Bipolar disorders

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Course Objectives :

  • Recognize l’manic state;
  • Recognize l’melancholy outburst;
  • Diagnose manic-depressive psychoses;
  • Namely prescribing drugs to treat manic and depressive phase;
  • Knowing prophylaxis access.

HISTORICAL :

What n’that is’in 1854 that J.-P.. Falret and Baillarger described almost at the same time the same disease called by the first / b / j’e circular .

In 1899, Kraepelin collected all the psychoses described above and the proposed categorize called manic depression seen as essentially endogenous psychosis .

etiopathogeny :

1- Role of brain damage :

tumors, trauma, l’arteriosclerosis and circulatory disorders, encephalitis, meningoencephalitis could cause manic attacks s’they are located at the diencephalic level where the ‘thymic functions ” .

2- hormonal factors :

Some endocrine glands play an important role in the genesis of manic episodes. Emotional changes are clinically correlated with endocrine disorders.

3- toxic factors :

Many toxic substances can cause clinical pictures of mania such as’alcohol (in L’excito-motor drunkenness), hashish, cocaine, nitrous oxide. amphetamines…

4- biogenic amines :

Biogenic amines include 3 catecholamines: dopamine, norepinephrine and epinephrine.

catecholamines

L’hypothesis d’a catecholamine ethiology is based on the effects of mono-amine oxidase inhibitors (HAD) and tricyclic anti-depressants potentiating or decreasing the release of catecholamines in the brain which induce behavioral stimulation and’arousal and have an anti-depressant effect.

A l’opposite, lithium salts decrease or inhibit the’mood leading to sedation or depression. Lithium is very effective in the treatment of mania by reducing the release

serotonin

serotonin : It was observed that the serotonin metabolite (5-think) is reduced in the cerebrospinal fluid in some depressed patients. Antidepressants stimulate the’serotoninergic activity in the brain.

DEFINITION :

Manic-depressive illness is a periodic psychosis evolving phase.

The manic or depressive phases alternate in an irregular manner by respecting free intervals disorders (science) a few weeks to several years.

mANIC ACCESS :

acute psychotic state characterized by psychomotor excitation associated with an expansive mood.

1- Epidemiology :

  • The onset of the disease before 30 years.
  • The prevalence is between 0.5 fct 1.2%
  • The sex ratio showed no preponderance of one sex over another.

2- Clinique :

The onset is usually sudden occurring in a young adult with similar history of manic or melancholic, personal or family. The onset may be gradual or develop after a traumatic event (family dispute, mourning, festive atmosphere..)

The status stage : the presentation is hyper expressive indeed the face is animated, he bets without stopping, familiarities, laughs, the patient moves sings gesticulates, exaltation of mood with joy and optimism with infatigabilité feeling of omnipotence. The psychic hyperactivity quick ideas, wordplay, grandiosity and mégalomaniaque, jump from one subject to another, memory is invaded by memories uninterrupted. Insomnia almost complete, voracious appetite and sexual excitement.

3- Differential diagnosis :

The mania may be symptomatic of :

  1. head injury
  2. endocrine disease : hyperthyroidism, maladie de cushing.
  3. Intoxications : cocaine, amphetamines, alcohol…
  4. frontal tumors : providing a table of cheerfulness niaise (front die-off).

The differential diagnosis may also arise with :

  • The delirious
  • Atypical mania can be an input mode in schizophrenia.
  • The psychopathic agitation aggressively, easy passage to act, concept of making all the toxic grafted onto a pathological personality.

4- Treatment :

Before such symptoms, hospitalization is required in a psychiatric ward.

The treatment will be based on incisive neuroleptics such as haloperidol or haldol in the form of’IM injectable ampoules. associated with a sedative neuroleptic to release the’restlessness and l’instability like chlorpromazine or largactil ( amp inj en IM).

As soon as the’patient's condition allows it, one passes to oral treatment :

Haldol gttes 02% 50 50 50.
NOZINON CP 100mg : 1 1 1.

Combined with a synthetic kind antiparkinsonnien parkidyl PC 5mg : lcp/j.

Meanwhile psychotherapeutic attitudes made empathic support and kindness are needed.

In the treatment of’maintenance, 2nd generation antipsychotics can be prescribed instead of conventional neuroleptics ( zyprcxa, risperdal..).

L’addition of’a thymoregulator is necessary in these cases and lithium salts find their place, Nevertheless, the risk of drug interactions, the lethal dose is very close to the therapeutic dose fact that prefers a lithium -like namely Carbamazepine Tegretol or.

It is best to monitor the patient's blood count while taking Tegretol as there is a risk of’agranulocytose.

The dose is 400mg and 1200mg / day (tablet 200mg and 400mg).

The duration of treatment varies 10 at 24 month.

The psychotherapeutic component and especially psychoeducation remains beneficial in this kind of disorder.

DEPRESSIVE STATES

Definition :

It is defined as a state of deep sadness and sustainable associated with a slowdown and an inhibition of the psychic functions and psychomotor, the major risk is suicide.

Epidemiology :

  • This is the most common psychiatric syndrome.
  • The prevalence of 2 at 3% for men and 05 at 10% for women.

Clinique :

The depressive syndrome consists of :

  • Thymie collapsed with a pessimistic lived, dissatisfaction and self- depreciation, worthlessness, tendency to isolation feeling of a catastrophic past, of this distressing and a stuffy future In severe forms, sadness becomes painful "moral pain" with guilt ideas, indignity and incurable, the risk of suicide is very important at this stage of the disease.
  • Psychomotor slowing with general asthenia, clinophilia trend with scarcity of gestures and immobility. Anxiety can cause agitation

The associated somatic syndrome :

especially the terminal type of insomnia sleep disorders, constant anorexia, loss of any sexual desire.

melancholy ACCESS

Clinique :

The onset is often sudden.

  • significant inhibition with psychomotor retardation, droopy features, gaze frowning, the words are rare issued a monotone and monotonous realizing a bradypsychia.
  • moral pain : the patient complains of not feeling anything (emotional anesthesia) and have more fun (anhedonia).
  • Delusions of guilt and unworthiness of incurable.
  • Ideas death, death becomes a deserved punishment.
  • Sleeping troubles, sexual and instinctual functions.

The clinical forms :

  • The hallucinatory form
  • The hypochondriac form
  • The forms stuporeuse
  • The delirious form
  • The anxious form.
  • Masked depression
  • Melancholy of involution.
  • Seasonal affective disorder
  • The brief recurrent depression

Evolution :

  • The % depressive states heal under treatment.
  • 15% become chronic.
  • 10% resist any therapeutic.

Treatment :

L’hospitalization is the rule for melancholy because the risk of suicide is very present.

Biological treatment :

  • Antidepressants such sorting cyclic or Clomipramine Anafranil (150 to 225mg / day). the cure to Anafranil which is as follows :

J1 : 1 bulb l’Anafranil at 25 mg in 250 cc of SGI to 5%
J2 : 2
D3 to D15 3

  • All combined with a sedative neuroleptic such as Levomepromazine or Nozinon 100mg / d to prevent the lifting of the’inhibition caused by antidepressants.
  • The relay will be taken orally at twice the dose of the parenteral treatment : 150mg / d and a sedative treatment Anafranil.

The use of electroconvulsive in case of resistance or very inhibited form.

Other antidepressants are prescribed especially selective inhibitors of serotonin reuptake ( ISRS) without side effects such as :

  • fluoxetine
  • sertraline
  • paroxetine
  • mirtazapine

cognitive psychotherapy with updating dysfunctional patterns and cognitive restructuring was used recently in the first of cognitive Interest depressions psychoeducation

PLACE DU DSM IV.R :

In bipolar disorder type I : the patient suffers from manic or mixed episodes and often depressive episodes.

If someone has first manic episode, the disease is still considered bipolar depression although none has taken place so far.

It is highly probable that future episodes of depression will take place as well as mania unless effective treatment is received.

In bipolar II disorder : the patient suffers from hypomania and

depression without manic or mixed episode. This is the most common form This form is often difficult to recognize because hypomania may seem normal if the person is very productive and avoid being involved in serious problems Unfortunately, if a mood stabilizer is not prescribed an antidepressant ave through unrecognized bipolar disorder II, l’antidepressant alone may be responsible for’an uplifting mood or making the cycles more frequent

Professor M's course. BENABBAS – Faculty of Constantine