Bipolar Affective Disorder

early manic episodes

By:
Wulladah Nur Jihan
Tasya Felicia Macellin
Azilu Fala biba rusda
Definition
• Bipolar affective disorder, or manic-depressive illness (MDI), is a
common, severe, and persistent mental illness
• characterized by periods of deep, prolonged, and profound
depression that alternate with mania
• But this bipolar affective disorder is discuss about manic episodes
Sign & Symptoms
Manic episodes  at least 1 week of profound mood disturbance,
characterized by elation, irritability, or expansiveness (referred to as gateway
criteria). At least 3 of the following symptoms must also be present :
• Grandiosity
• Diminished need for sleep
• Excessive talking or pressured speech
• Racing thoughts or flight of ideas
• Clear evidence of distractibility
• Increased level of goal-focused activity at home, at work, or sexually
• Excessive pleasurable activities, often with painful consequences
Cont..
Hypomanic episodes  characterized by an elevated, expansive, or irritable
mood of at least 4 consecutive days’ duration. At least 3 of the following
symptoms are also present :
• Grandiosity or inflated self-esteem
• Diminished need for sleep
• Pressured speech
• Racing thoughts or flight of ideas
• Clear evidence of distractibility
• Increased level of goal-focused activity at home, at work, or sexually
• Engaging in activities with a high potential for painful consequences
American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013.
How to diagnose
Bipolar affective disorder early episode-manic

• You have an intense sense of well-being, energy and optimism. It can

be so strong that it affects your thinking and judgement. You may
believe strange things about yourself, make bad decisions, and
behave in embarrassing, harmful and - occasionally - dangerous ways.

• Like depression, it can make it difficult or impossible to deal with day-

to-day life. Mania can badly affect both your relationships and your
work. When it isn't so extreme, it is called 'hypomania'.
If you become manic, you may notice that
you are
Emotional
• very happy and excited
• irritated with other people who don't share your
optimistic outlook
• feeling more important than usual.

Thinking
• full of new and exciting ideas
• moving quickly from one idea to another
• hearing voices that other people can't hear.
Physical
• full of energy
• unable or unwilling to sleep
• more interested in sex.
Behaviour
• making plans that are grandiose and unrealistic
• very active, moving around very quickly
• behaving unusually
• talking very quickly - other people may find it hard to understand what you are talking
about
• making odd decisions on the spur of the moment, sometimes with disastrous
consequences
• recklessly spending your money
• over-familiar or recklessly critical with other people
• less inhibited in general.
• If you are in the middle of a manic episode for the first time, you may
not realise that there is anything wrong – although your friends,
family or colleagues will. You may even feel annoyed if someone tries
to point this out to you. You increasingly lose touch with day-to-day
issues – and with other people's feelings.
Treatment
Bipolar Affective Disorder Early
Bipolar disorder cannot be cured, but it can be treated effectively over
the long-term.
Treatment is more effective if you work closely with a doctor and talk
openly about your concerns and choices. An effective maintenance
treatment plan usually includes a combination of medication and
psychotherapy.
Medications

• Different types of medications can help control symptoms of bipolar

disorder. Not everyone responds to medications in the same way.
• The types of medications generally used to treat bipolar disorder
include mood stabilizers, atypical antipsychotics, and antidepressants.
Medications

Mood stabilizers are usually the first choice to treat bipolar disorder. In
general, people with bipolar disorder continue treatment with mood
stabilizers for years. Lithium (also known as Eskalith or Lithobid) is an
effective mood stabilizer.
• Anticonvulsants are also used as mood stabilizers. They were originally
developed to treat seizures, but they also help control moods.
Anticonvulsants used as mood stabilizers include:
1. Valproic acid or divalproex sodium (Depakote), approved by the FDA for
treating mania. It is a popular alternative to lithium.
2. Lamotrigine (Lamictal), FDA-approved for maintenance treatment of
bipolar disorder. It is often effective in treating depressive symptoms.
3. Other anticonvulsant medications, including gabapentin (Neurontin),
topiramate (Topamax), and oxcarbazepine (Trileptal).
• Lithium can cause side effects such as:
o Restlessness
o Dry mouth
o Bloating or indigestion
o Acne
o Unusual discomfort to cold temperatures
o Joint or muscle pain
o Brittle nails or hair.
• Common side effects of other mood stabilizing medications include:
o Drowsiness
o Dizziness
o Headache
o Diarrhea
o Constipation
o Heartburn
o Mood swings
o Stuffed or runny nose, or other cold-like symptoms.
Atypical antipsychotics are sometimes used to treat symptoms of bipolar
disorder. Often, these medications are taken with other medications, such as
antidepressants. Atypical antipsychotics include:
• Olanzapine (Zyprexa), which when given with an antidepressant
medication, may help relieve symptoms of severe mania or
psychosis. Olanzapine can be taken as a pill or a shot. The shot is often
used for urgent treatment of agitation associated with a manic or mixed
episode. Olanzapine can be used as maintenance treatment as well, even
when psychotic symptoms are not currently present.
• Aripiprazole (Abilify), which is used to treat manic or mixed episodes.
Aripiprazole is also used for maintenance treatment. Like olanzapine,
aripiprazole can be taken as a pill or a shot. The shot is often used for
urgent treatment of severe symptoms.
• Quetiapine (Seroquel), risperidone (Risperdal) and ziprasidone (Geodon)
also are prescribed to relieve the symptoms of manic episodes.
Side effects of many antipsychotics include:

• Drowsiness
• Dizziness when changing positions
• Blurred vision
• Rapid heartbeat
• Sensitivity to the sun
• Skin rashes
• Menstrual problems for women.
• Antidepressants are sometimes used to treat symptoms of
depression in bipolar disorder. Fluoxetine (Prozac), paroxetine (Paxil),
sertraline (Zoloft), and bupropion (Wellbutrin) are examples of
antidepressants that may be prescribed to treat symptoms of bipolar
depression.
• Antidepressants can cause:
oHeadache
oNausea (feeling sick to your stomach)
oAgitation (feeling jittery)
oSexual problems, which can affect both men and women. These
include reduced sex drive and problems having and enjoying sex.
Psychotherapy
Some psychotherapy treatments used to treat bipolar disorder include:
• Cognitive behavioral therapy (CBT), which helps people with bipolar disorder
learn to change harmful or negative thought patterns and behaviors.
• Family-focused therapy, which involves family members. It helps enhance family
coping strategies, such as recognizing new episodes early and helping their loved
one. This therapy also improves communication among family members, as well
as problem-solving.
• Interpersonal and social rhythm therapy, which helps people with bipolar
disorder improve their relationships with others and manage their daily routines.
Regular daily routines and sleep schedules may help protect against manic
episodes.
• Psychoeducation, which teaches people with bipolar disorder about the illness
and its treatment. Psychoeducation can help you recognize signs of an impending
mood swing so you can seek treatment early, before a full-blown episode occurs.
Usually done in a group, psychoeducation may also be helpful for family members
and caregivers.
References
• American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric
Association; 2013.
• Goodwin, G.M. (2003) Evidence-based guidelines for treating Bipolar
Disorder: recommendations from The British Association for
Psychopharmacology. Journal of Psychopharmacology, 17; 149-173.
• Geddes, J. (2003) Bipolar disorder. Evidence Based Mental Health, 6 (4):
101-2.
• Morriss, R. (2004). The early warning symptom intervention for patients
with bipolar affective disorder. Advances in Psychiatric Treatment, 10: 18 -
26.
• Bowden C, Singh V. Long-term management of bipolar disorder. Available
at http://www.medscape.com/viewprogram/2686.
Hebefrenic Schizophrenia
Definition
• known as disorganized schizophrenia
• a form of schizophrenia characterized by severe disintegration of
personality including erratic speech and childish mannerisms and
bizarre behavior (Princeton University, 2012)
Symptoms
There are three prominent symptoms :
• Disorganized speech  when responding to a question, the person may give an
answer which has little or no relevance to the question. It often experience
something known as “thought blocking”. They may stop suddenly while talking, as
if the thought abruptly left them
• Disorganized behavior  unable to or lacks the motivation to start or carry out a
given task, such as preparing a meal or getting dressed. Their behavior may be
bizarre, such as wearing layer upon layer of clothing in the middle of summer
• Blunted or inappropriate emotional expression and response  A person will
often appear to have no emotions. His/her face may look completely blank, and
his/her speech may be monotone, at times may have an emotional response such
as laughing or giggling suddenly, when nothing funny has occurred
How to diagnose
 Schizophrenia hebephrenic
Hebephrenic schizophrenia tends to have an earlier onset
than the other subtypes and tends to develop very insidiously.
Although delusions and hallucinations are present, they are
relatively minor, and the clinical picture is dominated by
- bizarre behavior
- loosened associations, and
- bizarre and inappropriate affect.

Overall the behavior of these patients seems at times a caricature of childish silliness. Senselessly they
may busy themselves first with this, then with that, generally to no purpose, and often with silly, shallow
laughter. At other times they may be withdrawn and inaccessible. Delusions, when they occur, are
unsystematized and often hypochondriacal in nature. Some may display very marked loosening of
associations to the point of a fatuous, almost driveling incoherence
• A doctor must make a diagnosis of schizophrenia on the basis of a standardized list of
outwardly observable symptoms, not on the basis of internal psychological processes.
There are no specific laboratory tests that can be used to diagnose schizophrenia.
Researchers have, however, discovered that patients with schizophrenia have certain
abnormalities in the structure and functioning of the brain compared to normal test
subjects. These discoveries have been made with the help of imaging techniques such as
computed tomography scans (CT scans).

• When a psychiatrist assesses a patient for schizophrenia, he or she will begin by excluding
physical conditions that can cause abnormal thinking and some other behaviors
associated with schizophrenia. These conditions include organic brain disorders (including
traumatic injuries of the brain), temporal lobe epilepsy, Wilson's disease, prion diseases,
Huntington's chorea, and encephalitis. The doctor will also need to rule out heavy metal
poisoning and substance abuse disorders, especially amphetamine use.

• After ruling out organic disorders, the clinician will consider other psychiatric conditions
that may include psychotic symptoms or symptoms resembling psychosis. These disorders
include mood disorders with psychotic features; delusional disorder; dissociative disorder
not otherwise specified (DDNOS) or multiple personality disorder; schizotypal, schizoid, or
paranoid personality disorders; and atypical reactive disorders. In the past, many
individuals were incorrectly diagnosed as schizophrenic. Some patients who were
diagnosed prior to the changes in categorization should have their diagnoses, and
treatment, reevaluated. In children, the doctor must distinguish between psychotic
symptoms and a vivid fantasy life, and also identify learning problems or disorders.
• After other conditions have been ruled out, the patient must meet a set of
criteria specified:

the patient must have two (or more) of the following symptoms during a one-
month period:
- delusions
- hallucinations
- disorganized speech
- disorganized or catatonic behavior
- negative symptoms
- decline in social, interpersonal, or occupational functioning, including self-care

the disturbed behavior must last for at least six months

- mood disorders
- substance abuse disorders
- medical conditions, and developmental disorders have been ruled out
Treatment
Treatments
• Because the causes of schizophrenia are still unknown, treatments
focus on eliminating the symptoms of the disease. Treatments include
antipsychotic medications and various psychosocial treatments.
• Antipsychotic medications
• Antipsychotic medications have been available since the mid-1950's.
The older types are called conventional or "typical" antipsychotics.
Some of the more commonly used typical medications include:
• Chlorpromazine (Thorazine)
• Haloperidol (Haldol)
• Perphenazine (Etrafon, Trilafon)
• Fluphenazine (Prolixin).
Other atypical antipsychotics were also developed. None cause agranulocytosis. Examples include:
• Risperidone (Risperdal)
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
• Ziprasidone (Geodon)
• Aripiprazole (Abilify)
• Paliperidone (Invega)

Side effects of many antipsychotics include:

• Drowsiness
• Dizziness when changing positions
• Blurred vision
• Rapid heartbeat
• Sensitivity to the sun
• Skin rashes
• Menstrual problems for women.
Psychosocial treatments
• Psychosocial treatments can help people with schizophrenia who are
already stabilized on antipsychotic medication. Psychosocial
treatments help these patients deal with the everyday challenges of
the illness, such as difficulty with communication, self-care, work, and
forming and keeping relationships.
• Rehabilitation. Rehabilitation emphasizes social and vocational
training to help people with schizophrenia function better in their
communities. Because schizophrenia usually develops in people
during the critical career-forming years of life (ages 18 to 35), and
because the disease makes normal thinking and functioning difficult,
most patients do not receive training in the skills needed for a job.
References
• Lane, Cheryl. 2012. Schizophrenia.
• Andreasen NC. Negative symptoms in schizophrenia : definition and
reliability. Archives of General Psychiatry 2002;39:784–788.
• Barta PE, Pearlson GD, Powers RE, et al. Auditory hallucinations and
smaller superior temporal gyral volume in schizophrenia. The American
Journal of Psychiatry 1990;147:1457–1462.
• Black DW, Boffeli TJ. Simple schizophrenia : past, present and future. The
American Journal of Psychiatry 2009;146:1267–1273.
• Byne W, Buchsbaum MS, Mattiace LA, et al. Postmortem assessment of
thalamic nuclear volume in subjects with schizophrenia. The American
Journal of Psychiatry 2002;159:59–65.
• U.S. Department of Health and Human Services
National Institutes of Health
NIH Publication No. 12-3679
Revised 2012
• U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
NIH Publication 09-3517
Revised 2009