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Bipolar disorders
Dr.Bezawit S.(R1)
september,2020
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Outline
 Inroduction to bipolar disorders
 Epidemiology
 Etiology
 Clinical features and diagnosis of bipolar I disorder
 Coarse, Risk factors and prognosis
3 Introduction to bipolar disoders

 Bipolar disorders (previously called manic-depressive psychosis) consist

of at least one hypomanic, manic, or mixed episode and a depressive
episode
 The bipolar disorders were classically described as psychotic mood
disorders with both manic and major depressive episodes (MDEs) (now
termed bipolar I disorder)
 Recent clinical studies have shown the existence of a spectrum of
ambulatory depressive states that alternate with milder, short-lived
periods of hypomania rather than full-blown mania (bipolar II disorder)
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 Mixed episodes represent a simultaneous mixture of depressive and

manic or hypomanic manifestations
 Although a minority of patients experience only manic episodes,
most bipolar disorder patients experience episodes of both polarity
 Manias predominate in men, depression and mixed states in women
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 There are several types of bipolar disorder categories included in DSM-5

 bipolar I disorder
 bipolar II disorder
 cyclothymic disorder
 Specified & unspecified bipolar disorders
 substance or medication induced bipolar disorder
 bipolar disorder due to another medical condition
6 Bipolar I Disorder

 Typically begins in the teenage years, the 20s, or the 30s, the first episode
of bipolar I disorder could be manic, depressive, or mixed
 One common mode of onset is mild retarded depression or hypersomnia
for a few weeks or months, which then switches into a manic episode
 Others begin with a severely psychotic manic episode with
schizophreniform features; only when a more classic manic episode occurs
is the affective nature of the disorder clarified
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 A careful history taken from significant others often reveals

hyperthymic or cyclothymic traits that antedated the frank onset of
manic episodes by several years,
 In a third group, several depressive episodes occur before the first
manic episode
 On average, manic episodes predominate in youth, and depressive
episodes predominate in later years
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 Bipolar I disorder in children is not as rare as previously thought;

most reported cases are in boys, and mixed manic and rapid-cycling
presentations are the mode
 Childhood-onset depression must also be considered a major risk for
ultimate bipolar transformation
 Mania can also very rarely first appear after 65 years of age, although a
diligent search often reveals a past mild, forgotten, or untreated
depressive or excited episode in earlier years
9 Epedemiology

 In the past few decades, the lifetime prevalence of Bipolar I disorder was
generally estimated at about 1 percent
 The most recent estimates of lifetime prevalence of bipolar I disorder is 3.3,
Bipolar II is 1.1 with corresponding 12 month rates of 2.0 and 0.8, respectively
 Lifetime prevalence rates of bipolar disorder in youth range from 0.2 percent to
2.9 percent
 Bipolar disorder with rapid cycling 5-15% lifetime prevalence
 Cyclothymia 0.5-6.3%
10 Epidemiological correlates

Gender
 In contrast to unipolar depression, the gender ratio in bipolar
disorders (all subtypes combined) is approximately 1:1
 mixed episodes, depressive episode, bipolar depression with
atypical clinical features, rapid cycling bipolar disorder) are
common in women
 Consequently, in the rare cases of unipolar mania (manic episode
without any major or minor depression), men are markedly
overrepresented
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Age
 The onset of bipolar I disorder is earlier than that of major
depressive disorder
 The age of onset of bipolar disorder most commonly around 20
years of age, is substantially (about 10 years) lower than that of
unipolar depression
 The age of onset for bipolar I disorder ranges from childhood (as
early as age 5 or 6 years) to 50 years or even older in rare cases,
with a mean age of 18 years
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 Like unipolar depression, bipolar patients with positive family

history of mood disorders are significantly younger at the beginning
of the illness and need less stressors to precipitate the illness
 Bipolar men appear to have 4 to 5 years earlier onset than bipolar
women, In more than half of the cases, onset is before the age of 20
frequently in late adolescence
 First-onset mania is very rare among elderly people
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Marital Status
 the rate of family breakdown (separation, divorce) is elevated
markedly in bipolar I disorder and bipolar II disorder patients
 Mood disorders are generaly common in single than married people
 The presence of mania, hypomania, or major depression is a strong
predictor for future separation or divorce
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Socioeconomic Factors
 Individuals with lower socioeconomic status have a lower level of
educational status, lower income, and poorer living conditions, as
well as a higher rate of unemployment , homelessness which
predisposes to different mental conditions
 Mood disorder can easily lead to unemployment, divorce, or low
income, resulting in regression on the social hierarchy scale
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Seasonal Factors and geographic Trends

 Statistically, spring and fall are the peak times for depression, just as
summer is for mania
 Seasonal affective disorders occur in approximately 20 to 25
percent of the patients with recurrent major mood disorders
 There is a general, but weak, trend for lower prevalence of
depression and higher rate of mania in regions located closer to the
Equator
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Social Stressors and social support

 Social stressors, in general, have been well recognized as risk
factors for mood disorders
 In the case of major depression and bipolar disorder, the association
of acute stressors and the onset of illness become progressively
weaker with the increasing number of previous episodes, and
patients at high genetic risk for mood disorders commonly
experience depressive or manic episodes without any negative life
event
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 In the development of major mood disorders, chronic stressors (e.g.,

unemployment, difficult marriage) play a more important role than specific, acute
stressors
 However, accumulation of stressful negative life events is the strongest
predisposing factor
 Social support can improve coping and modify the occurrence of psychosocial
stressors or the adverse consequences of them
 weak or lacking social support (including social network, social interaction, and
instrumental support) can also be considered a major risk factor
18 Etiology

Biological Factors
 Biogenic Amines
 Of the biogenic amines, norepinephrine and serotonin are the two
neurotransmitters most implicated in the pathophysiology of mood
disorders
 classical neurotransmitter hypothesis-NE high in mania and low in
depression with superimposed low serotonin
 current data suggests that dopamine activity may be reduced in
depression and increased in mania
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Other Neurotransmitter Disturbances

Acetylcholine: low acetylcholine in mania and increased
acetylcholine in depression and
GABA: Relatively the same levels of GABA in BPD in CSF
 Second Messengers and Intracellular Cascades
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 Alterations of Hormonal Regulation

• THYROID AXIS ACTIVITY
• GROWTH HORMONE
• PROLACTIN

 Alterations of Sleep Neurophysiology

 Immunological Disturbances
 Structural and Functional Brain abnormalities
21 Genetic Factors

 Family linkage studies have shown that bipolar disorder is substantially genetical
 Concordance rates for bipolar disorder have been estimated to be up to 90% for
monozygotic twins & 14% for dizygotic twins
 One parent with Bipolar I Disorder: child has 25% chance of a mood disorder
 Both parents with Bipolar I Disorder: child has 50-75% chance of a mood disorder
 First-degree relatives of proband with Bipolar I Disorder: 8-18 times more likely
than general population to have Bipolar Disorder
22 Psychosocial Factors

Life Events and Environmental Stress

 A long-standing clinical observation is that stressful life events more often
precede first, rather than subsequent, episodes of mood disorders
 This association has been reported for both patients with major depressive
disorder and patients with bipolar I disorder
 One theory proposed to explain this observation is that the stress accompanying
the first episode results in long-lasting changes in the brain’s biology
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 These long-lasting changes may alter the functional states of various

neurotransmitter and intraneuronal signaling systems, changes that
may even include the loss of neurons and an excessive reduction in
synaptic contacts
 As a result, a person has a high risk of undergoing subsequent
episodes of a mood disorder, even without an external stressor
24 Psychodynamic Factors in Mania

 Most theories of mania view manic episodes as a defense against

underlying depression
 Abraham, for example, believed that the manic episodes may
reflect an inability to tolerate a developmental tragedy, such as the
loss of a parent
 The manic state may also result from a tyrannical superego, which
produces intolerable self-criticism that is then replaced by euphoric
self-satisfaction
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 Bertram Lewin regarded the manic patient’s ego as overwhelmed

by pleasurable impulses, such as sex, or by feared impulses, such as
aggression
 Klein also viewed mania as a defensive reaction to depression,
using manic defenses such as omnipotence, in which the person
develops delusions of grandeur
26 Clinical features and diagnosis

 There are several types of bipolar disorder categories included in

DSM-5
 Bipolar disorder can present with mania, hypomania , major
depression or mixed features
 The severity of these syndromes varies widely across patients, as
well as within individual patients, and subsyndromal symptoms are
common
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 The mood episode at onset of bipolar one disorder is usually major

depression In different patients the first lifetime episode was :
●Major depression in 54 percent
●Mania in 22 percent
●Mixed in 24 percent
28 Prodrome

 Many studies indicate that prodromal signs and symptoms such as

irritability, anxiety, mood swings, agitation, aggressiveness, sleep
disturbance, and hyperactivity may precede onset of diagnosable
bipolar disorder
 However, the same features can occur during the prodrome of other
psychiatric disorders
29 Manic episode

 A manic episode is a distinct period of an abnormally and

persistently elevated, expansive, or irritable mood lasting for at least
1 week or less if a patient must be hospitalized
 Manic episodes involve clinically significant changes in mood,
energy, activity, behavior, sleep, and cognition
30 Mood Disturbance

 Abnormally elevated, irritable, and labile mood is a core symptom required to

diagnose mania
MOOD ELEVATION
 Classic mania is marked by an unusually good, euphoric, or high mood, which may be
accompanied by disinhibition (eg, wearing garish clothes or disrobing in public), disregard
for social boundaries, expansiveness, and a relentless pursuit of stimulation and social
activities (eg, acting flirtatious, renewing old friendships, or lengthy telephone calls with
strangers)
 The elevated mood may have an infectious quality that initially engages others; however,
patients often become offensive due to their insensitivity to the needs of others
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LABILITY AND IRRITABILITY

 The prevailing positive mood in mania is not stable, and momentary

crying or bursting into tears is common
 In addition, the high is so excessive that many patients experience it
as intense nervousness
 When crossed, patients can become extremely irritable and hostile.
Thus, lability and irritable hostility are as much features of the
manic mood as is elation
32 Persistently increased energy and activity

 Increased planning and activity is typically marked by impulsivity, poor judgement, and
disregard for risks
Examples include taking on new and foolish business ventures, unaffordable spending sprees,
sexual infidelity or sexual encounters with strangers, and driving recklessly
 In addition, patients are often unable to complete the many tasks or projects that are started
 Increased goal-directed activity was the most commonly endorsed symptom based on
different studies
33 Psychomotor Acceleration

 Accelerated psychomotor activity, the hallmark of mania, is characterized by overabundant

energy and activity and rapid, pressured speech
 Subjectively, the patient experiences an unusual sense of physical well-being (eutonia)
FLIGHT OF IDEAS
 Thinking processes are accelerated, subjectively experienced as racing thoughts, and
thinking and perception are unusually sharp
 The patient may speak with such pressure that associations are difficult to follow
 The pressure to speak may continue despite the development of hoarseness
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 Manic speech is generally loud, pressured or accelerated, and

difficult to interrupt, and may be accompanied by jokes, singing,
clanging (choosing words based upon sounds rather than meaning),
and dramatic gesticulations
 Irritable patients often make hostile comments, insult more than
usual, or go off on angry tirades
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IMPULSIVE BEHAVIOR
 Manic patients are typically impulsive, disinhibited, and meddlesome
 Pathological familiarity with total strangers is also a feature not specifically listed
in the DSM-5 schema for mania, yet it is one of its cardinal signs
 They are intrusive in their increased involvement with others, leading to friction
with family members, friends, and colleagues
 They are distractible and move quickly, not only from one thought to another but
also from one person to another, showing heightened interest in every new
activity that strikes their fancy
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 They engage in various activities in which they usually display poor

social judgment
Examples include; preaching or dancing in the street; buying new
cars, expensive jewelry, or other unnecessary items; paying the bills of
total strangers in bars; giving away furniture; marrying impulsively;
engaging in risky business ventures; gambling; and taking sudden trips
 Such pursuits can lead to personal and financial ruin
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DELIRIOUS MANIA
 Although not listed in DSM-5, an extremely severe expression of
mania (once known as Bell’s mania) called delirious mania involves
frenzied physical activity that continues unabated and leads to
delirium and disorientation—a life-threatening medical emergency
 This complication, the manic counterpart of stupor, is rare today
38 VEGETATIVE DISTURBANCES

 Vegetative disturbances are more difficult to evaluate in mania than in depression

Hyposomnia
 Hyposomnia is the cardinal sign of decreased need for sleep —the patient sleeps
only a few hours but feels energetic on awakening
 Manic patients may feel well-rested, or energetic and “wired,” despite sleeping
for only a few (eg, three) hours or some patients may actually go sleepless for
several days
 This could lead to dangerous escalation of manic activity, which might continue
despite signs of physical exhaustion
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Inattention to Nutrition
 There does not seem to be a clinically significant level of appetite
disturbance as such, but weight loss may occur because of increased
activity and neglect of nutritional needs
Sexual Excesses
 Hypersexuality is a cardinal sign of mania
 The sexual appetite is typically increased and may lead to sexual
indiscretion
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 Married women may associate with men below their social status
 Men typically overindulge in alcohol, frequent bars, and may
squander their savings on prostitutes
 The sexual misadventures of manic patients result in marital
disasters hence the multiple separations or divorces that are almost
pathognomonic of the disorder
41 Cognitive Distortions

 Manic thinking is overly positive, optimistic, and expansive

 Common cognitive symptoms of mania include increased mental
activity, racing thoughts, distractibility, and difficulty
distinguishing between relevant and irrelevant thoughts; these
symptoms result in flight of ideas
 In addition, patients may not recall events that occur during manic
episodes
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GRANDIOSITY, LACK OF INSIGHT, AND POOR JUDGMENT

 The patient exhibits inflated self-esteem and a grandiose sense of
confidence and achievements
 Denial and lack of insight are cardinal psychological derangements
of mania
 Insight (if present at all) is transient, and manic patients are
notoriously refractory to self-examination and insight
 Manic patients generally have an exaggerated sense of wellbeing
and self-confidence, which may extend to grandiosity of psychotic
proportions
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As an example, some patients believe they have a special relationship with God or
celebrities, or possess talents that surpass the abilities of others
 Among individuals with mania in the general population, increased self-esteem
and grandiosity are the least commonly endorsed symptom
 It is this lack of insight coupled with poor judgment that leads manic patients to
engage in activities that harm themselves and their loved ones
 It also explains, in part, their nonadherence with medication regimens during the
manic phase
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DELUSION FORMATION
 Manic patients often harbor delusional beliefs, including delusions of exceptional
mental and physical fitness and talent; delusions of wealth, or other grandiose
identity; delusions of assistance (i.e., well-placed persons or supernatural powers
are assisting their endeavors); or delusions of reference and persecution, based on
the belief that enemies are observing or following them out of jealousy at their
special abilities
 At the height of mania, patients may even see visions or hear voices congruent
with their euphoric mood and grandiose self-image (e.g., they might see images
of heaven or hear cherubs chanting songs to praise them)
45 Chronic Mania

 About 5 percent of bipolar I disorder patients have a chronic manic

course
 These cases commonly represent deterioration of course dominated
by recurrent manic episodes grafted onto a hyperthymic baseline
 Recurrent excitement is personally reinforcing, subjective distress is
minimal, and insight is seriously impaired
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 Thus, the patient sees no reason to adhere to treatment Episodic or

chronic alcohol abuse, prevalent in such patients, has been
suggested as a contributory cause of the chronicity
 Some authorities further consider comorbid cerebral pathology to be
responsible for nonrecovery (and increased mortality) from manic
excitements occurring in late life
47 Major depression episode

 Psychomotor retardation, with or without hypersomnia, marks

the uncomplicated depressive phase of bipolar I disorder
 Onset and offset are often abrupt, although onset can also occur
gradually over several weeks
 Patients may recover into a free interval or may switch directly
into mania and switching into an excited phase is particularly
likely when antidepressants have been used
 Episodes typically last several months and residual symptoms
are common among patients who otherwise recover
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49 Mixed features

 Episodes of bipolar mania, hypomania, and major depression can be

accompanied by symptoms of the opposite polarity, and are referred to as
mood episodes with mixed features
 One review estimated that among bipolar patients, mixed features occur in
20 to 70 percent
 Manic or hypomanic episodes with mixed features are characterized by
episodes that meet full criteria for mania or hypomania , and at least three
of the following symptoms during most days of the episode
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●Depressed mood
●Diminished interest or pleasure in most activities
●Psychomotor retardation
●Low energy
●Excessive guilt or thoughts of worthlessness
●Recurrent thoughts about death or suicide, or suicide attempt
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 Major depressive episodes with mixed features are characterized by

episodes that meet full criteria for major depression , and at least
three of the following symptoms during most days of the episode:
●Elevated or expansive mood
●Inflated self-esteem or grandiosity
●More talkative than usual or pressured speech
●Flight of ideas or racing thoughts
●Increased energy or goal-directed activity
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●Excessive involvement in pleasurable activities that have a high potential

for painful consequences
●Decreased need for sleep
 Compared with bipolar patients without mixed features, patients with
mixed features are at greater risk for suicidal ideation and behavior, and
comorbid anxiety disorders and substance use disorders
 In addition, response to treatment is often poorer in mood episodes with
mixed features than in pure bipolar major depression or pure mania
53 Rapid cycling bipolar disorder

 Patients who experience at least four episodes during a 12-month period are
classified as “rapid cycling”
 General population studies done in ten different countries found that the estimated
12-month prevalence of rapid cycling bipolar disorder in the general population
was 0.3 percent
 The estimated one-year prevalence of rapid cycling mania among all bipolar
patients was aproximately 30 percent
 Onset of bipolar disorder occurred at a younger age among rapid cycling
individuals compared with non-rapid cycling individuals
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 Rapid cycling appears to equally affect females and males in the general
population
 However,some studies in clinical settings indicate that rapid cycling is associated
with female gender
 Neglect during childhood and parental divorce both appear to be more common
in rapid cycling individuals in the general population compared with non-rapid
cycling individuals
 Psychosocial functioning is generally significantly impaired in rapid cycling
bipolar disorder as compared to non-rapid cycling bipolar
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 Factors favoring its occurrence include (1) female gender, (2) borderline
hypothyroidism, (3) menopause, (4) temporal lobe dysrhythmias, (5) alcohol,
minor tranquilizer, stimulant, or caffeine abuse, and (6) long-term,
aggressive use of antidepressant medications
56 Suicidal behaviour

 The lifetime risk of suicide in individuals with bipolar disorder is estimated to be

at least 15 times that of the general population
 In fact, bipolar disorder may account for one-quarter of all completed suicides
Deaths A review estimated that approximately 10 to 15 percent of bipolar patients
die by suicide
 Two risk factors for completed suicide in bipolar disorder were
●History of attempted suicide
●Hopelessness
Attempts — Suicide attempts are common in bipolar disorder and a lifetime history
of at least one suicide attempt was found in 27 percent
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 Based upon studies,suicide attempts are associated with

●Marital status of never married (single)
●History of having been physically or sexually abused
●Early age of onset of bipolar disorder (eg, <25 years)
●Depressive symptoms
●Mixed features
●Progressive, increasing severity of depressive and manic episodes
●Comorbid psychiatric disorders, including anxiety disorders, drug abuse, and alcohol abuse
●Family history of suicide death
58 VIOLENCE

 Compared with the general population, patients with bipolar disorder appear to be
more likely to both perpetrate violence and be victimized by violence
Perpetration — Perpetration of violent behavior appears to be more common in
bipolar patients than the general population and other psychiatric patients,common
reasons for this are
 comorbidity (eg, substance use disorders)
 irritable mood
 grandiose psychosis with paranoid features
 delusions of infidelity leading to crimes of passion towards lovers or spouse
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LEGAL PROBLEMS
 Manic patients often incur criminal justice problems.
 The probability of arrest was increased in patients with prior arrests, psychosocial
impairment, and substance use disorders
 However, it’s not clear whether the rate of legal involvement in manic patients is greater
than the rate in the general population
Victimization
 Patients with bipolar disorder appear to be victims of violence at rates that are comparable
to or greater than the rate at which they perpetrate violence
60 Diagnostic criteria for manic episode

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and
abnormally and persistently increased goal-directed activity or energy, lasting at least 1
week and present most of the day, nearly every day (or any duration if hospitalization is
necessary)
B. During the period of mood disturbance and increased energy or activity, three (or more)
of the following symptoms (four if the mood is only irritable) are present to a significant
degree and represent a noticeable change from usual behavior:
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3. More talkative than usual or pressure to keep talking
4. Flight of ideas or subjective experience that thoughts are racing
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5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external

stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation (i.e., puφoseless non-goal-directed activity).
7. Excessive involvement in activities that have a high potential for painful consequences
(e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business
investments).
C. The mood disturbance is sufficiently severe to cause marked impairment in social or
occupational functioning or to necessitate hospitalization to prevent harm to self or others,
or there are psychotic features.
D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of
abuse, a medication, other treatment) or to another medical condition
62 COMORBIDITY

 The lifetime prevalence of three or more comorbid disorders was 44 percent in a

crossectional study done across 11 countries

●Anxiety disorders
●Substance use disorders
●Attention deficit hyperactivity disorder (ADHD)
●Eating disorders
●Intermittent explosive disorder
●Personality disorders
●Posttraumatic stress disorder
63 Coarse and development

 The course of illness in mania may be marked by a sudden onset, and episodes
progress quickly over a few days
 The duration of manic episodes ranges from weeks to months
 Resolution of mania typically does not involve residual symptoms
 Mean age at onset of the first manic, hypomanic, or major depressive episode is
approximately 18 years for bipolar I disorder
 Onset occurs throughout the life cycle, including first onsets in the 60s or 70s
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 Onset of manic symptoms (e.g., sexual or social disinhibition) in late mid-life or

late- life should prompt consideration of medical conditions (e.g., frontotemporal
neurocogni- tive disorder) and of substance ingestion or withdrawal
 More than 90% of individuals who have a single manic episode go on to have
recurrent mood episodes
 Approximately 60% of manic episodes occur immediately before a major
depressive episode
 Individuals with bipolar I disorder who have multiple (four or more) mood
episodes within 1 year receive the specifier "with rapid cycling"
65 Risk and Prognostic Factors

Genetic and physiological

 A family history of bipolar disorder is one of the strongest and most consistent
risk factors for bipolar disorders
 There is an average 10-fold increased risk among adult relatives of individuals
with bipolar I and bipolar II disorders
 Magnitude of risk increases with degree of kinship
 Schizophrenia and bipolar disorder likely share a genetic origin, reflected in
familial co-aggregation of schizophrenia and bipolar disorder
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Environmental
 Bipolar disorder is more common in high-income than in low-income countries

Marital status
 Separated, divorced, or widowed individuals have higher rates of bipolar I disorder than do
individuals who are married or have never been married, but the direction of the association is
unclear

Course modifiers
 After an individual has a manic episode with psychotic features, subsequent manic episodes are
more likely to include psychotic features
 Incomplete interepisode recovery is more common when the current episode is accompanied by
mood- incongruent psychotic features
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References
1. KAPLAN & SADOK'S COMPREHENSIVE TEXT BOOK OF
PSYCHIATRY (10th edition)
2.Synopsis of psychiatry(11th edition)
3.Uptodate
4.DSM-5
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