Defaru D.

(Assistant professor of Psychiatry )

Department of Psychiatry
Mattu University
 Bipolar I disorder
 Bipolar II disorder
 Cyclothymic disorder
 Substance/Medication-Induced Bipolar and Related
Disorder
 Bipolar and Related Disorder Due to Another
Medical Condition
 Other Specified Bipolar and Related Disorder
 Unspecified Bipolar and Related Disorder
 Bipolar I disorder – 0.2-4%
 Bipolar II disorder – 0.3-4.8%
 Cyclothymic disorder – 0.5-6.3%
 Hypomania – 2.6-.8%
 Bipolar I disorder has an equal prevalence among
men and women.
 Manic episodes are more common in men, and
depressive episodes are more common in women
 Females are more likely to experience rapid
cycling and mixed states, and to have patterns of
comorbidity that differ from those of males
 Age of onset of bipolar I disorder is earlier than
MDD
 Age of onset of bipolar I disorder is 5/6 – 50 years
 Mean age of 30 years
 Bipolar I disorder is more common in divorced and
single persons than among married persons
 But, this difference may reflect the early onset and
the resulting marital discord characteristic of the
disorder.
 Bipolar I disorder is higher among
 The upper socioeconomic groups.
 Persons who did not graduate from college than in
college graduates
 No difference among races
 The lifetime risk of suicide in individuals with
bipolar disorder is estimated to be at least 15 times
that of the general population
 In fact, bipolar disorder may account for one-
quarter of all completed suicides.
 Substance use disorders – 61 %
 Panic disorder – 21 %
 OCD – 21 %,
 Comorbid substance use disorders and anxiety
disorders
 Worsen the prognosis of the illness
 Markedly increase the risk of suicide
Environmental.
 Bipolar disorder is more common in high-income
than in low-income countries
 Separated, divorced, or widowed individuals have
higher rates of bipolar I disorder than do
individuals who are married or have never been
married, but the direction of the association is
unclear.
Genetic and physiological.
 A family history of bipolar disorder – 10-fold
increased risk among adult relatives of individuals
with bipolar I and bipolar II disorders.
 Magnitude of risk increases with degree of kinship.
Course modifiers.
 After an individual has a manic episode with
psychotic features, subsequent manic episodes are
more likely to include psychotic features.
 Incomplete interepisode recovery is more
common when the current episode is accompanied
by mood- incongruent psychotic features.
 For a diagnosis of bipolar I disorder, it is necessary
to meet the criteria for a manic episode.
 The manic episode may have been preceded by and
may be followed by hypomanic or major depressive
episodes.
A. A distinct period of abnormally and persistently elevated,
expansive, or irritable mood and 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).
B. During the period of mood disturbance and increased energy
or activity, three (or more) of the following symptoms
(four if the mood is only irritable) are present to a
significant degree and represent a noticeable change from
usual behavior:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of
sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or
irrelevant external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school,
or sexually) or psychomotor agitation (i.e., purposeless non-goal-
directed activity).
7. Excessive involvement in activities that have a high potential for
painful consequences (e.g., engaging in unrestrained buying sprees,
sexual indiscretions, or foolish business investments).
C. The mood disturbance is sufficiently severe to
cause marked impairment in social or occupational
functioning or to necessitate hospitalization to
prevent harm to self or others, or there are
psychotic features.
D. Not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication, other
treatment) or to another medical condition.
A. A 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.
B. During the period of mood disturbance and increased energy
and activity, three (or more) of the following symptoms
(four if the mood is only irritable) have persisted, represent a
noticeable change from usual behavior, and have been
present to a significant degree:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of
sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or
irrelevant external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school,
or sexually) or psychomotor agitation.
7. Excessive involvement in activities that have a high potential for
painful consequences (e.g., engaging in unrestrained buying sprees,
sexual indiscretions, or foolish business investments).
C. The episode is associated with an unequivocal change in
functioning that is uncharacteristic of the individual when
not symptomatic.
D. The disturbance in mood and the change in functioning are
observable by others.
E. 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.
F. Not attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication, other treatment).
A. Five (or more) of the following symptoms have been present
during the same 2-week period and represent a change from
previous functioning: at least one of the symptoms is either
(1) depressed mood or (2) loss of interest or pleasure.
1. Depressed mood most of the day, nearly every day, as indicated by
either subjective report (e.g., feels sad, empty, hopeless) or
observation made by others (e.g., appears tearful).
2. Markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day (as indicated by either
subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a
change of more than 5% of body weight in a month), or decrease or
increase in appetite nearly every day.
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable
by others, not merely subjective feelings of restlessness or being
slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt
(which may be delusional) nearly every day (not merely self-
reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly
every day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent
suicidal ideation without a specific plan, or a suicide attempt or a
specific plan for committing suicide.
B. The symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas
of functioning.
C. The episode is not attributable to the physiological effects of
a substance or to another medical condition
A. Criteria have been met for at least one manic
episode
B. Not better explained by schizoaffective disorder,
schizophrenia, schizophreniform disorder,
delusional disorder, or other specified or
unspecified schizophrenia spectrum and other
psychotic disorder
 With anxious distress
 With mixed features
 With rapid cycling
 With melancholic features
 With atypical features
 With mood-congruent psychotic features
 With mood-incongruent psychotic features
 With catatonia
 With peripartum onset
 With seasonal pattern
Bipolar I Disorder, Single Manic Episode.
 Patients must be experiencing their first manic
episode.

Bipolar I Disorder, Recurrent

 Manic episodes are considered distinct when they
are separated by at least 2 months without
significant symptoms of mania or hypomania.
 General description
 Excited, talkative, sometimes amusing, and frequently
hyperactive
 Grossly psychotic and disorganized

 Mood, Affect, and Feelings

 Euphoric, irritable,
 Low frustration tolerance – w/c leads to feelings of
anger and hostility
 Emotionally labile
 Speech
 Cannot be interrupted
 As the mania gets more intense, speech becomes louder,
more rapid, and difficult to interpret
 As the activated state increases, their speech is filled
with puns, jokes, rhymes, plays on words, and
irrelevancies.
 At a still greater activity level, associations become
loosened, the ability to concentrate fades, and flight of
ideas, clanging, and neologisms appear.
 Perceptual disturbances
 Delusions occur in 75 % of all manic patients
 Mood-congruent manic delusions are often concerned
with great wealth, extraordinary abilities, or power.
 Bizarre and mood-incongruent delusions and
hallucinations also appear in mania.
 Thought
 Content: self-confidence and self-importance
 Form: unrestrained and accelerated flow of ideas
 Sensorium and Cognition.
 Orientation and memory are intact
 May answer questions testing orientation incorrectly
 Impulse control
 75% are assaultive or threatening
 Attempt suicide and homicide
 Judgment and insight
 Impaired judgment is a hallmark of manic patients.
 Have little insight into their disorder.
 Reliability
 Unreliable in their information
 Because lying and deceit are common in mania
 Same for MDD when it has MDE
 When a patient is manic,
 Bipolar I disorder,
 Bipolar II disorder,
 Cyclothymic disorder,
 Mood disorder caused by a GMC,
 Substance-induced mood disorder
 Goals
 patient’s safety
 Complete diagnostic evaluation of the patient
 Treatment plan that addresses not only the
immediate symptoms but also the patient’s
prospective well-being
 Hospitalization
 Pharmacotherapy
 Psychosocial Therapy
 Pharmacotherapy
 Objective is symptom remission, not just symptom
reduction.
 Has two phases
 Acute phase
 Maintenance phases
Treatment Of Acute Mania
 Alone or in combination
 Lithium Carbonate
 Therapeutic lithium levels are between 0.6 and 1.2
mEq/L.
 Valproate
 750 to 2,500 mg per day, achieving blood levels
between 50 and 120 μg/mL.
 Rapid oral loading with 15 to 20 mg/kg of from day 1 of
treatment
 Carbamazepine and Oxcarbazepine
 600 and 1,800 mg per day associated with blood levels
of between 4 and 12 μg/mL
Treatment Of Acute Mania
 Clonazepam and Lorazepam
 Atypical and Typical Antipsychotics
 Olanzapine, Risperidone, Quetiapine, Ziprasidone, and
Aripiprazole
Treatment Of Acute Bipolar Depression
 Antidepressant drugs are often enhanced by a mood
stabilizer in the first-line treatment
 Combination of olanzapine and fluoxetine
 Lamotrigine or low-dose ziprasidone (20 to 80 mg
per day)
 Electroconvulsive therapy (ECT)
Maintenance Treatment Of Bipolar Disorder
 Lithium
 Carbamazepine
 Valproic acid,
 Lamotrigine has prophylactic antidepressant
 Thyroid supplementation
Course
 Starts with depression (75% in women and 67% in
men ) and recurring disorder
 10-20 % experience only manic episodes
 Untreated manic episode lasts about 3 months
 Of persons who have a single manic episode, 90 %
are likely to have another.
 As the disorder progresses, the time between
episodes often decreases.
 5-15% rapid cyclers
Prognosis
 Poorer prognosis than MDD
 40-50% have 2nd manic episode within 2 years
 7 % do not have a recurrence of symptoms
 45 % have more than one episode,
 40 % have a chronic disorder.
 40 % of all patients have >10 episodes
 On long term follow-up:
 15 % of all patients with bipolar I disorder are
well,
 45 % are well but have multiple relapses,
 30 % are in partial remission, and
 10 % are chronically ill.
 1/3rd of all patients with bipolar I disorder
have chronic symptoms and evidence of
significant social decline.
Poor prognosis indicators:
 Premorbid poor occupational status,
 Alcohol dependence,
 Psychotic features,
 Depressive features,
 Inter-episode depressive features,
 Male gender
Factors predicting better outcome:
 Short duration of manic episodes,
 Advanced age of onset,
 Few suicidal thoughts,
 Few coexisting psychiatric or medical problems
 Early age of onset
 Psychotic depression before 25 years of age
 Postpartum depression especially one with
psychotic features
 Rapid onset and offset of depressive episodes of
short duration (<3 months)
 Recurrent depression ( >5 episodes)
 Depression with marked psychomotor retardation
 Atypical features (reverse vegetative signs)
 Seasonality
 Bipolar family history
 Hypomania associated with antidepressants
 Repeated (at least 3 times) loss of efficacy of
antidepressants after initial response
 Depressive mixed state
Bipolar II disorder
 Requiring the lifetime experience of at least one
episode of major depression and at least one
hypomania episode.
A. Criteria have been met for at least one hypomania
episode and at least one major depressive episode
B. There has never been a manic episode.
C. Not better explained by schizophrenia spectrum and
other psychotic disorder.
D. Causes clinically significant distress or impairment
in social, occupational, or other important areas of
functioning.
 Hypomanic

 Depressed
 With anxious distress
 With mixed features
 With rapid cycling
 With mood-congruent psychotic features
 With mood-incongruent psychotic features
 With catatonia
 With peripartum onset
 With seasonal pattern – Applies only to the pattern
of major depressive episodes.
Risk factors:
 Family history of bipolar II disorders
 Genetic factors
Course modifiers:
 A rapid-cycling pattern is associated with a poorer
prognosis
 Return to previous level of social function is more
likely for individuals of younger age and with less
severe depression
Factors associated with functional recovery:
 More education
 Fewer years of illness
 Being married
 Patterns of illness and comorbidity seem to differ
by gender
 Females are more likely than males to report
hypomania with mixed depressive features and a
rapid-cycling course.
 Approx. 1/3rd report a lifetime history of suicide
attempt
 Lifetime attempted suicide in bipolar II and bipolar
I disorder is 32.4% and 36.3% respectively.
 Major depressive disorder
 Cyclothymic disorder.
 Schizophrenia spectrum and other related psychotic
disorders
 Panic disorder or other anxiety disorders.
 Substance use disorders
 Attention-deficit/hyperactivity disorder.
 Personality disorders
 Other bipolar disorders.
 60% have 3 or more co - occurring mental disorders
 75% have anxiety disorder
 37% have substance use disorder
 14% have at least one lifetime eating disorder
 Diagnosis is stable because there is a high
likelihood that patients will have the same
diagnosis up to 5 years later.
 Chronic disease that requires long-term treatment
strategies.
Cyclothymic Disorder
 Mild form of bipolar II disorder

 “chronic, fluctuating mood disturbance” with

many periods of hypomanic symptoms and periods
of depressive symptoms
 Life time prevalence is 0.4% - 1%
 3 to 5 % of all psychiatric outpatients
 Equally common in females and males
 Coexists 10 and 20 % of outpatient and inpatients
with borderline personality disorder respectively
 50 – 75 % have onset between 15 and 25 years
 Biological factors
 +ve family history of bipolar I disorder – 30%
 Psychosocial factors
 Traumas and fixations during the oral stage
 ego’s attempt to overcome a harsh and punitive
superego
A. For at least 2 years (at least 1 year in children and
adolescents) there have been numerous periods with
hypomania symptoms that do not meet criteria for a
hypomania episode and numerous periods with depressive
symptoms that do not meet criteria for a major depressive
episode.
B. During the above 2-year period (1 year in children and
adolescents), the hypomania and depressive periods have
been present for at least half the time and the individual
has not been without the symptoms for more than 2
months at a time.
C. Criteria for a major depressive, manic, or
hypomania episode have never been met.

D. Not better explained by schizophrenia spectrum and

other psychotic disorder.

E. Not attributable to the physiological effects of a

substance or another medical condition

F. Cause clinically significant distress or impairment

in social, occupational, or other important areas of
functioning
 Bipolar and related disorder due to AMC
 Depressive disorder due to AMC
 Substance/medication-induced bipolar and related
disorder
 Substance/medication-induced depressive disorder
 Bipolar I disorder, with rapid cycling,
 Bipolar II disorder, with rapid cycling.
 Personality disorders like Borderline, antisocial,
histrionic, and narcissistic
 ADHD
 Some patients are having been sensitive,
hyperactive, or moody as young children
 Onset – insidiously in the teens or early 20s.
 Patients with adaptive coping strategies have better
outcome
 About 1/3rd develop a major mood disorder, most
often bipolar II disorder
 Biological therapy
 Mood stabilizers and antimanic drugs – 1st line
 Antidepressant – should be with caution
 Psychosocial therapy
 Directed toward increasing patients’ awareness of their
condition and helping them develop coping mechanisms
for their mood swings
 Family and group therapies
 Patients often require lifelong treatment because of long
term nature of the disorder
Substance/Medication-Induced
Bipolar and Related Disorder
A. A prominent and persistent disturbance in mood
that predominates in the clinical picture and is
characterized by elevated, expansive, or irritable
mood, with or without depressed mood, or
markedly diminished interest or pleasure in all, or
almost all, activities.
B. Evidence from the history, physical examination, or
laboratory findings of both (1)and (2):
1. The symptoms in Criterion A developed during or soon
after substance intoxication or withdrawal or after
exposure to a medication.
2. The involved substance/medication is capable of
producing the symptoms in Criterion A.
C. Not better explained by a bipolar or related disorder
that is not substance/medication-induced
D. Does not occur exclusively during the course of a
delirium.
E. Causes clinically significant distress or impairment
in social, occupational, or other important areas of
functioning.
 With onset during intoxication:
 If the criteria are met for intoxication with the substance
and the symptoms develop during intoxication.

 With onset during withdrawal:

 If criteria are met for withdrawal from the substance
and the symptoms develop during, or shortly after,
withdrawal.
Bipolar And Related Disorder
Due To Another Medical
Condition
A. Prominent and persistent period of abnormally
elevated, expansive, or irritable mood and
abnormally increased activity or energy that
predominates in the clinical picture.
B. Evidence from the history, physical examination, or
laboratory findings that the disturbance is the direct
pathophysiological consequence of another medical
condition.
C. Not better explained by another mental disorder.
D. Does not occur exclusively during the course of a
delirium.
E. Causes clinically significant distress or impairment
in social, occupational, or other important areas of
functioning, or necessitates hospitalization to
prevent harm to self or others, or there are
psychotic features.
 With manic features
 With manic- or hypomanic-like episode
 With mixed features
Other Specified Bipolar and
Related Disorder
 Presentations in which symptoms characteristic of a
bipolar and related disorder that cause clinically
significant distress or impairment in social,
occupational, or other important areas of
functioning predominate but do not meet the full
criteria for any of the disorders in the bipolar and
related disorders diagnostic class
 Used in situations in which the clinician chooses to
specify the reason that the criteria are not met for a
specific bipolar and related disorder,
1. Short-duration hypomanic episodes (2-3 days) and
MDE
2. Hypomanic episodes with insufficient symptoms
and major depressive episodes
3. Hypomanic episode without prior MDE
4. Short-duration cyclothymia (less than 24 months)
(less than 12 months for children and adolescents)
 Presentations in which symptoms characteristic of a
bipolar and related disorder that cause clinically
significant distress or impairment in social,
occupational, or other important areas of
functioning predominate but do not meet the full
criteria for any of the disorders in the bipolar and
related disorders diagnostic class
 Used in situations in which the clinician chooses
not to specify the reason that the criteria are not
met for a specific bipolar and related disorder,
 Includes presentations in which there is insufficient
information to make a more specific diagnosis
(e.g., in emergency room settings)