Bipolar Affective Disorder and Suicide

1. Dr. Aziz Mohammad
FCPS
Asstt: Prof: Psychiatry KMC/KTH

2. Learning Objectives
 Mood Disorders:
 Bipolar Affective Disorder
 Symptoms
 Course and Prognosis
 Etiology
 Treatment
 A little something about Suicide.

3. Concept Of Mood Disorder
 Mental Disorders in which the predominant
disturbance is the Mood.
Takes Three forms
 Depression: (Depression/Recurrent Depression[ICD] ,
Major Depressive Disorder [DSM],
 Hypomania: [Bipolar-II ; DSM]
 Mania: Bipolar Affective Disorder [ICD, DSM]

4. Mood Disorders
Mania
with
Psychosi
s
Severe
Depressi
on
with
Psychosis
Mania
Severe
Depressi
on
Hypo-
mania
Moderate
Depressio
n
Elation
Mild
Depressio
n
Norma
l Mood
Dys-
thymia
Depressive Disorders
Cyclothymia
Recurrent Depressive Disorder
Bipolar Disorder
1. Diagnostic and Statistical Manual of Mental Disorders, DSM IVTM American Psychiatric Association, Washington DC.

5. Diagnoses of Depression1
4 or more features of the following list in the past 2 wks.
1. Low Mood
2. Anhedonia (Lack of Interest in activities)
3. Lack of Energy
4. Decreased Concentration
5. Low self Esteem
6. Guilt Feeling
7. Thought of Self harm or Suicidal Thoughts
8. Pessimistic view of self or Future (hopelessness)
9. Disturbance of Appetite
10. Disturbance of Sleep
1. International Classification of Disease ( ICD-10)

6. Psychotic Depression
 When Severe Depression is accompanied by Psychotic
Symptoms, i-e Delusions and Hallucinations.
The common Delusions in Psychotic Depression are
1. Nihilistic Delusion
2. Delusions of Poverty
3. Hypochondriacal Delusions
4. Paranoid Delusion

7. Hypomania and Mania
 Core Features are
1. Elevation of mood
2. Increased activity,
3. Self-important ideas
When severe and associated with social and
occupational impairment  Mania

8. Other Features of Hypomania/Mania
 Appearance/Beh: Excessive Grooming to Self
Neglect, Agitation, Social Disinhibition, Cheerfulness.
 Speech: Pressured, Flight of Ideas
 Thoughts: Expansive/Grandiose Ideas or Delusion
 Lack of Insight

9. Bipolar Affective Disorder
 This disorder is characterized by repeated (i.e. at least
two) episodes in which the patient's mood and activity
levels are significantly disturbed, this disturbance
consisting on some occasions of an elevation of mood
and increased energy and activity (mania or
hypomania), and on others of a lowering of mood and
decreased energy and activity (depression). [ICD-10]

10. 10
Common Signs/Symptoms of Bipolar Disorder Episodes
Manic Stage Depressed Stage
Mixed Stage
1. Diagnostic and Statistical Manual of Mental Disorders, DSM IVTM American Psychiatric Association, Washington DC.

11. • Reduced need for sleep
• Rapid speech
• Racing thoughts
• Inability to concentrate
• Increase in goal directed
activity
• Euphoria or Dysphoria
11
Symptoms of Mania1
Manic Stage
1. Diagnostic and Statistical Manual of Mental Disorders, DSM IVTM American Psychiatric Association, Washington DC.

12. • Depressed mood
• Lack of interest in activities
• Weight loss or gain
• Insomnia or hypersomnia
• Fatigue
• Feelings of worthlessness
• Inability to concentrate
• Thoughts of death / suicide
12
Symptoms of Depression1
Depressed Stage
1. Diagnostic and Statistical Manual of Mental Disorders, DSM IVTM American Psychiatric Association, Washington DC.

13. BIPOLAR DEPRESSION UNIPOLAR DEPRESSION
Current or past history of episode of
hypomania/mania
Present None
Characteristics/Features
More withdrawn and retarded with
tendency for hypersomnia
Anxiety symptoms, somatic complaints,
and anger more common
Agitation and weight loss Less common More common
Age of onset of symptoms Relatively young Relatively older
Atypical symptoms of depression More common Less common
Family history of bipolar disorder Relatively more common Relatively less common
Pattern of illness
More recurrent and relatively brief
episodes
Relatively less recurrence, but longer
episodes of illness
Response to antidepressant therapy Less Responsive More responsive
Postpartum onset and premenstrual
syndrome
More common Less common
Psychotic features More common Less common
Mood lability and seasonal pattern More common Less common
Substance use and suicide attempt More common Less common than bipolar
1. Singh T. & Rajput M., Misdiagnosis of Bipolar Disorder. Psychiatry October 2006; 57-63
2. Charles L. Bowden. A different depression: clinical distinctions between bipolar and unipolar depression. Journal of
Affective Disorders 84 (2005) 117– 125
Distinguishing Features1

14. Course & Prognosis
 The age of onset of bipolar disorder is typically about 21
years in hospital studies, but earlier (about 17 years) in
community surveys.
 Bipolar disorder usually begins as depression, with the first
manic episode manifesting about 5 years later.
 The average length of a manic episode (treated or
untreated) is about 6 months.
 At least 90% of patients with mania experience further
episodes of major mood disturbance.
 Over a 25-year follow-up, on average bipolar patients
experience about 10 further episodes of major mood
disturbance.

15. Course & Prognosis
 The interval between episodes becomes progressively
shorter with both age and the number of episodes.
 Over long-term follow-up, patients with bipolar
disorder experience mood-related symptomatology of
varying severity for about one-third of the time. This
most commonly takes the form of depressive
symptoms.
 Nearly all bipolar patients recover from acute episodes.

16. Etiology
 Genetic
 Biological Factors
 Environmental Factors

17. Genetics

18. Treatment of Hypomania/Mania
Treatment of Acute Episode
 Stop Antidepressants if already taking
 Second or First Generation Antipsychotics
Medications (Oral or I.V/I.M)
 Mood Stabilizers: Sod.Valproate, Lithium.
 Electroconvulsive Therapy
Treatment for prophylaxis of Mania/Hypomania
 Mood Stabilizers

19. Treatment of Bipolar Depression
 Olanzapine+Fluoxetine
 Lamotrigine
 Quetiapine
 ECT

20. Suicide

21. Suicide

22. Suicide

23. Suicide

25. Suicide

26. Assessing the Suicide Risk
 ‘How do you feel about the future?’
 ‘Have you ever thought that life was not worth living?’
 ‘Have you ever wished you could go to bed and not
wake up in the morning?’
 ‘Have you had thoughts of ending your life?’
 ‘Have you thought about how you would do it?’
 ‘Have you made any preparations?’
 ‘Have you tried to take your own life?’