A Manic Episode is defined by a distinct period during which there is an abnormally and persistently elevated, expansive, or irritable mood.

(1)

Bipolar disorder

Bipolar (manic-depressive illness) is a recurrent mode disorder. The patient may feel stable at baseline level but experience recurrent shifts to an emotional high (mania or hypomania)

alternative with an emotional low (major or mild depression).

Incidence of this disorder is equal in females and males

The first episode for females is usually marked by a depressive episode.

For males the first episode is marked by a manic episode

(2)

• A Manic Episode is defined by a distinct period during which there is an abnormally and persistently elevated, expansive, or irritable mood. This period of abnormal mood must last at least 1 week (or less if

hospitalization is required).

• The mood disturbance must be accompanied by at least three additional symptoms from a list that

includes inflated self-esteem or grandiosity, decreased need for sleep, pressure of speech, flight of ideas,

distractibility, increased involvement in goal-directed activities or psychomotor agitation, and excessive

involvement in pleasurable activities with a high potential for painful consequences.

(3)

Types and Classifications:

• Bipolar l: This type is characterized by

occurrence of manic episodes and major depressive episodes

• Bipolar ll: This type is characterized by

occurrence of hypomanic episodes and major depressive episodes.

(4)

• .

• A hypomanic episode is like that of manic episodes with two differences:

• 1)The mood usually is not sever enough to cause problems with persons working or

socializing with others (e.g they do not have to take time off work during the episode)

• 2)There are never any psychotic features present in hypomanic episode.

.

(5)

During the period of mood disturbance, 3 or more of the following symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree: • Inflated self-esteem or grandiosity

• Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

• More talkative than usual or pressure to keep talking

• Flight of ideas or subjective experience that thoughts are racing

(6)

• Distractibility (e.g., attention too easily drawn to unimportant or irrelevant external stimuli)

• Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

• Excessive involvement in pleasurable activities that have a high potential for painful

consequences (e.g., the person engages in

unrestrained (uncontrolled) buying sprees, sexual indiscretions (irresponsible relations), or foolish business investments.

(7)

• Cyclothymia: This type is defined as numerous episodes of hypomania and mild depressive episodes that cannot classified as major

depressive episodes. Diagnosis requires that cyclothymia occurs for at least 2-year period.

(8)

Drug Treatment: Lithium:

For acute treatment and prophylaxis of manic

episodes associated with bipolar disorders. It is effective for both the manic and the depressive component.

Contraindications:

Renal disease, severe cardiovascular disease, history of leukemia, the first trimester of pregnancy, and hypersensitivity to lithium.

(9)

• Precautions:

• Use with precaution in patients who have thyroid disease, patients who are receiving diuretics, or dehydrated patients.

• Monitoring:

• Lithium may cause hypothyroidism , so the function of the thyroid must be monitored periodically

(10)

• Serum creatinine and blood urea nitrogen (BUN) levels must be monitored periodically • Periodical monitoring of the complete blood

count because lithium may cause leukocytosis and may reactivate leukemia.

• Monitoring of sodium level because

hyponatremia may lead to lithium toxicity.

• Monitoring of ECG because lithum may cause cardiotoxicity.

(11)

• Divalproex sodium:

• It is considered first-line treatment for manic episodes

• . It is helpful in the management of agitation and aggression.

• Contraindication: • Hepatic dysfunction

• Hypersensitivity to divalpproex sodium • Pregnancy

(12)

• Carbamazepine:

• Is considered second-line therapy for acute and prophylactic treatment of bipolar

disorder.

• Contraindication:

• Histroy of previous bone marrow depression and hypersensitivity to carbamazepine.

(13)

• Lamotregine

• Is approved for maintenance treatment of bipolar l disorder.

• Titration of the dose is required to monitor for signs and symptoms of sever and potentially life-threatening skin rashes

(14)

• Other therapies:

• Olanzapine and fluoxetine • Gabapentin

• Oxcarbazepine

(15)

Schizophrenia

• Schizophrenia is a psychiatric disorder characterized by a profound disruption in perception, cognition, and

emotion.

• Clinical presentation:

• Symptoms include the following:

• Hallucinations (auditory, visual, tactile, olfactory or gustatory)

• Delusions (usually persecutory or grandiose) • Disorganized thoughts or speech

• Impaired cognition, attention, concentration, judgment, and motivation

(16)

• These symptoms are usually referred to as

positive (hallucination, or delusions); negative (flat affect, anhedonia, and poverty of

thoughts) or disorganized (disorganized speech or behavior)

• Most patients fluctuate between acute episode and remission, but complete remission without any symptoms is uncommon.

(17)

• Treatment:

• Antipsychotics:

• These drugs include

• Chlorpromazine which is the first antipsychotic used.

• Thioredazine • Perphenazine • Fluphenazine

(18)

• Haloperidol

• These drugs block the post-synapticdopamin-2 receptors

• They have anticholinergic, antihistaminic, and

-blocking properties. • Adverse effects:

• Sedation effects which are worse initially, but become more tolerable over time

(19)

• Orthostasis. It is more problemetic in elderly patients

• Weight gain. To diminish such effect low doses should be used, appropriate diet and exercise should be encouraged • Anticholinergic effects e.g dry mouth, blurred vision,

constipation, and urinary hesitancy may occur.

• Extrapyramidal symptoms (parkinson-like symptoms) due to decreased dopaminergic activity

• Dystonic reactions .These reactions occur within 24-96 hours from initiating or changing the dose. The appear as painful, involuntary spasms in skeletal muscles (facial and neck muscles). IM injection of benzotropine or

(20)

• Akathisia which occur within a few weeks of initiating the antipsychotic and described as feeling of discomfort, usually seen as motor restlessness of the legs (inability to stand still or sit still). It is treated with propranolol,

benzodiazepines, clonidine, and anticholonergics(benzotropine)

• Allergy to medication (dermatologic effects e.g photosensitivity and pigmentation).