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FAKULTAS KEDOKTERAN UNIVERSITAS MUHAMMADIYAH MALANG

JOURNAL PRESENTATION

Bipolar Affective Disorder16 Mei 2011Author: Stephen Soreff, MD; Chief Editor: Stephen Soreff, MD

OverviewBipolar disorder, or manic-depressive illness

(MDI), is one of the most common, severe, and persistent mental illnesses

Bipolar disorder is characterized by periods of deep, prolonged, and profound depression that alternate with periods of an excessively elevated or irritable mood known as mania.

Bipolar disorder constitutes 1 pole of a spectrum of mood disorders that includes including bipolar I (BPI), bipolar II (BPII), cyclothymia, and major depression.

PathophysiologyThe pathophysiology of bipolar disorder has

not been determined, and no objective biologic markers correspond definitively with the disease state. However, twin, family, and adoption studies all indicate that bipolar disorder has a genetic component.

GENETICBPI, has a major genetic component, with the

involvement of the ANK3,CACNA1C, and CLOCK genes

A parent with bipolar disorder have a 50% chance of having another major psychiatric disorder

Twin studies demonstrate a concordance of 33-90% for BPI in identical twins.

BIOCHEMICAL1. A number of neurotransmitters have been

linked to this disorder, largely based on patients’ responses to psychoactive agents.

2.Drugs like cocaine, which also act on this neurotransmitter system, exacerbate mania

3.Hormonal imbalances and disruptions of the hypothalamic-pituitary-adrenal axis involved in homeostasis and the stress response may also contribute to the clinical picture of bipolar disorder.

4.Tricyclic antidepressants can trigger mania.

EpidemiologyThe lifelong prevalence of bipolar disorder

in the United States has been noted to range from 1% to 1.6%.

The age of onset of bipolar disorder varies greatly. Most cases commence when individuals are aged 15-19 years. The second most frequent age range of onset is 20-24 years.

BP I occurs equally in both sexes. The incidence of BPII is higher in females than in males.

HistoryThese criteria are based on the

specifications of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR).

Manic episodes at least 1 week of profound mood disturbance, characterized by elation, irritability, or expansiveness

At least 3 of the following symptoms must also be present:

1.Grandiosity2.Diminished need for sleep3.Excessive talking or pressured speech4.Racing thoughts or flight of ideas5.Clear evidence of distractibility6.Increased level of goal-focused activity at

home, at work, or sexually7.Excessive pleasurable activities, often with

painful consequences

Hypomanic elevated, expansive, or irritable mood of at least 4 days’ duration.

At least 3 of the following symptoms are also present:

1.Grandiosity or inflated self-esteem2.Diminished need for sleep3.Pressured speech4.Racing thoughts or flight of ideas5.Clear evidence of distractibility6.Psychomotor agitation at home, at work, or

sexually7.Engaging in activities with a high potential for

painful consequences

Major depressive episodes For the same 2 weeks, the person experiences 5 or more of the following symptoms, with at least 1 of them being either a depressed mood or characterized by a loss of pleasure or interest:

1. Depressed mood

2. Markedly diminished pleasure or interest in nearly all activities

3. Significant weight loss or gain or significant loss or increase in appetite

4. Hypersomnia or insomnia

5. Psychomotor retardation or agitation

6. Loss of energy or fatigue

7. Decreased concentration ability or marked indecisiveness

8. Preoccupation with death or suicide; patient has a plan or has attempted suicide

9. The symptoms cause significant impairment and distress.

10. The mood is not the result of substance abuse or a medical condition.

Prognosis Factors suggesting a worse prognosis include the

following:Poor job historyAlcohol abusePsychotic featuresDepressive features between periods of mania and

depressionEvidence of depressionMale sex

Factors suggesting a better prognosis include the following:Manic phases (short in duration)Late age of onsetFew thoughts of suicideFew psychotic symptomsFew medical problems

Physical ExaminationUse the Mental Status Examination (MSE)

to diagnose bipolar disorder. This section highlights the major findings for a person with bipolar disorder. Because the patient’s mental status depends on whether he or she is depressed, hypomanic, manic, or mixed, the following discussions of the various areas of the MSE include consideration of each of these particular phases

AppearancePersons experiencing a depressed episode

may demonstrate poor to no eye contact.Persons experiencing a hypomanic episode

are busy, active, and involved. a patient in the manic phase is the

opposite of that of a person in the depressed phase. Patients experiencing the manic phase are hyperactive and might be hypervigilant.

Affect/moodIn persons experiencing a depressed

episode, sadness dominates the affect. In persons experiencing a hypomanic

episode, the mood is up, expansive, and often irritable.

In persons experiencing a manic episode, the mood is inappropriately joyous, elated, and jubilant.

Perceptions Persepsi Patients experiencing a hypomanic episode do

not experience perceptual disturbances. Approximately three fourths of patients

experiencing a manic episode have delusions. Manic delusions reflect perceptions of power, prestige, position, self-worth, and glory.

Patients experiencing a mixed episode might exhibit delusions and hallucinations consistent with either depression or mania or congruent to both.

Suicide/self-destructionPatients experiencing a depressed episode

have a very high rate of suicide. Patients experiencing a hypomanic or manic episode have a low incidence of suicide.

Homicide/violence/aggression Patients who are hypomanic frequently show

evidence of irritability and aggressiveness. Persons experiencing a manic episode can be

openly combative and aggressive. The homicidal element is particularly likely to

emerge if these individuals have a delusional content to their mania.

Judgment/insight Persons experiencing a hypomanic episode

generally have good but expansive judgment.

In patients experiencing a manic episode, judgment is seriously impaired.

CognitionImpairments in orientation and memory are

seldom observed in patients with bipolar disorder unless they are very psychotic.

ComplicationsThe main complications of bipolar disorder

are suicide, homicide, and addictions.

TreatmentPropose a regular exercise schedule for all

patients, especially those with bipolar disorder. Both the exercise and the regular schedule are keys to surviving this illness.

The indications for inpatient treatment in a person with bipolar disorder include the following:Danger to selfDanger to othersTotal inability to functionTotal loss of controlMedical conditions that warrant medication monitoring

Outpatient treatment has 4 major goals, as follows.

1.Look at areas of stress and find ways to handle them.

2.Monitor and support the medication. 3.Develop and maintain the therapeutic

alliance. 4.Provide education.

Pharmacologic TherapyAppropriate medication depends on the stage of

the bipolar disorder the patient is experiencing

Electroconvulsive Therapy ECT is useful in a number of instances. It has

proven to be highly effective in the treatment of acute mania. Often, the severity of the symptoms, the lack of response to medications, or the presence of contraindications to certain medications necessitates the use of ECT. In a study of 400 patients with acute mania who received ECT, 313 showed significant clinical improvement.

“Pharmacologic Therapy”-Mood stabilizersLithium is the drug commonly used for

prophylaxis and treatment of manic episodes. -AnticonvulsantsAnticonvulsants have been effective in preventing

mood swings associated with bipolar disorder, especially in those patients known as rapid cyclers.

-Atypical AntipsychoticsAtypical antipsychotics are being used

increasingly for treatment of both acute mania and mood stabilization.