2. Epidemiology
The lifetime prevalence is 0.4-1.6%.
The lifetime prevalence in monozygotic
twin of patients is up to 90%.
Male to Female ratio 1:1.
Manic episode: more in males.
Depressive episode: more in females.
3. Diagnosis
Presence of one or more manic episodes with or without
presence of major depressive episodes.
Manic episode:
Elated mood or irritable mood for one week or more.
If mood is elated (3) or more of the following must be present but
if mood is irritable (4) or more of the following must be present:
Inflated self-esteem or grandiosity.
Decreased need for sleep.
More talkative than usual.
Flight of ideas.
Distractability.
psychomotor agitation.
Loss of normal social and sexual inhibition.
Excessive involvement in pleasurable activities that have a high potential for
painful consequences.
Not substance-induced or not due to general medical condition.
Significant impairment of occupational and social functioning.
4. Aetiology
1) Neurotransmitter hypothesis: increased activity of biogenic
amines serotonin, norepinephrine, and dopamine.
2) Genetic theory:
Increase the incidence of bipolar I disorder in subjects related to
an affected person.
Associations between bipolar I disorder and genetic markers
have been reported for chromosomes 5, 11, X.
3) Brain structure theory:
Some patients showed enlarged cerebral ventricles.
Magnetic resonance spectroscopy showed abnormal regulation
of membrane phospholipid metabolism.
4) Psychosocial theory:
o Feeling of inadequacy and worthlessness are converted by
means of denial, reaction formation and projection to grandiose
delusions.
5. Differential diagnosis
1. Bipolar II disorder:
Major depressive episodes with hypomanic episodes.
2. Cyclothymic disorder:
Numerous episodes of hypomania and numerous
episodes of depressive symptoms for at least 2 years.
The symptoms are not sufficient to diagnose manic
episodes or major depressive episodes.
Significant social and occupational impairment.
3. Secondary mood disorder:
Substance-induced mood disorder.
Mood disorder due to general medical condition.
7. Psychopharmacotherapy
A. For manic episodes: “Mood stabilizers”
1)Lithium:
It is the standard treatment of bipolar disorder.
Therapeutic blood level is 0.8-1.2 mEq/litre.
Toxic levels start after 1.5 mEq/litre.
2)Anti-convulsants:
Valproate, Carbamazepine, oxacarbazepine,....
3)Atypical antipsychotics:
All except Clozapine.
8. B. For major depressive episode:
Lamotrigine
Olanzapine plus Flouxetine “Symbyax”
Quetiapine
Antidepressant drugs should be used with
caution to avoid switching to mania.
9. Electroconvulsive therapy
At least equal to lithium in the treatment of acute and
severe manic episodes.
Limited to:
1. Acute suicide.
2. Severe mania with psychotic symptoms.
3. Catatonia.
4. Failure of medical ttt “Resistent Bipolar”.
10. Psychotherapy
1) Cognitive therapy: to increase compliance with
pharmacotherapy.
2) Supportive therapy: with chronic patients who
may have significant interepisodic residual
symptoms and social dysfunction.
3) Family therapy: if patient’s disorder is disrupting
the family stability, and because the disorder is
strongly familial.