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1. Bipolar disorder
Dr. Abdirahim

2. Bipolar Disorder’s Criteria
• According to the American
Psychiatric Association’s
Diagnostic and Statistical
Manual of Mental Disorders,
fourth edition (DSM-IV);
“Bipolar Disorder is
characterized by the
occurrence of one or more
Major Depressive Episodes
accompanied by at least one
Manic Episode.”

3. What Is Bipolar Disorder?
• A mood disorder that alters:
Feelings
Thoughts
Behaviors
Perceptions
(Within episodes of mania and depression)
 Bipolar Disorder is previously known as Manic Depression

4. Characteristics of Mania
• Feeling of being able to do anything
• Little sleep is needed
• Feeling filled with energy
• Not caring about financial situations
• Delusions
• Substance abuse
• The DSM-IV has a list of symptoms and three or more must be present.

5. Characteristics of Hypomania
• Feeling of creativity
• Don’t worry about problems seriously
• Feeling as if nothing can bring you down
• Have confidence in yourself
• Similar to Mania except Hypomania is of lesser intensity

6. Characteristics of Depression
• Sleep more than you normally would
• Feeling of tiredness
• Crying uncontrollably
• Withdrawing from activities you once enjoyed
• Staying in bed for days
• Weight Loss/Weight Gain
• The DSM-IV has a list of symptoms and five or more must be present
during the same two week period.

7. The Two Sides of Bipolar Disorder
• Bipolar I
• Episodes of full mania
alternating with episodes of
major depression
• Diagnosed in patients
typically in early 20’s
• Bipolar II
• Episodes of major
depression and hypomania

8. Bipolar Disorder
Difficulties
(Griswold, 2000)
Children
Hyperactivity is most
Common; Makes BP
Difficult to diagnose
Adolescents
Symptoms similar to adults
Psychosis can be a
Presentation of BP.
Substance abuse can be
Present which makes
Diagnosis difficult
Pregnancy
Planning of pregnancy is a
Necessity because of
Medication
Rapid cycling could occur

9. • Hypomania literally means mild mania. Decreased need for sleep and
lack of daytime fatigue are red flags. The symptoms are the same as for a
Manic Episode. To differentiate from manic, consider the length of time
and severity of the impairment. Hypomania is characterized by a CHANGE
in functioning that is uncharacteristic and observable to others, whereas
mania causes marked IMPAIRMENT in functioning.
• Individuals in a hypomanic state don’t usually view it as bad, and may feel
more confident, more gregarious or outgoing, or more energetic.
• Not likely to get treatment, or even to be recognized as pathological. A
state likely missed in initial diagnosis (the individual may not even
remember hypomania).
• In addition to looking for a decreased need for sleep and lack of daytime
fatigue, also ask about periods where the person feels really good, can
conquer the world, is going to have great things happen, etc. And the flip
side… inquire about periods of time where they may be irritable, have lots
of thoughts going through head, need to get lots of things accomplished,
and feel that others are moving too slowly.

10. What Causes Bipolar?
• No single cause may ever be found for bipolar disorder.
Among the biological factors observed in bipolar disorder,
as detected by using imaging cans and other tests, are the
following:
– Over secretion of cortisol, a stress hormone.
– Excessive influx of calcium into brain cells.
– Abnormal hyperactivity in parts of the brain associated with
emotion and movement coordination and low activity in parts of
the brain associated with concentration, attention, inhibition,
and judgment. (Well Connected, 2002)

11. How Serious is Bipolar Disorder?
According to Well-Connected, 2002:
• Risk for Suicide
– An estimated 15-20% of patients who suffer from bipolar
disorder and do not receive medical attention commit suicide.
• In a 2001 study of Bipolar I disorder, more than 50% of patients
attempted suicide; the risk was highest during depressive episodes.
• Patients with mixed mania, and possible when it is marked by
irritability and paranoia, are also at particular risk.
• Many young children with bipolar disorder are more severely ill than
are adults with the disorder. According to a study in 2001, 25% of
children with the disorder are seriously suicidal.

12. 12
Diagnosis
NIMH (2007)

13. 13
DSM-5 Diagnosis
• Manic Episode Criteria
– 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:
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep
3. Pressured speech or more talkative than usual
4. Flight of ideas or racing thoughts
5. Distractibility
6. Psychomotor agitation or increase in goal-directed
activity
7. Hedonistic interests
APA (2013

14. 14
Diagnosis: Manic Symptoms at School
Symptom/Definition Example
Euphoria: Elevated (too happy, silly,
giddy) and expansive (about everything)
mood, “out of the blue” or as an
inappropriate reaction to external events
for an extended period of time.
A child laughs hysterically
for 30 minutes after a
mildly funny comment by a
peer and despite other
students staring at him.
Irritability: Energized, angry, raging, or
intensely irritable mood, “out of the blue”
or as an inappropriate reaction to external
events for an extended period of time.
In reaction to meeting a
substitute teacher, a child
flies into a violent 20-
minute rage.
Inflated Self-Esteem or Grandiosity:
Believing, talking or acting as if he is
considerably better at something or has
special powers or abilities despite clear
evidence to the contrary
A child believes and tells
others she is able to fly
from the top of the school
building.
From Lofthouse & Fristad (2006, p. 215)

15. 15
Diagnosis: Manic Symptoms at School
Symptom/Definition Example
Decreased Need for Sleep:
Unable to fall or stay asleep or
waking up too early because of
increased energy, leading to a
significant reduction in sleep yet
feeling well rested.
Despite only sleeping 3 hours the
night before, a child is still
energized throughout the day
Increased Speech: Dramatically
amplified volume, uninterruptible
rate, or pressure to keep talking.
A child suddenly begins to talk
extremely loudly, more rapidly, and
cannot be interrupted by the teacher
Flight of Ideas or Racing
Thoughts: Report or observation
(via speech/writing) of speeded-
up, tangential or circumstantial
thoughts
A teacher cannot follow a child’s
rambling speech that is out of
character for the child (i.e., not
related to any cognitive or language
impairment the child might have)
From Lofthouse & Fristad (2006, p. 215)

16. 16
Diagnosis: Manic Symptoms at School
Symptom/Definition Example
Distractibility: Increased
inattentiveness beyond child’s
baseline attentional capacity.
A child is distracted by sounds
in the hallway, which would
typically not bother her.
Increase in Goal-Directed Activity
or Psychomotor Agitation: Hyper-
focused on making friends, engaging
in multiple school projects or hobbies
or in sexual encounters, or a striking
increase in and duration of energy..
A child starts to rearrange the
school library or clean
everyone’s desks, or plan to
build an elaborate fort in the
playground, but never finishes
any of these projects.
Excessive Involvement in
Pleasurable or Dangerous
Activities: Sudden unrestrained
participation in an action that is likely
to lead to painful or very negative
consequences.
A previously mild-mannered
child may write dirty notes to the
children in class or attempt to
jump out of a moving school
bus.
From Lofthouse & Fristad (2006, p. 215)

17. Treatment of Bipolar Disorder
(a four phase process)
Evaluation and diagnosis of presenting
symptoms
Acute care and crisis stabilization for psychosis
or suicidal or homicidal ideas or acts
Movement toward full recovery from a
depressed or manic state
Attainment and maintenance of euthymia
 This four phase process was according to (Himanshu P. Upadhyaya, MBBS, MS.,2002)

18. Treatments
• Inpatient Care
• Assess the patient
• Diagnose the condition
• Ensure safety of patient and others
– This care is necessary for:
» Psychotic features
» Suicidal or homicidal ideations

19. Treatments
• Antidepressant therapy
• Mood stabilizer
– Lithium carbonate
– Sodium divalproex
– Carbamazepine
• Antipsychotic Agents
– Risperidone
– Haloperidol

20. Treatments
• Electroconvulsive therapy (ECT)
– Inpatient basis
– Severe cases
– Patient requires hospitalization often
• Faster than medications for therapeutic responses
• Memory loss before and after treatments
• 3-8 sessions
• Medications are still required in maintenance phase of
treatment

21. Mood Stabilizers
(Upadhyaya,2002)
Mood Stabilizer Common Adverse
Effects
Doses Special Concerns
Lithium carbonate
(Eskalith CR,
Lithobid)
Lethargy or sedation,
tremor, enuresis,
weight gain, overt
hypothroidism occurs
in 5-10% of patients
300-600 PO tid/qid
Must be adjusted by
monitoring serum
level and patient
response
Hypothyroidism,
diabetes insipidus,
polyuria, polydipsia
Sodium divalproex/
valproic acid
(Depakote,
Depakene)
Sedation, platelet
dysfunction, liver
disease, weight gain
10-20 mg/kg/d
Must be adjusted by
monitoring serum
levels
Elevated liver
enzymes or liver
disease, bone
marrow suppression
Carbamazepine
(Tegretol)
Suppressed WBS,
dizziness,
drowsiness, rashes,
liver toxicity(rarely)
200 mg PO bid Must
be adjusted by
monitoring serum
blood levels
Drug-Drug
interactions, bone
marrow suppression

22. Mood Stabilizers Cont…
Gabapentin
(Neurontin)
Headache,
fatigue, ataxia,
dizziness,
sedation, weight
gain
Not established Withdrawal
seizures
Lamotrigine
(Lamictal)
Sedation,
dizziness, nausea
or emesis, diplopia,
ataxia, headache,
sleep disruption,
benign rash
Not established Stevens-
Johnson
syndrome
Topiramate
(Topamax)
Nephrolithiasis,
psychomotor
slowing,
somnolence
Not established Decrease doses
in liver or renal
impairment