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OLEH:
JAYA MUALIMIN
Musicians:
Britney Spears
Jim Carey
Robert Downey Jr.
Linda Hamilton
Vivien Leigh
Ben Stiller
Robin Williams
Richard Dreyfuss
Marilyn Monroe
Tim Burton
Francis Ford Coppola
Beethoven
Mozart
DMX
Jimi Hendrix
Axl Rose
Sting
Brian Wilson
Kurt Cobain
Ozzy Ozbourne
Politicians:
Winston Churchill
Theodore Roosevelt
Abraham Lincoln
Napoleon Bonaparte
Writers:
Edgar Allen Poe
Mark Twain
Virginia Woolf
Charles Dickens
Ralph Waldo Emerson
F. Scott Fitzgerald
Ernest Hemingway
Kurt Vonnegut
Emily Dickinson
T.S. Eliot
Hans Christian Anderson
Victor Hugo
Diagnos
is ?
Treatme
nt ?
Trial &
Error
Medicatio
n
Cerebrotoxi
c
Complexity of
Psikotoxic
Sosiotoxic
Multi-facet Disorder
Treatm
entresistant
Preventative Phase
Preventative Phase
Bipolar Disorders
MANIA
HYPOMANIA*
MIXED
EPISODE
NORMAL
MOOD
SUBSYNDROMAL
DEPRESSION
DEPRESSION
*Hypomania is a milder form of mania with similar yet less severe symptoms and less overall impairment.
Mixed Episode is an episode that simultaneously presents symptoms of both depression and mania.
Stahl SM. Essential Psychopharmacology. New York, NY: Cambridge University
Press; 2000.
Mood Spectrum
Structure of a Recurrent
Illness
Precipitant
Episode
Underlying illness
Unstable
Radical mood instability:
-interepisode instability
-mixed states
-frequent episodes
-incomplete recovery
-high incidence of complications
-early onset
-stronger genetic loading?
Episode
0-2 months
Symptomatic
Continuation
2-12 months
Functional
Maintenance
Indefinite
Stability/adaptive
unrecognized
Often untreated
Often misdiagnosed
Often inadequately treated
Exacerbated by incorrect
treatment
Akiskal. J Clin Psychopharmacol. 1996;16(suppl
1):4S-14S.
49%
bipolar disorder
Diagnosed with
31%
depression
but not bipolar disorder
Bipolar depression
MDD
Onset: younger
Onset: older
Rapid symptom
onset
Less rapid
symptom
onset
Acute
symptoms
History of mania /
hypomania
Diagnostic
challenge
No mania /
hypomania
Ghaemi et al 2000
Hirschfeld et al 2003
Suppes et al 2005
Bipolar Disorder
Clinical Manifestations
DSM-IV Major depression episode
Persistent depressed mood or irritability for at
least 2 weeks and:
Motivation, sleep, appetite, concentration, and
energy disturbances
Guilt, suicidal thoughts or behaviors
Impairment in psychosocial functioning
1 week
Bipolar II
4 Days
Bipolar NOS
< 4 Days
Bipolar III
Antidepressant-related hypomania
Adapted from Akiskal HS, Pinto O. Psychiatr Clin North Am. 1999;22:517-534.
Bipolar IV
Adapted from Akiskal HS, Pinto O. Psychiatr Clin North Am. 1999;22:517-534.
Akiskal HS, et al. J Affect Disord. 2006;96:197-205.
Patients (%)
80
60
55%
40
20
23%
n = 38
0
Mania/
Hypomania
n = 35
Rapid
Cycling
Depressive Episode
Manic or Mixed
Episode
Hypomanic Episodes
Bipolar I Disorder
1 required
Bipolar II Disorder
1 required
None allowed
1 required
Bipolar Disorder
NOS*
None allowed
Cyclothymic
Disorder
None allowed
Major Depressive
Disorder
1 required
None allowed
None allowed
Dysthymic Disorder
None allowed
None allowed
DSM-V ??
DSM-V
??
Rather than
defining
bipolar
disorder solely as one of
episodic mood disturbances, we
should consider defining it as a
multisystem
disorder
involving disturbances in all of
the above mentioned domains.
Bipolar
I Disorder
Subtypes:
Current or Most Recent
Current or Most Recent
Current or Most Recent
Current or Most Recent
Episode
Episode
Episode
Episode
Hypomanic
Manic
Depressed
Unspecified
DSM V proposed
2010 American Psychiatric
Association
Bipolar
II Disorder
Subtypes:
Current or Most Recent Episode Hypoma
nic
Current or Most Recent Episode Depres
sed
DSM IV: Bipolar II Disorder (Recurrent
Major Depressive Episodes With
Hypomanic Episodes)
DSM V proposed
BOOKS/BOOKLETS:
Mondimore, F. (1999). Bipolar disorder: A guide
for patients and families. City: Johns Hopkins
Press.
Geller, B., & DelBello, M. P. (Eds.). (2003).
Bipolar disorder in childhood and early
adolescence. New York: Guilford Press.
Educating the child with bipolar disorder.
Available from: www.bpkids.org
Anderson, M., Kubisak, J.B., Field, R., &
Vogelstein, S. (2003). Understanding and
educating children and adolescents with bipolar
RESOURCES
disorder: A guide for educators.
DSM-IV-TR
Five
types of
episodes
Four subtypes
Four severity levels
Three course
specifiers
Manic Episode
Symptoms:
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep
3. Pressured speech or more talkative than
usual
4. Flight of ideas or racing thoughts
5. Distractibility
6. Psychomotor agitation or increase in
goal-directed activity
7. Hedonistic interests
Similarities
Same symptoms
Differences
Length of time
Impairment not as severe
Hypomanic Episode
Symptoms:
1. Depressed mood (in children can be irritable)
2. Diminished interest in activities
3. Significant weight loss or gain
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue/loss of energy
7. Feelings of worthlessness/inappropriate guilt
8. Diminished ability to think or
concentrate/indecisiveness
9. Suicidal ideation or suicide attempt
Mixed Episode
Both Manic and Major Depressive
Episode criteria are met nearly every
day for a least a one week period.
Subtypes
Bipolar Disorder I = more classic form; clear
episodes of depression & mania
Bipolar Disorder II = presents with less intense
and often unrecognized manic phases
Cyclothymia = chronic moods of hypomania &
depression, often evolves into a more serious
type
Bipolar Disorder Not Otherwise Specified (NOS)
= largest group of individuals
EPIDEMIOLOGY
Prevalence
Estimated
between 3-6%
Subsyndromal bipolar disorder
Equal distribution across gender variables
Average age @ onset = 20 years old
Course
Initial
Age at Onset
Pediatric,
IMPAIRMENTS
Comorbidity
Attention
(ADHD)
Between 60-80%
Criteria Comparison
Bipolar Disorder
(mania)
1. More talkative than
usual, or pressure to
keep talking
2. Distractibility
3. Increase in goal
directed activity or
psychomotor
agitation
ADHD
1. Often talks
excessively
2. Is often easily
distracted by
extraneous stimuli
3. Is often on the go
or often acts as if
driven by a motor
Comorbidity
(cont.)
Oppositional
Substance
Abuse
40-50%
Anxiety
35-40%
Disorders
Suicidal Behaviors
Prevalence
of suicide attempts
40-45%
Age
of first attempt
Multiple attempts
Severity of attempts
Suicidal ideation
Executive
Functions
Attention
Memory
Sensory-Motor
Integration
Nonverbal Problem-Solving
Academic Deficits
Mathematics
Cognitive Deficits
Psychosocial Deficits
Relationships
Peers
Family members
Recognition
TREATMENT
APPROACHES
Psychopharmacological
DEPRESSION
Mood Stabilizers
Lamictal
Anti-Obsessional
Paxil
Anti-Depressant
Wellbutrin
Atypical Antipsychotics
Zyprexa
MANIA
Mood Stabillizers
Lithium, Depakote,
Depacon, Tegretol
Aypical Antipsychotics
Zyprexa, Seroquel,
Risperdal, Geodon, Abilify
Anti-Anxiety
Benzodiazepines
Klonopin, Ativan
diagnosis
Obtain longitudinal history
Assess risk (eg, suicide)
Manage comorbidity
Involve significant others
Treatment of Bipolar
Disorder
Mood
stabilizer/Antipsychotic
w/ antidepressant effects
Antidepressan
t
Exercise
Psychotherapies
Cognitive-Behavioral
Interpersonal/Social
Rhythm
Family Focused
(Light therapies)
1940
ECT
1950
1960
1970
1980
Lithium*
First-generation antipsychotics
and antidepressants
2000
2002
Second-generation antipsychotics
and antidepressants
Clozapine
Risperidone+
Olanzapine*
Quetiapine+
Ziprasidone+
Aripiprazole+
Chlorpromazine*
Trifluoperazine
Fluphenazine
Thioridazine
Haloperidol
Mesoridazine
1990
Anticonvulsants
Anticonvulsants
Carbamazepine
Valproate*
Gabapentin
Lamotrigine
Topiramate
Oxcarbazepine
Therapy
Psychoeducation
Family Interventions
Cognitive-Behavioral Therapy
RAINBOW Program
Interpersonal and Social Rhythm
Schema-focused Therapy
Therapy
EDUCATIONAL
IMPLICATIONS
IDEA Classification
Emotional
Considerations
Rapidly
Possible
Accommodations/Modifications
Provide
Other Considerations
Educating
staff
Communication
Hospitalization