Wande's Thesis

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INTRODUCTION

CHAPTER ONE: DEFINITION

Bipolar disorder (or manic depressive disorder) is a psychiatric disorder characterized by

periods of prolonged and profound depression alternating with periods of excessivelyelevated and/or irritable moods, known as mania. A milder form of mania (hypomania),

associated with episodes of depression may also occur.

There are 2 types of bipolar disorder recognized by DSM-IV: Type I and type II Bipolar

disorder.

1. Type I Bipolar disorder- this is defined by a single manic episode lasting for at least a

week (or less if hospitalization is required), but generally the course involves a

cycling between mania anddepression. In-between episodes, the patient is generally

without psychiatric symptoms

2. Type II Bipolar disorder- the patient has experienced at least one major depressive

episode and at least one hypomanic episode

By this definition, type II is a milder form than type I bipolar disorder. Persons who

experience subsyndromal manic-depressive mood fluctuations over an extended period

without major mood episodes are diagnosed with cyclothymic disorder.


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CHAPTER TWO: ETIOPATHOGENY

The exact cause of bipolar disorder is unknown but several factors are often said to be

triggers for episodes. Main points to be explained in this chapter are-

1. Biological rhythms

2. Neurotransmitter hypothesis

3. Inherited traits/ genetic link

4. Environment

5. Higher risk groups

BIOLOGICAL RHYTHMS

A large number of studies have demonstrated seasonal peaks in the onset of affective

episodes or hospitalizations for mood disorders. For manic-depressive disorder, the

predominant seasons appear to be spring and fall, although other patterns may occur with

some consistency across years.

NEUROTRANSMITTER HYPOTHESIS

This occurs when there is an imbalance in neurotransmitters. Three chemicals- Noradrenalin

(Norepinephrine), Serotonin (SLC6A4 and TPH2) and Dopamine (DRD4 and SLC6A3) are

involved in both brain and bodily functions. Noradrenalin and Serotonin have been

consistently linked to psychiatric mood disorders such as depression and bipolar disorder.

Dopamine (which is catecholamine neurotransmitter) is commonly linked with the pleasure

system of the brain and disruptions to this system are connected to Psychosis and

Schizophrenia.

INHERITED TRAITS/ GENETIC RISK

First degree relatives are seven times more likely to develop the condition than the general

population (10-15% risk). Children of a parent with bipolar disorder have a 50% chance of

developing a psychiatric disorder (genetic liability appears shared for schizophrenia, schizo-

affective, and bipolar affective disorder).

Monozygotic twins (MZ) twins have a 40-70% concordance

Dizygotic twins (DZ) - around 23%


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In other findings, people with first degree relatives diagnosed with bipolar I or II are at an

increased risk for major depression when compared to those that have no history of the

disease and the lifetime risk of affective disorders in relatives with affected family members

increases, depending on the number of diagnosed relatives.

There is also some recent evidence that raises the possibility that the expression of psychiatric

illness is coded genetically, specifically small sections of DNA (3 base pairs in length called

trinucleotide repeats) appear to be overrepresented in genetic disorders with prominent

psychiatric symptoms.

Advanced paternal age- this also has a link to an increased chance of bipolar disorder in

offspring, consistent with a hypothesis of increased new genetic mutations.

ENVIRONMENT

This has to do with things like increased stress, sudden lifestyle changes (such as childbirth),and lack of sleep.

HIGHER RISK GROUPS

In this category, the disease may be accompanied by a previous genetic disposition which is

triggered by an external factor. This doesnt necessarily mean that the patient would not have

developed bipolar disorder without these but they can accelerate the onset

1. Recreational drug use- such as cocaine, heroin, marijuana, PCP and ecstasy (MDMA)

2. Patients on some Medications -such as antidepressants, steroids, psychotropic drugs,cardiovascular drugs, etc.

3. Women are said to have higher incidence(for bipolar type II) and symptoms are

milder in elderly patients

4. Some medical disorders are commonly associated with mania, for example: Stroke,

Head trauma, Dementia, Brain tumors, Infection (including HIV), Multiple sclerosis,

Huntingtons disease, postpartum status and Hyperthyroidism.


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CHAPTER FOUR: DIAGNOSIS AND CRITERIA (DSM-IV)

Bipolar I Disorder-

1. At least one manic or mixed episode

2. The mood episodes are not better accounted for by another disorder (such as schizo-

affective disorder) and the symptoms are not secondary to a psychotic disorder

Bipolar II Disorder-

1. At least one Major Depressive Episode, and

2. At least one Hypomanic episode

3. But never have had a Manic Episode

Cyclothymic disorder-

1. Essentially a minor version of bipolar disorder, with milder mood fluctuations and

episodes of Hypomania

2. No Manic, Major Depressive or mixed episode

Here, we have discuss the criteria for each condition (MIXED EPISODES, MANIA,

HYPOMANIA, MAJOR DEPRESSIVE EPISODE)

MIXED EPISODES (DSM-IV-TR)

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

Typical presentations include:

1. Depression plus over activity/ pressure of speech

2. Mania plus agitation and reduced energy/ libido


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3. Dysphoria plus manic symptoms (with exception of elevated mood)

4. Rapid cycling (fluctuating between mania and depression for 4 or more episodes/year)

B) The mood disturbance is sufficiently severe to cause marked impairment in occupational

functioning or in usual social activities or relationships with other, or to necessitatehospitalization to prevent harm to self or others, or there are psychotic features

C) The symptoms are not due to the direct physiology effects of a substance (e.g., a drug of

abuse, a medication, or other treatment) or a general medical condition (e.g.,

hyperthyroidism)

Note: Mixed- like episodes that are clearly caused by somatic antidepressant treatment (e.g.,

medication, electroconvulsive therapy, and light therapy) should not count toward a

diagnosis of manic-depressive I disorder.

MANIC EPISODE (DSM-IV-TR)

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:

1. Inflated self-esteem or grandiosity

2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

3. More talkative than usual or pressure to keep talking

4. Flight of ideas or subjective experience that thoughts are racing

5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external

stimuli)

6. Increase in goal-directed activity (at work, at school, or sexually) or psychomotor

agitation

7. 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.


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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, and light therapy) should not count toward a

diagnosis of bipolar I disorder.

HYPOMANIC EPISODE (DSM-IV-TR)

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) 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:

1. Inflated self-esteem or grandiosity

2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

3. More talkative than usual or pressure to keep talking

4. Flight of ideas or subjective experience that thoughts are racing

5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external

stimuli)

6. Increase in goal-directed activity (either socially,at work or school,or sexually) or

psychomotor agitation

7. Excessive involvement in pleasurable activities that have a high potential for

painful consequences (e.g., the person engagaes in unrestrained buying sprees,

sexual indiscretions, or foolish business investments)

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) 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)


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Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant

treatment (e.g., medication, electroconvulsive therapy, and light therapy) should not count

toward a diagnosis of bipolar II disorder.

MAJOR DEPRESSIVE EPISODE (DSM-IV-TR)

A) 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 loss when not dieting or weight

gain (e.g., a change of more than 5% of body weight in a month), or decrease orincrease 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 bedelusional) 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 thought of death (not just fear of dying), recurrent suicidal ideation

without specific plan, or a suicide attempt or a specific attempt or a specific plan

for committing suicide.

B) The symptoms do not meet criteria for a mixed episode


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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.

CHAPTER FIVE: CLINICAL PICTURE

Onset/ course:

Onset of bipolar disorder usually occurs in the late teens or early 20s. In a little greater than

half of bipolar patients, the first episode is a depressive episode. At least 10% of those who

experience a first lifetime event of major depression will eventually become bipolar, so it is

important to monitor any patient with major depressive disorder for later onset of mania.

Manic episodes begin with a rapid onset and can last weeks to month. Manic episodes are

sometimes staged by the level of severity:

Stage I (hypomania). Stage I is defined by heightened mood, grandiosity, pressured

speech, a rapid flow of ideas, decreased concentration, increased distractibility,hyperactivity, more energy and less need for sleep.

Stage II (acute mania). In stage II all of the symptoms of Stage I are present and

intensified, in addition, the patient experiences either delusions of grandeur or

paranoia.

Stage III (delirious mania). In stage III, all of the symptoms of stage II are

exacerbated, and the patient presents with hallucinations, incoherence and bizarre

behavior.

While all manic episodes display Stage I and a majority progress to Stage II, only some

reach Stage III. Recovery from an episode of mania is usually thought to be around 4

months, with great variance.


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CHAPTER SIX: TREATMENT

This includes various treatment plans which is usually a combination of Drug therapy and

Psychotherapy which includes counseling and support groups.

The medications used here are for Bipolar Mania and Bipolar Depression. So the

specific drugs given would depend on the phase of the disease and symptoms.

Psychotherapy:

Ongoing Psychotherapy or talk therapy: this includes support programs and also

education for the family about the disease to help them cope and also be able to reduce

the incidence of the illness; this usually involves creating a conducive environment and

efforts to eliminate various triggers. Programs that offer outreach and community support

services can help people who do not have family and social support.

1. Cognitive Therapy: CT is based on the premise that the negative emotions of

depression are reactions to negative thinking derived from dysfunctional global

negative attitudes. Treatment involves systematically monitoring negative cognitions

whenever the patient feels depressed; recognizing the association between cognition,

affect and behavior; generating data that support or refute the negative cognition;

generating alternative hypothesis to explain the event that precipitated the negative

cognition; and identifying the negative schemata predisposing to the emergence of

global negative thinking when one side of an all-or-nothing assumption is

disappointed. In the course of examining dysfunctional attitudes, the patient learns tolabel and counteract information-processing errors such as over generalization from

single negative events. According to various studies, the onset of antidepressants has

been found to be faster than the onset of action of CT. Some studies suggest that

starting treatment with an antidepressant and the adding CT (Sequential combination

therapy) may be effective than adding antidepressants to CT (Hollan et al.1992)

2. Interpersonal Psychotherapy: IPT is designed to improve depression by enhancing the

quality of the patients interpersonal world. The treatment begins with an explanation

of the diagnosis and treatment options; this first step serves to legitimate depression as

a medical illness. The acute course of the treatment is done over a period of 12-16weeks. Role playing is used to help the patient acquire new interpersonal skills, and


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structure conjoint meetings are used to help partners clarify their expectations of each

other.

3. Family Therapy: involvement of the family is a defining characteristic of IPT. The

goals of this approach are to alter family interactions that interfere with medication

adherence and to promote affective recurrences. A recent study demonstrated that

family-focused treatment added to open treatment with mood-stabilizing medications

was associated with fewer relapses and longer delays before relapses (Miklowitz et al.

2000). In everyday practice, family involvement is important for most patients with

mood disorders, whether or not specific family therapies are employed.

4. Behavior Therapy: behavior therapies use education, guided practice, homework

assignments, and social reinforcement of successive approximations of nondepressed

behavior in a time-limited format, typically over 8-16 weeks. Depressive behaviors

such as self-blame, passivity, and negativism are ignore, whereas behaviors that are

inconsistent with depression, such as activity, experiencing pleasure, and solving

problems, are rewarded. Rewards can be anything that the patient seems to seek out-

from attention, to praise, to being permitted to withdraw or complain, to money.

Giving the patient small, discrete tasks that very gradually become more demanding

reverses learned helplessness. Social skills training teaches self-reinforcement,

assertive behavior, and the use of social reinforcers such as eye contact and

compliments.


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