Dr. Luh Nyoman Alit Aryani SpKJ Dr.

Nyoman Hanati SpKJ (K)

Bipolar disorder, formerly known as manic depressive illness, is not a new illness. Bipolar I and Bipolar II disorder each affect males and females equally, approximately 1% of the population. Bipolar disorder is a chronic episodic illness and up to 15% of patients commit suicide. It emerges early in life, typically below the age of 20 years

Bipolar disorder is characterized by recurrent episodes of mania and depression. Severity disturb the quality of live as a result of behavioral problems during manic episodes and difficulty in continuing work during depressive episodes, and threatens life by suicide. Four bipolar disorder catagories are included in DSM IV TR : bipolar I disorder, bipolar II disorder, cyclothymic disorder, and bipolar disorder not otherwise spesific.

Enviromental factors can contributes to the onset and development of mood episodes. Research suggest that psychosocial events or psychosocial stressors may contribute both directly and via interactions with genetic factors. Structural and functional brain changes along with neuroendocrine and neurocognitive changes have been identified in bipolar disorder. Bipolar disorder has a neurobiological basis but its detailed pathophysiology is unknown.

Environmental

Psychodynamic Biochemical

Genetic

Konas Bipolar I, Surabaya 090312

A distinc period that represents a break from premorbid functioning A duration of at least 1 week. An elevated or irritable mood At least three to four classic manic signs and symptoms The absence of any physical factors that could account for the clinical picture

F31 Bipolar affective disorder F31.0 Bipolar affective disorder, current episode hypomanic F31.1 Bipolar affective disorder, current episode manic without

psychotic symptoms F31.2 Bipolar affective disorder, current episode manic with psychotic symptoms F31.3 Bipolar affective disorder, current episode mild or moderate depression F31.4 Bipolar affective disorder, current episode severe depression without psychotic symptoms F31.5 Bipolar affective disorder, current episode severe depression with psychotic symptoms F31.6 Bipolar affective disorder, current episode mixed F31.7 Bipolar affective disorder, current ly in remission F31.8 Other bipolar affective disorders F31.9 Bipolar affective disorder, unspecified

Mood Symptoms
Elated, euphoric mood Irritable mood Grandiosity

Bodily Symptoms
High risk behavior

Increased energy level

Decreased need for sleep Erratic appetite Increased libido psychomotor agitation

Cognitive (Thinking) Symptoms

Feelings of heightened concentration Distractibility, flight of idea Accelerated thinking (racing thoughts)
Symptoms of Psychosis
Grandiose delusion Hallucinations

A milder form of mania where only some of the symptoms of mania occur. The individual does not have hallucinations or delutions. The symptoms may alter functioning but overall functioning is not significantly impaired and hence hospitalization not usually required for the treatment of hypomania

In practice hypomania can be difficult to diagnose because the symptoms can be subtle or fall to register as problematic. However, hypomania can be a precursor to mania and is important to detect as it can alter the diagnosis from mayor depression to that Bipolar II disorder. A duration of at least for 4 days

Mood Symptoms

Depressed mood Dysphoric mood Diurnal variation of mood (early-morning depression, mood improving as day goes on) Guilty feelings
Loss of ability to feel pleasure (anhedonia) Social withdrawal Suicidal thoughts

Bodily Symptoms

Sleep disturbance:
Appetite disturbance: Loss of interest in sex Fatigue Constipation Headaches Worsening of painful conditions Delusional thinking Hallucinations Catatonic states
weight loss weight gain Insomnia hypersomnia

Symptoms of Psychosis

Cognitive (Thinking) Symptoms

Poor concentration Poor memory

Konas Bipolar I, Surabaya 090312

Konas Bipolar I, Surabaya 090312

Cyclothymic disorder is characterized in DSM IV TR by frequent short cycle of subsyndromal depression and hypomania. The course of cyclothymia is continous of intermittent, with infrequent periods of euthymia.

Shifts in mood often lack adequate precipitants. Circadian factors may account for some of the extremes of emotional lability, such as the person,s going to sleep in good spirits and waking up early with suicidal idea. Mood swings in these ambulatory patients are overshadowed by the chaos that the swings produce in their personal lives.

Two to four depressive symptoms from the list of depressed mood, or both in the setting of manic syndrome appear to suffice for the diagnosis of mixed manic states, which occur in 50 percent of patients with bipolar disorder. The duration of symptom at least for 1 week

Mixed states occur predominantly in women in whom mania is superimposed on a depressive temperament or a disthymic baseline. These consideration suggest that the DSM IVTR concept of mixed episode as a crosssectional mixture of mania and depression

Bipolar II Disorder exist an overlapping group of intermediary forms characterized by reccurent mayor depressive episodes and hypomania. It was described as soft bipolarity. It is actually more prevalent than bipolar I disorder, and it appears to be true in the outpatient setting, in which average 50 percent of person with mayor depressive disorder

Bipolar I Mania + Mayor Depressive Disorder Bipolar II Hypomania + Mayor Depressive Disorder Bipolar III Cyclothimia Disorder Bipolar IV Hipomania can be induced by Anti Depresan Bipolar V Reccurent Mayor Depressive Disorder with bipolar disorder in family history Bipolar VI Mania Unipolar

Physical examination, Observation Psychiatric interview Full medical history (substance abuse, family history of cardiovascular and cerebrovascular disease, pregnancy and contraception) Laboratory evaluation prior to commencement of pharmacotherapy. Patients with depressive symptoms must be screened for a diagnosis of bipolar disorder by routinely asking for symptoms of mania /hypomania.

Bipolar disorder usually underdiagnosis Misdiagnosis as mayor depressive disorder, Consequences of misdiagnosis let to mismanagement, Prognosis become worse, Rapid cycling, Increase suicidal rate Higher cost management.

Early detection, Control of symptoms Prophylaxis, Prevent relapse Reduce suicide risk, reduce cycling frequency or milder degrees of mood instability, Improve overall function.

Mood stabilizers such as lithium and divalproex (depakote) are the first choice of drugs used for bipolar disorder but second generation antipsychotic such as olanzapine are also used. Carbamazepine is also a well established treatment. Lamotrigine is used in the maintenance phase of bipolar disorder. Topiramate is another anticonvulsant used in bipolar disorder.

ECT is highly effective in all phase of bipolar disorders. Carbamazepine, Divalproex and valproic acid may be more effective than lithium in the treatment of mixed or dysphoric mania, rapid cycling, and psychotic mania and the treatment of patients with a history of multiple manic episodes or comorbid substance abuse.

Recommendations for pharmacological treatment of acute mania bipolar

First Line Lithium, divalproex, olanzapine, risperidone, quetiapine, aripiprazole, ziprasidone, lithium or divalproex + quetiapine, lithium or divalproex + olanzapine Second Line Carbamazepine, oxcarbazepine, ECT, lithium + divalproex Third Line Haloperidol, chlorpromazine, lithium or divalproex + haloperidol, lithium + carbamazepine, clozapine Not Recommended Monotherapy with gabapentin, topiramate, lamotrigine, verapamil, tiagabine, risperidone + carbamazepine

First

Line Lithium, lamotrigine, lithium or divalproex + SSRI, olanzapine + SSRI, lithium + divalproex, quetiapine monotherapy

Second Line Quetiapine + SSRI, lithium or divalproex + lamotrigine

Third

Line

Carbamazepine, olanzapine, divalproex, lithium + carbamazepine, lithium + pramipexole, lithium or divalproex + venlafaxine, ECT, lithium or divalproex or AAP + TCA, lithium or divalproex or carbamazepine + SSRI + lamotrigineb, adjunctive EPA, adjunctive topiramate

Not Recommended Monotherapy with gabapentin

Psychological treatments are used mainly as adjuncts to pharmacotherapy. Psychotherapy in conjunction with antimanic drugs is more effective than either treatment alone. Psychotherapy is not indicated when a patient is experiencing a manic episode. In this situation the safety of patient and the others must be paramount.

Cognitive : in relation to increasing compliance with mood stabilizer therapy Behavioral : Help to set limits on impulsive or inapropriate behavior through techniques as positive and negative reinforcement Psychoanalytically oriented : if patients is capable of and desires insightinto underlying conflicts that may triger manic episodes

Supportive : during acute phase and in early recompensation Group : Helpful in reintegrating patients socially Family : because their disorder is strongly familial and so disruptive to patiens. Ways to help with compliance and recognizing triggering events can be explored Psychoeducation is cheap and effective and should be offered to all patients with bipolar disorder.

Relapses occur in most patients with bipolar disease and can be life-threatening. Thus, multiple treatment guidelines recommend maintenance pharmacotherapy for every patient

Konas Bipolar I, Surabaya 090312

THANK YOU
31