Basic concept regarding BPAD

1. TOPIC PRESENTATION ON BIPOLAR AFFECTIVE DISORDER
Presenter : Sambita Chatterjee
(M.PHIL. PSW 1st 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
o 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).
o 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 Upper socioeconomic groups.

9. ETIOLOGY -
o 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.
o Genetic Factors –
1. Family Studies
2.Adoption Studies
3. Twins Studies
o Psychosocial Factors –
1. Life events
2. 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) -
F31 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) -
F31.2 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 –
1. 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 –
1. 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)

24. 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.

25. 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.

26. MANAGEMENT -
• Non-Pharmacological Treatment –
1. 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.
2. 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.
3. Behaviour Therapy - This includes the various short term modalities such as social skill training,
problem solving techniques, activity scheduling and decision making techniques.
4. Group Therapy – It is a very useful method of psychoeducation.

27. 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.

28. 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.

29. MOOD GRAPH

30. MOOD CHART

31. 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)

32. 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.

33. 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

34. Thank You