymic disorder– Cyclic disorder

oscillating between hypomania and dysthymia

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REFERENCES• Kaplan USMLE STEP 2 CK Lecture Notes 2010,

psychiatry section

• http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002517/

• http://www.nimh.nih.gov/health/publications/bipolar-disorder/complete-index.shtml

• BluePrints Psychiatry, Lippincott Williams and Wilkins, 2009, mood disorders, pg 8

• http://en.wikipedia.org/wiki/Bipolar_disorder