Bipolar affective disorder

Lecture № 10 Mood ( affective ) disorders . Bipolar affective disorders . Cyclothymia . Clinical displays , types of motion . Principles of therapy. Mental disorders of epilepsy. Clinical pictures, diagnosis, treatment, rehabilitation. The first aid at epileptic status. Examination. Lecturer Savka Svitlana Dmitryvna

Mood ( affective ) disorders
Mood ( affective ) disorders contains disorders in which the fundamental disturbance is a change in affect or mood to depression or to elation. The mood change is usually accompanied by a change in the overall level of activity; most of the other symptoms are either secondary to, or easily understood in the context of, the change in mood and activity. Most of these disorders tend to be recurrent and the onset of individual episodes can often be related to stressful events or situations.

Bipolar affective disorder
A disorder characterized by two or more 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 (hypomania or mania) and on others of a lowering of mood and decreased energy and activity (depression). Repeated episodes of hypomania or mania only are classified as bipolar.

Mania without psychotic symptoms
Mood is elevated out of keeping with the patient's circumstances and may vary from carefree joviality to almost uncontrollable excitement. Elation is accompanied by increased energy, resulting in hyperactivity, pressure of speech, and a decreased need for sleep. Attention cannot be sustained, and there is often marked distractibility. Self-esteem is often inflated with grandiose ideas and overconfidence. Loss of normal social inhibitions may result in behaviour that is reckless, foolhardy.

Mania with psychotic symptoms
In addition to the clinical picture described in manic syndrome and delusions (usually grandiose) or hallucinations (usually of voices speaking directly to the patient) are present, or the excitement, excessive motor activity, and flight of ideas are so extreme that the subject is incomprehensible or inaccessible to ordinary communication.

Episode depression
In typical depressive episodes, the patient suffers from lowering of mood, reduction of energy, and decrease in activity. Capacity for enjoyment, interest, and concentration is reduced, and marked tiredness after even minimum effort is common. Sleep is usually disturbed and appetite diminished. Self-esteem and self-confidence are almost always reduced and, even in the mild form, some ideas of guilt or worthlessness are often present. Somatic symptoms: loss of interest and pleasurable feelings, waking in the morning several hours before the usual time, depression worst in the morning, marked psychomotor retardation, agitation, loss of appetite, weight loss, and loss of libido.

Episode depression
mild
moderate
severe
Type of depression
Anesthetic depression
Agitate depression
Masked depression
Adynamic depression

Warning Signs of Clinical Depression
Feeling depressed and irritable most of the day
Feeling of hopelessness
Social withdrawl
Impaired concentration
Sleeping more/less than usual
Increased/decreased appetite
Siginificant weight gain/loss
Diminished ability to think

Warning Signs of Clinical Depression
Indecisiveness
Loss of interest in activities that used to be enjoyed
Fatigue, low energy
Missing class
Low self-esteem
Feeling guilty or worthless
Moving or speaking more slowly than usual
More agitated than usual
Recurrent thoughts of death

Cycle of Depression

C yclothymia
A persistent instability of mood involving numerous periods of depression and mild elation, none of which is sufficiently severe or prolonged to justify a diagnosis of bipolar affective disorder or recurrent depressive disorder. This disorder is frequently found in the relatives of patients with bipolar affective disorder. Some patients with cyclothymia eventually develop bipolar affective disorder.

Dysthymia
A chronic depression of mood, lasting at least several years, which is not sufficiently severe, or in which individual episodes are not sufficiently prolonged, to justify a diagnosis of severe, moderate, or mild recurrent depressive disorder.

Treatment of Depressive Disorder
Antidepressant Drugs
Mood stabilisers
Electroconvulsive Therapy
Psychotherapy

Classification anti-depressants
1. TRICYCLICS
2. MONOAMINE OXIDASE INHIBITORS
3. REVERSIBLE INHIBITOR OF MONOAMINE OXIDASE
4. SELECTIVE SEROTONIN REUPTAKE INHIBITORS
5. SELECTIVE SEROTONIN NORADRENALINE REUPTAKE INHIBITOR
6. NORADRENERGIC AND SPECIFIC SEROTONIN ANTAGONIST
7. HETEROCYCLIC
8. SELECTIVE NORADRENALINE REUPTAKE INHIBITORS

1.Tricyclics antidepressants
GENERIC NAME BRAND NAME(S)
amitriptyline Tryptanol, Endep
clomipramine Anafranil, Placil, ETC
dothiepin Prothiaden, Dothep
doxepin Sinequan, Deptran
imipramine Tofranil, Melipramine
nortriptyline Allegron
trimipramine Surmontil

2. MONOAMINE OXIDASE INHIBITORS
These were used in patients resistant to tricyclic treatment and in phobic anxiety disorders, but are now rarely prescribed.
GENERIC NAME BRAND NAME
phenelzine Nardil
tranylcypromine Parnale

3. REVERSIBLE INHIBITOR OF MONOAMINE OXIDASE A
Reversible inhibition of the MAO enzyme limits the problem of food and drug interactions. This class of drug is a safer alternative to MAOIs and no major dietary precautions are needed. RIMAs have fewer interactions, fewer cardiovascular effects and greater safety in overdose.
moclobemide Aurorix, Arima

4. SELECTIVE SEROTONIN REUPTAKE INHIBITORS
This class of antidepressant is well tolerated, and relatively safe in overdose.
citalopram Cipramil, Celepram, Talohexal,etc
Escitalopram Lexapro
fluoxetine Prozac-20, Lovan, Erocap, Zactin, etc
fluvoxamine Luvox, Faverin, Movox
paroxetine Aropax, Paxtine, Oxtine, etc
sertraline Zoloft,Xydem

5. SELECTIVE SEROTONIN NORADRENALINE REUPTAKE INHIBITOR
At low doses venlafaxine acts like an SSRI.and at higher doses it is a bit more like a tricylic without some of the adverse effects.
venlafaxine Efexor, Efexor XR
6. NORADRENERGIC AND SPECIFIC SEROTONIN ANTAGONIST
mirtazapine Avanza, Remeron.

7. Heterocyclic
mianserin Tolvon, Lumin
8. Selective noradrenaline
reuptake inhibitors
reboxetine Edronax

Treatment for mania
Antipsychotic Drugs
Mood stabilisers
ECT (Electroconvulsive Therapy)
Psychotherapy

Mood stabilisers
This group of drugs effectively treat a current episode of mania or depression. They also help prevent future episodes of mania and depression when taken consistently.
lithium carbonate Lithicarb, Quilonum SR
carbamazepine Tegretol, Teril
sodium valproate Epilim, Valpro
lamotrigine Lamictil

TYPICAL ANTIPSYCHOTICS
SHORT ACTING INJECTIBLES
chlorpromazine Largactil
haloperidol Serenace
trifluoperazine Stelazine
LONG ACTING INJECTIBLES
flupenthixol decanoate Fluanxol
fluphenazine decanoate Modecate
haloperidol decanoate Haldo
zuclopenthixol decanoate Clopixol Depot

ATYPICAL ANTIPSYCHOTICS
amisulpride Solian
aripiprazole Abilify
clozapine Clozaril, Clopine
olanzapine Zyprexa, Zydis (wafers)
quetiapine Seroquel
risperidone Risperdal

Electroconvulsive therapy (ECT)
Electroconvulsive therapy , also known as electroshock, is a well-established, albeit controversial, psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect. Today, ECT is most often used as a treatment for severe major depression which has not responded to other treatment, and is also used in the treatment of mania (often in bipolar disorder), catatonia and schizophrenia.

Psychotherapy
Psychoanalytic
Cognitive behavioral
Psychodynamic
Existential
Humanistic
Transpersonal
Hypnotherapy
Gestalt Therapy

Epilepsy
is a chronic psychoneurological disorder caused by impaired brain function, which manifests in recurrent, periodic, paroxysmal states (seizures), and in some cases causes concomitant chronic alterations of personality and/or cognitive processes.

Genuine (idiopathic) epilepsy or the epileptic disease is an illness with hereditary predisposition and belongs to the group o а endogenous mental disorders;
Organic (symptomatic) epilepsy may develop as the consequence of a brain injury (traumatic epilepsy), encephalitis, meningitis, cerebrovascular haemorrhage or thrombosis or any other organic brain damage, in which an epileptogenic focus is formed.

Symptoms of Epilepsy
Seizures
Centrencephalic (generalised)
a) grand mal b) petit mal
Focal
Mental equivalents (psychic seizures)
Changed states of consciousness.
Perceptual changes,changes of thought,
changes of mood.
Chronic impairment of mental functions:
Epileptic personality, cognitive changes

Diagnosis
Skull X-rays;
Lumbar puncture;
Blood serology;
Fasting blood sugar;
Brain scan;
Electroencephalogram (EEG).
Physical examination;
Neurological examination;
Psychical examination;
Routine clinical laboratory examination;
Careful history (recent drug intake).

Classification of Epileptic Seizures
Centrencephalic
Grand mal - 50% have brief aura, unconsciousness, followed by tonic-clonic seizure.
Petit mal - no aura; 2 to 15 seconds of unconsciousness may show 3 per second blinking.
Myoclonic - lightning muscle twitches.
Salaam - falling forward and unconsciousness.
Akinetic (atonic) - loss of muscle tone and unconsciousness.

Classification of Epileptic Seizures
Focal
Jacksonian - onset is most common I thumb of face, motor or sensory march of symptoms.
Psychomotor (temporal lobe) - may end with grand mal; may have independent grand mal seizures.
Frontal - aura common; related to localization; onset with adversive eye movements in grand mal, focal fits.
Midtemporal - facial movements at onset.
Occipital - visual aura; grand mal seizure; strabismus common.

Aura
The aura is perhaps of equal importance to the epileptic himself, for it warns him of the onset of a seizure and allows him a little time to find a safe place. The aura is often present, even in the primary grand mal epileptic, although not in the petit mal. The acute phenomenon is frequently described as diffusely visceral. This feeling may last for a few seconds or days of increasing irritability, restlessness, mild depressive symptoms may precede a major seizure. These symptoms usually disappear after the seizure himself.

Grand Mal seizures
may have a brief aura;
are often initiated by a cry;
loss of consciousness;
falling to the floor;
often physical injury;
the advent of extreme tonic spasm;
the extensor muscles dominating the flexors;
cyanosis is often marked until the seizure terminates;
may be relaxation of the sphincters;
the EEG is dominated with high voltage and fast activity;
on recovery he often complains of muscular aches and of a severe headache;
after depression, despair.

Petit Mal seizure
the classic absence;
myoclonic seizures;
lightning jerks;
atonic seizures;
bilaterally synchronous EEG wave;
duration 10 to 30 seconds;
total unconsciousness.

Psychic seizures
1.Perceptual changes:
- changes in the size of an object (everything may look very small or quite large)
2. Changes of Self-Awareness:
- depersonalization ; serialization; déjà vu; jamais vu.
3. Changes of thought:
- forced thought; disorganization of thought.
4. Changes of mood and affect:
- fear; anxiety; despair and depression; dysphonic.
5. Complex Hallucinatory Experiences;
6. Complex stereotyped automatisms.

Twilight States
Postictal Twilight State:
- usually follows one or several seizures;
- lasts from minutes to (rarely) several days;
- the excitement may include the agitation, paranoid ideation, hallucinations, delusions;
- complete amnesia for this status;
- clear completely and with surprising abruptness;
- the EEG shows diffuse symmetrical slow activity, not the paroxysmal activity of the seizure state.

Twilight States
Ictal Twilight State:
- focal disturbance (temporal lobe);
- searching movements of the head and eyes, lip-smacking, masticatory movements, and swallowing;
- allo disorientation;
- last for 5 – 10 minutes;
- agitation, expressions of fear, anxiety, incoherent talk, aggressive acts.

“ Epileptic Personality”
Slowness of reactions; Perseveration; Rigid emotional attitudes;
Kind of “black-and-white” assessment of people and events;
Fixed opinions;
Particularly concerning religious issues;
Excessive accurateness;
Preciseness and punctuality;
Strict adherence to social norms and rules;
Unresponsiveness to external factors;
Sometimes – self-centeredness an в hypochondriasis;
A tendency to hobbies which demand great patience and persistence;
Tendency to long-lasting emotional states (emotional rigidity) or explosion readiness.

Status epilepiicus.
The recurrence without interruption of grand mal seizures in an epileptic. Seizures repeat approximately every 10 minutes, and the patient remains unconscious between them.

Treatment
Medication;
Psychotherapy;
Surgical Intervention;
Ketogenic diet ;
Prevention of Epilepsy.

The main principles of medication
Selectivity and combined treatment.
Gradual beginning of treatment.
Constant prolonged use of drugs without intermissions.
In the absence of seizures for a prolonged time (1 to 3 years), termination of medication can be considered.

Medication
Tridione (Trimethadione )
Dilantin
Phenurone
Diamox
Phinlepsin
Depacin
Depacin-chrono
Paradione (Paramethadione)

Psychotherapy
The physician may have to intervene in some situations, especially in those school systems that exclude epileptic children of normal intelligence from classroom activities.

Surgical intervention
Epilepsy surgery is an option for patients whose seizures remain resistant to treatment with anticonvulsant medications who also have symptomatic localization-related epilepsy; a focal abnormality that can be located and therefore removed. The goal for these procedures is total control of epileptic seizures, although anticonvulsant medications may still be required.
Ablation of the anterior temporal lobe.

Treatment of status epilepticus.
The complications caused by this state are various and dangerous: brain or lung oedema, inhibition of the breathing centre in the brain, heart failure. Status epilepticus demands urgent treatment measures. All the drugs are injected by parenteral way.
solutions of magnesium sulfate (25 %-20.0)
anxiolytic drugs, in particular benzodiazepines (chlordiazepoxide).
If seizures prevail in spite of medication, it is sometimes necessary to narcotize the patient. Symptomatic treatment to prevent complications (diuretics, drugs to support heart activity, breathing analeptics).

Ketogenic diet
a high fat, low carbohydrate diet developed in the 1920s, largely forgotten with the advent of effective anticonvulsants, and resurrected in the 1990s. The mechanism of action is unknown. It is used mainly in the treatment of children with severe, medically-intractable epilepsies.

Bipolar affective disorder

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