1. BIPOLAR DISORDERS Presented by:
Chris Miller, 4th Year Medical Student (USESOM), Psychiatry Rotation
For: Dr. D. Martinez

2. TOPICS COVERED Bipolar I Disorder Bipolar II Disorder
Cyclothymic Disorder
The epidemiology, etiology, clinical manifestations, and management of each disorder will also be covered.

3. BIPOLAR I DISORDER Most 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.

4. 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.

5. 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

6. 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

7. 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 stressors
Sleep/wake cycle changes

8. CLINICAL MANIFESTATIONS OF BIPOLAR I DISORDER
Defined 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%

9. 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.

10. 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.

11. BIPOLAR II DISORDER
Bipolar 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.

12. BIPOLAR II DISORDER EPIDEMIOLOGY ETIOLOGY
The lifetime prevalence of bipolar II disorder is about 0.5%
Same factors as bipolar I disorder
More common in women

13. CLINICAL MANIFESTATIONS OF BIPOLAR II DISORDER
Characterized 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)

14. 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.

15. 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.

16. The lifetime prevalence of cyclothymic disorder is 0.4% to 1%.
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

17. CLINICAL MANIFESTATIONS OF CYCLOTHYMIC DISORDER
Cyclothymic 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.

18. 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

19. CONCLUSION Bipolar I disorder Bipolar II disorder Cyclothymic 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

20. REFERENCES
Kaplan USMLE STEP 2 CK Lecture Notes 2010, psychiatry section 7/
disorder/complete-index.shtml
BluePrints Psychiatry, Lippincott Williams and Wilkins, 2009, mood disorders, pg 8