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 Gangguan bipolar
Bipolar I
one or more manic episodes
sometimes, major depressive episodes
Bipolar II
episodes of major depression
hypomania rather than mania
*mixed episode a period of at least 1 week
in which both a manic episode and a major
depressive episode occur almost daily
 Etiologi
Norepinephrine
Antidepressant drug noradrenergic effect
Serotonin
Low serotonin depression
Dopamine
Decrease activity depression
Increase activity mania
Growth hormone
Decrease CSF somatostatin level in depression
Increase CSF somatostatin level in mania
Genetic factor
Chromosome 18, 21q, 22q
Psychosocial factors
Stressful life events
 DSM-IV-TR Criteria for Major
Depressive Episode
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.
Note: Do not include symptoms that are
clearly due to a general medical condition, or
mood-incongruent delusions or hallucinations.
1. depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g.,
feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and
adolescents, can be irritable mood
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 made by others)
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. Note: In children,
consider failure to make expected weight gains.
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 do not meet criteria for a mixed episode.
C. The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
D. The symptoms are not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general
medical condition (e.g., hypothyroidism).
E. The symptoms are not better accounted for by bereavement, i.e.,
after the loss of a loved one, the symptoms persist for longer than
2 months or are characterized by marked functional impairment,
morbid preoccupation with worthlessness, suicidal ideation,
psychotic symptoms, or psychomotor retardation.
 DSM-IV Criteria for Manic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable
mood, lasting at least 1 week (or any duration if hospitalization is necessary)
B. During the period of mood disturbance, three (or more) of the following
symptoms have persisted (four if the mood is only irritable) and have been
present to a significant degree:
inflated self-esteem or grandiosity
decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
more talkative than usual or pressure to keep talking
flight of ideas or subjective experience that thoughts are racing
distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation
excessive involvement in pleasurable activities that have a high potential for painful
consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish
business investments)
C. The symptoms do not meet criteria for a mixed episode.
D. The mood disturbance is sufficiently severe to cause marked
impairment in occupational functioning or in usual social activities
or relationships with others, or to necessitate hospitalization to
prevent harm to self or others, or there are psychotic features.
E. The symptoms are not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication, or other
treatment) or a general medical condition (e.g., hyperthyroidism).
Note: Manic-like episodes that are clearly caused by somatic
antidepressant treatment (e.g., medication, electroconvulsive
therapy, light therapy) should not count toward a diagnosis of
bipolar I disorder.
 DSM-IV Criteria for Hypomanic
Episode
A. A distinct period of persistently elevated, expansive, or irritable mood,
lasting throughout at least 4 days, that is clearly different from the usual
nondepressed mood
B. Same as Criteria B on Manic Episode
C. The episode is associated with an unequivocal change in functioning that
is uncharacteristic of the person 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, and there
are no psychotic features.
F. Same as Criteria E in Manic Episode
DSM-IV Criteria for Mixed Episode
A. The criteria are met both for a manic episode
and for a major depressive episode (except
for duration) nearly every day during at least
a 1-week period
B. Same as Criteria D in Manic Episode
C. Same as Criteria E in Manic Episode
 DSM-IV Bipolar I Disorder, Single
Manic Episde
A. Presence of only one manic episode and no past
major depressive episodes
Recurrence is defined as either a change in polarity
from depression or an interval of at least 2 months
without manic symptoms
B. The manic episodes in Criteria A and B are not
better accounted for by schizoaffective disorder
and are not superimposed on schizophrenia,
schizophreniform disorder, delusional disorder,
or psychotic disorder not otherwise specified
 DSM-IV Bipolar I Disorder, Most
Recent Episode Manic
A. Currently (or most recently) in a manic episode
B. There has previously been at least one major
depressive episode, manic episode, or mixed
episode
C. The mood episodes in Criteria A and B are not
better accounted for by schizoaffective disorder
and are not superimposed on schizophrenia,
schizophreniform disorder, delusional disorder,
or psychotic disorder not otherwise specified
 DSM-IV Bipolar I Disorder, Most
Recent Episde Hypomanic
A. Currently (or most recently) in a hypomanic episode
B. There has previously been at least one manic episde
or mixed episde
C. The mood symotims cause clinically significant
distress or impairment in socialm occupationa, or
other important areas of functioning
D. The mood episodes in Criteria A and B are not better
accounted for by schizoaffective disorder and are not
superimposed on schizophrenia, schizophreniform
disorder, delusional disorder, or psychotic disorder
not otherwise specified
 DSM-IV Bipolar I Disorder, Most
Recent Episode Depressed
A. Currently (or most recently) in a major
depressive episode
B. There has previously been at least one manic
episode or mixed episode
C. The mood episodes in Criteria A and B are not
better accounted for by schizoaffective disorder
and are not superimposed on schizophrenia,
schizophreniform disorder, delusional disorder,
or psychotic disorder not otherwise specified
 DSM-IV Bipolar I Disorder, Most
Recent Episode Mixed
A. Currently (or most recently) in a mixed episode
B. There has previously been at least one major
depressive episode, manic episode, or mixed
episode
C. The mood episodes in Criteria A and B are not
better accounted for by schizoaffective disorder
and are not superimposed on schizophrenia,
schizophreniform disorder, delusional disorder,
or psychotic disorder not otherwise specified
 DSM-IV Diagnostic Criteria for Bipolar
II Disorder
A. Presence (or history) of one or more major depressive
episodes
B. Presence (or history) of at least one hypomanic episode
C. There has never been a manic episode or a mixed episode
D. The mood symptoms in Criteria A and B are not better
accounted for by schizoaffective disorder and are not
superimposed on schizophrenia, schizophreniform
disorder, delusional disorder, or psychotic disorder not
otherwise specified.
E. The symptoms cause clinically significant distress or
impairment in social, occupational, or other important
areas of functioning
DSM-IV Criteria for Postpartum Onset
Specifier
Onset of episode within 4 weeks postpartum
 Depressive Episodes
depressed mood
loss of interest or pleasure
suicide attempt or suicidal ideation
Anxiety
decreased appetite and weight
early morning awakening (i.e., terminal insomnia) and multiple
awakenings at night
difficulty finishing tasks
reduced energy
impaired at school and work
have less motivation to undertake new projects
 Manic Episodes
elevated, expansive, or irritable mood
inattention to small details
Pathological gambling
often preoccupied by religious, political,
financial, sexual, or persecutory ideas that can
evolve into complex delusional systems
Occasionally, manic patients become
regressed and play with their urine and feces
 Mental Status Examination
(depressive)
General Description
Generalized psychomotor retardation or agitation
Hand-wringing and hair-pulling
stooped posture, no spontaneous movements, and a downcast, averted gaze
Mood, Affect, and Feelings
Depression although patient deny depressive feelings
Speech
decreased rate and volume of speech
Perceptual Disturbances
Mood-congruent delusions
Thought
have negative views of the world and of themselves
often includes nondelusional ruminations about loss, guilt, suicide, and death
 Orientation
oriented to person, place, and time although some may not have sufficient
energy or interest to answer questions
Memory
a cognitive impairment (depressive pseudodementia)
Impulse Control
commit suicide or suicidal ideation
often lack the motivation or the energy to act in an impulsive or violent way
Judgement and insight
often hyperbolic
Reliability
overemphasize the bad and minimize the good
Mental Status Examination (manic)
General Description
excited, talkative, sometimes amusing, and frequently hyperactive
Sometimes, grossly psychotic and disorganized
Mood, Affect, and Feelings
euphoric, but they can also be irritable
Speech
cannot be interrupted while they are speaking
flight of ideas, clanging, and neologisms
Perceptual Disturbances
Delusions
Mood-congruent manic delusions
Thought
Unrestrained and accelerated flow of ideas
 Sensorium and Cognition
orientation and memory are intact
May be delirious mania
Impulse Control
assaultive or threatening
Judgment and Insight
Impaired judgment
break laws
Reliability
lying and deceit are common
Pharmacotherapy
For Bipolar Disorder FDA Approval
 Dysthimic disorder
presence of a depressed mood that lasts most
of the day and is present almost continuously
classified as having depressive neurosis (also
called neurotic depression)
 DDx
Minor Depressive Disorder
Recurrent Brief Depressive Disorder
Double Depression
Alcohol and Substance Abuse
 Treatment
cognitive therapy
taught new ways of thinking and behaving to replace faulty negative
attitudes
behavior therapy
increase activity, to provide pleasant experiences, and to teach
patients how to relax
Insight-Oriented (Psychoanalytic) Psychotherapy
Patients' understanding of how they try to gratify an excessive need
for outside approval to counter low self-esteem and a harsh superego
pharmacotherapy
selective serotonin reuptake inhibitors (SSRIs) venlafaxine and
bupropion
 Cyclothymic disorder
a mild form of bipolar II disorder,
characterized by episodes of hypomania and
mild depression
A chronic, fluctuating disturbanceswith many
periods of hypomania and of depression
 DDx
substance-related causes of depression and
mania
Borderline, antisocial, histrionic, and
narcissistic personality disorders
Attention-deficit/hyperactivity disorder
(ADHD)
 Treatment
Biological Therapy
mood stabilizers and antimanic drugs (lithium)
Psychosocial Therapy
directed toward increasing patients' awareness of
their condition and helping them develop coping
mechanisms for their mood swings
POSTPARTUM DEPRESSION
 Definition
A depression that occurs after the birth of a
baby is called a "postpartum" depression
(PPD).
 Classification
Moline and colleagues describe 2 main kinds
of PPD:
1. postpartum or maternity "blues," a mild mood
problem of short duration
2. postpartum major depression, a severe and
potentially life-threatening illness
3. postpartum psychosis.
 Sign & Symptom
Symptoms may include In general, postpartum psychosis
mood swings with times of feeling evolves rapidly and is characterized by
anxious, depressed or elated mood,
irritable, disorganized behavior,
tearful interspersed with times of mood lability,
feeling well. delusions and hallucinations
Sleeping difficulties may also occur.
Postpartum psychosis of the bipolar
The earliest symptoms are typically type is characterized by
restlessness, elated mood
irritability, disorganized behavior
sleep disturbance. mood lability
the presence of hallucinations or
delusions. In extreme cases, the risks of
suicide and/or infanticide are high, thus
these women often require
hospitalization
 The symptoms usually begin 3-4 days after delivery worsen
by days 5-7 and tend to resolve by day 12.
For symptoms that last longer than 2 weeks, seek medical
attention (approximately 1 in 5 women with postpartum blues
develop postpartum major depression)
For the majority of women with postpartum psychosis,
symptoms develop within the first 2 weeks after delivery
 Risk Factors
Biological risk factors that contribute to the
development of PPD include:
A history of depression in previous pregnancies or
postpartum period.
A previous history of depression.
A history of depression in blood relatives.
poor social support, adverse life events, marital
instability, and ambivalence towards the pregnancy.
 Etiology
There are many factors that may contribute to the increase in
pregnancy-associated affective syndromes.
Hormonal factors play a major role in influencing central
nervous functioning.
other factors
genetics
socioeconomic issues
stress
emotional support system for the new mother
 Diagnostic
The Diagnostic and Statistical Manual (DSMIV-TR)
delineates "postpartum" as a "modifier" or
addition to other diagnoses. For example, a
postpartum diagnosis could be described as
major depression with postpartum onset, or
bipolar disorder with postpartum onset, or
brief psychotic disorder with postpartum onset.
Postpartum "blues" is not an official diagnostic
entity but it is commonly seen by practitioners.
 The criteria used to diagnose depression is the same in postpartum states. In
addition to these criteria,
other symptoms may include fear or feelings of guilt about being a "bad" mother,
or possibly extreme fear that some harm will come to the baby.
Women with postpartum major depressive episodes may also have
severe anxiety,
panic attacks,
spontaneous crying long after the usual duration of "baby blues" (ie, 3-7 days
postpartum),
disinterest in the new infant,
insomnia (manifested as difficulty falling asleep).
When assessing whether a symptom is a sign of depression or a normal
postpartum reaction, the individual's circumstances need to be considered.
A woman's level of exhaustion or irritability may be quite normal when her infant
is 2 weeks old and nursing frequently, but
may not be normal when her baby is 4 months old and sleeping soundly through
the night. Sleep deprivation can cause fatigue and poor concentration, but the
degree of these symptoms needs to be carefully assessed.
 Treatment
Treatment of PPD generally depends on the type and severity of the
symptoms.
With postpartum blues, additional emotional support or extra help caring for the
newborn may be the only intervention necessary.
Patient education is important and women should be directed to contact their
physicians if symptoms persist beyond the second postpartum week.
If symptoms persist or become more severe then professional treatment may be
warranted.
In mild cases in which the depression does not interfere with the mother's
functioning, psychotherapy may be of benefit.
If the symptoms are of a more severe major depression then carefully selected
antidepressant medication may be needed and this should be combined with
counseling and support as well
Some studies have suggested that progesterone and estrogen may be effective agents
for treatment of PPD (additional research is required)
for severe depression in which medication is either not an option or problematic,
electroconvulsive treatment may be a viable alternative.
Women who are breastfeeding must be informed that all psychotropic medications,
including antidepressants, are secreted in the breast milk at varying concentrations.