12 - Bipolar

Question 1

Explain the demographics of bipolar

Answer 1

• 1.6-6% of population
• equal gender split
• similar rates across all SES
• maybe more common in left handers?
• onset: 15-19yrs (12.5yr tx delay)
• tx gap: 56%
• 15-20% suicide rate; 30% attempt (2x the rate of MDD)
• seasonal variations: mania in summer, depression in winter
• 4th leading cause of loss of life years (death + unable to work etc.) > HUGE functional impairment
• 50% have at least one other axis 1 dx (typically substance use or anxiety)

Question 2

What are some reasons behind the treatment delay in bipolar? What is one way that this can this be improved?

Answer 2

• MDD typically presents first > conversion rate is high (~40%) > clinically, must check every person with MDD carefully for personal hx of hypomanic sx or family hx of mania
• enjoy sx (not help-seeking)
• misdiagnosis: MDD, SCZ, BPD, antisocial PD

Question 3

What should you look for in differentiating unipolar from bipolar depression? (10)

Answer 3

• fam hx BP
• atypical features (hypersomnia, leaden paralysis)
• psychosis
• melancholic features
• psychomotor disturbance
• early onset (particularly <21yrs)
• high frequency of episodes
• comorbid anx (OCD, panic etc.)
• severe suicidal behaviour
• MDD non-responsive to 2 lines to anti-depressants

Question 4

Differentiate bipolar I, II, cyclothymic disorder and bipolar NOS

Answer 4

• bipolar I: 1 manic ep
• bipolar II: depressive ep + hypomanic ep
• cyclothymic: 2 yrs, numerous sub-threshold hypomanic and depressive eps (not absent for >2mths)
• NOS: very rapid alteration of manic/MDD sx > meet sx criteria, but not minimum duration

Question 5

Explain the “bipolar spectrum”

Answer 5

Bipolar I1 full-blown ani
Bipolar 1.5: depression + protracted mania
Bipolar 2: depression + hypomania
Bipolar 2.5: cyclothymic
Bipolar 3: anti-depressant associated hypomania
Bipolar 3.5: bipolarity masked/unmasked by stimulant use
Bipolar 4: hyperthymic depression

** good clinical utility, but not widely used

Question 6

Explain “mixed episodes”

Answer 6

• meet crit for mania + dep ep > nearly every day for past week + functional impairment + not caused by substances/meds
• > 40% of people with BP will have a mixed ep
• more common in youth
• poorer response to lithium
• high correlation with suicide (really low, but energy to do something about it) > compared to euthymia: suicide attempts 60x higher in MDD, 120x in mixed episode

Question 7

Explain the pie charts of bipolar

Answer 7

** over 13 years **

BIPOLAR I

• 53% asymptomatic
• 32% depressed
• 9% manic
• 6% mixed

BIPOLAR II

• 50% depressed
• 46% asymptomatic
• 2.3% mixed/cycling
• 1.3% hypomanic

Question 8

Explain the biological components of bipolar

Answer 8

GENETICS

• gene CHDH
• higher in dizygotic twins than monozygotic
• mix of genes + epigenetics + environmental interactions etc. (impossible to be entirely genetic)

BIOCHEMICAL/NEUROLOGICAL

• low NE (depressed mood?)
• 5HT + DA (manic + psychotic sx)
• reduced activation of DLPFC + orbitofrontal
• increased activation of amygdala
• smaller volume: PF + subgenual cingulate
• larger volume: subcortical/medial temporal + basal ganglia
• overactive microglia
• elevated pro-inflammatory cytokines

MENSTRUAL CYCLE
- subgroup of women with BP experience menstrual cycle effect on dep, hypomanic and manic eps

Question 9

Explain the psychological components of bipolar

Answer 9

MANIC DEFENCE

• mania as a defence arising from failure of containing processes which normally occur during attachment > catastrophic fragmentation of the ego
• in everyday life: people stay busy > this may be protective
• pragmatic inference task
• recall rather than endorsement (recall -ve words)
• high goal-setting
• higher DAS “need for approval” than people with unipolar MDD/controls
• schema congruency (events that are congruent trigger us > also seek out congruence)
• attribution regarding early signs/sx
• larger impact of +ve or -ve events
• behavioural activation/inhibition
• sleep/activity levels
• attentonal bias (mood congruent)
• (autobiographical) memory bias
• variable self-esteem even in remission
• higher fear of failure
• perfectionism
• lower self-compassion (in remitted BP)
• unhelpful meta-cognitive beleifs: social control (I won’t tell others how I feel), worry (I’ll worry about smaller things instead), punishment (punish self for having that thought)
• cog styles alone (+ with recent life events) predict course of dep and possibly mania too

PERFECTIONISM

• higher perfectionism = elevated dep scores across acute tx period (regardless of CBT, CBT + meds, meds, placebo)
• eg. If I fail at work, I am a failure as person; I must be useful/productive or life has no purpose

SCHEMAS

• self-sacrifice
• unrelenting standards
• abandonment, failure to achieve, insufficient self-control, enmeshment, entitlement
• EMS more prev in adults with BP than adults with MDD

Question 10

What treatment is effective for bipolar? What are the outcomes?

Answer 10

YES

• strong evidence base for CBT
• psychoed, medication adherence, lifestyle regularity, cog/behavioural patterns ,relapse prevention
• involve family
• jury still out/unsure about mindfulness
• BUT many BP patients excluded from clinical trials for one reason or another > evidence doesn’t really relate to real-world clients

OUTCOMES

• reduced: sx, relapses, impulsivity, no. of inpatient admission
• improves: social functioning, global functioning, problem-solving, medication adherence

Question 11

What are the key take-aways?

Answer 11

• bipolar disorders relatively common + sig impact on functioning
• aetiology: multi-factorial; psych factors play a sig role in onset + maintainence
• evidence that CBT if effective, but need further study and greater applicability to “real-life” clients