Bipolar I disorderDr. Mohamed AbdelghaniM.B.B.Ch., M.Sc., M.D. Psych.
Epidemiology The lifetime prevalence is 0.4-1.6%. The lifetime prevalence in monozygotictwin of patients is up to 90%. Male to Female ratio 1:1. Manic episode: more in males. Depressive episode: more in females.
Diagnosis Presence of one or more manic episodes with or withoutpresence of major depressive episodes. Manic episode: Elated mood or irritable mood for one week or more. If mood is elated (3) or more of the following must be present butif mood is irritable (4) or more of the following must be present: Inflated self-esteem or grandiosity. Decreased need for sleep. More talkative than usual. Flight of ideas. Distractability. psychomotor agitation. Loss of normal social and sexual inhibition. Excessive involvement in pleasurable activities that have a high potential forpainful consequences. Not substance-induced or not due to general medical condition. Significant impairment of occupational and social functioning.
Aetiology1) Neurotransmitter hypothesis: increased activity of biogenicamines serotonin, norepinephrine, and dopamine.2) Genetic theory: Increase the incidence of bipolar I disorder in subjects related toan affected person. Associations between bipolar I disorder and genetic markershave been reported for chromosomes 5, 11, X.3) Brain structure theory: Some patients showed enlarged cerebral ventricles. Magnetic resonance spectroscopy showed abnormal regulationof membrane phospholipid metabolism.4) Psychosocial theory:o Feeling of inadequacy and worthlessness are converted bymeans of denial, reaction formation and projection to grandiosedelusions.
Differential diagnosis1. Bipolar II disorder: Major depressive episodes with hypomanic episodes.2. Cyclothymic disorder: Numerous episodes of hypomania and numerousepisodes of depressive symptoms for at least 2 years. The symptoms are not sufficient to diagnose manicepisodes or major depressive episodes. Significant social and occupational impairment.3. Secondary mood disorder: Substance-induced mood disorder. Mood disorder due to general medical condition.
PsychopharmacotherapyA. For manic episodes: “Mood stabilizers”1)Lithium: It is the standard treatment of bipolar disorder. Therapeutic blood level is 0.8-1.2 mEq/litre. Toxic levels start after 1.5 mEq/litre.2)Anti-convulsants: Valproate, Carbamazepine, oxacarbazepine,....3)Atypical antipsychotics: All except Clozapine.
B. For major depressive episode: Lamotrigine Olanzapine plus Flouxetine “Symbyax” Quetiapine Antidepressant drugs should be used withcaution to avoid switching to mania.
Electroconvulsive therapy At least equal to lithium in the treatment of acute andsevere manic episodes. Limited to:1. Acute suicide.2. Severe mania with psychotic symptoms.3. Catatonia.4. Failure of medical ttt “Resistent Bipolar”.
Psychotherapy1) Cognitive therapy: to increase compliance withpharmacotherapy.2) Supportive therapy: with chronic patients whomay have significant interepisodic residualsymptoms and social dysfunction.3) Family therapy: if patient’s disorder is disruptingthe family stability, and because the disorder isstrongly familial.
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