Affect refers to mood or emotional state. Affective disorders are a set of psychiatric disorders, also called mood disorders.  This includes : Depression Bipolar and unipolar disorder Mania and hypomania

1. Affective disorders
Mania and
Bipolar disorders
part – 2
BY ,
M. TEJASHREE
PHARM D 4TH YEAR

2. CONTENTS
 INTRODUCTION on affective disorders
 Manic Disorder
 Classification Manic Disorder
 Pathophysiology
 cause
 signs and symptoms
 Diagnosis
 Treatment
 Introduction on Bipolar disorder
 Epidemiology
 Types
 Clinical features
 Differential diagnosis
 Management

3. INTRODUCTION
 DEFINITION: Affect refers mood or emotional state.
 Affective disorders are a set of psychiatric disorders, also called mood disorders.
 This includes :
 Depression
 Bipolar and unipolar disorder
 Mania and hypomania

4. Manic Disorder
 A mania is a distinct period during which there is an abnormally and persistently elevated,
expansive, or irritable mood.
 This period of abnormal mood must last at least 1 week.
 Mania is the mood of an abnormally elevated arousal energy level.
 Mania is a state of extreme physical and emotional elation.
 The word is derives from the Greek (mania) meaning "madness, frenzy"
 The mean age for first manic episode is early 20s
 Some people experience onset in adolescence, whereas others start experiencing symptoms
when they are older than 50
 Manic episodes typically begin suddenly, with rapid escalation of symptoms over a few days,
and they last from a few weeks to several months

5. classification
 Mania can be classified into three categories which are:
 1. MIXED STATUS:
 In a mixed state the individual has co-occurring manic and depressive features
 2. HYPOMANIA:
 In hypomania, there is less need for sleep and both goal-motivated behavior and metabolism
increase.
 3. ASSOCIATED DISORDER:
 A single manic episode is sufficient to diagnose bipolar 1 disorder 5.

6. Pathophysiology
 The mechanism underlying mania is unknown, but the neurocognitive profile of mania is highly
consistent with dysfunction in the right prefrontal cortex.
 Neurochemical influences of neurotransmitters (chemical messengers) focus on serotonin and
norepinephrine as the two major biogenic amines implicated in mood disorders.
 Deficits of serotonin found in the blood or cerebrospinal fluid occur in people with mania
 Norepinephrine levels may be increased in mania.
 This catecholamine energizes the body to mobilize during stress and inhibits kindling .
 Dysregulation of acetylcholine and dopamine also is being studied in relation to mood
dysorders .

7. cause
 The exert mechanism by which mania occurs is not yet known.
 person may experience mania as a result of a range of factors, including:
 stressful events
 genetic factors
 biochemical factors (neurotransmitter abnormalities or imbalances)
 seasonal influences
 bipolar affective disorder (BPAD).

8. signs and symptoms
 The mood disturbance must be accompanied by at least three of the following symptoms;
 Inflated self-esteem or grandiosity
 Decreased need for sleep
 pressure to keep talking
 Flight of ideas
 Distractibility
 Increase in goal-directed activity or psychomotor agitation
 Excessive involvement in pleasurable activities that have a high potential for painful
consequences

10. Treatment
 There are basically 2 types treatment modalities;
1. Psychological Treatments
2. Organic Treatments
 Organic Treatments :this involve the used of drugs
 Mood stabilizers:
 lithium (0.6—1.2 mEq/L)
 carbamazepine (6—12 mg/L)
 valproate (50—125 mg/L)
 Anticonvulsants:
 gabapentine topiramate lamotrigine

11.  Agitated or psychotic patient – coadministartion of :
 antipsychotics of second generation
 (olanzapine, risperidone)
 Benzodiazepine
 (lorazepam, clonazepam)
 IF MOOD STABILIZERS AND ANTICONVULSANTS FAIL THEN ELECTRIC
CONVULSIVE THERAPY MAY ALSO BE GIVEN TO PREVENT CLIENT FROM
SUICIDAL

12. Bipolar disorder
Defintion :
Bipolar mood or affective disorder is characterized by recurrent episodes of mania and depression
in the same patient at different times.
 Earlier known as manic depressive psychosis (MDP)
 Types
 Bipolar I: Characterized by episodes of severe mania and severe depression.
 Bipolar II: Characterized by episodes of hypomania (not requiring hospitalization) and severe
depression.

14. Epidemiology
 Lifetime prevalence among 14 to 18 year olds, 1%
 Subsyndromal symptoms, 5.7%
 Mean age of onset, 10 to 12 years. First episode usually depression.
 Bipolar disorder affects men and women equally, as well as all races, ethnic
groups, and socioeconomic classes.
 Bipolar disorder often develops in a person's late teens or early adult years. At
least half of all cases start before age 25.
 Suicide Risk : The prevalence rates of attempted suicide in bipolar II and bipolar I
disorder appear to be similar (32.4% and 36.3%).

15. types
 Bipolar I Disorder is mainly defined by manic or mixed episodes that last at least
seven days, or by manic symptoms that are so severe that the person needs immediate
hospital care.
 Usually, the person also has depressive episodes, typically lasting at least two weeks. The
symptoms of mania or depression must be a major change from the person's normal behavior.
 Bipolar II Disorder is defined by a pattern of depressive episodes shifting back and
forth with hypomanic episodes, but no full-blown manic or mixed episodes.
 Bipolar Disorder Not Otherwise Specified (BP-NOS) is diagnosed
when a person has symptoms of the illness that do not meet diagnostic criteria for either
bipolar I or II. The symptoms may not last long enough, or the person may have too few
symptoms, to be diagnosed with bipolar I or II. However, the symptoms are clearly out of the
person's normal range of behavior.
 Cyclothymic Disorder, or Cyclothymia, is a mild form of bipolar disorder. People
who have cyclothymia have episodes of hypomania that shift back and forth with mild
depression for at least two years.

16. Etiology •
 Etiology is not known.
 Theories:
 Genetic hypothesis
 Biochemical theories
 Neuroendocrine theories
 Sleep studies
 Brain imaging

17.  Genetic hypothesis
 The life-time risk for the first degree relatives getting bipolar disorder is 25%.
 Children with one parent having bipolar disorder has a risk of 27% of life time risk, children with
both parents having bipolar disorder is 74%.
 The risk in monozygotic twins is 65% and dizygotic twins is 20%
 Biochemical theories
 Catecholamine's abnormality (norepinephrine, dopamine and serotonin) in one or more sites at
brain.
 Acetyl choline and GABA may also play a role.
 The effects of antidepressants and mood stabilizers also provide additional evidence.

18.  Neuroendocrine theories
 Mood symptoms are prominently present in endocrine disorders like
hypothyroidism, Cushing’s disease, and Addison’s disease.
 Sleep studies
 In depression, decreased REM latency (i.e., the time between falling asleep
and the first REM period is decreased).
 Increased duration of the first REM period.
 Delayed sleep onset.
 Brain imaging
 CT scan, MRI scan of brain, PET scan and SPECT have yielded inconsistent,
but suggestive findings.
 Findings include ventricular dilatation, white matter hyper-intensities, and
changes in the blood flow and metabolism in prefrontal cortex, anterior
cingulate cortex, and caudate.

19. Clinical features
 Clinical features Depression Form: -
 constantly feeling sad or worthless
 sleeping too much or too little
 feeling tired and having little energy
 appetite and weight changes
 problems focusing
 thoughts of suicide Manic Form:
 increase in energy level
 less need for sleep
 easily distracted
 nonstop talking
 increased self confidence
 focused on getting things done, but does not accomplish much
 involved in risky activities even though bad things may happen

20. Course of the disorder
 • Earlier age of onset
 Average manic episodes last for 3-4 months,
 depressive episode lasts for 4-6 months
 With rapid institution of treatment symptoms of mania are controlled within 2 weeks and of
depression within 6-8 weeks
 Rapid cyclers
 Ultra rapid cyclers
 Increased mortality almost 2 times the normal population

21. Differential diagnosis
 • Rule out organic causes (drug induced, dementia)
 Rule out acute and transient psychotic disorders, schizo-affective disorders,
and schizophrenia
 Rule out delusional disorders
 Rule out adjustment disorders with depressed mood, generalized anxiety
disorder, normal grief reaction, and OCD (with or without secondary
depression)

22. Management
 Antidepressants
 ECT
 Lithium
 Antipsychotics
 Other mood stabilizers

23.  Antidepressants
 Antidepressant Usual therapeutic range (mg/day)
 Imipramine 150-300
 Amitryptyline 150-300
 Nortryptyline 150-300
 Clomipramine 75-250
 Fluoxetine - 10-60
 Paroxetine - 10-40
 Sertraline - 50-200
 Escitalopram - 10-20
 Mirtazepine - 15-45

24.  Lithium
 Drug of choice for manic episode and preventing further episodes in bipolar disorder.
 1-2 week period lag before appreciable improvement.
 Usual dose 900-1500mg of LiCO3 per day.
 Low therapeutic index.
 Plasma levels >2mEq/L is toxic and 2.5-3mEq/L may be lethal.
 Antipsychotics
 • Risperidone, olanzepine, quetipine, haloperidol and chlorpromazine can be used.
 Indications: • Acute manic episode • Delusional depression
 Other mood stabilizers
 Sodium valproate (1000-3000mg/day)
 Carbamazepine (600-1600mg/day) and oxcarbazepine •
 Lorazepam and clonazepam
 Topiramate • Lamotrigine
 T3 and T4 as adjuncts in rapid cyclers.

25. Thank you