BIPOLAR DISORDERS

Bipolar disorders (previously called

manic-depressive psychosis)
consists of at least one hypomanic,
manic, or mixed episode. Mixed
episodes represent a simultaneous
mixture of depressive and manic or
hypomanic manifestations.
BIPOLAR I DISORDER
Defined as having a clinical course of
one or more manic episodes and,
sometimes, major depressive episodes
A mixed episode is a period of at least 1
week in which a manic episode and a
major depressive episode occur almost
daily
BIPOLAR I DISORDER
Includes separate bipolar I disorder diagnoses
for a single manic episode and a specific type
of recurrent episode, based on the symptoms
of the most recent episode
episodes are considered distinct when they
are separated by at least 2 months without
significant symptoms of mania or hypomania
BIPOLAR I DISORDER
Single Manic Episode
MRE Manic
MRE Hypomanic
MRE Depressed
MRE Mixed
BIPOLAR I D/O, Single Manic
Episode
Patients experiencing their first manic
episode must meet the criteria for
bipolar I dosorder
Because patients having their first
episode of bipolar I depression cannot
be distinguished from patients with
MDD
DSM IV Criteria for Bipolar I
Disorder, Single Manic Episode
A. Presence of only one manic episode and
no past major depressive episodes

B. The manic episode is not accounted for by

schizoaffective disorder, schizophrenia,
schizophreniform disorder, delusional disorder,
psychotic disorder
DSM IV Criteria for Bipolar I
Disorder, Single Manic Episode

Specify if:
- Mixed
- severity, with or without psychotic
features
 With catatonic features

 With postpartum onset

DSM-IV Criteria for BIPOLAR I
D/O, MRE 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 not accounted for by
schizoaffective d/o and not superimposed
on schizophreniform, delusional, or
psychotic disorders not otherwise specified
DSM-IV Criteria for BIPOLAR I
D/O, MRE HYPOMANIC
A. Currently (or most recently) in a hypomanic
episode
B. There has previously been at least one
manic episode, or mixed episode
C. The mood symptoms cause clinically
significant distress or impairment in social,
occupational, or other important areas of
functioning
D. The mood episodes not accounted for by
schizoaffective d/o and not superimposed
on schizophreniform, delusional, or
psychotic disorders not otherwise specified
DSM-IV Criteria for BIPOLAR I
D/O, MRE 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 not accounted for by
schizoaffective d/o and not superimposed
on schizophreniform, delusional, or
psychotic disorders not otherwise specified
DSM-IV Criteria for BIPOLAR I
D/O, MRE MIXED
A. Currently (or most recently) in a major
depressive episode
B. There has previously been at least one
major depressive episode, manic episode,
or mixed episode
C. The mood episodes not accounted for by
schizoaffective d/o and not superimposed
on schizophreniform, delusional, or
psychotic disorders not otherwise specified
DSM-IV Criteria for BIPOLAR I
D/O, MRE UNSPECIFIED
A. Criteria, except for duration, are currently
(or most recently) met for a manic, a
hypomanic, a mixed, or a major depressive
episode
B. There has previously been at least one
manic episode or mixed episode
C. The symptoms cause clinically significant
distress or impairment in social,
occupational, or other important areas of
functioning
COURSE
Most often starts with depression and is a
recurring disorder
Most patients experience both depressive and
manic episodes, although 10 to 20%
experience only manic episodes
Manic episodes has a rapid onset of hours or
days and evolve over a few weeks
COURSE
Untreated manic episode: 3 months
Most patients with a single manic
episode are likely to have another
Time between episodes decreases as
the disease progresses (at 5 episodes,
interval stabilizes at 6 to 9 months)
Rapid cyclers: 4 or 5 episodes per year
PROGNOSIS
Poorer prognosis than patients with
MDD
40-50% may have a second manic
episode within 2 years of the first
episode
Only 50-60% achieve significant control
of their symptoms with lithium
PROGNOSIS
Poor prognosis for: those with premorbid
poor occupational status, alcohol
dependence, depressive features,
interepisode depressive features, male
gender
Good prognosis: short duration of manic
episodes, advanced age of onset,few suicidal
thoughts, few coexisting pyschiatric or
medical problems
BIPOLAR II DISORDER
A variant of bipolar disorder
characterized by episodes of major
depression hypomania rather than
mania
DSM-IV Criteria for BIPOLAR
II DISORDER
A. Presence/History of 1 or more major
depressive episode
B. Presence/History of at least 1 hypomanic
episode
C. There has NEVER been a manic or mixed
episode
D. Schizoaffective/ schizophrenia/
schizophreniform/delusional/ psychotic
disorder exclusion
E. Significant distress or social/occupational
dysfunction
COURSE AND PROGNOSIS

Not yet established

Preliminary data: stable
DSM-IV Criteria for BIPOLAR
II DISORDER
- Specify current or most recent episode:
Hypomanic
Depressed
- Specify if:
Mild, moderate, severe with/out psychotic
features
Chronic
With catatonic/melancholic/atypical
features/postpartum onset
In Partial/full remission
PHARMACOTHERAPY

Lithium
Anticonvulsants – carbamazepine,
valproate
Other agents – clonazepam, clonidine,
clozapine and verapamil
LITHIUM
MOA: alteration of sodium levels and
transport; increase in norepinephrine
reuptake
Indications: bipolar disorder, cyclothymia;
possibly schizophreniform and schizoaffective
disorder
SE: CNS (headache, tremors, lethargy, slurred
speech), GI (diarrhea, nausea, vomiting,
anorexia), endocrinologic (hypo or
hyperthyroidism, goiter, hyperglycemia)
LITHIUM
Renal (thirst, polyuria, polydypsia, diabetes
insipidus), cardiac (myocarditis, arrhythmias,
bradycardia, syncope, QRS widening,
hypotension), and dermatologic (folliculitis,
acne, psoriasis, alopecia and exfoliative
dermatitis)
Therapeutic levels: 0.6-1.5mEq/L
Overdose/Intoxication: Na depletion,
dehydration, renal dysfunction, nausea,
vomiting, dysarthria, tremor, ataxia, delirium,
seizures and coma
ANTICONVULSANTS
Carbamazepine (Tegretol)
- MOA: reduction of synaptic responses
- Indication: acute mania, bipolar
disorder, cyclothymia
- Dosage: 800-1200mg/day
- SE: sedation, blurred vision, nausea, GI
upset, ataxia, vertigo, dysarthria,
tremor, arrhythmias, aplastic anemia
ANTICONVULSANTS
Clonazepam (Klonopin)
- Indication: bipolar disorder, panic
disorder, anxiety
- Dosage: 2mg BID/TID
- Therapeutic levels: 20-80ng/mL
- SE: addictive, sedation, ataxia, GI
upset, hypersalivation, withdrawal
symptoms
ANTICONVULSANTS
Valproic acid (Depakene) and Divalproex
(Depakote)
- MOA: potentiation of postsynaptic gamma
aminobutyric acid
- Indications: acute mania, bipolar disorder
- Dosage: 250mg PO bid/tid
- Therapeutic levels: 50-100mcg/mL
- SE: CNS depression, elevations of
aminotransferase, hepatitis, GI upset, weight
gain, drowsiness, ataxia, headache and rash
- Overdose: restlessness, hallucinations, coma
DYSTHYMIC AND
CYCLOTHYMIC DISORDERS

Characterized by the presence of

symptoms that are less severe than
those of major depressive disorder and
bipolar I disorder
DYSTHYMIC DISORDER

Characterized by at least 2 years of

depressed mood that is not severe
enough to fit the diagnosis of MDD
DSM IV Criteria for Dysthymic
Disorder
A. Depressed mood for most of the day, as
indicated by subjective account or
observation by others for at least 2 years
B. Presence, while depressed, of 2 or more of
the ff:
 Poor appetite or overeating
 Insomnia or hypersomnia
 Low energy or fatigue
 Low self-esteem
 Poor concentration or difficulty making decisions
 Feelings of hopelessness
DSM IV Criteria for Dysthymic
Disorder
C. During the 2-yr period of the
disturbance, the person has never
been without the symptoms in criteria
A and B for more than 2 months
D. No major depressive episode has
been present during the first 2 yrs of
the disturbance
E. There has never been a manic
episode, a mixed episode, or
hypomanic episode and criteria is not
met for cyclothymic disorder
DSM IV Criteria for Dysthymic
Disorder
F. The disturbance does not occur exclusively
during the course of a chronic psychotic
disorder
G. The symptoms are not due to the direct
physiological effects of a substance or general
medical condition
H. The symptoms cause clinically significant
distress or impairment in social, occupational,
or other areas of functioning
Specify if: early onset (onset before 21y/o),
late onset (onset at 21y/o or older
Treatment
Combination of pharmacotherapy (SSRIs,
MAOIs), and either cognitive or behavior
therapy may be the most effective
Cognitive therapy-patients are taught new ways
of thinking and behaving to replace faulty
negative attitudes about themselves, the world
and the future
Behavior therapy-focus on specific goals to
increase activity, to provide pleasant
experiences, and to teach patients how to relax
CYCLOTHYMIC DISORDER
Characterized by at least 2 years of
frequently occuring hypomanic
symptoms that cannot fit the diagnosis
of manic episode and of depressive
symptoms that cannot fit the diagnosis
of MDD
DSM IV Criteria for Cyclothymic
Disorder
A. For at least 2yrs, the presence of numerous
periods with hypomanic symptoms and
numerous periods with depressive symptoms
that do not meet criteria for a major depressive
episode
B. During the 2-yr period, the person has not
been without the symptoms in criterion A for
more than 2 months
C. No major depressive episode, manic episode,
or mixed episode has been present during the
first 2yrs of the disturbance
DSM IV Criteria for Cyclothymic
Disorder
D. The symptoms in criterion A are not better
accounted for by schizoaffective disorder and
are not superimposed on schizophrenia,
schizophreniform disorder, delusional disorder,
or psychotic disorder
E. The symptoms are not due to the direct
effects of a substance or a general medical
condition
F. The symptoms cause clinically significant
distress or impairment in social, occupational, or
other areas of functioning
Treatment
Biological therapy
 Carbamazepine, Valproate, Lithium
 Dosage and plasma concentrations same as

in bipolar I
Psychosocial therapy
 Should be directed towards increasing
patients’ awareness of their condition and
helping them develop coping mechanisms for
their mood swings
 Often require lifelong treatment
THANK YOU!!! 
tweet