BIPOLAR DISORDER AND MOOD STABILIZERS

BIPOLAR DISORDER is one of the main mood disorders. Patient with mood
disorders experience an abnormal range of moods and lose some level of
control over them. Distress may be caused by the severity of their moods
and their resulting impairment in social and occupational functioning.
Mood disorders have also been called affective disorders.

Mood Episodes Mood Disorders

Are distinct periods of time in which Are defined by their patterns of

some abnormal mood is present. mood episodes.

Types of Mood Episodes: The main Mood Disorders:

• Major depressive episode
(can be present in either MDD
or Bipolar I/II disorders)
• Manic episode
• Mixed episode
• Hypomanic episode
• Major Depressive Disorder
(MDD)
• Bipolar I disorder
• Bipolar II disorder
• Dysthymic disorder
• Cyclothymic disorder

They often have chronic courses

that are marked by relapses with
relatively normal functioning
between episodes.

Like most psychiatric diagnoses,

they may be triggered by a medical
condition or drug (prescribed or
illicit)

Always investigate medical or

substance-induced causes before
making a diagnosis

*some may have psychotic features (delusions or hallucinations)

MOOD EPISODES (DSM-IV-TR Criteria)

1) Major depressive episode

Must have at least 5 of the following symptoms (must include either

number 1 or number 2) for at least a 2-week period:
I. Depressed mood
II. Anhedonia (loss of interest in pleasurable activities)
III. Change in appetite or body weight (increased or decreased)
IV. Feelings of worthlessness or excessive guilt
V. Insomnia or hypersomnia
VI. Diminished concentration
 VII. Psychomotor agitation or retardation (i.e. restlessness or
slowness)
VIII. Fatigue or loss of energy
IX. Recurrent thoughts of death or suicide

• symptoms cannot be due to substance use or medical conditions

• symptoms must cause social or occupational impairment

SUICIDE AND MAJOR DEPRESSIVE EPISODES

=> A person who has been previously hospitalised for a major
depressive episode has a 15% risk of committing suicide later in life.

2) Manic episode

A period of abnormally and persistently elevated, expansive or irritable

mood, lasting at least 1 week and including at least 3 of the following (4
if mood is irritable):
I. Distractibility
II. Inflated self-esteem or grandiosity
III. Increase in goal-directed activity (socially, at work, or sexually)
IV. Decreased need for sleep
V. Flight of ideas or racing thoughts
VI. More talkative or pressured speech (rapid and uninterruptible)
VII. Excessive involvement in pleasurable activities that have a high
risk of negative consequences (e.g; buying sprees, sexual
indiscretions)

• these symptoms cannot be due to substance use or medical

conditions
• symptoms must cause social and occupational impairment
• 75% of manic patients have psychotic symptoms
• A manic episode is a psychiatric emergency; severely impaired
judgment makes patient dangerous to self and others

3) Mixed episode

Criteria are met for both manic episode and major depressive episode.
These criteria must be present nearly every day for at least 1 week. As
with a manic episode, this is a psychiatry emergency.

*irritability is usually the predominant mood state in mixed episodes.

Patients with mixed episodes have a poorer response to lithium. Anti-
convulsants may help.

4) Hypomanic episode

Is a distinct period of elevated, expansive, or irritable mood that

includes at least 3 of the symptoms listed for the manic episode criteria
 (4 if mood is irritable). These are significant differences between mania
and hypomania.

Differences between Manic and Hypomanic episodes

Manic
• Lasts at least 7 days
• Causes severe impairment in
social or occupational
functioning
• May necessitate
hospitalisation to prevent
harm to self or others
• May have psychotic features
Hypomanic
• Lasts at least 4 days
• No marked impairment in social
or occupational functioning
• Does not require hospitalisation
• No psychotic features

Differential Diagnosis for Mood Disorders secondary to........

General medical conditions that General medical conditions that

causes depressive episode causes manic episode

• Cerebrovascular disease •
• Endocrinopathies (cushing’s
syndrome, Addison’s disease,
hypoglycemia,
hyper/hypothyroidism,
hyper/hypocalcemia)
• Parkinson’s disease
• Viral illnesses (e.g;
mononucleosis)
• Carcinoid syndrome
Medication/ substance induced Medication/ substance induced
depressive episode manic episode

• •

Bipolar Disorders

Bipolar I Disorder Bipolar II Disorder

Description • Involves episodes of • Alternatively called
mania and of major recurrent major
depression depressive episodes
• However, episodes of with hypomania
major depression are not
required for the
diagnosis
• It is traditionally known
 as manic depression

Diagnosis and • The only requirement for • History of one or

DSM-IV Criteria this diagnosis is the more major
occurence of one depressive
manic or mixed episodes and at
episode (10-20% of least one
patients experience only hypomaniac
manic episodes). episode
• Between manic • Remember: If there
episodes, there may be has been a full manic
interspersed euthymia, episode even in the
major depressive past, then the
episodes, dysthymia, or diagnosis is not
hypomanic episodes, but Bipolar II disorder,
none of these are but Bipolar I
required for diagnosis

Epidemiology • Lifetime prevalence: 1% • Lifetime prevalence:

• Women and men equally 0.5%
affected • Slightly more
• No ethnic differences common in women
seen • Onset usually before
• Onset usually before age age 30
30 • No ethnic differences
seen

Etiology 1. Biological
2. Environmental
3. Psychosocial
4. Genetic factors
Are all important.

• 1st degree relatives of patients with Bipolar

Disorder are 8-18 times more likely to develop the
illness
• Concordance rates for monozygotic twins are
approximately 75%, and rates for dizygotic twins
are 5-25%
Course and • Tends to be chronic,
Prognosis requiring long-term
treatment
Treatment
Bipolar I / Bipolar II Disorder

Epidemiology

• prevalence: 0.6-0.9%
• M:F = 1:1
• age of onset: teens to 20’s
• slight increase in upper socioeconomic groups
• 60-65% of bipolar patients have family history of major mood disorders

Definition

• Bipolar I Disorder
• disorder in which at least one manic or mixed episode is present
• commonly accompanied by one or more MDE but not required for
diagnosis
• Bipolar II Disorder
• disorder in which there is one MDE and one hypomanic episode
• no past manic or mixed episode

Diagnosis

• mood episodes in Bipolar I/II cannot be due to a GMC or substance

induced
• symptoms cannot be caused by a psychotic disorder
• both can occur with rapid cycling (presence of at least 4 mood
episodes within 1 year; must be symptom free for at least 2 months
between episodes)

classification

A. classification of Bipolar disorder involves describing the current or most

recent mood episode as
either manic, hypomanic, mixed or depressed
B. the most recent episode can be further classified as follows
• without psychotic features, with psychotic features, with catatonic
features, with
postpartum onset

treatment

• biological: lithium, valproic acid, carbamazepine, lamotrigine,

gabapentin, topiramate,
antipsychotics, ECT
• psychological: supportive and psychodynamic psychotherapy, cognitive
or behavioural therapy
• social: vocational rehabilitation, leave of absence from school/work, drug
and EtOH avoidance,
substitute decision maker for finances, sleep hygiene, social skills training,
education for
family members

differential diagnosis

• cyclothymic disorder
• psychotic disorder
• substance induced mood disorder
• mood disorder due to a GMC
• delirium

MOOD EPISODES

Major Depressive Episode (MDE)

A. at least 5 of the following symptoms present for 2 weeks, one of which

must be either depressed mood or loss of interest
• M ood - depressed
• S leep - increased or decreased (if decreased, often early morning
awakening)
• I nterest - decreased
• G uilt/worthlessness
• E nergy - decreased or fatigued
• C oncentration/difficulty making decisions
• A ppetite and/or weight increase or decrease
• P sychomotor activity - increased or decreased
• S uicidal ideation
B. symptoms do not meet criteria for mixed episode
C. symptoms cause significant social or occupational impairment/distress
D. exclude if substance-induced or due to a GMC
E. symptoms not better accounted for by bereavement (a constellation of
depressive symptoms meeting criteria for a MDE appearing within
2 months of the death of a close relative)

Manic Episode

A. a period of abnormally and persistently elevated, expansive, or irritable

mood lasting at least 1 week (or less if hospitalized)
B. during this period three of the following symptoms
(four if mood is only irritable; mnemonic - GST PAID)
• G randiosity or inflated self-esteem
• S leep, decreased need for
• T alkative, pressured speech
• P leasurable activities with P ainful consequences - increased
(e.g. spending, sex, speeding, substance use, inappropriate speech)
• A ctivity, goal-directed or psychomotor - increased
• I deas, flight of
• D istractibility
C. symptoms do not meet criteria for a mixed episode
D. mood disturbance is severe enough to cause psychotic features,
marked
impairment in social/occupational functioning, or necessitate
hospitalization
E. symptoms not substance-induced or due to a GMC

Mixed Episode

_ criteria met for both manic episode and MDE nearly every day for 1 week

Hypomanic Episode

_ criteria A of mania but duration is at least 4 days

_ criteria B and E of mania
_ episode associated with an uncharacteristic change in functioning that is
observable by others
_ change in function is NOT severe enough to cause marked impairment in
social or occupational functioning or to necessitate hospitalization
_ absence of psychotic features