Medical overview of bipolar disorder

1. BIPOLAR DISORDER
Bipolar disorder, previously known as manic
depression, is a mental disorder characterized
by periods of depression and periods of
abnormally elevated mood that last from days to
weeks each

2. Psychoanalytic Approach
The psychoanalytic
approach to bipolar
disorder says that the cause
of both manic/depressive
episodes arise from a low
self-concept.
Depressive episodes
represent this, while manic
episodes represent a
defense against the low
self- concept.

3. Trait Approach
 Mania:
Excessive happiness
Irritability
Less need for sleep
Racing thoughts
Increased energy
Depression:
Sadness
Loss of energy,
Increased need for sleep
Change in appetite
Thoughts of death/suicide

4. Biological Approach
The biological approach to bipolar disorder suggests
that high or low levels of neurotransmitters such as
dopamine, serotonin, or norepinephrine is the cause.

5. Humanistic Approach
The humanistic approach
suggests that bipolar disorder
occurs when circumstances
stop or hinder a person and
force them to loose there
drive toward self-
actualization, and the ultimate
fulfillment of one’s dreams,
desires, and potential.

6. Behavioral and Social Learning Approach
The behavioral/social
learning approach to
bipolar disorder
suggests that these
behaviors are learned
and therefore can be
unlearned.

7. Cognitive Approach
Individuals in a manic phase often have
grandiose thoughts, such as one being capable
of doing anything.
Those in a depressive phase often have self-
deprecating thoughts, such as “I am terrible at
this, or why can’t I do anything right?”

8. Etiology and Risk Factors
Brain Structure and Functioning:
Some studies indicate that the brains of people with
bipolar disorder may differ from the brains of people
who do not have bipolar disorder or any other mental
disorder. Learning more about these differences may
help scientists understand bipolar disorder and
determine which treatments will work best. At this
time, health care providers base the diagnosis and
treatment plan on a person’s symptoms and history,
rather than brain imaging or other diagnostic tests.

9. Etiology and Risk Factors
Genetics:
Some research suggests that people with certain genes are
more likely to develop bipolar disorder. Research also shows
that people who have a parent or sibling with bipolar disorder
have an increased chance of having the disorder themselves.
Studies of identical twins have shown that the twin of a
person with bipolar illness does not always develop the
disorder. The study results suggest factors besides genes are
also at work.
Many genes are involved, and no one gene can cause the
disorder. Learning more about how genes play a role in
bipolar disorder may help researchers develop new treatments.

10. Who Is At Risk?
 Bipolar disorder often develops in a person's
late teens or early adult years. At least half of
all cases start before age 25.
 Some people have their first symptoms during
childhood, while others may develop
symptoms late in life.

11. Prevalence
 No data on the prevalence of preadolescent
bipolar disorder
 Lifetime prevalence among 14 to 18 year olds, 1%
Subsyndromal symptoms, 5.7%
 Main age of onset of type-I bipolar disorder (BPD)
typically averages 12-24 years, is older among patients
with type-II BPD
 First episode usually depression

12. Epidemiology
 Bipolar disorder affects men and women equally, as
well as all races, ethnic groups, and socioeconomic
classes.
 Bipolar disorder often develops in a person's late
teens or early adult years. At least half of all cases
start before age 25.
 However, some people have their first symptoms
during childhood, while others may develop

13. Symptoms
 People with bipolar disorder experience unusually
intense emotional states that occur in distinct
periods called "mood episodes" An overly joyful or
overexcited state is called a manic episode, and an
extremely sad or hopeless state is called a
depressive episode
 Sometimes, a mood episode includes symptoms of
both mania and depression. This is called a mixed
state

14. Symptoms
 In addition to mania and depression, bipolar
disorder can cause a range of moods, as shown on
the scale.
A person having a hypomanic episode may feel very good, be highly productive,
function well, and may not feel that anything is wrong even as family and friends
recognize the mood swings. Without proper treatment, however, people with
hypomania may develop severe mania or depression.

15. Symptoms of Mania and Hypomania
• Abnormally upbeat, jumpy or wired
• Increased activity, energy or agitation
• Exaggerated sense of well-being and self-
confidence (euphoria)
• Decreased need for sleep
• Unusual talkativeness
• Racing thoughts
• Distractibility
• Poor decision-making — for example, going on
buying sprees, taking sexual risks or making foolish
investments

16. Symptoms of Depression
• Depressed mood, such as feeling sad, empty, hopeless or tearful
(in children and teens, depressed mood can appear as irritability)
• Marked loss of interest or feeling no pleasure in all — or almost
all — activities
• Significant weight loss when not dieting, weight gain, or
decrease or increase in appetite (in children, failure to gain
weight as expected can be a sign of depression)
• Either insomnia or sleeping too much
• Either restlessness or slowed behavior
• Fatigue or loss of energy
• Feelings of worthlessness or excessive or inappropriate guilt
• Decreased ability to think or concentrate, or indecisiveness
• Thinking about, planning or attempting suicide

17. Bipolar and Psychosis
• Sometimes, a person with severe episodes of mania
or depression may experience psychotic symptoms,
such as hallucinations or delusions.
• The psychotic symptoms tend to match the person’s
extreme mood and they are called congruent
For example:
People having psychotic symptoms during a manic episode may have the
unrealistic belief that they are famous, have a lot of money, or have special
powers.
People having psychotic symptoms during a depressive episode may falsely
believe they are financially ruined and penniless, have committed a crime, or
have an unrecognized serious illness.

18. As a result, people with bipolar disorder who also
have psychotic symptoms are sometimes incorrectly
diagnosed with schizophrenia. When people have
symptoms of bipolar disorder and also experience
periods of psychosis that are separate from mood
episodes, the appropriate diagnosis may be
schizoaffective disorder.
Bipolar and Psychosis

19. Manic Episodes
• Mania involves an increase in energy of psychomotor activity
• Mania can also present with increased self-esteem or grandiosity, racing thoughts, pressured
speech that is difficult to interrupt, decreased need for sleep, disinhibited social behavior,
increased goal-oriented activities and impaired judgment
• Exhibition of behaviors is impulsive or high-risk: hypersexuality or excessive spending
• To meet the definition for a manic episode, these behaviors must impair the individual's
ability to socialize or work
• If untreated, a manic episode usually lasts three to six months
• In severe manic episodes, a person can experience psychotic symptoms, where thought
content is affected along with mood
• The severity of manic symptoms can be measured by rating scales such as the Young Mania
Rating Scale
• The onset of a manic or depressive episode is often foreshadowed by sleep disturbance
• Mood changes, psychomotor and appetite changes, and an increase in anxiety can also occur
up to three weeks before a manic episode develops
• Manic individuals often have a history of substance abuse developed over years as a form of
"self-medication"

20. Hypomanic Episodes
• Hypomania is the milder form of mania, defined as at least four days of the same criteria as
mania, but which does not cause a significant decrease in the individual's ability to
socialize or work, lacks psychotic features such as delusions or hallucinations and does not
require psychiatric hospitalization.
• Overall functioning may actually increase during episodes of hypomania and is thought to
serve as a defense mechanism against depression by some.
• Hypomanic episodes rarely progress to full-blown manic episodes. Some people who
experience hypomania show increased creativity while others are irritable or demonstrate
poor judgment.
• Hypomania may feel good to some persons who experience it, though most people who
experience hypomania state that the stress of the experience is very painful.
• Bipolar people who experience hypomania tend to forget the effects of their actions on
those around them. Even when family and friends recognize mood swings, the individual
will often deny that anything is wrong.
• If not accompanied by depressive episodes, hypomanic episodes are often not deemed
problematic, unless the mood changes are uncontrollable, or volatile.
• Most commonly, symptoms continue for a few weeks to a few months

21. Depressive Episodes
• Symptoms of the depressive phase of bipolar disorder include
persistent feelings of sadness, irritability or anger, anhedonia,
excessive or inappropriate guilt, hopelessness, sleeping too
much or not enough, changes in appetite and/or weight, fatigue,
problems concentrating, self-loathing or feelings of worthlessness,
and thoughts of death or Suicide.
• The earlier the age of onset, the more likely the first few episodes
are to be depressive.
• For most people with bipolar types 1 and 2, the depressive episodes
are much longer than the manic or hypomanic episodes.
• Since a diagnosis of bipolar disorder requires a manic or
hypomanic episode, many affected individuals are
initially misdiagnosed as having major depression and incorrectly
treated with prescribed antidepressants.

22. Mixed Affective Episodes
• In bipolar disorder, a mixed state is an episode during which
symptoms of both mania and depression occur simultaneously.
• Individuals experiencing a mixed state may have manic symptoms
such as grandiose thoughts while simultaneously experiencing
depressive symptoms such as excessive guilt or feeling suicidal.
• They are considered to have a higher risk for suicidal behavior as
depressive emotions such as hopelessness are often paired
with mood swings or difficulties with impulse control.
• Anxiety disorders occur more frequently a comorbidity in mixed
bipolar episodes than in non-mixed bipolar depression or mania.
• Substance abuse (including alcohol) also follows this trend,
thereby appearing to depict bipolar symptoms as no more than a
consequence of substance abuse.

23. Types of Bipolar
 Bipolar disorder usually lasts a lifetime.
Episodes of mania and depression typically
come back over time. Between episodes,
many people with bipolar disorder are free of
symptoms, but some people may have
lingering symptoms
 There are four basic types of bipolar disorder

24. Types of Bipolar
1. Bipolar I Disorder is mainly defined by manic or mixed
episodes that last at least seven days, or by manic symptoms
that are so severe that the person needs immediate hospital
care. Usually, the person also has depressive episodes,
typically lasting at least two weeks. The symptoms of mania
or depression must be a major change from the person's
normal behavior.
2. Bipolar II Disorder is defined by a pattern of depressive
episodes and hypomanic episodes, but not the full-blown
manic episodes that are typical of Bipolar I Disorder

25. 3. Bipolar Disorder Not Otherwise Specified (BP-NOS) is
diagnosed when a person has symptoms of the illness that
do not meet diagnostic criteria for either bipolar I or II. The
symptoms may not last long enough, or the person may have
too few symptoms, to be diagnosed with bipolar I or II.
However, the symptoms are clearly out of the
person's normal range of behavior
4. Cyclothymic Disorder or Cyclothymia, is a mild form of
bipolar disorder. People who have cyclothymia have
episodes of hypomania that shift back and forth with mild
depression for at least two years.
Types of Bipolar

26. Seasonal Affective Disorder (SAD)
Seasonal changes in bipolar disorder
In some people with bipolar disorder, spring
and summer can bring on symptoms of mania
or a less intense form of mania (hypomania),
and fall and winter can be a time of depression

27. Bipolar and Comorbidity
o Anxiety disorders
o Eating disorders
o Attention-deficit/hyperactivity disorder
(ADHD)
o Alcohol or drug problems
o Physical health problems, such as heart
disease, thyroid problems, headaches or
obesity

28. Suicide Risk
 The prevalence rates of attempted suicide in
bipolar II and bipolar I disorder appear to be
similar (32.4% and 36.3%)
 However, the lethality of attempts, may be higher
in individuals with bipolar II disorder compared
with bipolar I disorder

29. Treatments
 Medications
Mood stabilizing medications are usually the first
choice to treat bipolar disorder.
Lithium; Valproate; Carbamazepine; Lamotrigine
Antipsychotic medications: Typical or Atypical.
 Risperidone; Quetiapine; Haloperidol;
Olanzapine; Aripiprazole.
Antidepressant medications
SSRI; SNRI; TCA and etc.

30. Nonpharmacological Treatment
 Psychotherapy
🞑 In addition to medication, psychotherapy, or "talk" therapy,
can be an effective treatment for bipolar disorder. It can
provide support, education, and guidance to people with
bipolar disorder and their families.
 Cognitive behavioral therapy (CBT)
 Family-focused therapy
 Psychoeducation

31. Other Treatment Options
 Electroconvulsive Therapy (ECT) - For cases in which
medication and/or psychotherapy does not work,
electroconvulsive therapy (ECT) may be useful.
 Transcranial magnetic stimulation (TMS): is a newer
approach to brain stimulation that uses magnetic waves. It is
delivered to an awake patient most days for 1 month.
Research shows that TMS is helpful for many people with
various subtypes of depression, but its role in the treatment of
bipolar disorder is still under study.
 Supplements: Although there are reports that some
supplements and herbs may help, not enough research has
been conducted to fully understand how these supplements
may affect people with bipolar disorder.

32. Rapid Cycling Bipolar Disorder
 Rapid cycling is a pattern of frequent, distinct episodes
in bipolar disorder.
 In rapid cycling, a person with the disorder experiences
four or more episodes of mania or depression in one
year.
 It can occur at any point in the course of bipolar
disorder, and can come and go over many years
depending on how well the illness is treated; it is not
necessarily a "permanent" or indefinite pattern of
episodes.

33. How is it treated
Because symptoms of depression dominate in
most people with a rapid cycling course of
bipolar disorder, treatment is usually aimed
toward stabilizing mood, mainly by relieving
depression while preventing the comings-and-
goings of new episodes.

34. Rapid Cycling Bipolar Treatment
 Antidepressants such as Fluoxetine, Paroxetine and Sertraline have not been
shown to treat the depression symptoms of rapid cycling bipolar disorder, and may
even increase the frequency of new episodes over time. Many experts therefore
advise against the use of antidepressants (especially long term) in bipolar patients
with rapid cycling.
 Mood-stabilizing drugs – such as Carbamazepine, Lamotrigine, Lithium,
and Valproate are the core treatments of rapid cycling. Often, a single mood
stabilizer is ineffective at controlling episode recurrences, resulting in a need for
combinations of mood stabilizers.
 Several antipsychotic medicines such as Olanzapine or Quetiapine also have been
studied in rapid cycling and are used as part of a treatment regimen, regardless of
the presence or absence of psychosis.
P.S. Treatment with mood stabilizers is usually continued (often indefinitely) even
when a person is symptom-free. This helps prevent future episodes. Antidepressants,
if and when used, are generally tapered as soon as depression is under control.