Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual

shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks.

There are four basic types of bipolar disorder; all of them involve clear changes in mood, energy,
and activity levels. These moods range from periods of extremely up, elated, and energized
behavior (known as manic episodes) to very sad, down, or hopeless periods (known as
depressive episodes). Less severe manic periods are known as hypomanic episodes.

Bipolar I Disorder defined by manic episodes that last at least 7 days, or by manic
symptoms that are so severe that the person needs immediate hospital care. Usually,
depressive episodes occur as well, typically lasting at least 2 weeks. Episodes of
depression with mixed features (having depression and manic symptoms at the same
time) are also possible.
Bipolar II Disorder defined by a pattern of depressive episodes and hypomanic
episodes, but not the full-blown manic episodes described above.
Cyclothymic Disorder (also called cyclothymia) defined by numerous periods of
hypomanic symptoms as well numerous periods of depressive symptoms lasting for at
least 2 years (1 year in children and adolescents). However, the symptoms do not meet
the diagnostic requirements for a hypomanic episode and a depressive episode.
Other Specified and Unspecified Bipolar and Related Disorders defined by bipolar
disorder symptoms that do not match the three categories listed above.

Signs and Symptoms

People with bipolar disorder experience periods of unusually intense emotion, changes in sleep
patterns and activity levels, and unusual behaviors. These distinct periods are called mood
episodes. Mood episodes are drastically different from the moods and behaviors that are typical
for the person. Extreme changes in energy, activity, and sleep go along with mood episodes.

People having a manic episode may:
Feel very up, high, or elated
Have a lot of energy
Have increased activity levels
Feel jumpy or wired
Have trouble sleeping
Become more active than usual
Talk really fast about a lot of different
things
Be agitated, irritable, or touchy
Feel like their thoughts are going very
fast
Think they can do a lot of things at once
Do risky things, like spend a lot of
money or have reckless sex
People having a depressive episode may:
Feel very sad, down, empty, or hopeless
Have very little energy
Have decreased activity levels
Have trouble sleeping, they may sleep
too little or too much
Feel like they cant enjoy anything
Feel worried and empty
Have trouble concentrating
Forget things a lot
Eat too much or too little
Feel tired or slowed down
Think about death or suicide
Sometimes a mood episode includes symptoms of both manic and depressive symptoms. This is
called an episode with mixed features. People experiencing an episode with mixed features may
feel very sad, empty, or hopeless, while at the same time feeling extremely energized.

Bipolar disorder can be present even when mood swings are less extreme. For example, some
people with bipolar disorder experience hypomania, a less severe form of mania. During a
hypomanic episode, an individual may feel very good, be highly productive, and function well.
The person may not feel that anything is wrong, but family and friends may recognize the mood
swings and/or changes in activity levels as possible bipolar disorder. Without proper treatment,
people with hypomania may develop severe mania or depression.

Diagnosis

Proper diagnosis and treatment help people with bipolar disorder lead healthy and productive
lives. Talking with a doctor or other licensed mental health professional is the first step for
anyone who thinks he or she may have bipolar disorder. The doctor can complete a physical
exam to rule out other conditions. If the problems are not caused by other illnesses, the doctor
may conduct a mental health evaluation or provide a referral to a trained mental health
professional, such as a psychiatrist, who is experienced in diagnosing and treating bipolar
disorder.

Note for Health Care Providers: People with bipolar disorder are more likely to seek help
when they are depressed than when experiencing mania or hypomania. Therefore, a careful
medical history is needed to ensure that bipolar disorder is not mistakenly diagnosed as major
depression. Unlike people with bipolar disorder, people who have depression only (also called
unipolar depression) do not experience mania. They may, however, experience some manic
symptoms at the same time, which is also known as major depressive disorder with mixed
features.

Bipolar Disorder and Other Illnesses

Some bipolar disorder symptoms are similar to other illnesses, which can make it hard for a
doctor to make a diagnosis. In addition, many people have bipolar disorder along with another
illness such as anxiety disorder, substance abuse, or an eating disorder. People with bipolar
disorder are also at higher risk for thyroid disease, migraine headaches, heart disease, diabetes,
obesity, and other physical illnesses.

Psychosis: Sometimes, a person with severe episodes of mania or depression also has psychotic
symptoms, such as hallucinations or delusions. The psychotic symptoms tend to match the
persons extreme mood. For example:

Someone having psychotic symptoms during a manic episode may believe she is famous,
has a lot of money, or has special powers.
Someone having psychotic symptoms during a depressive episode may believe he is
ruined and penniless, or that he has committed a crime.
As a result, people with bipolar disorder who also have psychotic symptoms are sometimes
misdiagnosed with schizophrenia.

Anxiety and ADHD: Anxiety disorders and attention-deficit hyperactivity disorder (ADHD) are
often diagnosed among people with bipolar disorder.

Substance Abuse: People with bipolar disorder may also misuse alcohol or drugs, have
relationship problems, or perform poorly in school or at work. Family, friends and people
experiencing symptoms may not recognize these problems as signs of a major mental illness
such as bipolar disorder.

Risk Factors
Scientists are studying the possible causes of bipolar disorder. Most agree that there is no single
cause. Instead, it is likely that many factors contribute to the illness or increase risk.

Brain Structure and Functioning: Some studies show how the brains of people with bipolar
disorder may differ from the brains of healthy people or people with other mental disorders.
Learning more about these differences, along with new information from genetic studies, helps
scientists better understand bipolar disorder and predict which types of treatment will work most
effectively.

Genetics: Some research suggests that people with certain genes are more likely to develop
bipolar disorder than others. But genes are not the only risk factor for bipolar disorder. Studies of
identical twins have shown that even if one twin develops bipolar disorder, the other twin does
not always develop the disorder, despite the fact that identical twins share all of the same genes.

Family History: Bipolar disorder tends to run in families. Children with a parent or sibling who
has bipolar disorder are much more likely to develop the illness, compared with children who do
not have a family history of the disorder. However, it is important to note that most people with a
family history of bipolar disorder will not develop the illness.

Treatments and Therapies

Treatment helps many peopleeven those with the most severe forms of bipolar disordergain
better control of their mood swings and other bipolar symptoms. An effective treatment plan
usually includes a combination of medication and psychotherapy (also called talk therapy).
Bipolar disorder is a lifelong illness. Episodes of mania and depression typically come back over
time. Between episodes, many people with bipolar disorder are free of mood changes, but some
people may have lingering symptoms. Long-term, continuous treatment helps to control these
symptoms.

Medications
Different types of medications can help control symptoms of bipolar disorder. An individual may
need to try several different medications before finding ones that work best.

Medications generally used to treat bipolar disorder include:

Mood stabilizers
Atypical antipsychotics
Antidepressants

Anyone taking a medication should:

Talk with a doctor or a pharmacist to understand the risks and benefits of the medication
Report any concerns about side effects to a doctor right away. The doctor may need to
change the dose or try a different medication.
Avoid stopping a medication without talking to a doctor first. Suddenly stopping a
medication may lead to rebound or worsening of bipolar disorder symptoms. Other
uncomfortable or potentially dangerous withdrawal effects are also possible.
Report serious side effects to the U.S. Food and Drug Administration (FDA) MedWatch
Adverse Event Reporting program online at http://www.fda.gov/Safety/MedWatch or by
phone at 1-800-332-1088. Clients and doctors may send reports.

For basic information about medications, visit the NIMH Mental Health Medications webpage.
For the most up-to-date information on medications, side effects, and warnings, visit the FDA
website .

Psychotherapy

When done in combination with medication, psychotherapy (also called talk therapy) can be an
effective treatment for bipolar disorder. It can provide support, education, and guidance to people
with bipolar disorder and their families. Some psychotherapy treatments used to treat bipolar
disorder include:

Cognitive behavioral therapy (CBT)

Family-focused therapy
Interpersonal and social rhythm therapy
Psychoeducation

Visit the NIMH Psychotherapies webpage to learn about the various types of psychotherapies.

Other Treatment Options

Electroconvulsive Therapy (ECT): ECT can provide relief for people with severe bipolar
disorder who have not been able to recover with other treatments. Sometimes ECT is used for
bipolar symptoms when other medical conditions, including pregnancy, make taking medications
too risky. ECT may cause some short-term side effects, including confusion, disorientation, and
memory loss. People with bipolar disorder should discuss possible benefits and risks of ECT
with a qualified health professional.

Sleep Medications: People with bipolar disorder who have trouble sleeping usually find that
treatment is helpful. However, if sleeplessness does not improve, a doctor may suggest a change
in medications. If the problem continues, the doctor may prescribe sedatives or other sleep
medications.

Supplements: Not much research has been conducted on herbal or natural supplements and how
they may affect bipolar disorder.

It is important for a doctor to know about all prescription drugs, over-the-counter medications,
and supplements a client is taking. Certain medications and supplements taken together may
cause unwanted or dangerous effects.

Keeping a Life Chart: Even with proper treatment, mood changes can occur. Treatment is more
effective when a client and doctor work closely together and talk openly about concerns and
choices. Keeping a life chart that records daily mood symptoms, treatments, sleep patterns, and
life events can help clients and doctors track and treat bipolar disorder most effectively.

Finding Treatment

A family doctor is a good resource and can be the first stop in searching for help.
For general information on mental health and to find local treatment services, call the
Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment
Referral Helpline at 1-800-662-HELP (4357).
The SAMHSA website has a Behavioral Health Treatment Services Locator that can
search for treatment information by address, city, or ZIP code.
Visit the NIMHs Help for Mental Illnesses webpage for more information and resources.

For Immediate Help

If You Are in Crisis: Call the toll-free National Suicide Prevention Lifeline at 1-800-273-
TALK (8255), available 24 hours a day, 7 days a week. The service is available to anyone. All
calls are confidential.

If you are thinking about harming yourself or thinking about suicide:

Tell someone who can help right away

Call your licensed mental health professional if you are already working with one
Call your doctor
Go to the nearest hospital emergency department

If a loved one is considering suicide:

Do not leave him or her alone

 Try to get your loved one to seek immediate help from a doctor or the nearest hospital
emergency room, or call 911
Remove access to firearms or other potential tools for suicide, including medications

1. Bipolar Disorder Depression&Presentor Kapil S. Kulkarni Moderator Dr. J.P. Rawat

2. 2. What is Bipolar Disorder?It is a mood disorder characterized by one ormore episodes
of mania or hypomaniaoften with a history of one or more major depressive
episodes.Mood episodes: Manic, Depressed, or Mixed
3. 3. Correct diagnosis and treatment are essential as early aspossible in the course of the
illness to prevent complications.and maximize response to treatment
4. 4. EPIDEMIOLOGY AND ETIOLOGY
5. 5. Bipolar I disorder is characterized by one or moremanic or mixed mood
episodesBipolar II disorder is characterized by one or more major.depressive episodes
and at least one hypomanic episodeHypomania is an abnormally and persistently
elevated,expansive, or irritable mood, but not of sufficient severity tocause significant
impairment in social or occupational function.and does not require hospitalization
6. 6. The lifetime prevalence of bipolar I disorder is estimated to be between 0.3% and
2.4%. The lifetime prevalence of bipolar II disorder ranges from 0.2% to 5%. Bipolar I
disorder affects men and women equally. Bipolar II seems to be more common in
women. Rapid cycling and mixed mania occur more often in women.
7. 7. The mean age of onset of bipolar disorder is 20 yrs. Although onset may occur in
early childhood to the mid-40s. If the onset of symptoms occurs after 60 years of age,
then its probably secondary to medical causes. The most common comorbid conditions
include anxiety, substance abuse, and eating disorder..
8. 8. The precise etiology of bipolar disorder is unknown. -Genetically based -
Environmental factors -Neurotransmitters
9. 9. Genetic The lifetime risk of bipolar disorder in relatives of a bipolar patient is 40% to
70% for a monozygotic twin and 5% to 10% for another first-degree relative. Dizygotic
twins have 20% to 25% chances and children of parent with bipolar disorder have 50%
risk.Environmental HPA axis dysfunction due to environmental stress.Neurotransmitters
NA, DA, 5HT and Glutamate are implicated.
10. 10. PATHOPHYSIOLOGY
11. 11. Neurochemical The pathophysiology of bipolar disorder has been poorly
understood. Imbalance of cholinergic and catecholaminergic neuronal activity Bipolar
disorder is also related to inositol disterbance.
12. 12. TheoriesAbnormal programmed cell deathStudies in animal have shown that
antidepressent, lithium and valproate indirectly regulate factors involved in cell survival.
(BDNF, Bcl2 etc)Kindling Older hypothesis, same as in epilepsy, states that genetically
 predisposed persons experience minor neurological insult ( Due to excess of
glucocorticoids, other acute or chronic stressors, drug abuse)
13. 13. Theories These eventually result in mania. After first episode, sufficient neuronal
damage persists which allow recurrence with or without minor environmental or
behavioral stressors.This view also provides explanation to why anticonvulsants are
useful in BMD.
14. 14. CLINICAL PRESENTATION AND DIAGNOSIS
15. 15. Symptoms1-Mood Expansive/ eleted mood Irritable mood Mania Excess
happiness Sad/ low mood Hopelessness Depression Suicidality
16. 16. 2-Physical/Behavioral: Agitation Impulsivity Aggression Rapid, pressured
speech Decreased need for sleep (Insomnia) Mania Hyper sexuality Increased physical
energy Inflated self-esteem Grandiosity
17. 17. Clinical Presentation1. Lack of energy2. Excessive lethargy3. Lack of initiative4.
Hopelessness Depression5. Helplessness6. Worthlessness7. Suicidal tendancy
18. 18. 3-Thought ProcessesFlight of ideas (FOI)Easy distractibilityDelusions of grandeosity
ManiaIdeas of reference
19. 19. Clinical Presentation Suicidal ideations Negative thoughts Lack of initiative
Depression Ideas of hopelessness Nihilistic delusion
20. 20. Lab test to rule out other medical disorder. A mood disorder questionnaire.
(YMRS, HDRS)
21. 21. Bipolar I disorder (periods of major depressive, manic, and/or mixed episodes)
Bipolar II disorder (periods of major depression and hypomania) Cyclothymic disorder
(periods of hypomanic episodes and depressive episodes) Bipolar disorder, NOS
22. 22. Bipolar I disorder diagnosis require one episode of mania, for at least 1 week or
longer with elevated, expansive, or irritable mood , decreased need for sleep, excessive
energy. If Bipolar disorder 1 diagnosed as MDD and the patient is treated by
antidepressant this can precipitate mania or induce rapid cycling of mania.
23. 23. The distinguishing feature of bipolar II disorder is depression with past hypomanic
episodes.
24. 24. Cyclothymic disorder is a chronic mood disturbance generally lasting at least 2
year.(1 year in children and adolescents) Characterized by mood swings including
periods of hypomania and depressive symptoms. Hypomanic symptoms (grandiosity,
decreased need for sleep, pressure of speech, flight of ideas, distractibility)
25. 25. Patients with bipolar disorder have a high risk of suicide.
26. 26. >= 2-week period of either depressed mood or loss of interest, associated with at least
5 of the following symptoms:Depressed/sad mood Decreased interest and pleasure in
normal activities Decreased appetite, weight loss Insomnia or hypersomnia
Psychomotor retardation or agitation Decreased energy or fatigue Feeling of guilt or
worthlessness Impaired concentration and decision making Suicidal thoughts or
attempts
27. 27. >= 1-week period of abnormal and persistent elevated mood (expansive or irritable),
associated with at least 3 of the following symptoms (four if the mood is only irritable):
Inflated self-esteem (grandiosity) Decreased need for sleep(insomnia) Increased talking
(pressure of speech) Racing thoughts (flight of ideas) Distractible (poor attention)
Increased activity (either socially, at work, or sexually) or increased motor activity or
agitation Excessive involvement in activities that are pleasurable but have a highrisk for
 serious consequences (buying sprees, sexual indiscretions, poorjudgment in business
ventures)
28. 28. At least 4 days of abnormal and persistent elevated mood (expansive or irritable);
associated with at least 3 of the following symptoms (four if the mood is only irritable):
Inflated self-esteem (grandiosity) Decreased need for sleep Increased talking (pressure
of speech) Racing thoughts (flight of ideas) Increased activity (either socially, at work,
or sexually) or increased motor activity or agitation. Excessive involvement in activities
that are pleasurable but have a high risk for serious consequences (buying sprees, sexual
indiscretions, poor judgment in business ventures)
29. 29. Criteria for both a major depressive episode and manic episode (except for duration)
occur nearly every day for at least a 1-week period.
30. 30. Greater than 3 major depressive or manic episodes (manic, mixed, or hypomanic) in
12 months.
31. 31. Personality disorders Alcohol and substance abuse or dependence Anxiety
disorders, including panic disorder, Obsessive compulsive Eating disordersMedical
comorbidities include: Migraine Multiple sclerosis Cushings syndrome Brain tumor
Head trauma
32. 32. Reduce the symptoms of mania Reduce the symptoms of bipolar depression
Prevent the recurrence of a manic or depressive episode Avoid or minimize adverse
treatment effects Promote treatment adherence Improve quality of life
33. 33. Mood stabilizing agents are the cornerstone of treatment. Complete assessment
and careful diagnosis to rule out non-psychiatric causes. Treatment is lifelong.
34. 34. Interpersonal, family and group therapy. Cognitive-behavioral therapy (CBT).
Electroconvulsive therapy (ECT). Psychoeducation.
35. 35. Mood-stabilizing drugs are the usual first-choice treatments and include lithium,
divalproate, carbamazepine, and lamotrigine. Atypical antipsychotics other than
clozapine are also approved for treatment of acute mania Lithium, lamotrigine,
olanzapine, and aripiprazole are approved for maintenance therapy. Benzodiazepines are
used adjunctively for mania. Antidepressants may be used for bipolar depression, but
usually along with a mood-stabilizing agent to prevent a mood switch to mania Mood-
stabilizing drugs are considered the primary pharmacotherapy for relapse prevention.
36. 36. Maintenance Therapy
37. 37. First, 2 or 3 drug combination Lithium or valproate +benzodiazepine for short term t
treatment of agitation or insomnia If psychosis is present consider atypical antipsychotic
w with above Alternative, carbamazepine.no response or tolerate c consider
oxcarbazepineSecond if inadequate response then use 3 drugs c combination
Lithium +Anticonvulsant +Atypical antipsychotic Anticonvulsant +Anticonvulsant
+atypical antipsychoticThird if still inadequate response ECT
38. 38. Hypomania First initiate and/or optimize- Mood stabilizing medication (lithium
,DVP, or a carbamazepine) c Consider adding BZD for short term of g g agitation or
insomnia . Alternative Carbamazepineif no response consider a antipsychotic
Second if response is inadequate to above medication . T Then consider2 drug
combination Lithium +Anticonvulsant or atypical antipsychotic Anticonvulsant +
Anticonvulsant or atypical a n antipsychotic
39. 39. First - Mood stabilizing medication( lithium or lamotrigine)Alternative -
Anticonvulsant (valproate ,carbamazepine or o oxcarbazepine )
40. 40. First 2 or 3 drug combination - Lithium or Lamotrigine +antidepressant - Lithium +
Lamotrigine If psychosis is present ..add on antipsychotic Alternative anticonvulsant :
valproate ,Carbamazepine or o oxcarbazepineSecond if inadequate response consider
adding on atypical a antipsychotic (Quetiapine )Third if inadequate response .3 drug
combination Lamotrigine + Anticonvulsant +Antidepressant Llamotrigine + Lithium
+AntidepressantForth if response is inadequate .ECT
41. 41. A first-line agent (Still Gold standard for BMD despite of side effect profile)
Mechanism of action : Not well understood -Altered ion transport (Na, K, Ca, Mg) -
Increased brain-derived neurotrophic factor(BDNF), -Inhibition of second messenger
systems (adenyl y cyclase, ITP, Protein kinase C, Ca, Protein G)
42. 42. Dosing and monitoring: 900- 1800 mg /day in acute phases 600- 900 mg /day in
maintenance phase Has a narrow therapeutic index , periodic monitoring is
recommended. Serum lithium concentration of 0.6 to 1.4 mMol/L.
43. 43. Pharmacokinetics Half life is 18-24 hrs. Not protein bound. Bioavailability not
affected by food. 98% drug is excreted unchanged in urine.
44. 44. Adverse Effects Common : GIT upset, Tremor, and Polyuria, Polydipsia
Nephrogenic : Lithium-induced Diabetes Insipidus (when urine volume exceed 3 L /
day) Hypothyroidism Poor concentration, Acneiform rash, Alopecia, Worsening of
Psoriasis, Weight gain ,Metallic taste, and Glucose dysfunction. Benign Leukocytosis
Acute lithium toxicity serum concentration over 2 mEq/L
45. 45. Acute Lithium Toxicity Early signs- (1.5-2.0 mMol/L)- Tremulousness, anorexia,
nausea, vomiting, diarrhea, dehydration Further (>2.0mMol/L)- Neurological
menifestations- Restlessness, muscle fasciculation, hypertonia, ataxia, Dysarthria,
drowsiness, delirium. Cardiac problems- Hypotension, arrythmias, collapse. If levels too
high (>2.5mMol/L)- Coma, seizure or permanent neurological damage
46. 46. Lithium dosage should be reduced by 33% to 50% when used with thiazide Acute
lithium toxicity -Discontinue lithium -IV fluid to correct electrolyte imbalance -
HemodialysisTremor Beta blockersLithium induced DI .HCTZ,
AmilorideHypothyroidism ...LevothyroxineGI upset .Take
medication in divided doses with food.
47. 47. Drug InteractionsLithium levels are increased by- ACE inhibitors, NSAIDS, SSRIs,
Antiepileptics, Thiazide diuretics, CCB, methyldopa, Tetracyclines.Lithium levels are
decreased by- Theophylline, CPZ, Antacids, Bicarbonates.
48. 48. Mechanism of action : Uncertain - Modulates voltage sensetive Na ion transport -
Enhance activity of GABA -Enhance BDNF Dosing and monitoring : 500 1000 mg
/day The dosage is then titrated according to response, o tolerability, and serum
concentration. Valproate is preferred over lithium for mixed I episodes and rapid cycling.
49. 49. Adverse EffectsLoss of appetite, Nausea, Dyspepsia, Diarrhea, Tremor,
andDrowsiness ,Weight gain, Alopecia.Hair loss can be minimized by supplementation
with a vitamin containingselenium and zinc.Polycystic ovarian
syndromeThrombocytopeniaDrug is usually stopped if the platelet
count<100,000/mm3.RareHepatic toxicity and pancreatitis.
50. 50. Drug interaction : It is a weak inhibitor of some of the drug by metabolizing liver
enzymes. The risk of a dangerous rash due to lamotrigine is increased when given
concurrently with divalproex. When divalproex is added to lamotrigine, the lamotrigine
dosage should be reduced by 50%. Levels of valproate are decreased by- CBZ,
 Phenytoin, Rifampicin, Topiramate Levels increased by- CPZ, Clarithromycin, TCA
and fluoxetine.
51. 51. Use as mood stabilizing Mechanism of action -Block Na, Ca ion channels -Inhibit
repetitive neuronal excitationDosing and monitoring : 400-600 mg /dayAdverse effect
:Drowsiness, Dizziness, Ataxia, Lethargy, and Confusion.Aplastic
anemiaAgranulocytosis rare but life threatening.Hyponatremia, exfoliative
dermatitis.
52. 52. Drug interactions Carbamazepine induces the hepatic metabolism of many drugs
(Antiepileptic, antipsychotics, some antidepressants, oral contraceptives,) .need dose
adjustment Carbamazepine is also an autoinducer. Carbamazepine can be slowed by
enzyme-inhibiting drugs (antidepressants,macrolide ,azole antifungal )
53. 53. Effective for the maintenance treatment of bipolar disorder More effective for
depression relapse prevention than for mania relapse. Dosing and Monitoring 25 mg
daily for the first 1 to 2 weeks, then titrate according to response upto 200 to 400 mg per
day.
54. 54. Adverse Effects : Maculopapular rash..10% of patient Some rashes can progress
to life-threatening Stevens-Johnson syndrome Dizziness, drowsiness, headache, blurred
vision and nausea .Drug Interactions: DVP..downward adjustment Carbamazepine
..upward adjustment
55. 55. Used as adjunctive therapy, especially during acute mania episodes, to reduce
anxiety and improve sleep.
56. 56. Atypical antipsychotics act as mood stabilizers.They are used either alone or with
combination with mood stabilizers in resistant cases.
57. 57. Should be combined with a mood-stabilizing drug to reduce the risk of mood switch
to hypomania or mania.TCA and SNRI..switch mood to mania or hypomaniaSSRI are
used.Bupropion ..the least one precipitate mania
58. 58. The key issue is the relative risk of teratogenicity with drug use during pregnancy
versus risk of bipolar relapse without treatment with consequent potential harm to both
the pregnant patient and the fetus.Judgment depends on -history of the patient -whether
the pregnancy is planned or unplanned.Lithium can cause floppy baby syndrome,
Ebestein anomaly.During first trimesterVPA and Carbamazepine ..neural tube defect
(spinal bifida )Carbamazepine can cause ..fetal vitamin K deficiencyLamotrigine
with cleft palate
Doctors don't completely understand the causes of bipolar disorder. But they've gained a greater
understanding in recent years of the bipolar spectrum, which includes the elated highs of mania to
the lows of major depression, along with various mood states between these two extremes.

Bipolar disorder seems to often run in families and there appears to be a genetic part to this mood
disorder. There is also growing evidence that environment and lifestyle issues have an effect on the
disorder's severity. Stressful life events -- or alcohol or drug abuse -- can make bipolar disorder
more difficult to treat.

The Brain and Bipolar Disorder

Experts believe bipolar disorder is partly caused by an underlying problem with specific brain
circuits and the functioning of brain chemicals called neurotransmitters.

Three brain chemicals -- noradrenaline (norepinephrine), serotonin, and dopamine -- are involved in
both brain and bodily functions. Noradrenaline and serotonin have been consistently linked to
psychiatric mood disorders such as depression and bipolar disorder. Nerve pathways within areas of
the brain that regulate pleasure and emotional reward are regulated by dopamine. Disruption of
circuits that communicate using dopamine in other brain areas appears connected to psychosis and
schizophrenia, a severe mental disorder characterized by distortions in reality and illogical thought
patterns and behaviors.

The brain chemical serotonin is connected to many body functions such as sleep, wakefulness,
eating, sexual activity, impulsivity, learning, and memory. Researchers believe that abnormal
functioning of brain circuits that involve serotonin as a chemical messenger contribute to mood
disorders (depression and bipolar disorder).

Is Bipolar Disorder Genetic?

Many studies of bipolar patients and their relatives have shown that bipolar disorder sometimes runs
in families. Perhaps the most convincing data come from twin studies. In studies of identical twins,
scientists report that if one identical twin has bipolar disorder, the other twin has a greater chance of
developing bipolar disorder than another sibling in the family. Researchers conclude that the
lifetime chance of an identical twin (of a bipolar twin) to also develop bipolar disorder is about 40%
to 70%.

In more studies at Johns Hopkins University, researchers interviewed all first-degree relatives of
patients with bipolar I and bipolar II disorder and concluded that bipolar II disorder was the most
common affective disorder in both family sets. The researchers found that 40% of the 47 first-
degree relatives of the bipolar II patients also had bipolar II disorder; 22% of the 219 first-degree
relatives of the bipolar I patients had bipolar II disorder. However, among patients with bipolar II,
researchers found only one relative with bipolar I disorder. They concluded that bipolar II is the
most prevalent diagnosis of relatives in both bipolar I and bipolar II families.
Studies at Stanford University that explored the genetic connection of bipolar disorder found that
children with one biological parent with bipolar I or bipolar II disorder have an increased likelihood
of getting bipolar disorder. In this study, researchers reported that 51% of the bipolar offspring had a
psychiatric disorder, most commonly major depression, dysthymia (low-grade, chronic depression),
bipolar disorder, or attention deficit hyperactivity disorder (ADHD). Interestingly, the bipolar
parents in the study who had a childhood history of ADHD were more likely to have children with
bipolar disorder rather than ADHD.

In other findings, researchers report that first-degree relatives of a person diagnosed with bipolar I
or II disorder are at an increased risk for major depression when compared to first-degree relatives
of those with no history of bipolar disorder. Scientific findings also show that the lifetime risk of
affective disorders in relatives with family members who have bipolar disorder increases, depending
on the number of diagnosed relatives.

What Role Does Environment and Lifestyle Play in Bipolar

Disorder?
Along with a genetic link to bipolar disorder, research shows that children of bipolar parents are
often surrounded by significant environmental stressors. That may include living with a parent who
has a tendency toward mood swings, alcohol or substance abuse, financial and sexual indiscretions,
and hospitalizations. Although most children of a bipolar parent will not develop bipolar disorder,
some children of bipolar parents may develop a different psychiatric disorder such as ADHD, major
depression, schizophrenia, or substance abuse.

Environmental stressors also play a role in triggering bipolar episodes in those who are genetically
predisposed. For example, children growing up in bipolar families may live with a parent who lacks
control of moods or emotions. Some children may live with constant verbal or even physical abuse
if the bipolar parent is not medicated or is using alcohol or drugs.

Can Lack of Sleep Worsen the Symptoms of Bipolar

Disorder?
Some findings show that people with bipolar disorder have a genetic predisposition to sleep-wake
cycle problems that may trigger symptoms of depression and mania.

The problem for those with bipolar disorder, however, is that sleep loss may lead to a mood episode
such as mania (elation) in some patients. Worrying about losing sleep can increase anxiety, thus
worsening the bipolar mood disorder altogether. Once a sleep-deprived person with bipolar disorder
goes into the manic state, the need for sleep decreases even more.

Studies at Stanford University that explored the genetic connection of bipolar disorder found that
children with one biological parent with bipolar I or bipolar II disorder have an increased
likelihood of getting bipolar disorder. In this study, researchers reported that 51% of the bipolar
offspring had a psychiatric disorder, most commonly major depression, dysthymia (low-grade,
chronic depression), bipolar disorder, or attention deficit hyperactivity disorder (ADHD).
Interestingly, the bipolar parents in the study who had a childhood history of ADHD were more
likely to have children with bipolar disorder rather than ADHD.

In other findings, researchers report that first-degree relatives of a person diagnosed with bipolar
I or II disorder are at an increased risk for major depression when compared to first-degree
relatives of those with no history of bipolar disorder. Scientific findings also show that the
lifetime risk of affective disorders in relatives with family members who have bipolar disorder
increases, depending on the number of diagnosed relatives.

What Role Does Environment and Lifestyle Play in Bipolar Disorder?

Along with a genetic link to bipolar disorder, research shows that children of bipolar parents are
often surrounded by significant environmental stressors. That may include living with a parent
who has a tendency toward mood swings, alcohol or substance abuse, financial and sexual
indiscretions, and hospitalizations. Although most children of a bipolar parent will not develop
bipolar disorder, some children of bipolar parents may develop a different psychiatric disorder
such as ADHD, major depression, schizophrenia, or substance abuse.

Environmental stressors also play a role in triggering bipolar episodes in those who are
genetically predisposed. For example, children growing up in bipolar families may live with a
parent who lacks control of moods or emotions. Some children may live with constant verbal or
even physical abuse if the bipolar parent is not medicated or is using alcohol or drugs.
Can Lack of Sleep Worsen the Symptoms of Bipolar Disorder?

Some findings show that people with bipolar disorder have a genetic predisposition to sleep-
wake cycle problems that may trigger symptoms of depression and mania.

The problem for those with bipolar disorder, however, is that sleep loss may lead to a mood
episode such as mania (elation) in some patients. Worrying about losing sleep can increase
anxiety, thus worsening the bipolar mood disorder altogether. Once a sleep-deprived person with
bipolar disorder goes into the manic state, the need for sleep decreases even more.
 Bipolar 1 disorder, once known as manic depression, is a mental illness that involves vast, out-of-control mood swings from depressed to elevated moods. There are four types of bipolar
disorder:

1. bipolar 1
2. bipolar 2
3. cyclothymia
4. bipolar not otherwise specified

Bipolar 1 is the type most easily diagnosed as it contains the most pronounced elevated mood, called mania. A person with bipolar 1 (also noted as bipolar i) has episodes of both mania and
depression. The presence of these episodes are the hallmark symptoms of bipolar I.

About 6 million people, or 2.5% of the U.S. population, suffers from bipolar disorder. About 1% of the people in the U.S. are thought to have bipolar 1 disorder.

Bipolar I Symptoms of Mania

A Bipolar I diagnosis requires at least one manic episode in the person's lifetime with a duration of one week or more. In order to be considered a manic episode, it must drastically impair a
person's social or occupational functioning, or lead to hospitalization. It must not be attributable to another condition.

A manic episode is characterized by a profound mood disturbance of elation, irritability or expansiveness. According to the
current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), at least three of the following bipolar 1 symptoms of mania must also be present: 1

Grandiosity

Diminished need for sleep

Excessive talking or pressured speech

Racing thoughts or flight of ideas

Clear evidence of distractibility

Increased level of goal-focused activity at home, at work, or sexually

Excessive pleasurable activities, often with painful consequences

People are most frequently diagnosed with bipolar type 1 when they have a manic episode that results in hospitalization. Bipolar psychosis can also be part of mania.

Detailed information on Bipolar Mania

Bipolar 1 Symptoms of Depression

Bipolar 1 disorder also requires the presence of major depressive episodes. According to the DSM-IV-TR, a major depressive episode must consist of either a marked depressed mood or loss
of pleasure / interest for at least two weeks. Bipolar I symptoms of a major depressive episode must cause significant impairment or distress and must not be explained by another illness.

A depressed episode also must contain four or more of the following bipolar 1 symptoms of depression (three if the person shows both a depressed mood and lack of pleasure):

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

Hypersomnia or insomnia too much sleep or too little

Psychomotor retardation or agitation lethargic or agitated movements and demeanor; can be seen by others
 Loss of energy or fatigue

Decrease in self-worth or feelings of guilt

Decreased concentration ability or marked indecisiveness

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

Detailed information on Bipolar Depression

Bipolar I Symptoms of a Mixed-Episode

A bipolar 1 disorder episode may be diagnosable as both a manic and a depressed episode. This is known as a mixed episode and is quite common in bipolar disorder type 1. For a mixed
episode diagnosis, the depression need only be present for one week.

Bipolar Type 1 is considered the most severe form of this illness.

According to the DSM, Bipolar I is characterized by one or more manic episode or

mixed episodes accompanied by episodes of depression.

This is the most distinguishing, defining element of Bipolar I, i.e. at least one truly
manic episode.

A patient may display psychotic symptoms such as delusions of grandeur or

hallucinations.

In these cases, a patients condition is described as bipolar I with psychotic features.

Bipolar 1 episodes of mania are so profound that some experts use the term raging
bipolar.

A key point is the symptoms are severe enough to disrupt the patients ability to work
and socialize.

The nature of raging bipolar has been captured in this Psychcentral discussion of
bipolar types with a focus on how Bipolar 1 is actually experienced.

Someone suffering from bipolar I can have great difficulty functioning. You could have
trouble holding down a job or dealing with your family.

Some symptoms you might experience during a manic episode include:

1. Decreased need for sleep.

2. Racing thoughts.
Reminder

Bipolar 1 is classic or textbook manic-depressive illness, with serious and

damaging episodes of both mania and depression.

3. Pressured speech.

4. Excess energy. and

5. The need to engage in reckless behavior.

It
is this reckless behavior that makes a manic episode the most dangerous to a patient.
Driving carelessly, spending excessively and engaging in unsafe and reckless sex can
have serious consequences that just do not matter to you at the time.

In a severe manic episode a person can lose all touch with reality. Left untreated a
manic episode can last anywhere from a few days to several years. Most of the time
these symptoms will last for a few weeks or a few months.

As the key difference between Bipolar 1 and Bipolar 2 is the presence of mania versus
hypomania, it is important to understand this distinction in detail. See this explanation of
Bipolar 1 mania types from Brown University.

Bipolar Type 1 mania is often followed by a depressive episode. It can come within days
or not pop up for several weeks or months.

During a depressive episode you may feel drained, in deep despair, guilty for no reason,
worthless and irritable.
Activities you normally enjoy will hold no interest. You may experience sudden weight
loss or gain and uncontrollable crying spells. At your lowest moment you may even
have thoughts of suicide.

Again, possible consequences mean nothing. These depressive episodes can last for
years, that is why bipolar type I is often mistaken for chronic depression.

Many people with bipolar type I disorder can enjoy longs spells without any symptoms in
between episodes at all. A minority of patients have rapid-cycling symptoms between
mania and depression. In extreme cases symptoms of mania and depression can even
alternate in the same day.

The exact cause of bipolar disorders is not precisely understood. It seems to be a

combination of 3 things:

1. Genetics.

2. Chemical imbalances in the brain.

3. Stress and triggering events that somehow activate an inherited predisposition to

bipolar.

Are bipolar I and bipolar II treated differently?

When you go for an assessment, just like with any other illness, you will be asked about
family history. A close relative such as a parent with suspected or diagnosed bipolar
disorder greatly increases the likelihood of also having the illness.

If you are concerned, take a bipolar test.

So far, there does not seem to be any way to prevent the illness, but you can prevent
some episodes of mania or depression once a doctor establishes that you do in fact
have Bipolar Type 1.

Bipolar Type 1 almost always requires medication for effective management. Dont
worry stability and sanity is SO worth it!

The key factor is stabilization. Regular therapy, steady diet and

exercise and MOST OF ALL mood stabilizing medications such as
lithium can greatly reduce the frequency and severity of Bipolar Type 1
episodes.