A description of Bipolar Disorder

1. Bipolar Disorder
Dr Ajay Nihalani
MD,MRCPsych
www.nihalaniclinics.com
www.drnihalanipsychiatristdelhi.in

2. Clinical Picture
Debilitating illness
High rates of relapse
Chronic recurrent course
Lingering residual symptoms
Functional impairment
Psychosocial disability
Diminished well being

3. Features of Bipolar Disorder
Illness of abnormal mood states
Abnormal mood states....depressive,elevated,mixed
Abnormal mood episodes typically relapsing and remitting in
nature with chronic,recurrent course across the lifespan
Abnormal mood episodes consist of disturbances in mood,vital
sense,self attitude

4. Major Depressive Episode
5(or more ) of the following symptoms have been present
during the same 2 week period and represent a change from
previous functioning; atleast one of the symptoms is either
(1) depressed mood or (2) loss of interest or pleasure
Depressed mood
Markedly diminished interest or pleasure
Significant weight loss or gain
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue
Feelings of worthlessness or inappropriate guilt
Diminished ability to think or concentrate or indecisiveness
Recurrent thoughts of death or suicide

5. Manic Episode
(A) Distinct period of abnormally and persisitently elevated
,expansive or irritable mood,lasting atleast 1 week (less if
hospitalisation necessary)
(B) During the period of mood disturbance,3 or more have been
present to a signifcant degree:
1.Infalted self esteem or grandiosity
Decreased need for sleep
3.More talkative than usual or pressure to keep talking
4 Flight of ideas or racing thoughts
5 Distractibility
6 Increase in goal directed activity or psychomotor agitation
7 Excessive involvement in pleasurable activities that have high
potential for painful consequences

6. Hypomanic Episode
(a) A distinct period of persistently elevated,expansive, or
irritable mood lasting atleast 4 days
that is clearly different from the usual non depressed mood.
(b) During the period of mood disturbance 3 or more of the
following symoptoms have been present
1 Inflated self esteem or grandiosity
2 Decreased need for sleep
3 More talkative than usual or pressre to keep talking
4 Flight of ideas or subjective experience that thoughts are
aracing
5 Distaractibility
6 Increase in goal directed activity or psychomotor agaitation
7 Exccessive involvement in pleasurable activities that have a
high potential of painful consequences

7. Mixed Episode
(a) Criteria are met for both a manic and depressive episode for
a 1 week period.
(b) Mood disturbance is sufficiently severe to impair social or
occupational functioning or relationships with others or
hospitalisation is required or psychotic features are present
The symptoms are not due to the direct effect of a substance or
a general medical condition

8. Rapid Cycling
At least 4 episodes in the last 1 year meeting criteria for
MDD,manic,hypomanic or mixed state.

9. Bipolar disorder subtypes
Bipolar 1 (BPAD1)
h/o manic or mixed episodes with amjor deoressive episodes
typically present but not required for diagnosis.
Bipolar 2(BPAD 2)
One or more episode of hypomania,no mania or mixed state
wih h/o major depressive episodes.
Cyclothymia
For the last 2 yrs numerous periods of hypo manic symptoms
with numerous periods of depressive symptoms

10. Cyclothymia
Chronic,fluctuating mood disturbances
Insidious onset
Numerous hypomanic and depressive episodes
Failure to meet criteria for mania or major depressive episode
BPAD 1or 2 may develop in upto 50% people with cyclothymia

11. Misdiagnosis
2000 survey of National Depressive & manic depressive
association (US) showed 69% of respondents were given
misdiagnosis of
Unipolar depression...60%
Anxity disorder …...26%
Schizophrenia.....18%
Borderline or antisocial personality disorder....17%
Of the patients initially misdiagnosed 35% did not receive a
correct diagnosis for 10 years or longer after seeking
treatment.

12. Improving diagnosis of Bipolar Disorder
Requires careful history and well directed questions
Ask patients as well as family members and significant others
about h/o mania,hypomania.

13. Clues for differentiating Bipolar from unipolar depression
Depressive episodes with reversed neurovegetative symptoms
eg hypersomnia,hyperphagia,anergia
Racing thoughts ,irritability
Brief,sudden or paradoxiacal responses to antidepressants
Early age of onset(before 25)
Family h/o bipolar disorder

14. Epidemiology
At onset patients typically in teens or early twenties.
Lifetime prevalence roughly 1 %
No gender bias unlike unipolar depression

15. Thanks
Dr Ajay Nihalani
MD,MRCPsych
www.nihalaniclinics.com
www.drnihalanipsychiatristdelhi.in