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JOURNAL PRESENTATION

Oleh : Ayu Lidya Paramita S.Ked 201010401011032 Pembimbing: dr. IWAN SYS, Sp KJ FAKULTAS KEDOKTERAN UNIVERSITAS MUHAMMADIYAH MALANG

Bipolar Affective Disorder


16 Mei 2011 Author: Stephen Soreff, MD; Chief Editor: Stephen Soreff, MD

Overview
y Bipolar disorder, or manic-depressive illness (MDI), is one of

the most common, severe, and persistent mental illnesses y Bipolar disorder is characterized by periods of deep, prolonged, and profound depression that alternate with periods of an excessively elevated or irritable mood known as mania. y Bipolar disorder constitutes 1 pole of a spectrum of mood disorders that includes including bipolar I (BPI), bipolar II (BPII), cyclothymia, and major depression.

Pathophysiology
y The pathophysiology of bipolar disorder has not been

determined, and no objective biologic markers correspond definitively with the disease state. However, twin, family, and adoption studies all indicate that bipolar disorder has a genetic component.

y GENETIC

BPI, has a major genetic component, with the involvement of the ANK3,CACNA1C, and CLOCK genes A parent with bipolar disorder have a 50% chance of having another major psychiatric disorder Twin studies demonstrate a concordance of 33-90% for BPI in identical twins.

y BIOCHEMICAL

A number of neurotransmitters have been linked to this disorder, largely based on patients responses to psychoactive agents. 2. Drugs like cocaine, which also act on this neurotransmitter system, exacerbate mania 3. Hormonal imbalances and disruptions of the hypothalamicpituitary-adrenal axis involved in homeostasis and the stress response may also contribute to the clinical picture of bipolar disorder. 4. Tricyclic antidepressants can trigger mania.
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Epidemiology
y The lifelong prevalence of bipolar disorder in the United

States has been noted to range from 1% to 1.6%. y The age of onset of bipolar disorder varies greatly. Most cases commence when individuals are aged 15-19 years. The second most frequent age range of onset is 20-24 years. y BP I occurs equally in both sexes. The incidence of BPII is higher in females than in males.

History
y These criteria are based on the specifications of the Diagnostic

and Statistical Manual of Mental Disorders, Fourth Edition,Text Revision (DSM-IV-TR).

Manic episode Major depressive episode

Hypomanic episode

Mixed episode

Manic episodes at least 1 week of profound mood disturbance, characterized by elation, irritability, or expansiveness

At least 3 of the following symptoms must also be present: 1. Grandiosity 2. Diminished need for sleep 3. Excessive talking or pressured speech 4. Racing thoughts or flight of ideas 5. Clear evidence of distractibility 6. Increased level of goal-focused activity at home, at work, or sexually 7. Excessive pleasurable activities, often with painful consequences

Hypomanic elevated, expansive, or irritable mood of at least 4 days duration.


At least 3 of the following symptoms are also present: 1. Grandiosity or inflated self-esteem 2. Diminished need for sleep 3. Pressured speech 4. Racing thoughts or flight of ideas 5. Clear evidence of distractibility 6. Psychomotor agitation at home, at work, or sexually 7. Engaging in activities with a high potential for painful consequences

Major depressive episodes For the same 2 weeks, the person experiences 5 or more of the following symptoms, with at least 1 of them being either a depressed mood or characterized by a loss of pleasure or interest: Depressed mood 2. Markedly diminished pleasure or interest in nearly all activities 3. Significant weight loss or gain or significant loss or increase in appetite 4. Hypersomnia or insomnia 5. Psychomotor retardation or agitation 6. Loss of energy or fatigue 7. Decreased concentration ability or marked indecisiveness 8. Preoccupation with death or suicide; patient has a plan or has attempted suicide 9. The symptoms cause significant impairment and distress. 10. The mood is not the result of substance abuse or a medical condition.
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Prognosis
y Factors suggesting a worse prognosis include the following:

Poor job history Alcohol abuse Psychotic features Depressive features between periods of mania and depression Evidence of depression Male sex
y Factors suggesting a better prognosis include the following:

Manic phases (short in duration) Late age of onset Few thoughts of suicide Few psychotic symptoms Few medical problems

Physical Examination
y Use the Mental Status Examination (MSE) to diagnose

bipolar disorder. This section highlights the major findings for a person with bipolar disorder. Because the patients mental status depends on whether he or she is depressed, hypomanic, manic, or mixed, the following discussions of the various areas of the MSE include consideration of each of these particular phases

Appearance y Persons experiencing a depressed episode may demonstrate poor to no eye contact. y Persons experiencing a hypomanic episode are busy, active, and involved. y a patient in the manic phase is the opposite of that of a person in the depressed phase. Patients experiencing the manic phase are hyperactive and might be hypervigilant.

Affect/mood y In persons experiencing a depressed episode, sadness dominates the affect. y In persons experiencing a hypomanic episode, the mood is up, expansive, and often irritable. y In persons experiencing a manic episode, the mood is inappropriately joyous, elated, and jubilant.

Perceptions Persepsi
y Patients experiencing a hypomanic episode do not experience

perceptual disturbances. y Approximately three fourths of patients experiencing a manic episode have delusions. Manic delusions reflect perceptions of power, prestige, position, self-worth, and glory. y Patients experiencing a mixed episode might exhibit delusions and hallucinations consistent with either depression or mania or congruent to both.

Suicide/self-destruction y Patients experiencing a depressed episode have a very high rate of suicide. Patients experiencing a hypomanic or manic episode have a low incidence of suicide. Homicide/violence/aggression y Patients who are hypomanic frequently show evidence of irritability and aggressiveness. y Persons experiencing a manic episode can be openly combative and aggressive. y The homicidal element is particularly likely to emerge if these individuals have a delusional content to their mania.

Judgment/insight y Persons experiencing a hypomanic episode generally have good but expansive judgment. y In patients experiencing a manic episode, judgment is seriously impaired. Cognition y Impairments in orientation and memory are seldom observed in patients with bipolar disorder unless they are very psychotic.

Complications
y The main complications of bipolar disorder are suicide,

homicide, and addictions.

Treatment
y Propose a regular exercise schedule for all patients, especially

those with bipolar disorder. Both the exercise and the regular schedule are keys to surviving this illness. y The indications for inpatient treatment in a person with bipolar disorder include the following:
Danger to self Danger to others Total inability to function Total loss of control Medical conditions that warrant medication monitoring

y Outpatient treatment has 4 major goals, as follows.

Look at areas of stress and find ways to handle them. 2. Monitor and support the medication. 3. Develop and maintain the therapeutic alliance. 4. Provide education.
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y Pharmacologic Therapy

Appropriate medication depends on the stage of the bipolar disorder the patient is experiencing
y Electroconvulsive Therapy

ECT is useful in a number of instances. It has proven to be highly effective in the treatment of acute mania. Often, the severity of the symptoms, the lack of response to medications, or the presence of contraindications to certain medications necessitates the use of ECT. In a study of 400 patients with acute mania who received ECT, 313 showed significant clinical improvement.

Pharmacologic Therapy
-Mood stabilizers Lithium is the drug commonly used for prophylaxis and treatment of manic episodes. -Anticonvulsants Anticonvulsants have been effective in preventing mood swings associated with bipolar disorder, especially in those patients known as rapid cyclers. -Atypical Antipsychotics Atypical antipsychotics are being used increasingly for treatment of both acute mania and mood stabilization.

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