2003 August Dar Al-Ajaza Al-Islamia Hospital in Beirut1 Bipolar Disorder An Update Presented by Dr...

2003 August2003 August Dar Al-Ajaza Al-Islamia Hospital Dar Al-Ajaza Al-Islamia Hospital in Beirut in Beirut

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Bipolar DisorderBipolar DisorderAn UpdateAn Update

Presented by Dr Ismail HabliModerator: Dr Elio Sassine


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DefinitionDefinition

Bipolar disorder is a mood disorder which is Bipolar disorder is a mood disorder which is characterized by manic episodes alternating characterized by manic episodes alternating with major depressive episodes.with major depressive episodes.

It is a chronic disorderIt is a chronic disorder


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Bipolar I:Bipolar I: At least 1 manic or mixed episode, At least 1 manic or mixed episode, usually with major depressive episodesusually with major depressive episodes

Bipolar II:Bipolar II: At least 1 hypomanic episode At least 1 hypomanic episode with at least 1 major depressive episode; no with at least 1 major depressive episode; no manic episodesmanic episodes

Mixed or rapid cycling:Mixed or rapid cycling: Manic and Manic and depressive symptoms occur depressive symptoms occur simultaneously; at least 4 episodes of mood simultaneously; at least 4 episodes of mood disturbances in prior 12 monthsdisturbances in prior 12 months

Bipolar Disorder SubtypesBipolar Disorder Subtypes


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Depressed mood +/- loss of interest or pleasureDepressed mood +/- loss of interest or pleasure

Change in appetite, weight, sleepChange in appetite, weight, sleep

Fatigue/ Fatigue/ energy/agitation energy/agitation

Poor concentration; indecisivenessPoor concentration; indecisiveness

Feelings of worthlessness/guiltFeelings of worthlessness/guilt

Suicidal thoughtsSuicidal thoughtsAmerican Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994.American Psychiatric Association, 1994.

Diagnostic Criteria For DepressionDiagnostic Criteria For Depression


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Any antidepressant can trigger switch to maniaAny antidepressant can trigger switch to mania

More common in bipolar I disorder?More common in bipolar I disorder?

Goodwin et al. Goodwin et al. Arch Gen Psychiatry.Arch Gen Psychiatry. 1998;55:23. 1998;55:23.Sachs et al. Sachs et al. J Clin PsychiatryJ Clin Psychiatry. 1994;55:391.. 1994;55:391.

Young et al. Presented at 2nd International Conference on Bipolar Disorder. June, 1997; Pittsburgh, PA.Young et al. Presented at 2nd International Conference on Bipolar Disorder. June, 1997; Pittsburgh, PA.

Antidepressant Induction Of ManiaAntidepressant Induction Of Mania


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TCAs Increase FrequencyTCAs Increase FrequencyOf Bipolar CyclesOf Bipolar Cycles

Wehr et al. Wehr et al. Arch Gen PsychiatryArch Gen Psychiatry. 1979;36:555.. 1979;36:555.

Dep

ress

ion

M

ania

Dep

ress

ion

M

ania

150 75150 75

Desipramine HydrochlorideDesipramine HydrochlorideLithium CarbonateLithium Carbonate

00 5050 100100 150150 200200 250250 300300


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•Etiology :

•Biological Factors :

•Biogenic Amines , Norepinepherine , Serotonin , Dopamine.

•Other Nerochemical Factors:

•Neuroendocrine Regulation:

- Adrenal Axis DST Depression.

-Thyroid Axis.

•Sleep Abnormalities .

•Kindling.

Neuroaimmune Regulation.

•Brain imaging.

•Neuroanatomical considerations.


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Genetic Factors :Genetic Factors :

1.1. Adoption studies.Adoption studies.

2.2. Twin studies.Twin studies.

3.3. Family studies.Family studies.

4.4. Linkage studies : Chr 5 , 11 , x.Linkage studies : Chr 5 , 11 , x.


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Psychosocial Factors :Psychosocial Factors :

1.1. Life Events & Environmental stress.Life Events & Environmental stress.

2.2. Family.Family.

3.3. Premobid personality factors.Premobid personality factors.


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Specifiers Describing Most Recent Episode:Specifiers Describing Most Recent Episode:

With Psychotic features.With Psychotic features.

With Atypical features.With Atypical features.

With Catatonic features.With Catatonic features.

Postpartum Onset.Postpartum Onset.

Chronic.Chronic.

Describing course of Recurrent Episodes:Describing course of Recurrent Episodes:

Rapid cycling.Rapid cycling.

Seasonal pattern.Seasonal pattern.

Longitudinal course specifiers.Longitudinal course specifiers.


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Differential Diagnosis :Differential Diagnosis :Bipolar I Disorder , Bipolar II Bipolar I Disorder , Bipolar II Disorder Bipolar III Disorder, Disorder Bipolar III Disorder, cyclothymic disorder, cyclothymic disorder, Schizophrenia.Schizophrenia.Mood Disorders due to a generalMood Disorders due to a generalMedical condition.Medical condition.Substance – induced Mood Substance – induced Mood Disorder.Disorder.


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Course & Prognosis :Course & Prognosis :

Bipolar I Disorder.Bipolar I Disorder.

Bipolar II Disorder.Bipolar II Disorder.


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High suicide rateHigh suicide rate Cardiovascular mortality may be increasedCardiovascular mortality may be increased Increased affective episodes and hospitalizationsIncreased affective episodes and hospitalizations Residual symptomsResidual symptoms Substance abuseSubstance abuse Never married or marital discord/divorce likelyNever married or marital discord/divorce likely Work impairment/academic underachievementWork impairment/academic underachievement

Frequent ComplicationsFrequent ComplicationsOf Bipolar DisorderOf Bipolar Disorder


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Treatment :Treatment :Hospitalization.Hospitalization.Pharmaco Therapy :Pharmaco Therapy :

- Lithium.- Lithium.- Anticonvulsants.- Anticonvulsants.- Other Agents.- Other Agents.- Rapid Cycling.- Rapid Cycling.- Maintenance.- Maintenance.

Psychosocial Therapy.Psychosocial Therapy.- Cognitive Therapy.- Cognitive Therapy.- Interpersonal Therapy.- Interpersonal Therapy.- Behavior Therapy.- Behavior Therapy.- Psychoanalytically Oriented Therapy.- Psychoanalytically Oriented Therapy.- Family Therapy.- Family Therapy.


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Pharmacological TreatmentsPharmacological Treatments

Acute PhaseAcute Phase• Mood stabilizers Mood stabilizers

(antimanic)(antimanic)• Sedative agents:Sedative agents:

oBZDBZDoNeurolepticsNeuroleptics

• AntidepressantAntidepressant

Maintenance PhaseMaintenance Phase• Mood stabilizersMood stabilizers• Other agentsOther agents


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Limited data for bipolar I depression.Limited data for bipolar I depression.

Depression often persists despite mood Depression often persists despite mood stabilizer.stabilizer.

SSRIs better tolerated, less likely to trigger SSRIs better tolerated, less likely to trigger mania than TCA & MAOIs.mania than TCA & MAOIs.

Consider ECT for severe or delusional Consider ECT for severe or delusional bipolar depression.bipolar depression.

Treatment Resistant Bipolar Treatment Resistant Bipolar DepressionDepression


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Bipolar disorder is a recurring mood Bipolar disorder is a recurring mood disorder with a high morbidity and mortality disorder with a high morbidity and mortality (suicidal rate15 %). The acute phase (suicidal rate15 %). The acute phase (depressive or manic) has a good prognosis (depressive or manic) has a good prognosis with specific treatments, and the disease is with specific treatments, and the disease is preventable and treatable.preventable and treatable.

To Sum UpTo Sum Up


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Thank youThank you

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2003 August Dar Al-Ajaza Al-Islamia Hospital in Beirut1 Bipolar Disorder An Update Presented by Dr...

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