If I’m on fire they dance around it

and cook marshmallows.

And if I’m ice

they simply skate on me

in little ballet costumes

Anne Sexton was a poetborn in the US who sufferedfrom manic depression

DepressionDepression

Low mood (for at least 2 weeks) withLow mood (for at least 2 weeks) withat least 4 of:at least 4 of:

disturbed sleepdisturbed sleeppoor concentrationpoor concentrationloss of interest & pleasureloss of interest & pleasure // withdrawalwithdrawalreduced appetite & weight lossreduced appetite & weight lossagitation or retardationagitation or retardationloss of energyloss of energyinnapropriate guiltinnapropriate guiltrecurrent thoughts of deathrecurrent thoughts of death

Bipolar Affective Disorder

Is the term used to distinguish those who have manic episodes from those who have only (unipolar) depressive episodes

The relationships with other psychiatric disorders

Symptoms of mania A change in mood often elated but also irritabiltyA change in mood often elated but also irritabilty

This is usually accompanied by This is usually accompanied by

A decreased need for sleep A decreased need for sleep An increased level of energy and activity An increased level of energy and activity Talking more and quickly – difficult to interuptTalking more and quickly – difficult to interuptDistractibilty Distractibilty Disinhibition - doing and saying what we usually only thinkDisinhibition - doing and saying what we usually only thinkOverconfidence – can be grandiose to the level of delusionsOverconfidence – can be grandiose to the level of delusions

Impairment of function – at work or in the family or socially Impairment of function – at work or in the family or socially Usually because of irritability or disinhibition Usually because of irritability or disinhibition

Hypomania is the same symptoms but to a less severelevel and no major impairment in function.

Flight of ideas

“People are cleaning up the house, working very hard, there’s Flash on the floor. The dog doesn’t like Flash. There’s a flash in my eye as I’m looking at the trees, there’s not much oxygen from the trees. There’s water on the floor, agua. Run the water, don’t block the sink.”

Digression with loss of goals. Talk uses combinations Digression with loss of goals. Talk uses combinations of words, sounds and ideas with humour and flippancy of words, sounds and ideas with humour and flippancy

Psychotic symptoms in mania

Delusions are usually grandiose but often paranoid

Depressive delusions can also be present

particularly in mixed states

A mood clock

Normal

Mania Depression

Mixed

0 20 40 60 80 100

MZ Twins

Both parents

DZ Twins

Sibling

Children

One parent

1/2 sib

Grandparent

Uncle/aunt

Cousin

Spouse

General Pop

Unipolar

Bipolar

% risk of major affective disorder

Age of Onset in bipolar illness

0

5

10

15

20

25

30

-15 20 25 30 35 40 45 50 55 60

All

Females

Males

Age

No.ofPatients

Recovery from a manic episode

Kraepelin: “one could hope with great probability for complete restoration of health”

?Average untreated length of about 1 year?– Pollock 1931

Recent studies: 2-3 months

Recurrence of mania

More common than in depressive disorder

– single manic episodes occurred in 2 out of 393 patients in Angst et al 1973

– half will have a recurrence within 2 years

First episode manics

21 patients

15 female : 6 male

(including 5 females post partum)

Average age : 29 years (range 19-47)

Incidence of 5.5 per 100,000 per annum

Prognosis of first episode mania at two years

10 relapsed (8 manic & 7 depressive episodes)

9 remained well

1 died (murder)

1 not traced

Precipitants of recurrence in bipolar disorder

Seasonal changes

Personal adversity

Childbirth

Drugs

Season

Life events

Childbirth

stop lithium

Prophylactic efficacy of lithium in bipolar disorder

2 year placebo controlled study

205 patients on lithium following a manic episode entered trial on discharge.

Half randomly switched to placebo

Hospitalisation:

placebo lithium

70/104 31/101

67% 31%

Non relapsed completers at 2 years

11 (10%) 66 (66%)

Prien et al 1973

Tondo et al 2001

Suicide in bipolar disorderLifetime risk of 15-20%

Most have been recently (or are) depressed

Often late in the course of illness (15 years) particularly females

Inadequate (or non compliant) treatment

Isometsa 1994

Lithium and suicide

Mortality by suicide for bipolars is at least x 2-3 higher than the general population (up to x15?) a rate of 3.2 per 100 patient years

While on lithium ?similar level of suicides to general population 0.37 per 100 patient years

Suicide attempts x10 lower in bipolars when on lithiumcompared to when not on lithium

Schou 1998