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Gangguan Bipolar

OLEH:
PRISCA ANGELINA K.
DILLONIAR BAHNY ZULFIKAR
WAN ADI SURYA P.
KEVIN HORAS
FREDDY SAGITA PUTRA S.
SUU MYAT NOE H.

PEMBIMBING: DR. FRILYA RACHMA PUTRI, SP.KJ


Definisi

Gangguan mood yang ditandai dengan adanya episode


berulang (sekurang-kurangnya 2 episode) antara episode
manik dan depresif atau hanya dengan episode manik saja.
Epidemiologi

Prevalensi gangguan bipolar I 0-2,4 %.


Prevalensi gangguan bipolar II 0,3-4,8%.
Pria dan wanita risikonya sama.
Onset usia anak-anak (5-6 tahun) sampai 50 tahun atau lebih
tua (jarang), usia rata-rata 30 tahun.
Lebih sering pada orang yang lajang dan bercerai daripada yang
menikah.
Insiden yang lebih besar ditemukan pada kelompok sosioekonomi
yang lebih tinggi.
Lebih sering pada orang yang tidak lulus universitas daripada
lulusan universitas.
Etiologi

Faktor Biologis
Abnormalitas metabolit amin biogenik di darah, urin, dan CSF pasien
dengan gangguan mood.
Faktor neurotransmiter lain asetilkolin, GABA

Faktor Genetik
Memiliki risiko genetik lebih besar dibanding gangguan depresif berat.
80 90 % pasien bipolar memiliki keluarga (orang tua, anak, saudara
kandung) yang memiliki gangguan mood.

Faktor Psikososial
Peristiwa hidup dan stres lingkungan
Faktor kepribadian
Faktor psikodinamik depresi
Faktor psikodinamik mania
Klasifikasi

Gangguan mood yang ditandai oleh satu atau lebih


Gangguan bipolar I episode manik atau campuran yang biasanya disertai
episode depresif berat.

Varian gangguan bipolar yang ditandai dengan satu atau


Gangguan bipolar II lebih episode depresif berat dan episode hipomania, bukan
mania.

Bentuk ringan dari gangguan bipolar, ditandai dengan episode


hipomanik (yang tidak memenuhi kriteria diagnostik episode
Gangguan siklotimia mania) dan episode depresif (yang tidak memenuhi kriteria
diagnostik episode depresif berat) minimal 2 tahun.

Gangguan bipolar
Ada gejala penyakit namun tidak memenuhi kriteria
yang tidak diagnostik bipolar di atas.
ditentukan
Bipolar I Disorder

Depressio + Mania
n
Depressive Episodes

Depressed mood + a loss of interest or pleasure key


symptoms.
Feel blue, hopeless, in the dumps, or worthless,
agonizing emotional pain, unable to cry the
depressed mood often has a distinct quality that
differentiates it from the normal emotion of sadness or
grief.
2/3 of all depressed patients contemplate suicide 10 to
15% commit suicide.
Depressive Episodes cont

Withdrawal from family, friends, and activities that


previously interested them.
Reduced energy (97%) difficulty finishing tasks,
impaired at school and work, less motivation to undertake
new projects.
Trouble sleeping (80%) especially early morning
awakening (terminal insomnia), multiple awakenings at
night.
Decreased appetite and weight loss.
Increased appetite and weight gain and sleep longer than
usual atypical features.
Depressive Episodes cont

Anxiety (90% ) - including panic attacks


Changes in food intake aggravate coexisting medical
illnesses
Abnormal menses and decreased interest and performance
in sexual activities
Alcohol abuse
Somatic complaints (E.G., Constipation and headaches)
Diurnal variation in symptoms (50%)
Cognitive symptoms- inability to concentrate (84% in one
study), impairments in thinking (67% in another study)
Depression in Children &
Adolescents

Children:
School phobia
Excessive clinging to parents

Adolescents:
Poor academic performance
Substance abuse
Antisocial behavior
Sexual promiscuity
Truancy
Running away
Depression in Older People

More common in older persons (25-50%).


Causes low socioeconomic status, the loss of a spouse, a
concurrent physical illness, and social isolation.
Usually underdiagnosed & undertreated.
The disorder appears more often with somatic complaints in
older.
Ageism may influence and cause clinicians to accept depressive
symptoms as normal in older patients.
Manic Episodes

Elevated, expansive, or irritable mood hallmark.


Euphoric, infectious
Patients often exhibit a change of predominant mood from
euphoria early in the course of the illness to later
irritability.
Drink alcohol excessively
Excessive use of the telephone(long-distance calls during
the early morning hours).
Pathological gambling
Manic Episodes cont

Tendency to disrobe in public places.


Wearing clothing and jewelry of bright colors in unusual or
outlandish combinations.
Inattention to small details (e.G., Forgetting to hang up the
telephone).
Preoccupied by religious, political, financial, sexual, or
persecutory ideas that can evolve into complex
delusional systems.
Become regressed play with their urine and feces.
Mania in Adolescents

Often misdiagnosed as antisocial personality disorder or


schizophrenia
Psychosis
Alcohol or other substance abuse
Suicide attempts
Academic problems
Philosophical brooding
OCD symptoms
Multiple somatic complaints
Marked irritability resulting in fights, and other antisocial behaviors
Bipolar II Disorder

Depressive +
Hypomanic
disorder episode

More marital disruption and with onset at an earlier age


than bipolar I disorder.
Greater risk of both attempting and completing suicide than
patients with bipolar I disorder and major depressive
disorder.
Coexisting Disorders

Anxiety
Alcohol Dependence
Other Substance-Related Disorders
Medical Conditions
Episode
PEMERIKSA Depresi
AN STATUS
MENTAL Episode
Manik
Episode Depresi

Deskripsi umum
Retardasi psikomotor gejala yang paling umum, meskipun
agitasi psikomotor juga sering ditemukan, khususnya pada
pasien lanjut usia.
Postur membungkuk, tidak terdapat pergerakan spontan,
pandangan mata yang putus asa, dan memalingkan
pandangan.

Mood, afek dan perasaan


Pasien seringkali dibawa oleh anggota keluarga atau teman
kerjanya karena penarikan sosial dan penurunan aktivitas
secara menyeluruh.
Episode Depresi

Bicara
Penurunan kecepatan dan volume bicara, berespon terhadap
pertanyaan dengan kata tunggal dan respon yang melambat.

Gangguan persepsi
Pasien terdepresi dengan waham dan halusinasi dikatakan
menderita episode depresif berat dengan ciri psikotik.
Depresi psikotik digunakan untuk pasien terdepresi yang
jelas teregresi (membisu, tidak mandi, berpakaian kotor).
Waham sesuai mood adalah waham bersalah, memalukan,
tidak berguna, kemiskinan, kegagalan.
Waham tidak sesuai mood adalah tema kebesaran berupa
tenaga, pengetahuan, dan harga diri yang melambung.
Episode Depresi

Sensorium dan kognisi


Pasien biasanya tidak memiliki minat untuk menjawab pertanyaan
tentang orientasi.
Sekitar 50-70% pasien terdepresi memiliki gangguan kognitif
(pseudo demensia depresif).
Pasien sering mengeluhkan gangguan konsentrasi dan mudah lupa.

Pengendalian impuls
10-15% melakukan bunuh diri, 2/3 lainnya memiliki gagasan bunuh
diri. Terkadang pasien juga berpikiran untuk membunuh orang lain.
Pasien terdepresi yang paling parah tidak memiliki motivasi atau
energi untuk bertindak menyerang. Biasanya saat mulai membaik
mendapatkan kembali energi yang diperlukan untuk
merencanakan dan melakukan suatu bunuh diri (paradoxical
suicide).
Episode Depresi

Pertimbangan dan tilikan


Pertimbangan pasien paling baik dinilai dari
tindakan mereka belum lama berselang dan perilaku
mereka selama wawancara.
Tilikan pasien terhadap gangguannya seringkali
berlebihan. Sukar untuk meyakinkan bahwa
perbaikan adalah dimungkinkan.

Reliabilitas
Diperlukan konfirmasi dari sumber lain.
Episode Manik

Deskripsi umum
Biasanya pasien banyak bicara, kadang-kadang menggelikan
dan sering hiperaktif.
Kadang memerlukan pengikatan fisik dan penyuntikan obat
sedatif intramuskular.

Mood, afek, dan perasaan


Biasanya pasien euforik tetapi juga lekas marah.
Memiliki toleransi frustasi yang rendah, yang dapat
menyebabkan perasaan kemarahan dan permusuhan.
Secara emosional pasien labil, beralih dari tertawa menjadi
lekas marah, menjadi depresi dalam beberapa menit atau
jam.
Episode Manik

Bicara
Pasien manik tidak dapat disela saat berbicara dan seringkali
rewel dan pengganggu bagi orang-orang di sekitarnya. Saat
dalam fase manik pembiacaraan menjadi lebih lantang, lebih
cepat, dan sulit dimengerti. Saat keadaan teraktivasi lebih
meningkat asosiasi menjadi longgar.
Kemampuan untuk berkonsentrasi menghilang, menyebabkan
gagasan yang meloncat-loncat (flight of ideas), word salad,
dan neologisme.

Gangguan Persepsi
75% mengalami waham.
Episode Manik

Pikiran
Isi pikiran pasien manik termasuk tema kepercayaan
diri dan kebesaran diri.
Mudah dialihkan perhatiannya.

Sensorium dan kognisi


Orientasi dan daya ingat intak, walaupun beberapa
manik mungkin sangat euforik sehingga mereka
menjawab secara tidak tepat. Gejala ini disebut
Mania Delirium.
Episode Manik

Pengendalian Impuls
75% pasien manik senang menyerang atau mengancam. Pasien
yang mengancam terutama orang penting lebih sering menderita
gangguan bipolar I daripada skizofrenia.

Pertimbangan dan tilikan


Gangguan pertimbangan merupakan tanda dari pasien manik.
Pasien manik juga memiliki sedikit tilikan terhadap gangguan yang
dideritanya.

Reabilitas
Pasien manik tidak dapat dipercaya dalam informasinya.
Diagnosis
DSM-5 Diagnosis

1. Gangguan bipolar I
One or more Manic Episode or Mixed Manic Episode
Minor or Major Depressive Episodes often present
May have psychotic symptoms
Specifiers: anxious distress, mixed features, rapid
cycling, melancholic features, atypical features, mood-
congruent psychotic features, mood incongruent
psychotic features, catatonia, peripartium onset,
seasonal pattern.
Severity Ratings: Mild, Moderate, Severe (DSM-5, p.
154).
DSM-5 Diagnosis

2. Gangguan bipolar II
One or more Major Depressive Episode.
One or more Hypomanic Episode.
No full Manic or Mixed Manic Episodes.
Specifiers: anxious distress, mixed features, rapid
cycling, melancholic features, atypical features, mood-
congruent psychotic features, mood incongruent
psychotic features, catatonia, peripartium onset,
seasonal patter.
Severity Ratings: Mild, Moderate, Severe (DSM-5, p.
154).
DSM-5 Diagnosis

3. Cyclothymia
For at least 2 years (1 in children and
adolescents), numerous periods with hypomanic
symptoms that do not meet the criteria for
hypomanic.
Present at least the time and not without for longer than
2 months.
Criteria for major depressive, manic, or
hypomanic episode have never been met.
DSM-5 Diagnosis

4. Unspecified Bipolar and Related Disorder


Bipolar features that do not meet criteria for
any specific bipolar disorder.
DSM-5 Kriteria Diagnosis
Episode Manik

A distinct period of abnormally and persistently elevated,


expansive, or irritable mood.
Lasting at least 1 week.
Three or more (four if the mood is only irritable) of the
following symptoms:
Inflated self-esteem or grandiosity
Decreased need for sleep
Pressured speech or more talkative than usual
Flight of ideas or racing thoughts
Distractibility
Psychomotor agitation or increase in goal-directed activity
Hedonistic interests
DSM-5 Kriteria Diagnosis
Episode Manik (cont)

Causes marked impairment in occupational functioning in


usual social activities or relationships, or
Necessitates hospitalization to prevent harm to self or
others, or has psychotic features
Not due to substance use or abuse (e.g., drug abuse,
medication, other treatment), or a general medial
condition (e.g., hyperthyroidism).
A full manic episode emerging during antidepressant
treatment
Diagnosis: Gejala Manik di
Sekolah
Gejala/Definisi Contoh
Euforia: Elevated (too happy, silly, giddy) and A child laughs hysterically for
expansive (about everything) mood, out of 30 minutes after a mildly
the blue or as an inappropriate reaction to funny comment by a peer and
external events for an extended period of despite other students staring
time. at him.
Iritabilitas: Energized, angry, raging, or In reaction to meeting a
intensely irritable mood, out of the blue or as substitute teacher, a child
an inappropriate reaction to external events flies into a violent 20-minute
for an extended period of time. rage.
Inflated Self-Esteem or Grandiosity: A child believes and tells
Believing, talking or acting as if he is others she is able to fly from
considerably better at something or has the top of the school building.
special powers or abilities despite clear
evidence to the contrary.
Diagnosis: Gejala Manik di
Sekolah
Gejala/Definisi Contoh
Decreased Need for Sleep: Unable to Despite only sleeping 3 hours the
fall or stay asleep or waking up too night before, a child is still
early because of increased energy, energized throughout the day
leading to a significant reduction in
sleep yet feeling well rested.

Increased Speech: Dramatically A child suddenly begins to talk


amplified volume, uninterruptible rate, extremely loudly, more rapidly, and
or pressure to keep talking. cannot be interrupted by the
teacher
Flight of Ideas or Racing Thoughts: A teacher cannot follow a childs
Report or observation (via rambling speech that is out of
speech/writing) of speeded-up, character for the child (i.e., not
tangential or circumstantial thoughts related to any cognitive or language
impairment the child might have)
Diagnosis: Gejala Manik di Sekolah

Gejala/Definisi Contoh
Distractibility: Increased inattentiveness A child is distracted by sounds in
beyond childs baseline attentional the hallway, which would typically
capacity. not bother her.
Increase in Goal-Directed Activity or A child starts to rearrange the
Psychomotor Agitation: Hyper-focused school library or clean everyones
on making friends, engaging in multiple desks, or plan to build an
school projects or hobbies or in sexual elaborate fort in the playground,
encounters, or a striking increase in and but never finishes any of these
duration of energy. projects.
Excessive Involvement in Pleasurable A previously mild-mannered child
or Dangerous Activities: Sudden may write dirty notes to the
unrestrained participation in an action that children in class or attempt to
is likely to lead to painful or very negative jump out of a moving school bus.
consequences.
DSM-5 Kriteria Diagnosis Episode
Hipomanik

Similarities with Manic Episode


Same symptoms
Differences from Manic Episode
Length of time
Impairment not as severe
May not be viewed by the individual as
pathological
However, others may be troubled by erratic behavior
DSM-5 Kriteria Diagnosis
Episode Depresif Berat

A period of depressed mood or loss of interest or pleasure


in nearly all activities.
In children and adolescents, the mood may be irritable rather
than sad.
Lasting consistently for at least 2 weeks.
Represents a significant change from previous functioning.
DSM-5 Kriteria Diagnosis Episode
Depresif Berat (cont)

Five or more of the following symptoms (at least one of which


is either (1) or (2):
Depressed mood
Diminished interest in activities
Significant weight loss or gain
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue/loss of energy
Feelings of worthlessness/inappropriate guilt
Diminished ability to think or concentrate/indecisiveness
Suicidal ideation or suicide attempt
DSM-5 Kriteria Diagnosis Episode
Depresif Berat (cont)

Causes marked impairment in occupational functioning or


in usual social activities or relationships.
Not due to substance use or abuse, or a general medial
condition.
Not better accounted for by Bereavement
After the loss of a loved one, the symptoms persist for longer
than 2 months or are characterized by marked functional
impairment, morbid preoccupation with worthlessness, suicidal
ideation, psychotic symptoms, or psychomotor retardation.
Diagnosis: Gejala Depresif Berat
di Sekolah

Gejala/Definisi Contoh
Depressed Mood: Feels or looks sad A child appears down or flat or is
or irritable (low energy) for an cranky or grouchy in class and on
extended period of time. the playground.
Markedly Diminished Interest or A child reports feeling empty or
Pleasure in All Activities: Complains bored and shows no interest in
of feeling bored or finding nothing fun previously enjoyable school or peer
anymore. activities.

Significant Weight Lost/Gain or A child looks much thinner and


Appetite Increase/Decrease: Weight drawn or a great deal heavier, or
change of >5% in 1 month or has no appetite or an exce3sive
significant change in appetite. appetite at lunch time.
Diagnosis: Gejala Depresif Berat
di Sekolah

Gejala/Definisi Contoh
Insomnia or Hypersomnia: Difficulty A child looks worn out, is often
falling asleep, staying asleep, waking groggy or tardy, or reports sleeping
up too early or sleeping longer and through alarm despite getting 12
still feeling tired. hours of sleep.
Psychomotor A child is extremely fidgety or cant
Agitation/Retardation: Looks say seated. His speech or movement
restless or slowed down. is sluggish or he avoids physical
activities.
Fatigue or Loss of Energy: Child looks or complains of
Complains of feeling tired all the time constantly feeling tired even with
adequate sleep.
Diagnosis: Gejala Depresif
Berat di Sekolah

Gejala/Definisi Contoh
Low Self-Esteem, Feelings of A child frequently tells herself or others
Worthlessness or Excessive Im no good, I hate myself, no one
Guilt: Thinking and saying more likes me, I cant do anything. She feels
negative than positive things about bad about and dwells on accidentally
self or feeling extremely bad about bumping into someone in the corridor
things one has done or not done. or having not said hello to a friend.

Diminished Ability to Think or A child cant seem to focus in class,


Concentrate, or Indecisiveness: complete work, or choose unstructured
Increase inattentiveness, beyond class activities.
childs baseline attentional capacity;
difficulty stringing thoughts together
or making choices.
Diagnosis: Gejala Depresif
Berat di Sekolah

Gejala/Definisi Contoh
Hopelessness: Negative thoughts A child frequently thinks or says nothing
or statements about the future. will change or will ever be good for me.

Recurrent Thoughts of Death or A child talks or draws pictures about


Suicidality: Obsession with death, war casualties, natural disasters,
morbid thoughts or events, or or famine. He reports wanting to be
suicidal ideation, planning, or dead, not wanting to live anymore,
attempts to kill self wishing hed never been born; he draws
pictures of someone shooting or
stabbing him, writes a suicide note,
gives possessions away or tires to kill
self.
DSM-5 Rapid-Cycling Specifier
Diagnosis

Can be applied to Bipolar I or II.


Four or more mood episodes (i.e., Major Depressive, Manic,
Mixed, or Hypomanic) per 12 months.
May occur in any order or combination.
Must be demarcated by:
a period of full remission, or
a switch to an episode of the opposite polarity
Manic, Hypomanic, and Mixed are on the same pole
Differential Diagnosis

Bipolar I
Bipolar I + episode depresif = gangguan medis, gangguan
neurologis, gangguan mental, schizophrenia.
Bipolar I + episode manik = bipolar II, siklotimia, gangguan
mood yang disebabkan keadaan medis umum, gangguan
mood yang diinduksi zat.
Bipolar II
Gangguan mood lain, gangguan psikotik, gangguan ambang.
TERAPI
Tujuan Terapi

1. Mengurangi gejala bipolar


2. Mencegah episode berikutnya
3. Meningkatkan kepatuhan pasien pada pengobatan
4. Menghindari stressor yang dapat memicu kejadian episode
5. Mengembalikan fungsi-fungsi kehidupan menjadi normal
Terapi

Psikososial
(Nonfarmakologi) Farmakoterapi
Menggunakan obat-obat mood
stabilizer.
Lini pertama: Lithium, asam
valproat, dll.
Psikoedukasi pada keluarga dan pasien.
Lini kedua/alternatif:
Psikoterapi
Carbamazepin, gabapentin,
Pengurangan stress (relaksasi, yoga, massage,
lamotrigin, topiramat

dll).

Tidur cukup, makanan bergizi, olahraga


(antikonsvulsan), nimodipin,
support outcomes. verapamil (Ca bloker), olanzapin,
ECT (Electroconvulsive Therapy). risperidon (antipsikotik atipikal).
Prognosis

Gangguan bipolar I prognosis lebih buruk dibandingkan depresif


berat. Sekitar 40-50% pasien bipolar I dapat mengalami episode
manik kedua dalam 2 tahun sejak episode pertama.
Pemberian lithium hanya memberikan 50-60% kendali bermakna
gejalanya.
7% pasien tidak kambuh, 45 % memiliki lebih dari satu episode,
dan 40% memiliki gangguan kronik.
Gangguan bipolar II perjalanan penyakit dan prognosis baru
akan mulai dipelajari. Meskipun banyak data pendahulu,
menunjukkan diagnosanya stabil.
Kemungkinan tinggi pasien dengan gangguan bipolar II akan
memiliki diagnosis yang sama sampai lima tahun kemudian.
Prognosis

BAIK Disertai
BURUK
penyalahgunaan
alkohol
Disertai gejala
Masih dalam episode manik
psikotik
Usia lanjut
Gejaladepresi

Sedikit pemikiran bunuh diri

Tanpa atau dengan gejala psikotik yang


minimal lebih menonjol
THANK YOU