BIPOLAR DISORDER

INTRODUCTION

  • Earlier k/a Manic Depressive Psychosis (MDP).
  • A brain disorder that causes unusual shifts in mood, energy & daily activity levels in a person’s life.
  • Characterised by recurrent episodes of mania & depression in same patient at different times.

MANIC EPISODE

  • It is characterised by persistently elevated, expansive or irritable mood causing disruption in occupational or social activities  & having >3 of the following features that lasts for atleast 1week :-
  1. Inflated grandiosity.
  2. Decreased need of sleep.
  3. More talkative.
  4. Flight of ideas.
  5. Distractibility.
  6. Increase in goal-directed activity.
  7. Excessive involvement in activities that have a high potential for painful conse­quences.

DEPRESSIVE EPISODES

  • It is characterised by >5 of the following features that persists for at least 2weeks duration causing disruption in occupational or social activities :-
  1. Depressed mood most of the day.
  2. Markedly diminished interest in almost all activities.
  3. Significant weight loss or gain (>5% of body wt. in a month).
  4. Insomnia or hypersomnia.
  5. Psychomotor retardation.
  6. Fatigue or loss of energy.
  7. Feeling worthless or guilty.
  8. Decreased concentration or ability to think.
  9. Recurrent thoughts of death or suicidal tendencies.

TYPES OF BIPOLAR

  • BIPOLAR I DISORDER is mainly defined by manic or mixed episodes that last at least 7days, OR by severe manic symptoms that needs immediate hospitalization, along with depressive episodes lasting for at least 2weeks making a major change in person’s behaviour.
  • BIPOLAR II DISORDER is defined by a pattern of depressive episodes shifting back & forth with hypomanic episodes, but no full-blown manic or mixed episodes.
  • Hypomanic :- characterised by persistently elevated, expansive or irritable mood causing disruption in occupational or social activities for atleast >4 consecutive days & present almost whole day.
  • BIPOLAR DISORDER NOT OTHERWISE SPECIFIED (BP-NOS) is diagnosed when a person has symptoms of the illness that don’t meet the criteria for either I or II. The symptoms may not last long enough or are very few to be diagnosed for I or II. However, these are clearly out of person’s normal range of behaviour.
  • CYCLOTHYMIC DISORDER is a mild form of bipolar. Episodes of hypomania that shift back & forth with mild depression for atleast 2yrs.

ETIOLOGY

BIOLOGICAL

  • Genetic Hypothesis :- Risk in 1st degree relatives of bipolar = 25%. For children of 1 parent = 27% & of both parents =74%. For monozygotic twins = 65% & dizygotic = 20%.
  • Biochemical Theories :- NT also play imp role in this condition. Increase in NE can lead to manic episode while decrease in NE & 5 HT function can lead to depression. This mainly occur at the level of presynaptic and synaptic levels.
  • Sleep Studies :- Decreased need of sleep in mania whereas Insomnia and frequent awakenings in depression

PSYCHOSOCIAL

  • Psychoanalytic Theories :- In depression there can be loss of libidinal object, introjection of the lost object and intense craving of self love are some of the postulates of different psychodynamic theories.
  • Stress :- Increased number of stressful life events has a formative role in depression though act as precipitating factor in mania. However, increased stressors in early period of development are more important in depression.
  • Cognitive and Behavioural Theories :- The mechanisms of causations of depression according to these theories include depressive negative cognition, learned helplessness and anger directed inwards.

COURSE OF DISEASE

  • Early onset at third decade.
  • An average manic episode = 3-4months While depressive = 4-6months. However with treatment symptoms controlled of manic in 2wks and depression in 6-8wks.
  • Rapid cyclers :- >4episodes per year.
  • Ultra Rapid Cycling :- Phases of mania and depression alternate very rapidly i.e in matter of hrs. or days.

PROGNOSTIC FACTORS

GOOD PROGNOSIS

  • Acute or abrupt onset.
  • Typical clinical features.
  • Severe depression.
  • Good response to treatment.

BAD PROGNOSIS

  • Personality disorder or alcohol dependence.
  • Chronic ongoing stress.
  • Unfavourable environment.
  • Mood incongruent psychotic features.
  • Poor drug compliance.

MEDICAL MANAGEMENT

  1. ANTIDEPRESSANTS 
  • TCAs – Imipramine, Amitriptyline
  • SSRIs – Fluoxetine, Sertraline, Citalopram
  • SNRIs – Venlafaxine, Duloxetine

– Usually 75-150mg Imipramine is starting dose and after about 2weeks assessment for clinical improvement is done.

– If not improved, dosage increase to 300mg.

– Before Stopping or changing a drug the particular drug should be given in a therapeutically adequate dose dose for at least six weeks.

2) ANTIPSYCHOTICS

  • Commonly used drugs include Risperidone, Olanzapine, Haloperidol, Aripiprazole, etc.
  • Indications :- 1) Acute manic episode along with mood stabilisers for first few weeks, before the effect of mood stabilisers becomes apparent.       2) Delusional depression.     3) Bipolar depression.   4) Maintenance or prophylactic treatment in bipolar disorder .   

3) MOOD STABILISERS

  • Lithium :- DOC for manic episodes and further prevention of episodes in bipolar. The usual therapeutic dose range is 900-1500mg of lithium carbonate per day. Needs close monitoring by repeated blood levels due to narrow therapeutic index.
  • Sodium valproate :- Used in patients who are refractory to lithium. The dose range is usually 1000-3000mg per day having a faster onset of action than lithium.
  • Carbamazepine :- Used in patients who are refractory to lithium and valproate. The dose range is of 600-1600mg per day and particularly effective when EEG is abnormal.
  • BZDs :- Lorazepam and Clonazepam only for treatment of manic episode but rare.
  • Lamotrigine :- In bipolar depression.

ELECTROCONVULSIVE THERAPY (ECT)

INDICATIONS

  • Severe depression with suicidal risk.
  • Severe depression with stupor, psychomotor retardation.
  • Severe treatment refractory depression.
  • Intolerance to drugs or presence of side effects of any ongoing antidepressants.

— Rapid response. 6-8 ECTs needed (thrice a week).

—If 6 ECTs, 3 in 1st week, 2 in 2nd and 1 in 3rd week is the usual pattern.

PSYCHOSOCIAL MANAGEMENT

  • Cognitive Behaviour Therapy (CBT) aims to correct depressive negative cognitions such as worthlessness, hopelessness and helplessness replacing them by new cognitive response.
  • Interpersonal Therapy (IPT) attempts to recognise interpersonal stressors, social isolations or deficits which act as stimuli for depression.
  • Behaviour Therapy includes various short term modalities such as social skills training, problem solving techniques, self control techniques and decision making techniques.
  • Other psychosocial management methods include group therapy, Family and marital therapy, etc.

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