10/12 Mood Disorders: Bipolar - Palmeri Flashcards
types of bipolar disorder and related disorders
- type 1 → manic
- type 2 → hypomanic
- both feature presence of at least one manic (I) or hypomanic (II) episode
- depression may not be present but usually is at some point
- cyclothymic
- substance/medication-induced
- due to another medical condition
bipolar type 1
must meet criteria for a manic episode
- may be preceded or followed by hypomanic or major depressive episodes
what is a manic episode?
- elevated (euphoric/infectious), expansive, or irritable mood
- persistently increased goal-directed activity or energy
lasting at least 1 week and present during most of day, nearly every day in this period
patients do not perceive they are ill
at least 3 (4 if irritable mood) symptoms present during this pd:
- inflated self esteem
- decreased need for sleep
- more talkative or pressured
- flight of ideas
- distractibility
- incr in goal directed activity or psychomotor agitation
- engagement in pleasurable but potentially harmful behavior
NOT ATTRIBUTABLE to substance/med condition
what is a hypomanic episode
diff from mania is in degree of intensity of sx and impairment
- lite version of mania
- must last at least 4 days
doesn’t have to result in hospitalization, can go on for years
almost always followed by depression
behavior not characteristic of the individual
observable by others
doesn’t cause marked impairment
NOT ATTRIBUTABLE to substance/medical cond
specifies for bipolar/related disorders
with anxious distress
2 or more sx:
- feeling keyed up/tense
- feeling restless
- difficulty concentrating due to worry
- fear that something awful will happen
- feeling that pt might lose control of self
specifies for bipolar/related disorders
with mixed features
(manic/hypomanic)
for manic/hypomanic, episodes must have 3 or more sx:
- dysphoria
- depressed mood
- diminished interest
- psychomotor retardation
- fatigue
- worthlessness/guilt
- recurrent thoughts of death/suicide
specifies for bipolar/related disorders
with mixed features
(depression)
for depressive, episodes must have 3 or more sx:
- elevated, expansive mood
- inflated self esteem
- more talkative than usual
- flight of ideas
- incr in energy or goal directed activity
- risky behavior
- decr need to sleep
specifies for bipolar/related disorders
with rapid cycling
- at least 4 mood episodes in last 12 months meeting criteria for manic, hypomanic, or depressive episodes
- period of partial/full remission of at least 2 mo
v bad disease!
specifies for bipolar/related disorders
with psychotic features
- delusions and hallucinations present
- mood congruent (punishment, guilt)
- mood incongruent (atypical)
specifies for bipolar/related disorders
with catatonia
3 or more symptoms
- stupor (no psychomotor activity)
- catalepsy (passive induction of posture)
- wavy flexibility (move like wax)
- mutism (little or no verbal response)
- negativisim (opposition to instruction)
- posturing (posture against gravity)
- mannerism (odd caricatures)
- stereotypy (repetitive, nonsense movements)
- agitation
- grimacing
- echolalia, echopraxia
specifies for bipolar/related disorders
with peri partum onset
sx occur during preg or in 4 weeks following delivery with or without psychosis
- may be more common in first preg
- presentation with psychotic features more likely within second episode or with hx of MDD/bipolar
specifies for bipolar/related disorders
with seasonal pattern
regular relationship with onset of hypomanic/manic/depression and time of year (fall/winter)
- full remission or switch to depression/hypomania/mania occurs at a characteristic time of year
- last 2 years, 2 episodes without episodes at other times of year
- more seasonal than non-seasonal depressions
bipolar disorders ddx
- MDD
- cyclothymic disorder
- GAD, panic, PTSD
- medical/substance-induced states
- schizophrenia
- ADD/ADHD
- personality disorders
bipolar type 1
course
67-75% of bipolar 1 case have depression as first episode
10-20% have manic episodes only
- manic episodes can last 3mo
- 90% of pt have more than one episode
- time between episodes can decrease
5-15% are rapid cyclers
90% of pt never fully remit
bipolar disorder type 1
prognosis
poorper prognosis than MDD alone
poorer prognosis:
- young age of onset
- alcohol dependence
- psychotic ft
- lack of interepisode remission
- male gender
- poor social supports
good signs: short manic episodes, no comorbidity, older age of onset, good social supports
30% show severe impairment lifetime
bipolar disorder type 1
comorbidity
- anxiety disorder (75% patients)
- ADHD, impulse control or conduct disorder
- substance use disorders (50%)
- metabolid syndrome, migraines
bipolar disorder type 2
course and prognosis
onset: mid20s
* 5-15% will ultimately develop a manic episode
initial episode may be depressive; more time is spent in depressive episodes
15-20% may not recover between episodes
occupational cognitive decline
bipolar disorder type 2
risk, prognosis, gender
risk highest among relatives
10-20% of postpartum women may experience a hypomanic episode
risk: rapid cycling
good signs: late age of onset, higher education, marriage
bipolar 2 and suicide
1/3 of patients report a suicide attempt
lethality of attempt potentially greater in type 2 than type 1
pharmacologic tx of bipolar 1 and bipolar 2
- mood stabilizers
- ECT
- v v cautious use of antidepressants
* caution because can swing patients into hypo/mania → will inevitably swing back into depression
mood stabilizers for bipolar 1/2
- lithium carbonate
- antiepileptic drugs (valproate/valproic acid, carbamazepine, lamotrigine)
- atypical antipsychotics (olanzapine, risperidone, quetiapine, aripiprazole, lurasidone)
psychotherapeutic tx for bipolar 1/2
- crisis intervention
- supportive psychotherapy
- cognitive behavioral therapy
- family therapy
cyclothymia
chronic, fluctuating disorder of at least 2 yr duration marked by many periods with hypomanic sx that dont meet bipolar 2 criteria and many periods of depressive sx that dont meet criteria for MDD
- sx present for at least half of 2 years of hypomania and minor depression
- diff from bipolar2 bc depression is NOT MAJOR
- periods are usually brief, unpredictable, and change abruptly
- irritability is common
longest period free of sx: 2mo
v rarely diagnosed
- most common in 15-25 yr olds
- good chance that it will progress to bipolar 1 or 2
- potentially more sensitive to “switching” to hypo/mania with antidepressants
cyclothymic disorder tx
similar to that of major depression or bipolar illness
- be even more cautious with antidepressants → more sensitive to switching into hypo/mania
substance/med-induced bipolar/related disorders
elevated, expansive, irritable mood with evidence that mood change is direct consequence of/temporally related to a substance or medication
- medication, toxic substance, illicit substance (stimulants, PCP, steroids)
factors associated with depression in primary care
- compaints in multiple organ systems (neuro, GI, cardiac)
- recurrent emotionality
- sleep disturbances
- frequent/urgent visits
- chronic pain
