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BIPOLAR

OLEH:
JAYA MUALIMIN

Famous People with BPD


Hollywood:

Musicians:

Britney Spears
Jim Carey
Robert Downey Jr.
Linda Hamilton
Vivien Leigh
Ben Stiller
Robin Williams
Richard Dreyfuss
Marilyn Monroe
Tim Burton
Francis Ford Coppola

Beethoven
Mozart
DMX
Jimi Hendrix
Axl Rose
Sting
Brian Wilson
Kurt Cobain
Ozzy Ozbourne

Politicians:
Winston Churchill
Theodore Roosevelt
Abraham Lincoln
Napoleon Bonaparte

Writers:
Edgar Allen Poe
Mark Twain
Virginia Woolf
Charles Dickens
Ralph Waldo Emerson
F. Scott Fitzgerald
Ernest Hemingway
Kurt Vonnegut
Emily Dickinson
T.S. Eliot
Hans Christian Anderson
Victor Hugo

Diagnos
is ?
Treatme
nt ?

Trial &
Error
Medicatio
n
Cerebrotoxi

c
Complexity of
Psikotoxic
Sosiotoxic
Multi-facet Disorder

Treatm
entresistant

Is there anything that


differentiates bipolar
depression from unipolar
(Major Depression)?
Your next patient with
depression.
unipolar can treat with an
antidepressant;
bipolar can worsen with an

The course of Bipolar


Disorder
Mania
Hypomania
Euthymia
Minor
Depression
Major
Depression
Preliminary Phase
Frank E, et al. Biol Psychiatry. 2000;48(6):593-604

Preventative Phase

The course of Bipolar


Disorder
Mania
Hypomania
Euthymia
Minor
Depression
Major
Depression
Preliminary Phase
Frank E, et al. Biol Psychiatry. 2000;48(6):593-604.

Preventative Phase

Bipolar Disorders
MANIA

HYPOMANIA*
MIXED
EPISODE

NORMAL
MOOD

SUBSYNDROMAL
DEPRESSION

DEPRESSION
*Hypomania is a milder form of mania with similar yet less severe symptoms and less overall impairment.
Mixed Episode is an episode that simultaneously presents symptoms of both depression and mania.
Stahl SM. Essential Psychopharmacology. New York, NY: Cambridge University
Press; 2000.

Mood Spectrum

Dichotomies are useful for


education, communication, and
simplification.
Unfortunately, simplicity is
useful, but untrue -- whereas
complexity is true, but useless.

Structure of a Recurrent
Illness
Precipitant

Episode
Underlying illness

Nicol Ferrier, Psyhobiology research group

Spectrum of Illness Course


Episodic
Purely episodic course:
-interepisode stability
-no mixed states
-infrequent episodes
-good recovery
-low incidence of complications

Unstable
Radical mood instability:
-interepisode instability
-mixed states
-frequent episodes
-incomplete recovery
-high incidence of complications
-early onset
-stronger genetic loading?

Course of illness dictates response strategies for the acute episode


Nicol Ferrier, Psyhobiology research

Three Phases of Treatment

Episode

0-2 months
Symptomatic

Continuation

2-12 months
Functional

Maintenance

Indefinite
Stability/adaptive

ach phase has specific goals


ach phase has specific pharmacological and nonpharmacological
eatment must be harmonized across phases
Nicol Ferrier, Psyhobiology

Treatment Challenges in Bipolar


Disorder
Often

unrecognized
Often untreated
Often misdiagnosed
Often inadequately treated
Exacerbated by incorrect
treatment
Akiskal. J Clin Psychopharmacol. 1996;16(suppl
1):4S-14S.

Misdiagnosis Gangguan Bipolar


Skrining

positif menderita bipolar: 3.7% (N=


> 85.000)
Diagnosed with
(Di USA)
20%
Neither bipolar
disorder nor
depression
diagnosis

49%

bipolar disorder

Diagnosed with
31%
depression
but not bipolar disorder

Dari mereka yang skrining positif, hanya 20% yang diberitahu


oleh dokternya bahwa mereka menderita Bipolar
Hirschfeld RM, et al. J Clin Psychiatry. 2003;64:53-59.

Perbandingan Gambaran Klinis


Bipolar depression dan MDD:

Bipolar depression

MDD

Onset: younger

Onset: older

Rapid symptom
onset

Less rapid
symptom
onset

Acute
symptoms
History of mania /
hypomania

Diagnostic
challenge

No mania /
hypomania

Ghaemi et al 2000
Hirschfeld et al 2003
Suppes et al 2005

Bipolar Disorder Classical


Clinical Manifestations
DSM-IV Manic episode
Persistent elevated, expansive, or irritable
mood for at least one week and:
Inflated self-esteem; decreased need for sleep;
talkativeness; racing thoughts; distractibility;
increased activity; and daring behaviors
Impairment in psychosocial functioning
Not only due to other psychiatric and medical
conditions

DSM-IV Hypomanic episode: less


intensity than mania, at least 4 days

Bipolar Disorder
Clinical Manifestations
DSM-IV Major depression episode
Persistent depressed mood or irritability for at
least 2 weeks and:
Motivation, sleep, appetite, concentration, and
energy disturbances
Guilt, suicidal thoughts or behaviors
Impairment in psychosocial functioning

Not only due to other psychiatric and medical


conditions

The Bipolar Spectrum: Stronger


Bipolar I

1 week

Bipolar II

4 Days

Bipolar NOS

< 4 Days

Bipolar III

Antidepressant-related hypomania

Adapted from Akiskal HS, Pinto O. Psychiatr Clin North Am. 1999;22:517-534.

The Bipolar Spectrum: Weaker


Hyperthymic

Bipolar IV

Depressive Mixed State IV

Recurrent Unipolar Depression Bipolar V

Adapted from Akiskal HS, Pinto O. Psychiatr Clin North Am. 1999;22:517-534.
Akiskal HS, et al. J Affect Disord. 2006;96:197-205.

Unipolar Misdiagnosis May Lead


to Inappropriate Treatment

Bipolar disorder misdiagnosed as unipolar depression in 37% of patients


(N = 85)
100

Patients (%)

80
60

55%

40
20

23%
n = 38

0
Mania/
Hypomania

n = 35
Rapid
Cycling

Development of mania/hypomania or rapid cycling while taking antidepressants.


Ghaemi SN, et al. J Clin Psychiatry. 2000;61:804-808.

Diagnostic Criteria for Major Affective


Disorders (DSM-IV)
Disorder

Depressive Episode

Manic or Mixed
Episode

Hypomanic Episodes

Bipolar I Disorder

Common but not


required

1 required

Common but not required

Bipolar II Disorder

1 required

None allowed

1 required

Bipolar Disorder
NOS*

Common but not


required

None allowed

Required, but do not meet


criteria for a specific bipolar
disorder

Cyclothymic
Disorder

Dysthymia, but not


major depression

None allowed

Numerous periods over


2 years required

Major Depressive
Disorder

1 required

None allowed

None allowed

Dysthymic Disorder

2 years required but


not major depression

None allowed

None allowed

*NOS = Not otherwise specified


Adapted from the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000:345-428.

Redefining Bipolar Disorder:


Bipolar disorder
Toward
DSM-V
is often
accompanied by
anxiety, eating, and
substance use disorders and
high rates of medical illness, especially
cardiovascular, cerebrovascular, and
metabolic diseases.
marked disruption in sleep rhythms
and social relations.

Am J Psychiatry 163:7, July


2006

By employing a symptom-based rather


than an etiologically based approach,
DSM-IV fails to reflect the multisystem
presentation of bipolar disorder.

MARY L. PHILLIPS, M.D.


ELLEN FRANK, PH.D.

Am J Psychiatry 163:7, July 2006

DSM-V ??

DSM-V
??
Rather than
defining
bipolar
disorder solely as one of
episodic mood disturbances, we
should consider defining it as a
multisystem
disorder
involving disturbances in all of
the above mentioned domains.

How can DSM-V reflect the clinical complexity


and
pathophysiology
of is
bipolar
disorder
?
An
immediate
first step
initiating
large-scale

studies to identify the specific clinical


spectrum,
neurocognitive,
and
neuroimaging measures that best distinguish
individuals with bipolar disorder from those
with other mood and psychotic disorders and
incorporating
these
as
supplementary
diagnostic criteria into DSM-V.

Bipolar

I Disorder
Subtypes:
Current or Most Recent
Current or Most Recent
Current or Most Recent
Current or Most Recent

Episode
Episode
Episode
Episode

Hypomanic
Manic
Depressed
Unspecified

Bipolar I Disorder (DSM IV)


Single Manic Episode, Most Recent Episode Hypomanic, Most
Recent Episode Manic, Most Recent Episode Mixed, Most
Recent Episode Depressed, and Most Recent Episode
Unspecified.

DSM V proposed
2010 American Psychiatric
Association

Bipolar

II Disorder
Subtypes:
Current or Most Recent Episode Hypoma
nic
Current or Most Recent Episode Depres
sed
DSM IV: Bipolar II Disorder (Recurrent
Major Depressive Episodes With
Hypomanic Episodes)

DSM V proposed

2010 American Psychiatric


Association

BOOKS/BOOKLETS:
Mondimore, F. (1999). Bipolar disorder: A guide
for patients and families. City: Johns Hopkins
Press.
Geller, B., & DelBello, M. P. (Eds.). (2003).
Bipolar disorder in childhood and early
adolescence. New York: Guilford Press.
Educating the child with bipolar disorder.
Available from: www.bpkids.org
Anderson, M., Kubisak, J.B., Field, R., &
Vogelstein, S. (2003). Understanding and
educating children and adolescents with bipolar
RESOURCES
disorder: A guide for educators.

DSM-IV-TR
Five

types of
episodes
Four subtypes
Four severity levels
Three course
specifiers

American Psychiatric Association. (2000). Diagnostic and Statistical


Manual of Mental Disorders-Fourth Edition-Text Revision. Washington,
DC: Author.

Manic Episode
Symptoms:
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep
3. Pressured speech or more talkative than
usual
4. Flight of ideas or racing thoughts
5. Distractibility
6. Psychomotor agitation or increase in
goal-directed activity
7. Hedonistic interests

Similarities

with Manic Episode =

Same symptoms
Differences

Length of time
Impairment not as severe

Hypomanic Episode

Major Depressive Episode

Symptoms:
1. Depressed mood (in children can be irritable)
2. Diminished interest in activities
3. Significant weight loss or gain
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue/loss of energy
7. Feelings of worthlessness/inappropriate guilt
8. Diminished ability to think or
concentrate/indecisiveness
9. Suicidal ideation or suicide attempt

Mixed Episode
Both Manic and Major Depressive
Episode criteria are met nearly every
day for a least a one week period.

Subtypes
Bipolar Disorder I = more classic form; clear
episodes of depression & mania
Bipolar Disorder II = presents with less intense
and often unrecognized manic phases
Cyclothymia = chronic moods of hypomania &
depression, often evolves into a more serious
type
Bipolar Disorder Not Otherwise Specified (NOS)
= largest group of individuals

Children vs. Adults


(or early vs. late onset )
Irritability
Depression
Lack of mood
reactivity
Rejection
sensitivity
Less evident are
the classic
symptoms of
mania

EPIDEMIOLOGY

Prevalence
Estimated

between 3-6%
Subsyndromal bipolar disorder
Equal distribution across gender variables
Average age @ onset = 20 years old

Course
Initial

cycle typically major depressive


episode
Recovery
Relapse
Rapid Cycling
Rapid cycling=4 episodes/year
Ultrarapid cycling=5-364 episodes/year
Ultradian cycling=>365 episodes/year

Age at Onset
Pediatric,

prepubertal, or early adolescent


(prior to age 12)
Adolescent (12 - 18 years)
Adult onset (+ 18 years)

IMPAIRMENTS

Comorbidity
Attention

Deficit Hyperactivity Disorder

(ADHD)
Between 60-80%

Differentiation= elated mood, grandiosity,


decreased need for sleep, hypersexuality,
and irritable mood.

Criteria Comparison
Bipolar Disorder
(mania)
1. More talkative than
usual, or pressure to
keep talking
2. Distractibility
3. Increase in goal
directed activity or
psychomotor
agitation

ADHD
1. Often talks
excessively
2. Is often easily
distracted by
extraneous stimuli
3. Is often on the go
or often acts as if
driven by a motor

Comorbidity
(cont.)
Oppositional

Defiant Disorder (ODD)


& Conduct Disorder (CD)
70-75%

Substance

Abuse

40-50%
Anxiety

35-40%

Disorders

Suicidal Behaviors
Prevalence

of suicide attempts

40-45%
Age

of first attempt
Multiple attempts
Severity of attempts
Suicidal ideation

Executive

Functions

Attention
Memory
Sensory-Motor

Integration
Nonverbal Problem-Solving
Academic Deficits
Mathematics

Cognitive Deficits

Psychosocial Deficits
Relationships

Peers
Family members
Recognition

and Regulation of Emotion


Social Problem-Solving
Self-Esteem
Impulse Control

TREATMENT
APPROACHES

Psychopharmacological
DEPRESSION
Mood Stabilizers
Lamictal

Anti-Obsessional
Paxil

Anti-Depressant
Wellbutrin

Atypical Antipsychotics
Zyprexa

MANIA
Mood Stabillizers
Lithium, Depakote,
Depacon, Tegretol

Aypical Antipsychotics
Zyprexa, Seroquel,
Risperdal, Geodon, Abilify

Anti-Anxiety
Benzodiazepines
Klonopin, Ativan

General Treatment Principles


Confirm

diagnosis
Obtain longitudinal history
Assess risk (eg, suicide)
Manage comorbidity
Involve significant others

Treatment of Bipolar
Disorder

Mood
stabilizer/Antipsychotic
w/ antidepressant effects

Antidepressan
t
Exercise

Psychotherapies
Cognitive-Behavioral
Interpersonal/Social
Rhythm
Family Focused
(Light therapies)

The Evolution of Therapies for Bipolar Disorder

1940
ECT

1950

1960

1970

1980

Lithium*
First-generation antipsychotics
and antidepressants

Approved for use for acute mania


ECT = electroconvulsive therapy

2000

2002

Second-generation antipsychotics
and antidepressants
Clozapine
Risperidone+
Olanzapine*
Quetiapine+
Ziprasidone+
Aripiprazole+

Chlorpromazine*
Trifluoperazine
Fluphenazine
Thioridazine
Haloperidol
Mesoridazine

1990

Anticonvulsants

Anticonvulsants

Carbamazepine
Valproate*

Gabapentin
Lamotrigine
Topiramate
Oxcarbazepine

Therapy
Psychoeducation
Family Interventions
Cognitive-Behavioral Therapy
RAINBOW Program
Interpersonal and Social Rhythm
Schema-focused Therapy

Therapy

EDUCATIONAL
IMPLICATIONS

IDEA Classification
Emotional

Disturbance (ED) vs. Other


Health Impaired (OHI)

Considerations
Rapidly

changing moods of depression,


irritability, grandiosity, pressured speech,
racing thoughts, etc.
Need for movement
Poor relationships
Difficulties with concentration and focus
Difficulties with task completion
Impaired judgment and imulsivity
Disorganization
Becoming overwhelmed with stressful
situations

Possible
Accommodations/Modifications
Provide

student with a safe place and person


to go to when feeling overwhelmed or stressed
Shortened day (permit late start as needed)
Prior notice of transitions
Consistent schedule
Scheduling the students most challenging
tasks at a time of day when the child is best
able to perform
Modified or shortened assignments
Plan for unstructured times of the day
Adjust for medication needs, dispensing, as
well as plans for addressing side effects (e.g.,
sedation)

Other Considerations
Educating

staff
Communication
Hospitalization