BIPOLAR DISORDER

MANIA
Reverse of depression
Without significant psychosocial impairment-hypomania

CLINICAL FEATURES
Mood euphoria, irritability
Appearance
Behavior overactiity, distractibility, socially inappropriate
behavior, reduced sleep, increased appetite, increased
libido
Thinking and speech flight of ideas, expansive ideas,
grandiose delusion, hallucination
Impaired insight

CLINICAL PATTERNS
Hypomania manic symptoms present and noticeable,
but no serious degree of impairment
Mild mania physical activity, speech increased, mood
labile, euphoric at a time irritabile, ideas are expansive.
Significant social impairment
Moderate mania marked overactivity with pressure,
disorganization speech, euphoric mood increasingly
interrupted by period of iriitabilitym hostility and
depression, delusion
Severe mania frenzied overactivity, thinking is
incoherent, delusion become bizarre, hallucination
experienced, patient become immobile, mute (manic
stupor)

DSM IV CRITERIA
Increase mood + 3/7, irritable + 4/7 1 week
1. Distractable
2. Indiscretion excessive involvement in
pleasureable activities
3. Grandiose
4. Flight of ideas
5. Activity increased
6. Sleep reduce
7. Talkactive, pressured speech

DIFFERENTIAL DIAGNOSIS
1. Schizophrenia
Auditory hallucination and delusion can occur
including other delusion specific for schizophrenia
such as delusion of reference. Mania, symtoms o
change quickly in content
If equal mixture schizoaffaective
2. Dementia
Occur especially in middle aged/older with
expansive behavior and no past history of
affective disorder. Extreme social disinhibition
(urinating in public)
3. Endocrine disorder
Hyperthyroid, exclude symptoms and check
thyroid hormone test
4. Abuse of stimulant drugs
Amphetamine and urine examination for drugs,
usually subside quickly once patient is in hospital

EPIDEMIOLOGY
First degree relative
12% lifetime risk of bipolar,
12% lifetime risk of recurrent depressive disorder,
12% risk of dysthymic or other mood disorder

COURSE AND PROGNOSIS
90% starting before age of 50 years
Recurring course with recovery between episodes
Each episode last average 3 month

MANAGEMENT
TREATMENT OF MANIA
1. Antipsychotic drugs
a. Conventional
b. Atypical - olanzapine, quetiapine,
risperidone
2. Lithium
Used mainly in patients with milder manic
episodes, intended to continue treatment in the
long term to prevent relapse
Caution when used with haloperidol EPS
3. Anti-epileptic drugs
Valproate, can be given in high loading dose in
acute phase, more rapid respone shorter
hospitalization
Another drug carbamazepine
4. Electroconvulsive therapy
Used when antipsychotic are ineffective, patient
so disturbed and natural recovery is not justified

TREATMENT OF BIPOLAR DEPRESSION
1. Antidepressant drugs
Patients develop manic following treatment with
an antidepressant risk is worse with tricyclics
than with SSRIs
2. Antipsychotic drugs
Quetiapine, but carries little risk inducing manic
symptoms, not recommende as first line
treatment
Olanzapine more effective with SSRI
3. Lithium
4. Antiepileptic drugs
Valproate, carbamazepine, lamotrigine
5. Electroconvulsive therapy
When alternative therapies not effective
6. Psychological treatments
Cognitive behavioural therapy
Interpersonal therapy

TREATMENT OF MIXED MOOD EPISODES
Usually manic symptoms predominate over depressive
symptoms in mixed state.
Use treatment of manic episode with antipsychotic alone
or in combination with mood stabilizer
Mood stabilizer may be used alone

CONTINUATION THERAPY
Prevention of relapse in first few weeks or months
following recovery from mania and depression

Prevention of relapse
10-20% risk of a serious manic relapse occurring in any
year
Risk is greater when patients suffered multiple previous
episodes

Long term drug treatment
1. Lithium
Preventing manic than depressive episodes
SE; early effect plyuria, tremor, dry mouth,
metallic tasete, weakness; later effect fine
tremor, plyuria, polydipsia, hair loss, goiter,
hypothyroid, impaired concentration, weight gain;
long term nephrogenic diabetes insipidus
Should monitored regularly

2. Anti epileptic drugs
Valproate, carbamazepine
Lamotrigine depressive relapse

3. Antipsychotic drugs
Reserved for patients with antipsychotic
symptoms or when alternative treatment have not
proved effective

4. Education to recognize ealy signs of relapse
Reduced need for sleep
Increased physical activity
Racing thought
Elated mood
Irritability or rage if planes or wishes are not
satisfied
Unrealistic plans
Overspending

5. Psychological treatments
Family therapy
Cognitive therapy