This document discusses bipolar disorder and includes sections on: - The differences between discrete vs continuous and categorical vs dimensional classifications. - Early theorists in bipolar disorder classification including Falret, Hecker, Kraepelin, and Kielholz. - Changing definitions and paradigms in the DSM-IV and DSM-V. - Challenges in diagnosing bipolar disorder including delays in diagnosis, misdiagnosis as unipolar depression, and antidepressant-induced mania or rapid cycling.

1. Dr.G.RAMANUJAM MD
Associate Professor
Tirunelveli Medical College

4. DISCRETE
VS
CONTINUOUS

7.  CATEGORICAL
 WATER TIGHT
 NO OVERLAPS
 DISCRETE
 PRESENCE OR
ABSCENCE
 DIMENSIONAL
 SINGLE OR MULTIPLE
FACTORS
 PRESENT IN ALL
 CLASSIFIED
ACCORDING TO
DEGREE

11.  DENOTES TWO
EXTREMES
 EQUATES WITH MANIA
THE HIGH
 PATIENT DENIES BEING
MANIAC
 ACCEPTS DEPRESSION
 EITHER MANIA OR
DEPRESSION

14.  ITALIAN PSYCHIATRIST
 WORKED INFLORENCE
 DESCRIBED
CLASSIFICATION
 MANIA,
MELANCHOLIA,DEMEN
TIA

15.  German psychiatrist
 Director of Sachsenberg mental hospital
 Dysthymia mutabilis
 Mixture of Dysthyma atra (Black depression)
and Dysthyma candida (low-level mania).

16.  Saltpetriere Hospital
Paris
 La folie circulaire
1951
 Alternating Mania and
Melancholia
 Different from Mania
and melancholia

17.  French Psychiatrist
 Collegue at
Saltpetriete
 Claimed that he was
the first the describe
cyclic illness
 Tussle with Falret

18.  GERMAN PSYCHATRIST
 INTRODUCED THE
TERM CYCLOTHYMIA
 ASSOCIATE HECKER
 CATATONIA
 HEBEPHRENIA

19.  GERMAN
PSYCHIATRIST
 GREAT CLASSIFIER
 MANIC DEPRESSIVE
PSYCHOSIS
 DEMENTIA PRECOX
 UNITARY CONCEPT

20.  GERMAN
 STUDENT OF
WERNICKE
 COINED BIPOLAR
 AND UNIPOLAR

21.  ASSOCIATE OF KLIEST
 MULTIPLE SUBTYPES
 CYCLOID PSYCHOSIS
 POPULARIZED
UNIPOLAR BIPOLAR

23. Poles what is reality
Eca survey
 Incidence of Bipolar disorder is
1.2% (1988)
 Ratio of Unipolar : Bipolar is
4:1
RECENT
 6.4% (Judd &Akiskal 2003)

24. % among psy patients
 One third of Depressed outpatients (Cassano 1989)
 45% of Depressed Outpatients (Benazzi 1997)
 60% Depressed Ghaemi

27.  BIPOLAR ILLNESS IS COMMONLY MISSED
 48% INITIALDIAGNOSISWAS MISSED
 54% DIAGNOSED AS UNIPOLAR DEP
 34%AS BIPOLAR
 AVERAGE ITTOOK 8YRSTO DIAGNOSEAS
BPD

34. FOLLOW UP OF PREPUBRTAL AND
ADOLESCENT DEPRESSION

36. HOW TO APPROACH BIPOLAR

37. BIPOLAR Vs UNIPOLAR SAME OR DIFF

38.  CLINICALLY DIFFERENT?
 GENETICALLY DIFFERENT?
 NEUROBOLOGICALLY DIFFERENT?
 TREATMENT ?

39. IF BOTH BD &UD ARE DIFFERENT

41. CLINICAL DIFFERENCE BETWEEN BD
AND UD

46. BIPOLAR NOT NECESSARILY TWO
OPPOSITE ENDS

47. AGITATED DEPRESSION
 RACING THOUGHTS
 PSYCHOMOTOR AGITATION
 IRRITABILITY
 STRONG BIPOLAR FAMILY HISTORY
 ANTI DEPRESSANT INDUCED DESTABILIZATION
 Akiskal Benazzi 2004

52. BIPOLAR DISORDER

53. CHANGING PARADIGMS

56. AKISKAL

57. BIPOLAR DISORDER V
DEPRESSION WITH MIXED HYPOMANIA
BIPOLAR DISORDER VI
BIPOLAR IN THE SETTING OF DEMENTIA

60. BIPOLARITY INDEX

62. DSM V
 Better than DSM IV
 MANIC, HYPOMANIC, DEPRESSVE EPISODE
 No MIXED episode
 NOS omitted
 BIPOLAR I, II CYCLOTHYMIA, SUBSTANCE, OTHER
MEDICAL CAUSES

63. MIXED
 MIXED FEAUTURES IS A SPECIFIER
 DEPRESSIVE EPISODE WITH MIXED FEATURES-
Agitated Depression
 MANIC OR HYPOMANC EPISODE WITH MIXED
FEATURES- Dysphoric Mania

64. OTHER SPECIFIER
 ANXIOUS DISTRESS
 CATATONIC
 MIXED
 SEASONAL
 MOOD CONGRUENT PSYCHOTIC
 MOOD INCONGRUENT PSYCHOTIC
 ATYPICAL
 POST PARTUM ONSET


65. OTHER SPECIFIED BIPOLAR AND
RELATED DISORDER
 SHORT DURATION HYPOMANIC EPISODES AND
MAJOR DEPRESSVE EPISODES
 HYPOMANIC EPISODES WITH INSUFFECIENT
SYMPTOMS AND MAJOR DEPRESSIVE DISORDER
 HYPOMANIC EPISODE WITHOUT PRIOR
DEPRESSIVE EPISODE
 SHORT DURATION CYCLOTHYMIA

66. Neurobiology OF MANIA AND BIPOLAR
DISORDER*
Ambiguous till date
Biogenic amine neurotransmitters:
Noradrenergic system:
NE turnover increase in the cortical and thalamic areas of BD subjects where
decrease in depression
• Serotogenic system:
Reduced 5-hydroxytryptamine (5- HT)1A receptor binding potential in raphe
and hippocampus- amygdala of brain in depressed patients
Dopaminergic system
• DA agonists are effective antidepressants and are able to precipitate
mania.
• D2 receptor found in caudate, putamen, nucleus accumbens, cerebral
cortex and hypothalmus is negativly coupled to adenylyl cyclase. Older
antipsychotics act through blockage of D2 receptors , which eventualy
result in extrpyramidal system (muscle rigidty , involuntry movement,
pseudoparkinsonism)

68.  Worldwide disorder
 Age at onset : Adult , Children & Adolescent
 Among the top 10 of GBD ( Global Burden of diseases)
 Fifth / Sixth amongst reported disability
 An under diagnosed and under treated disorder
Bauer in, eds Tasman et al 2003

69. Bipolar depression Disease Burden
 Patients with onset in mid to late 20’s effectively
lose 9 years of life, 12 years of normal health
and 14 years of normal activity
 Increase likelihood of divorce by 3 X
Montgomery SA, Cassano GB, Management of bipolar disorder, 1996 , p5

70. Bipolar depression Disease Burden
 Years lived with disorder :
Depression > Mania / Hypomania
Comorbidity:
- Anxiety disorders : 52%
( Panic, GAD, Social Phobia )
- Substance abuse disorder : 39%
 Suicide
- 10% to 19-20% , 15 -30 times > general population
- At least 25% will attempt suicide
- 80% suicide attempts / completed suicide occur in depressed phase
- High mortality rates fro natural causes
Montgomery SA, Cassano 1996, Harris 1997
Judd et al 2002,2003

71. Bipolar depression
Diagnosis
Obstacles :
1. Under diagnosis , misdiagnosis
2. Misdiagnosed as unipolar depression ( MDD )
3. Often treated symptomatically with antidepressant
drugs
4. Antidepressant drugs : Despite evidence that they
induce mania or rapid cycling, ADDs are the most
frequently prescribed medication
5. Management overlooked in favor of mania
Thomas A. M. Kramer : Medscape General medicine, 2004 ; 6 /2 :29

72. Bipolar depression
Underdiagnosis or misdiagnosis
Presentation :difficult to diagnose
1. Less dramatic
2. Inadequate data ( Poor history)
3. Type II presentations, absence of manic symptoms
4. Normal v/s hypomania ???
Thomas A. M. Kramer : Medscape General medicine, 2004 ; 6 /2 :29
Kemps et al : Psychiatric times , Vol XXIII /9 , Aug ’06

74. BIPOLAR DISORDER

76. ANXIETY IN BIPOLAR
• EMILKRAEPLIN –ANXIOUS MANIA-1921
• ANXIETY AS SYMPTOM
• ANXIETY –CO MORBID
• CHILDREN

77. ANXIETY –BIPOLAR SYMPTOMS
• RACING THOUGHTS
• SPEED
• MOTOR RESTLESSNESS
• AGITATION
• PRESSURE OF SPEECH
• IRRITABILITY

78. • GAD
• Cognitive
• Free floating
• worry
• difficulty concentrating
• Energy
• keyed up, on edge
• restlessness, tension
• easily fatigued
• difficulty falling/staying
asleep
• Mood
• irritability
• BPD II
• Cognitive
• Racing thoughts
• [difficulty concentrating]
• Energy
• motor agitation
• restlessness
• extreme fatigue
• [profound insomnia]
• Mood
• dysphoria, irritability

79. 15% BIPOLAR HAVE OC SYMPTOMS
OBSESSION USED TO DESCRIBE MANIA –OBSESSED WITH T.V
OCD BIPOLAR
• COMPULSIONS
• PERFECTIONISM
• RELIGIOUSITY
• PUNCTUAL
• CHECKING
• RITUALISTIC
• DETAILED
• GOAL DIRECTEDACTIVITY
• SELF ESTEEM
• RELIGIOUS
• RESPONSIBLE
• LEADERSHIP
• RITUALISTIC
• DETAILED

80. PEDIATRIC BPD

82. TREATMENT OF BIPOLAR
 ANTI DEPRESSANTS
 MOOD STABILIZERS
 ANTIPSYCHOTICS
 OTHER
 rTMS

83. ANTI DEPRESSANTS IN BIPOLAR
ILLNESS
 CONTROVERSIAL
 COMMONLY USED
 DIAGNOSED AS UNIPOLAR DEPRESSION
 SOME ARE EFFECTIVE IN BPDEPRESSION
 LESS EFFICAY THAN LITHIUM
 NOT EFFECTIVE IN PROPHYLAXS

84. ANTI DEPRESSANTS
 ANTIDEPRESSANT INDUCED MANIA
 MIMICS MIXED PHASE
 SUICIDALITY IS COMMON
 AGITATION INCREASES
 RAPID CYCLING
 DESTABILISATION

85. Antidepressant-induced cycle acceleration in
bipolar disorder
10
8
6
4
2
0

86. Antidepressant-induced mania
in patients with unipolar
and bipolar depression
†
* ***
(n=10246) (n=3788) (n=125) (n=242) (n=48)
12
10
8
6
4
2
0
Peet 1994

87. ANTIDEPRESSANTS IN BPD
 CYCLOTHYMIA may switch to hypomania
 Young age
 Substance abuse

88.  Antidepressant associated
Chronic
Irritable
Dysphoria
El Mallakh and Karippot J Aff. Dis 2005

89.  Unique mode of action – Bidirectional mood stabilizer
 Clozapine like profile as an antagonist at multiple
receptors
 Moderate affinity for D2
 Greater affinity for 5HT2 to D2 ratio
 Modulates DA & other monoamine pathways with
antimanic and antidepressant properties
 No appreciable affinity for muscarinic & cholinergic

92. Intermittent blockade of D2 receptors & 5HT2A antagonist
No EPS
No TD
No se serum prolactin
 no menstrual irregularities
 no galactorrhoea
 no impotency
J Clin Psychiatry 2000;61(Suppl 8):31-33
Safest among all atypicals

94. CNPT2(2011) 12-23

96.  BIPOLAR DISORDER IS MORE COMMON THAN
WE THINK
 AVERAGE BIPOLAR DIAGNOSIS DELAYED BY
DECADE.
 PEOPLE WITH BPD SEPND MORE TIME IN
DEPRESSION
 SPECTRUM CONCEPT MAY ANSWER MANY
QUESTION

97.  THE QUESTION IS NOT
WHETHER THIS DEPRESSION IS BIPOLAR OR
NOT?
BUT
 HOW MUCH BIPOLAR THIS DEPRESSION IS?