P1

• Bipolar I Disorder


  Presence of one or more manic episodes
• Bipolar II Disorder


  Absence of any manic or mixed-state episodes, only symptoms that cause distress or impair normal function

  
• Bipolar Episodes and Disorders


  • MDE + manic/mixed episode = Bipolar I disorder
  • MDE + hypomanic episode = Bipolar II disorder
  • Hypomania &/or depressive symptoms for at least 2 years; asymptomatic for at most 2 months only; no MDE, manic/mixed episode = Cyclothymic disorder or Cyclothymia

  
• Rapid Cycling in Bipolar I Disorder

  At least 4 episodes of mania or depression in a year, more common in women, associated with use of conventional antidepressants and hypothyroidism
• Secondary Mania


  Patients are most likely older, negative family history for bipolar disorder, mostly presenting with irritable mood and mixed episodes

  
• Causes of Secondary Mania


  • Drug-related (alcohol, anticonvulsants, bronchodilators, cocaine, hallucinogens, steroids)
  • Infections (AIDS, encephalitis, neurosyphilis)
  • Metabolic disturbances (Cushing's disease, diabetes, hyperthyroidism, postoperative states)
  • Neurologic states (brain trauma, multiple sclerosis, stroke, tumors)

  
• Borderline personality disorder, schizophrenia, and substance abuse are differential diagnoses for bipolar disorders
• Epidemiology of Bipolar I Disorder


  • Lifetime prevalence of 0.5 to 1%, Female:Male ratio = 3:2, Age of onset 5-6 to 50 years old, Mean age = 30 y.o.

  
• Neuropathology Studies of Bipolar Disorder


  • Structural studies (MRI abnormalities in third ventricle, prefrontal cortex, temporal lobe, basal ganglia and cerebellum)
  • Functional studies (PET/SPECT studies showing decrease in frontal lobe metabolism, conflicting results on brain metabolism)
  • Biochemical studies (increased dopamine activity, decreased GABA activity)
  • Animal studies

  
• Kindling


  Repeated subthreshold stimulation of neuron eventually generates an action potential (in the brain → seizures), temporal lobes as areas of pathology, anticonvulsants effective in suppressing symptoms
• Genetic Aspect and Markers of Bipolar Disorder


  • Shows a genetic predisposition, first-degree relative 8-18x more likely to have bipolar I, 2-10x more likely to have MDD, genetic markers on chromosome 5, 11, and X chromosome

  
• Psychosocial Factors


  No single personality trait/type is associated with development of bipolar I, theories on defense against depression, ego overwhelmed by pleasurable/feared impulses, inability to tolerate a developmental tragedy
• Biological parents of adopted children with mood disorder have prevalence of mood disorder similar to that of parents of non-adopted children with mood disorder
• Prevalence of mood disorders in adoptive parents is similar to baseline prevalence in the general population
• Monozygotic twins


  • 33-90% concordance rate for mood disorders
• Dizygotic twins


  • 5-25% concordance rate for mood disorders
• Chromosome 5


  D2 receptor gene
• Chromosome 11


  Gene for tyrosine hydroxylase (rate-limiting enzyme for catecholamine synthesis)
• Mania


  Defense against depression
• Ego


  Overwhelmed by pleasurable or feared impulses
• Tyrannical superego


  Replaced by euphoric self-satisfaction
• Biological changes


  Increase risk of undergoing future episodes of mood disorder even without an external stressor
• Once you've had an episode


  The likelihood of developing succeeding episodes is increased
• Patient is more vulnerable


  To developing succeeding episodes even in the absence of a significant external stressor
• Indications for hospitalization in bipolar I disorder


  • Diagnostic procedures
  • Risk for suicide or homicide
  • Grossly reduced ability to get food and shelter
  • Rapidly progressing symptoms
  • Ruptured support systems
• Mood stabilizers for bipolar I disorder


  • Lithium carbonate
  • Carbamazepine
  • Valproate
  • Lamotrigine
• Antipsychotics for bipolar I disorder


  • Risperidone
  • Clozapine
  • Olanzapine
  • Quetiapine
  • Aripiprazole

  
• Other treatments for bipolar I disorder


  • Gabapentin
  • Verapamil: Calcium channel inhibitor
  • Clonidine: alpha-2 adrenergic receptor agonist
  • ECT: severe & drug-resistant cases
• Antidepressants may precipitate a manic episode in bipolar II disorder
• Treatment benefits of anticonvulsant drugs for bipolar II disorder are still under investigation

  
• Bipolar disorder often starts as depression (75% for women, 67% for men)

  
• Most experience depressive and manic episodes, 10-20% experience only manic symptoms/episodes
• Manic episodes have rapid onset within hours or days
• Untreated manic episodes last for around 3 months
• After 5 episodes, interepisode interval stabilizes at 6-9 months
• Bipolar disorder has poorer prognosis than major depression disorder
• 40-50% have second manic episode within 2 years of first episode
• Only 50-60% achieve significant control of symptoms with lithium
• Indicators of poor prognosis of bipolar disorder


  • Poor premorbid occupational status
  • Alcohol dependence
  • Psychotic features
  • Depressive features
  • Male gender

  
• Indicators of good prognosis of bipolar disorder


  • Short duration of manic episodes
  • Advanced age of onset
  • Few suicidal thoughts
  • Few coexisting psychiatric or medical problems