Bipolar Affective Disorder.pptx

Basic concept regarding BPAD

1. Topic Presentation on Bipolar Affective Disorder Presenter : Sambita Chatterjee (M.PHIL. PSW 1 st Year Trainee) Supervised By : Ms. Kamalika Bhattacharjee Psychiatric Social Worker Psychiatric Social Work Department Institute Of Psychiatry Center of excellence

2. Index Introduction Historical Background Theoritical Background Prevalence Prognosis Classifications Diagnostic Criteria Risk Factors Management Conclusion References

3. INTRODUCTION - Definitions According to ICD 10 , Bipolar Affective Disorder is characterized by repeated ( at least two ) episodes in which the patient’s mood and activity levels are significantly disturbed , this disturbance consisting on some occasions of an elevation of mood and increased energy and activity (Mania or Hypomania) and on others of a lowering of mood and decreased energy and activity (Depression) . Bipolar disorders are described by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-V) as a group of brain disorders that cause extreme fluctuation in a person’s mood, energy, and ability to function. Bipolar disorder is a category that includes three different condition– bipolar I, bipolar II , and  cyclothymic disorder .

4. HISTORICAL background - Around 30 AD, the Roman physician Celsus described melancholia in his work as a depression caused. In 1854, Jules Falret described a condition called folie circulaire , in which patients experience alternating moods of depression and mania. In 1882, the German psychiatrist Karl Kahlbaum , using the term cyclothymia, described mania and depression as stages of the same illness. In 1899, Emil Kraepelin , building on the knowledge of previous French and German psychiatrists, described manic-depressive psychosis using most of the criteria that psychiatrists now use to establish a diagnosis of bipolar I disorder. Kraepelin also described a depression that came to be known as involutional melancholia, which has since come to be viewed as a severe form of mood disorder that begins in late adulthood.

5. Theoretical background - Family and Twin Studies- Twin studies suggest that the aggregation of mood disorders in families is due to genetic factors, with the concordance rate for both bipolar and unipolar disorder being higher in monozygotic than dizygotic twins. Psychoanalytical Theory- The psychoanalytical theory of depression began with a paper by Abraham in 1911, and was developed by Freud in 1917 in a paper called ‘ Mourning and Melancholia’ . Freud drew attention to the resemblance between the phenomena of mourning and symptoms of depressive disorders, and suggested that their causes might be similar. Although this and subsequent theories have not been strongly supported by evidence. Cognitive Theory - Beck (1967) proposed that these depressive cognitions reveal negative views of the self, the world, and the future. The automatic thoughts appear to persist because of illogical ways of thinking (which Beck called cognitive distortions ).

6. Sign & Symptoms - Signs of Bipolar Affective Disorder Mania Depression Extremely High Energy Feelings of lethargy, both physically and mentally Grandiose levels of self esteem A sense of worthlessness Loud and Rapid speech Eating too much or too little Very little need for sleep Excessive Sadness Engaging in risky behaviours Thoughts of suicide

7. Sign & Symptoms - Symptoms of Bipolar Affective Disorder Manic and Hypomanic Episodes Major Depressive Episodes High level of self-esteem or grandiosity (feeling unusually important, powerful, or talented) Intense sadness or despair, including feelings of helplessness, hopelessness, or worthlessness and Loss of interest in activities once enjoyed Decreased need for sleep Sleep problems, sleeping too little or too much Talking more than usual, and talking loudly and quickly and Easily distracted Feeling restless or agitated, or having slowed speech or movements Doing many activities at once, scheduling more events in a day than can be accomplished Increase or decrease in appetite and Loss of energy, fatigue Risky behavior (e.g., eating and drinking excessively, spending and giving away a lot of money) Difficulty concentrating, remembering, or making decisions Uncontrollable racing thoughts or quickly changing ideas or topics Frequent thoughts of death or suicide

8. Prevalence- Sex - In contrast to major depressive disorder, bipolar disorder has an equal prevalence among men and women . Manic episodes are more common in men , and depressive episodes are more common in women . Age - The onset of bipolar disorder is earlier than that of major depressive disorder. 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 30 years . Marital Status – Bipolar disorder is more common in divorced and single persons than among married persons, but this difference may reflect the early onset and the resulting marital discord characteristic of the disorder. Socio economic and Cultural Factors - A higher than average incidence of bipolar disorder is found among the U pper socioeconomic groups .

9. Etiology - Biological Factors – 1. Neurotransmitter Disturbances – Serotonin, Dopamine, Acetylcholine (ACH) etc. 2. Structural and Functional Brain Imaging- Computed Axial Tomography (CT), Magnatic resonance imaging (MRI) etc. Genetic Factors – 1. Family Studies 2.Adoption Studies 3. Twins Studies Psychosocial Factors – Life events environmental stress

10. Prognosis Good Prognostic Factors Poor Prognostic Factors Acute or abrupt onset Co-morbid medical disorder, personality disorder or alcohol dependence Typical clinical features Chronic ongoing stress Depression Episodes Unfavorable early environment Well adjusted premorbid personality Presence of psychotic features Good response to treatment Poor drug compliance

11. Classifications - According to ICD 10 – F31 Bipolar Affective Disorder F31.0 Bipolar Affective Disorder, current episode Hypomanic F31.1 Bipolar Affective Disorder, current episode Manic without psychotic symptoms F31.2 Bipolar Affective Disorder, current episode Manic with psychotic symptoms F31.3 Bipolar Affective Disorder, current episode mild or moderate Depression F31.4 Bipolar Affective Disorder, current episode severe depression without psychotic symptoms F31.5 Bipolar Affective Disorder, current episode severe depression with psychotic symptoms F31.6 Bipolar Affective Disorder, current episode mixed F31.7 Bipolar Affective Disorder, current in remission F31.8 Other Bipolar Affective Disorder F31.9 Bipolar Affective Disorder, Unspecified

12. Classifications - According to DSM-V – 293.89 Bipolar I Disorder 296.89 Bipolar II Disorder 301.13 Cyclothymic Disorder 293.83 Bipolar and related disorder due to another medical condition 296.89 Other specified Bipolar and related Disorder 296.80 Unspecified Bipolar and related disorder

13. Diagnostic Criteria (According To ICD 10) - F 31 Bipolar Affective Disorder – Manic episodes usually begin abruptly and last for between 2 weeks and 4-5 months (median duration about 4 months). Depression tend to last longer (median length about 6 month), though rarely for more than a year, except in the elderly. F31.0 Bipolar Affective Disorder, Current episode Hypomanic – Current episode must fulfil the criteria for hypomania(F31.0) There must have been at least one other affective episode (hypomanic, manic, depressive or mixed) in the past. F31.1 Bipolar Affective Disorder, current episode Manic without Psychotic Symptoms – Current episode must fulfil the criteria for mania without psychotic symptoms (F30.1) There must have been at least one other affective episode (hypomanic, manic, depressive or mixed) in the past.

14. Diagnostic Criteria (According To ICD 10) - F 31.2 Bipolar Affective Disorder, current episode Manic with Psychotic Symptoms – Current episode must fulfil the criteria for mania with psychotic symptoms (F30.2) There must have been at least one other affective episode (hypomanic, manic, depressive or mixed) in the past. If required, delusions and hallucinations may be specified as congruent or incongruent with mood. F31.3 Bipolar Affective Disorder, Current episode mild or moderate depression – Current episode must fulfil the criteria for a depressive episode of either mild (F32.0) or moderate (F32.1) severity. There must have been at least one other affective episode (hypomanic, manic, depressive or mixed) in the past. F31.4 Bipolar Affective Disorder, current episode Severe Depression without Psychotic Symptoms – Current episode must fulfil the criteria for a severe depressive episode without psychotic symptoms (F32.2) There must have been at least one other affective episode (hypomanic, manic, depressive or mixed) in the past.

15. Diagnostic Criteria (According To ICD 10) - F31.5 Bipolar Affective Disorder, current episode Severe Depression with Psychotic Symptoms – Current episode must fulfil the criteria for a severe depressive episode with psychotic symptoms (F32.3) There must have been at least one other affective episode (hypomanic, manic, depressive or mixed) in the past. If required, delusions and hallucinations may be specified as congruent or incongruent with mood. F31.6 Bipolar Affective Disorder, Current Episode Mixed – Currently exhibits either a mixture or a rapid alternation of manic, hypomanic and depressive symptoms The patient has had at least one manic, hypomanic or mixed affective episode in the past. F31.7 Bipolar Affective Disorder, Currently In Remission – The patient has had at least one manic, hypomanic or mixed affective episode in the past. At least one other affective episode of hypomanic, manic, depressive or mixed type but Currently not suffering from any significant mood disturbance and has not done so for several months.

16. Diagnostic Criteria (According to DSM V) - 293.89 Bipolar I Disorder – Manic Episode – 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. 2. 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 . 3. 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.

17. Diagnostic Criteria (According to DSM V) - 293.89 Bipolar I Disorder – Hypomanic Episode – A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. 2. The disturbance in mood and the change in functioning are observable by others . 3. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. 4. 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. 3. 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

18. Diagnostic Criteria (According to DSM V) - 293.89 Bipolar I Disorder – Major Depressive Episode – Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning 1.Depressed mood most of the day 2. Markedly diminished interest or pleasure in all activities 3. Significant weight loss when not dieting or weight gain nearly everyday. 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day 6 . Feelings of worthlessness or excessive or inappropriate guilt 7 . Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

19. Diagnostic criteria (according to dsm v) - 296.89 Bipolar II Disorder – Hypomanic Episode – Same as Bipolar I Disorder (293.89) (Hypomanic Episode). Major Depressive Episode - Same as Bipolar I Disorder (293.89) (Major Depressive Episode).

20. Diagnostic criteria (according to dsm v) - 301.13 Cyclothymic Disorder – 1. For at least 2 years (at least 1 year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode . 2. During the above 2-year period (1 year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time. 3. Criteria for a major depressive, manic, or hypomanic episode have never been met . 4. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). 5. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

21. Diagnostic criteria (according to dsm v) - 293.83 Bipolar and related disorder due to another medical condition- 1.A prominent and persistent period of abnormally elevated, expansive, or irritable mood and abnormally increased activity or energy that predominates in the clinical picture. 2. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition. 3. The disturbance is not better explained by another mental disorder. 4. The disturbance does not occur exclusively during the course of a delirium. 5. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning, or necessitates hospitalization to prevent harm to self or others, or there are psychotic features

22. Diagnostic criteria (according to dsm v) - 296.89 Other specified Bipolar and related Disorder- 1. Short-duration hypomanic episodes (2–3 days) and major depressive episodes 2. Hypomanic episodes with insufficient symptoms and major depressive episodes 3. Hypomanic episode without prior major depressive episode 4. Short-duration cyclothymia (less than 24 months)

23. Risk Factors - Environmental - Bipolar disorder is more common in high-income than in low-income countries (1.4 vs. 0.7%). Separated, divorced, or widowed individuals have higher rates of bipolar disorder than do individuals who are married or have never been married, but the direction of the association is unclear. 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. Course modifiers- After an individual has a manic episode with psychotic features, subsequent manic episodes are more likely to include psychotic features. Incomplete inter episode recovery is more common when the current episode is accompanied by mood incongruent psychotic features .

24. Management - Pharmacological Treatment – 1. Antidepressants – some of the commonly used antidepressants are Escitalopram, Fluoxetine, Mirtazapine, Sertraline etc. 2. Antipsychotics – The commonly used drugs include risperidone, olanzapine, haloperidol and aripiprazole etc. 3. Other Mood Stabilizers - The other mood stabilizer are used to treatment of bipolar mood disorders include Sodium Valproate, Benzodiazepines etc.

25. Management - Non-Pharmacological Treatment – Cognitive Behaviour Therapy – It aims at correcting depressive negative cognitions or ideations such as hopelessness, helplessness, worthlessness and make simple ideas and replacing them by new cognitive and behavioral responses. Interpersonal Social Rhythm Therapy – Interpersonal and Social Rhythm Therapy (IPSRT) is designed to help people improve their moods by understanding and working with their biological and social rhythms. Behaviour Therapy - This includes the various short term modalities such as social skill training, problem solving techniques, activity scheduling and decision making techniques. Group Therapy – It is a very useful method of psychoeducation.

26. Management - Non-Pharmacological Treatment – 5. Family Therapy- Family therapy is an evidence-based intervention for adults and children with bipolar disorder (BD) and their caregivers, usually given in conjunction with pharmacotherapy after an illness episode . 6. Psychoeducation - Psychoeducation treatment involves providing patients with information about bipolar disorder and its treatment, with a primary goal being to improve adherence to pharmacological treatment and non pharmacological treatment. 7. Supportive therapy – It will improve therapeutic alliance to alleviate symptoms, improve self-esteem, restore relation to reality, regulate impulses and negative thinking, and improve the ability to cope with life stressors and challenges. 8. Activities Of Daily Living – It will improve the fundamental skills typically needed to manage basic physical needs, comprised the following areas: grooming/personal hygiene, dressing, toileting/continence, and eating .

27. Management - Non-Pharmacological Treatment – 9. Compliance Counselling- Compliance counselling describes the degree to which a patient correctly follows medical advice. It refers to medication and non pharmacological treatment compliance such as self care, self directed exercises, therapy sessions etc. 10. Stress Management – Relaxation techniques such as deep breathing, meditation, yoga and exercises can be very effective at reducing stress for BPAD.

28. Mood Graph

29. Mood Chart

30. Tools of Assessment Assessment Of Mania Assessment Of Depression Young Mania Rating Scale Hamilton Rating Scale for Depression (HDRS) Manic State Rating Scale Beck Depression Inventory Scale (BDI)

31. Conclusion - Bipolar disorder is a type of mental illness that causes drastic changes in a person’s mood, energy levels, train of thought, and overall ability to function in their day-to-day life. Bipolar disorder is considers as a lifelong disorder so awareness, intervention, psychoeducation need to be addressed in the present condition. In life, we all experience a range of emotions, including joy, sadness, anger, and fear, but tend to do it in response to a pertinent life event. When a person persistently experiences significant highs and lows of emotions that interfere with life, they may be suffering from something more serious—such as bipolar disorder. There is also evidence of stigmatization of these disorder which further decreases the quality of life of the patients. Stigmatization and self-stigmatization were shown to be one of the barriers that delay or prevent effective treatment.

32. Reference - Sadock B. J., Sadock, V. A., & Ruiz, P. (2015).  Kaplan & Sadock's Synopsis of psychiatry: Behavioural sciences/clinical psychiatry  (Eleventh edition.). Philadelphia: Wolters Kluwer. Gelder M., Harrison P., & Cowen P., (2009). Shorter Oxford Textbook of Psychiatry (Fifth edition). Oxford University Press. The ICD-10 Classification of Mental and Behavioural Disorders (2007). Clinical descriptions and diagnostic guidelines. World Health Organisation. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) American Psychiatric Association (2006). Practice Guidelines for the Treatment of Psychiatric Disorders Ahuja. N (2010) A short textbook of Psychiatry

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