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Juan Yakisich

on 10 May 2018

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Transcript of DDM II BIPOLAR


Previously known as manic depressive illness, is a severe chronic mood disorder characterised by episodes of mania, hypomania, and alternating or intertwining episodes of depression (figure 1). (Reference: Grande I, Berk M, Birmaher B, Vieta E. Bipolar disorder. Lancet. 2016 Apr 9;387(10027):1561-72. )

Bipolar disorder is a common, chronic, and often severe cyclic mood disorder characterized by recurrent fluctuations in mood, energy, and behavior (Reference: Shannon J. Drayton and Christine M. Pelic. Bipolar Disorder. In Pharmacotherapy, a practical approach. 9th Edition. McGraw-Hill Education. ISBN: 978-0-07-180054-9. Print version of this title: ISBN: 978-0-07-180053-2, MHID: 0-07-180053-0.

Bipolar disorders are brain disorders that cause changes in a person’s mood, energy and ability to function. (Reference: American Psychiatric Association. https://www.psychiatry.org/patients-families/bipolar-disorders/what-are-bipolar-disorders (Last Revised: January 2017))

manic episode
is a period of at least one week when a person is very high spirited or irritable in an extreme way most of the day for most days, has more energy than usual and experiences at least three of the following, showing a change in behavior:
Exaggerated self-esteem or grandiosity
Less need for sleep
Talking more than usual, talking loudly and quickly
Easily distracted
Doing many activities at once, scheduling more events in a day than can be accomplished
Increased risky behavior (e.g., reckless driving, spending sprees)
Uncontrollable racing thoughts or quickly changing ideas or topicsThe changes are significant and clear to friends and family. Symptoms are severe enough to cause dysfunction and problems with work, family or social activities and responsibilities. Symptoms of a manic episode may require a person to get hospital care to stay safe. The average age for a first manic episode is 18, but it can start anytime from early childhood to later adulthood.

hypomanic episode
is similar to a manic episode (above) but the symptoms are less severe and need only last four days in a row. Hypomanic symptoms do not lead to the major problems that mania often causes and the person is still able to function.

major depressive episode
is a period of two weeks in which a person has at least five of the following (including one of the
first two
Intense sadness or despair; feeling helpless, hopeless or worthless
Loss of interest in activities once enjoyed
Feeling worthless or guilty
Sleep problems — sleeping too little or too much
Feeling restless or agitated (e.g., pacing or hand-wringing), or slowed speech or movements
Changes in appetite (increase or decrease)
Loss of energy, fatigue
Difficulty concentrating, remembering making decisions
Frequent thoughts of death or suicide

American Psychiatric Association. https://www.psychiatry.org/patients-families/bipolar-disorders/what-are-bipolar-disorders (Last Revised: January 2017)
Bipolar disorders are classified according to the longitudinal course, which is often characterised by the presence of subthreshold symptoms .
Although bipolar I disorder might seem to have a more tortuous evolution and severe prognosis than bipolar II disorder because of cross-sectional symptom severity, bipolar II disorder has a high episode frequency, high rates of psychiatric comorbidities, and recurrent suicidal behaviours that impair quality of life

Bipolar I disorder
At least one manic episode must be presented, although major depressive episodes are typical but not needed for diagnosis

Bipolar II disorder
At least one hypomanic episode and one major depressive episode are needed for diagnosis

Cyclothymic disorder
Hypomanic and depressive periods that do not fulfil criteria for hypomania or major depression for at least 2 years

Other specified bipolar and related disorder
Bipolar-like disorders that do not meet criteria for bipolar I disorder, bipolar II disorder, or cyclothymia because of insufficient duration or severity
•Short-duration hypomanic episodes and major depressive disorder
•Hypomanic episodes with insufficient symptoms and major depressive disorder
•Hypomanic episode without prior major depressive disorder
•Short-duration cyclothymia
Unspecified bipolar and related disorder
Characteristic symptoms of bipolar and related disorders that do not meet full criteria for any category previously mentioned
Substance or drug-induced bipolar and related disorder
Bipolar and related disorder due to another medical condition

DSM-5=Diagnostic and Statistical Manual of Mental Disorders, 5th edition.

Affects more than 1% of the world's population irrespective of nationality, ethnic origin, or socioeconomic status and represents one of the leading causes of disability among young people.
In a worldwide mental health survey, the prevalence of bipolar disorders was consistent across diverse cultures and ethnic groups, with an aggregate lifetime prevalence of 0·6% for bipolar I disorder, 0·4% for bipolar II disorder, 1·4% for subthreshold bipolar disorder, and 2·4% for the bipolar disorder spectrum.
Access for patients to mental health systems, however, differs substantially across countries, making management of this disorder especially difficult in low-income countries.
With respect to sex, bipolar I disorder affects men and women equally whereas bipolar II disorder is most common in women.
The exact etiology of bipolar disorder is

Although bipolar disorder is one of the most heritable psychiatric disorders, a multifactorial model in which gene and environment interact is currently thought to best fit this disorder.
Many risk alleles of small effect, which partly overlap with schizophrenia (eg, CACNA1C, TENM4, and NCAN) and are described in genome-wide association studies, contribute to the polygenic risk of bipolar disorder.

Many theories have been proposed regarding the pathophysiology of mood disorders
Historically, mood disorders were thought to result from an imbalance in monoaminergic neurotransmitter systems such as the serotonergic, noradrenergic, and—in particular in bipolar disorder—the dopaminergic neurotransmitter system. Despite evidence showing that these circuits are likely to play a part, no singular dysfunction of these neurotransmitter systems has been identified.
Nevertheless, modulation of synaptic and neural plasticity seems to be important in the circuitry regulating affective and cognitive functions.52 Neurotrophic molecules, such as brain-derived neurotrophic factor, have a vital role in signalling pathways of dendritic sprouting and neural plasticity.53 Dendritic spine loss has been noted in post-mortem brain tissue of patients with bipolar disorder.54 Other pathways that can affect neuronal interconnectivity are also under study, including mitochondrial dysfunction and endoplasmic reticulum stress, neuroinflammation, oxidation, apoptosis, and epigenetic changes, particularly histone and DNA methylation.55 Because the core phenotype of bipolar disorder is a biphasic energy shift, corresponding monitoring of phasic dysregulation in mood, sleep, and behaviour is attracting attention. Awareness of the underlying molecular basis and neuroimaging changes, pathogenesis, and pathophysiology of bipolar disorder56 is essential to discover novel drug targets and develop biomarkers of risk, prognosis, and therapeutic response.57

Grande I, Berk M, Birmaher B, Vieta E. Bipolar disorder. Lancet. 2016 Apr 9;387(10027):1561-72.
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

https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml (Retrieved Jan-31-2017)
No biomarker has yet been approved for diagnosis of any mental disorder and clinical criteria endure.
The most widely acknowledged diagnostic classifications are the 10th revision of the International Classification of Diseases (ICD-10) and the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Correct diagnosis of bipolar disorder is aided, to a substantial degree, by a directed interview with the patient and their relatives, to discern the longitudinal course of the disorder, which often differs from answers given in a cross-sectional interview situation.
Only 20% of patients with bipolar disorder having a depressive episode are diagnosed with bipolar disorder within the first year of seeking treatment..
The mean delay between illness onset and diagnosis is 5–10 years.
The most common differential diagnoses—apart from major depressive disorder and schizophrenia—are anxiety disorder, substance misuse, personality disorder, and, in children, attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder, diagnoses that are typically comorbid with bipolarity
Episodes of mania or depression may be induced or caused by medical illness, medications, or substance intoxication or withdrawal

The first step in the management of bipolar disorder is to confirm the diagnosis of mania or hypomania and define the patient’s mood state, because the therapeutic approach differs considerably for hypomania, mania, depression, and euthymia.(Ref: Grande et al)
Treatment of bipolar disorder must be individualized because the clinical presentation, severity, and frequency of episodes vary widely among patients.
Treatment approaches should include both nonpharmacologic and pharmacologic strategies.
Patients and family members should be educated about bipolar disorder (e.g., symptoms, causes, and course) and treatment options. Long-term adherence to treatment is the most important factor in achieving stabilization of the disorder. (Ref: Shannon et al)

Grande I, Berk M, Birmaher B, Vieta E. Bipolar disorder. Lancet. 2016 Apr 9;387(10027):1561-72.
Shannon J. Drayton and Christine M. Pelic. Bipolar Disorder. In Pharmacotherapy, a practical approach. 9th Edition. McGraw-Hill Education. ISBN: 978-0-07-180054-9. Print version of this title: ISBN: 978-0-07-180053-2, MHID: 0-07-180053-0.
“The natural history of bipolar disorder often includes periods of remission, but recurrence is normal, particularly if adherence to treatment is poor”. (Grande et al, 2016)
“Even with treatment, about 37% of patients relapse into depression or mania within 1 year, and 60% within 2 years “ (Geddes et al, 2013)
Allostasis hypothesis: Neuroprogression overburdens adaptive mechanisms to stress (allostatic

Shannon J. Drayton and Christine M. Pelic. Bipolar Disorder. In Pharmacotherapy, a practical approach. 9th Edition. McGraw-Hill Education. ISBN: 978-0-07-180054-9. Print version of this title: ISBN: 978-0-07-180053-2, MHID: 0-07-180053-0
American Psychiatric Association. https://www.psychiatry.org/patients-families/bipolar-disorders/what-are-bipolar-disorders (Last Revised: January 2017)
Grande I, Berk M, Birmaher B, Vieta E. Bipolar disorder. Lancet. 2016 Apr 9;387(10027):1561-72. doi: 10.1016/S0140-6736(15)00241-X. Epub 2015 .
https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml (Retrieved Jan-31-2017)

Dickens was therefore a visionary
— both immersed in and ahead of his time—but his was a tainted genius. He suffered from what he called “fits” of depression, and had what he regarded as a desperate need for long, latenight walks to sustain his wellbeing and writing. However, even though he composed A Christmas Carol “weeping and laughing and weeping again”, Tomalin is clear that these were facets of his creative personality rather than any trendy notions that
he might have had bipolar disorder
" (Lawrie SM. Charles Dickens at Christmas at 200.
Lancet. 2012 Dec 8;380(9858):1994. )
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