1. Bipolar Disorder Dr. Ali Bahathig, FRCPC
Assistant Professor and Consultant of psychiatry, Consultation-Liaison Psychiatrist
Psychosomatic Unit, Psychiatry Department
King Khalid University Hospital
Bipolar Disorder

2. Special thanks to Dr. Ahmad Alhadi
Associate professor, consultant psychiatry and psychotherapy
Thanks to Dr. Fahad Alosaimi
Associate Professor, and consultant in Psychiatry and psychosomatic medicine consultant
Associate professor
KSU, Riyadh

3. Objectives: Analyze Discuss list
Analyze the symptoms & signs, both presented and expected in this case including mood, thoughts, cognition, perception and physical aspects.
Discuss
Discuss possible etiological reasons
list
list differential diagnoses
Discuss management of bipolar disorder. To discuss the roles of:
Medications (antidepressants, mood stabilizers, antipsychotics and benzodiazepines).
Psychotherapy
Electroconvulsive therapy(ECT)

4. Ms. Norah is a 35 year-old married housewife lady, mother of 6 kids.
Case Development 1
Ms. Norah is a 35 year-old married housewife lady, mother of 6 kids.
She had one episode of one month duration of elated mood, irritability, decrease need for sleep, talkativeness, grandiosity, overspending & purposeless hyperactivity.
There is positive family history of bipolar disorder in her brother & her mother.
Furthermore, one of her sisters was diagnosed to have major depressive disorder.

5. Mood Disorders
Depression
MDD
Dysthymia
Bipolar
Bipolar I
Bipolar II

7. Bipolar Disorder Major Depressive Episode (MDE) only = MDD
Manic Episode + MDE = Bipolar disorder
Manic Episode only = Bipolar disorder

8. Affective: Cognitive:
The Symptoms of Mania
Affective:
Elevated, expansive, irritable mood; if frustrated, may become aggressive
enthusiasm
Cognitive:
Self-assertion, grandiosity, flightiness, pressured thoughts, lack of focus and distractibility, poor judgment

9. The Symptoms of Mania
Behavioral: disinhibited, impulsive sexual activity, abusive discourse.
Impaired social and occupational function especially in mania
Hypomania: “High” mood and overactive purposeful behavior; decreased judgment, start many projects but complete few, dominate conversations, often grandiose
Mania: increased purposeless activity, grandiosity, irritability; flight of ideas speech, no tolerance for criticism or restraint
Physiological: Decreased need for sleep, plus high levels of arousal, Boundless energy.

11. Differences between Depression and Mania
-Table 11.2: Symptoms of Depression and Mania. 11

13. DSM-5 criteria of 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 (or any duration if hospitalization is necessary) B) During the period of mood disturbance and increased energy , three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: 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) 6) increase in goal-directed activity (at work, at school, or sexually) or psychomotor agitation 7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) C) The episode is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. D) The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment) or another medical condition.

14. DSM-5 criteria of Hypomanic 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 4 days
B) During the period of mood disturbance and increased energy , three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
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)
6) increase in goal-directed activity (at work, at school, or sexually) or psychomotor agitation
7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C) The episode is associated with unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic
D) The disturbance in mood and functioning are observable by others
E) the episode is not severe enough to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, and they are no psychotic features.
F) The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment) or another medical condition

15. Classification of Bipolar Disorders
Bipolar disorder I
Bipolar disorder II
Cyclothymic disorder
Substance/ medication induced bipolar and related disorder
Bipolar and related disorder due to another medical condition
Others
-Personal experience about issues with college and video of how bipolar works

16. Bipolar Disorders Bipolar I Disorders: a minimum of one manic episode.
Bipolar II Disorders : Recurrent major depressive episodes with minimum of one hypomanic episode but never manic episode.

17. Bipolar Disorders
Cyclothymic Disorder: Chronic and relatively continual mood disorder with hypomanic episodes and depressed moods that do not meet criteria for major depressive episode.
Symptoms present for more than 2 years, never symptom free for more than 2 months

18. Other Mood Disorders
Mood Disorder Due to another Medical Condition: Characterized by depressed mood and/or elevated or irritable mood as a direct result of another medical condition.
Depressive type or bipolar and related type.
Substance-Induced Mood Disorder: Prominent and persistent disturbance of mood attributable to use of a substance or cessation of substance use.
Depressive type or bipolar and related type

19. Symptom Features and Specifiers
Rapid Cycling: manic/depressive episodes occurred 4 or more times during the previous 12 months.
With psychotic features
Seasonal Pattern: Mood episodes are accentuated during certain times of the year.
Peripartum Onset: Occurs during pregnancy or within 4 weeks of childbirth.
With atypical features: MDE with mood reactivity, increased appetite and sleep, leaden paralysis and long standing rejection sensitivity.

20. Symptom Features and Specifiers
Specifiers: Describe either the episode itself or the mood disorder course overall:
Melancholia: (for MDE only) Loss of pleasure, lack of reactivity to pleasurable stimuli, depression that is worse in the morning, early morning awakening, excessive guilt, weight loss.
Catatonia: Motoric immobility, extreme agitation, negativism, or mutism.
With anxious distress.
With mixed features :mild depression mixed with full manic episode or mild hypomania mixed with full depressive episode.

21. One-Year and Lifetime Prevalence Rates of Mood Disorders in the United States
-Figure 11.1: One-Year and Lifetime Prevalence of Mood Disorders in the United States.

22. Epidemiology of mood disorders
-Table 11.1: Mood Disorders. 22

23. Heritability of Depressive and Bipolar Disorders
Genetic studies:
Increased incidence of manic disturbances in blood relatives of bipolar patients.
Evidence is stronger for BD,
- 50% of BP pts.---> one parent have M.D,
- BD. pt. ----> 27% any of their children will have M.D,
- Both parents have BD ----> 50-75% any child,
- MZ twins have BD ----> 75% concordance.
Relatives of unipolar patients have a greater probability of having unipolar disorders, but relatives of bipolar patients have a greater probability of having bipolar and unipolar disorders.

24. Etiology of Mood Disorders Neurotransmitters and Mood Disorders
Serotonin (5-HT)
Norepinephrine (NE)
Depressed Mood
Anxiety
Irritability
Thought process
Sex
Appetite
Aggression
Concentration
Interest
Motivation
Vague Aches and pain
-Some symptoms (e.g. appetite, attention) seem to be mediated more by one neurotransmitter than the other. Some other symptoms (e.g. anxiety) seem to be mediated by either.
-There are other symptoms (e.g. aches and pain) that seem to be mediated more consistently by a combination of both the neurotransmitters.
Both serotonin and norepinephrine mediate a broad spectrum of depressive symptoms

25. Treatment of Bipolar Disorder (acute mania)
Typical Antipsychotic: Haloperidol : dose 5 – 60 mg.
Atypical Antipsychotic:
- Risperidone –dose 2 – 8 mg./day
- Olanzapine –dose 5 – 20 mg./day.
Lithium :
Effective in 80%, takes 7-10 days
Full trail at least for 4 wks
Blood level 0.6 – 1.2 meq/L, toxicity more than 1.2meq/L.
Starting dose 300mg tid,- usual dose range mg per day

26. Treatment of Bipolar Disorder (acute mania):
Anticonvulsants:
Valproic acid :
Starting dose 500 mg, -- range 750 – 3000 mg,
Therapeutic level 40 – 100 ug/mL, toxic 200 ug/Ml.
Carbamazepine :
Dose 200mg bid / day, increase by 200mg. every wk.
Until plasma level mg/L.
Benzodiazepines:
Clonazepam : dose in acute mania 2 – 16 mg/day.
Same forms of psychotherapy and behavior therapy used for unipolar disorder are used for bipolar disorder (particularly family therapy).
Typical treatment for bipolar patient involves lithium carbonate, which is 60-80% effective.
Negative physical side effects; also, lack of compliance or self-regulation of dosage.
Anticonvulsant drugs are also being used.

27. Treatment of Bipolar Disorder
Bipolar, depressive episodes
Optimize current dosage of lithium, atypical antipsychotics or anticonvulsants.
Add Quetiapine, lamotrigine or lithium if not used already.
Consider adding SSRI or Bupropion antidepressants if no improvement with previous regimens.
Consider ECT
Psychotherapy esp. CBT
Bipolar disorder (maintenance phase)
Patients mostly need continuous use for life of :
Lithium, anticonvulsants and/or atypical antipsychotic to prevent future relapses.

28. COURSE & PROGNOSIS of Bipolar disorder
Untreated manic episode last 6 months.
High rate of manic/depressive recurrence, average 10.
80% of these bipolar episodes are Dep. episodes
PROGNOSIS: -
Fair.
15 % recover.
50 – 60 % partially recover
1/3 have some evidence of chronic symptoms & social deterioration.

29. Electroconvulsive therapy (ECT)
90% efficacy in some case (while medications are effective in 70%)
May be safer than TCA for some Pt.
Reserved for Pts. Who have failed other Rx.
For Pts. who are so acutely dangerous or suicidal or need fast Rx because severe low intake and poor self- care.
May be used prophylactically to prevent recurrence.
Do not cure but induce remission.
Should be combined with other Rx.

30. Electroconvulsive therapy (ECT) Indications:-
Major Depression,
Bipolar Disorder II :Depressive episodes
Bipolar Disorder I :Manic or depressive episodes
Schizophrenia --- acute, catatonic, paranoid, with Affective features.
High suicidality
Pregnancy

31. ECT Pretreatment: Physical investigation, Medical Hx
Blood & urine chemistry,
Chest X-ray
ECG
NPO.

32. ECT Procedure: Production of an epileptiform convulsion (35-80sec)
modified by muscle relaxant (succinylcholine),
under i.v. anesthesia (methohexitone),
by the passage of very small current of the order of milliamps, for up to 1 second duration, at a voltage not exceeding 150 volts.
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33. ECT Types:- Bilateral Unilateral (nondominant hemisphere( No. of Rx.
Less
more
Short term Amnesia
greater
less
Cognitive deficits
more likely

34. ECT Course:-
3 times / wk,
Pts with depression need = 6 – 12 treatments,
Pts with schizophrenia need = treatments,
Reassess pt. Between treatments,
Stop when there is no evidence of improvement.

35. ECT Side effects:- (Mortality is similar to general anesthesia:
- Ventricular Arrhythmias.
- Transient Memory Impairment 1-2 wks.
- Headaches.
- Prolonged Seizures.
- Prolonged Memory Impairment.
- Brain Herniation.
- Side effects of Anesthesia.
(Mortality is similar to general anesthesia:
1 in 10,000).
ECT is about 10 times safer than childbirth

36. ECT Contraindication Relative:-
- Fever, arrhythmia, extreme HTN, coronary ischemia
- Recent myocardial infarction, increased Intracranial
pressure, brain cancer, stroke.
* Absolute:- None.

37. Thank you