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Transcript of Bipolar Disorder
BIPOLAR DISORDERDr. D. Phani Bhushan, Prof & H. O. D Department of PsychiatryNRI Medical College & GH
overviewHistoryGeneticsNeuroimagingNeurobiologyWhat isManiaHypomaniaDepressive episode
Bipolar I disorderBipolar ll disorderCyclothymic disorderRapid cyclingSubstance inducedCANMAT guideline for BPADMood StabilizersECT in BPAD
BIPOLAR DIORDERChronic, reclusive & recurrent major mood disorderOften misdiagnosedHas high rates of psychiatric & medical morbidityHas high risk of suicideManagement can be a constant challenge
Historical perspectiveKnown since Hippocrates times described mania and depression as amic and melancholicClear connections between mania and melancholia established only in 19th century by jules BaillargerEmil krapelin Manic- depressive insanity1st introduced in DSM-3(1980), ICD10 (1992)
Past US PresidentWinston Churchill
Past UK prime MinisterColonel Gaaddafi
ExpresidentLibiaBipolar people in history
GeneticsGenome- wide association studies which are more powerful than linkage studies, have been used to assess for multiple causative disease genesFamily, twin and adoption studies all support a significant genetic burden in bipolar disorderGenetic variants near the ADRENOMEDULLIN (ADM) gene on chromosome11 p15 may be specific to Bipolar II Disorder
ContdBipolar Disorder is phenotypically heterogeneousLithium responders may have a unique genetic make-up that is distinct from that of individuals with other bipolar disorderEpigentetics( Gene expression) investigates gene and Environment (GXE) interplay.
NeuroimagingBPD associated with lateral ventricle enlargementWhite matter changes in total cortical volumeMore evidence is emerging to support the use of imaging markers for the Diagnosis of BPD and for differentiation of BPD from UPD
Neuroimaging ContdHigher rates of Deep white matter hyperintensitiesSmaller Cerebral CortexBigger Hippocampus and Basal GangliaInterplay between immune system and BPD is very complex at multiple levels
NeurobiologyMechanism of mood stabilisers may involve the Inhibition of Cyclooxygenase-2( COX2)and or reduction in proinflammatory cytokines.BDNF crosses Blood Brain barrier, its levels in serum are highly correlated with its levels in CSF.Peripheral BDNF may serve as a Biomarker of mood states and disease progression for Bipolar Disorder.
Neurobiology.Neurobiological correlates of BPDLimbic hyperactivityFrontal HypoactivityBrain glutamate levels are elevated in BD patients- supports the idea that glutamate play an important role in the pathophysiology of BDNegative Effects of illness burden on Prefrontal NAA( n-acetyl aspartate). Li treated patients improve NAA levels to that of Healthy controls.
Manic EpisodePeriod of Abnormally & persistently elevated, expansive, or irritable mood abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
Three or more of
Inflated self-esteem or grandiosity.Decreased need for sleep More talkative than usual or pressure to keep talking.Flight of ideas or subjective experience that thoughts are racing.Distractibility Increase in goal-directed activity, psychomotor agitation Excessive involvement in activities that have a high potential for painful consequences (buying sprees, sexual indiscretions, or foolish business investments)
Causing marked impairment in social or occupational functioning
not due to the physiological effects of a substance or to another medical condition.
Hypomanic EpisodeA distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.
The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.The episode is not attributable to the physiological effects of a substance, Other medical Condition.
Major Depressive EpisodeFive or more of in two week periodDepressed mood most of the day( feels sad, empty, or hopeless tearful). Markedly diminished interest or pleasure in almost all activities Significant weight loss or weight gain ( a change > 5% of body weight in a month Insomnia or hypersomnia. Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or excessive or inappropriate guilt Diminished ability to think or concentrate, or indecisiveness, nearly every day Recurrent thoughts of death (recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide)
The symptoms cause impairment in social, occupational, or other important areas of functioning.Not attributable to substance or another medical condition.
Unipolar vs Bipolar Bipolar depression was associated withBipolar family history.Earlier age of onset.Greater number of previous depressive episodes.Co morbities were more common in bipolar depression.Atypical features.Loss of response during antidepressant treatment.
Bipolar I Disorderat least one manic episodenot better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder or other specified or unspecified schizophrenia spectrum and other psychotic disorderSeverityMild, Moderate and Severe
ModifiersAnxious distressMixed featuresRapid cycling Melancholic features Atypical features Mood-congruent psychotic features Mood-incongruent psychotic features Catatonia Peripartum onsetSeasonal pattern
Bipolar I disorderPrevalence rate- 0.6%Male to female ratio 1.1:1Mean age of onset 18 yearsLate onset manic Sx -suspect medical conditionMore common in high income countries than low income countriesFemales more likely to express rapid cycling and mixed episodes and depressive episodes15 times more suicide risk than genral population
Differential DiagnosisMajor Depressive DisorderOther Bipolar disorders (1)Anxiety disorders GAD, Panic Disorder, PTSD, Substance/ medication Induced Attention- Deficit/ Hyperactivity DisorderPersonality DisorderDisorders with prominent irritability
Bipolar II DisorderHypomania + Depressive EpisodeNever been a Manic Episode12 month prevalence 0.3 %Average age of onset mid 20sMost often begins with depressive episodeRisk is high among relatives of Bioplar II disorderSuicide risk in bipolar II > Bipolar IMost of patients become functional in between episodes
Differential DiagnosisMajor Depressive disorderCyclothymic DisorderSchizophrenia spectrum & other related psychotic disorder.Panic or other anxiety disorderSubstance use disorderADHDPersonality Disorder
Cyclothymic DisorderNumerous periods of hypomanic Sx that do not meet criteria for hypomanic episodeNumerous periods with depressive Sx that do not meet criteria for a major depressive episodeDuration- 2 years ( 1 year in children and adolescents)Sx not due to drugs/ other medical conditionSignificant impairment in social and occupational functioning
Rapid CyclingFour or more distinct episodes of mania, hypomania, or depression within a 12-month period.
Risk factors: FemaleAntidepressant useYounger age of onsetThyroid disease (overt or subclinical)
Good response with valproate rather than LiAvoid antidepressantsFirst lineValproate in Bipolar 1Lamotrigine in Bipolar II
Reccurent Depressive DisorderRepeated Episodes of DepressionWith out any history of Independent episodes of mood elevation or over activity that fulfill the criteria Mania.
Substance inducedAlcoholPhencyclidine and other hallucinogensSedative,hypnotic & anxiolyticAmphetamine or Other stimuliCacaine
Bipolar Disorder types Bipolar 0 disorderSchizophreniaBipolar 1/2 disorderSchizobipolar disorderBipolar I disorder"Classic" bipolar disorderBipolar I 1 /2 Depression with protracted hypomaniaBipolar II disorderHypomania plus major depressionBipolar II1/2 disorderDepression superimposed on cyclothymic temperementBipolar III disorderRecurrent depression plus hypomania occurring solely in association with antidepressant or other somatotherapyBipolar III 1/2 Mood swings that persist beyond stimulant and/or alcohol abuseBipolar IV disorderDepression superimposed on a hyperthymic temperamentBipolar V disorderRecurrent depressions without discrete hypomania, but mixed hypomanic episodes (irritability/agitation/racing thoughts) during depressionBipolar VI DisorderBipolarity in the frame of dementia
Management Management involves treatment of acute episodes & maintenance therapyAfter the resolution of acute episodes, maintenance treatment is aimed at prevention of future episodes When a 1st line treatments are unsuccessful try alternate first line treatments before proceeding to 2nd line RxJudicious use of psychosocial interventions, alternate somatic treatments such as ECT, and the numerous experimental agents offer additional promise for management of Bipolar Disorder
CANMAT GUIDELINES FOR BPDIntroductionFoundations of managementAcute management of bipolar maniaAcute management of bipolar depressionMaintenance therapy for bipolar disorderSpecial populationsAcute and maintenance management of bipolar II disorderSafety and monitoring
Criteria for Rating strength of Evidence
1Meta analysis or replicated double blind( DB), Ran