4.1 Bipolar disorder: A lifespan perspective Flashcards by fientje suntrop

Waar gaat artikel Carvalho over?

Carvalho et al. (2020)

Wat is bipolar disorder (BD)
- BD I, BD II, cyclothymic disorder
- Epidemiology
- Genetics and neurobiological
- Management
- Treatment
- Acute depression

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Bipolar disorder (BD)

Carvalho et al. (2020)

Mood disorder with abnormal shifts in mood, energy, activity, sleep and cognitive functions during episodes of mania and depression.

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When does BD typically begin?

Carvalho et al. (2020)

Around 20 years old.

Early onset= associated with poorer prognosis, longer treatment delays, severe depressive episodes and higher prevalence of anxiety and substance use disorders.

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(First) pattern of BD

Carvalho et al. (2020)

1e episode= depressive

Depressive episodes often last longer than (hypo)manic episodes.

Pattern is often misclassified as MDD.

1/3 of BD patients, the disorder remains undiagnosed until 10 years after onset.

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Symptoms BD I

Carvalho et al. (2020)

Observable manic episodes with various manifestations, like:
- Heightened confidence
- Grandiosity
- Increased talkativeness
- Extreme disinhibition
- Irritability
- Reduced need for sleep
- Sig elevated mood

75% of manic episodes involve psychotic symptoms such as delusions and hallucinations

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Symptoms BD II

Carvalho et al. (2020)

Mainly episodes of depression

Alternating with hypomania rather than mania.

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Symptoms cyclothymic disorder

Carvalho et al. (2020)

Repeated depressive and hypomanic states lasting a minimum of tow years, but these do not reach the diagnostic criteria for a major affective episode.

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Prevalentie BD

Carvalho et al. (2020)

Differs between countries, from 2.4 till 1.5%

Bipolar I: same in male-female.
Bipolar II: more prevalent in female

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Comorbidity

Carvalho et al. (2020)

ADHD and anxiety –> increase burden and worsen prognosis
Chronic medical disorders –> more present among people with BD
People with BD have twice the risk of death (suicide, physical diseases)

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Heritability

Carvalho et al. (2020)

70-90%

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Genetic

Carvalho et al. (2020)

Enriched gene sets in bipolar populations, including sets involved in the regulation of insulin serotonin and endocannabinoid signaling

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Kindler hypothesis

Carvalho et al. (2020)

Model explaining how gradual stress sensitization leads to recurring affective episodes.
- 1e episode occurs after exposure to stressor
- Subsequent episode can occur whithout stressor.

Mechanisms behind hypothesis are strengthened if patient:
1. Does not receive care
2. Uses psychoactive substances
3. Lifestyle risks (smoking or sedentary behaviour)

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What happens to brain when BD occurs for a long time?

Carvalho et al. (2020)

Reduced cortical thickness of brain regions, like PFC (stress regulation)

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What are contributors to neuroprogression in BD?

Carvalho et al. (2020)

Epigenetic mechanisms
Dysregulation of mitochondrial function
Pathways related to neuroplasticity
Inflammation
Elevated oxidative and nitrosative stress

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Neuroprogression causes:

Carvalho et al. (2020)

Worsening of cognitive and functional impairments
Higher prevalence of coexisting medical conditions
Premature death

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What happens to response to mood stabilizers medications as BD progresses?

Carvalho et al. (2020)

Response to mood stabilizer medication may decrease

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3 factors that influence selection of initial treatment

Carvalho et al. (2020)

Patient’s preference
Coexisting medical and psychiatric conditions
Previous responses to treatment, including associated side effects

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Treatment acute mania

Carvalho et al. (2020)

If there is no response to med’s after 1 or 2 weeks, different medication may be considered.
Antipsychotic agent and mood stabilizer, especially for severe mania
Antipsychotic risperidone more effective than lithium, etc.

Treatment used for mania is often used for hypomanic episodes

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Which treatment may be effective for refractory mania and aggressive/psychotic symptoms?

Carvalho et al. (2020)

Bifrontal electroconvulsive therapy (ECT)

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What happens with treatment during acute depression?

Carvalho et al. (2020)

During depressive episodes pat’s have greater number of unacceptable side effects of pharmacological treatments.

Oplossing: low initial dose with gradual upward dose adjustment

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What is risk of antidepressants in BD?

Carvalho et al. (2020)

Risk of switching to mania or hypomania= affective switches

Risk of switches= higher among BD I than II

So: antidepr generally avoided, if necesarry in combi with mood stabilizers

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Which adjuvant psychotherapeutic approaches in management of Bipolar depression can be used?

Carvalho et al. (2020)

Psychoeducation
CBT
Family-focused therapy
Dialectical behavioural therapy (is for people who experience emotions very intens)
Mindfulness-based CBT
IPT and social rhythm (stability of daily behaviours) therapy

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Lithium

Carvalho et al. (2020)

Maintenance treatment

Is effective in prevention of both manic and depressive episodes.

Side effects:
- Renal failure
- Tremors en nog veel meer

Waar gaat artikel Marangoni over?

Marangoni et al. (2015)

ADHD en BD worden met elkaar vergeleken

Prevalence ADHD | Marangoni et al. (2015) ## Footnote In adolescents/adults

Adolescents= 1.7-16% Adults= 1-5% 1/3 persists in adulthood 2/3 still have symptoms in adulthood

Children with ADHD have increased risk of | Marangoni et al. (2015)

Comorbid BD

What are highest comorbidity rates with BD in youth | Marangoni et al. (2015)

- Anxiety disorders (54%) - ADHD (48%

Similarities BD and ADHD | Marangoni et al. (2015) ## Footnote 3

1. Neurodevelopmental disorders with onset in childhood and early adolescence 2. Common persistence in adulthood 3. Often underdiagnosed, misdiagnosed or overdiagnosed

# Differential diagnosis ADHD and BD Characteristics ADHD | Marangoni et al. (2015) ## Footnote 5

- Wobbling - Restlessness - Inefficient and disorganized performance due to inattention - Distractibility - Forgetfulness

# Differential diagnosis of ADHD and BD Characteristics BD | Marangoni et al. (2015) ## Footnote 3

1. Prominent mood 2. Sleep 3. Agressive behaviour (especially if impulsive behaviour comes from money, sex and substances)

Which are complex comorbidities that makes diagnosis complicated | Marangoni et al. (2015)

50% of pat's with ADHD or BD has: - **conduct disorder**(CD) - **Oppositional defiant disorder** (ODD) Symptoms of CD and/or ODD like rage and aggressive behaviour overlap with symptoms of manic or mixed episodes.

# Differences between ADHD and manic or mixed episodes Comparison by eliminating overlapping symptoms | Marangoni et al. (2015)

BD: - Elated mood - Grandiosity - Hypersexuality - Decreased need for sleep - Racing thoughts Both: - Hyper-energetic - Distractibility

# Differences between ADHD and manic or mixed episodes Comparison by chronological symptom appearance | Marangoni et al. (2015)

Different symptoms at different ages: - Age 1 to 6 in BD: tantrums, poor frustration tolerance, impulsivity, increased aggression, lower attention span, hyperactivity irritability - Age 7 to 12 in BD: adult depressive symptoms, mania and psychosis - More common in BD: nightmares, bed-wetting, inappropriate sexual behaviours, suicidal ideation and physical complaints.

# Differences between ADHD and manic or mixed episodes Child behaviour checklist (CBDI) | Marangoni et al. (2015)

When a child experiences BD with an increased anxiety/depression, aggressive pattern and attention problem, this distinguishes BD from ADHD

Family history BD and ADHD | Marangoni et al. (2015)

BD: - Family history= 90% - Heritability 58-85% ADHD: - Heritability= 60-80% Family member with ADHD --> also predicts BD with 27-30% Family member with BD --> predicts ADHD 6%

Course ADHD | Marangoni et al. (2015)

Symptoms hyperactivity improve, inattentive not. Chronic and unremitting disorder --> persistent in adulthood in half of cases.

Medication BD | Marangoni et al. (2015)

1. mood stabilizers and antipsychotics --> do not work for ADHD 2. Stimulants cannot be used for BD --> this causes disturbances in sleep and circadian rhythms.

Waar gaat artikel Uchida over? | Uchida et al. (2015)

To distinguish unipolar and bipolar forms of pedriatic MDD

# Results Clinical differences between bipolar and unipolar MDD | Uchida et al. (2015)

4 factors overrepresented in **bipolar** 1. High rates **psychiatric comorbidities** 2. HIgh rates **family history of psychiatric illness** 3. Higher **severity depression** 4. Higher level of **impairment**

# Results Psychiatric comorbidities | Uchida et al. (2015)

BD children: behavioural disorders + anxiety disorders Adolescent BD: substance disorder

# Results Famility history psychiatric illness | Uchida et al. (2015)

First-degree relatives more likely= - BD - MDD - Behavioural disorders - ODD - anxiety disorders - Mania or hypomania

# Results Severity depression | Uchida et al. (2015)

- More depressive episodes - More severe depressive - More hospitalization - More loss of interest - More irritable - Sleep problems - Experience more sadness, hoplessness - Suicidal ideation or self-harm

# Results Level of impairment | Uchida et al. (2015)

- Difficulties with peers and family - More behavioral problems at school

# Results Other characteristics associated with BD | Uchida et al. (2015)

- Extreme irritability - (Persistent irritability = MDD) - Early onset depressive episodes (1.5 years earlier than unipolar MDD)

Discussion | Uchida et al. (2015)

Bipolar MDD: - Higher severity - Greater levels of impairment Difference in pattern and familiy history.

Waar gaat artikel Kowatch over? | Kowatch (2016)

Diagnosis BD, voornamelijk vanuit kinderen naar volwassenheid. - Phenomenology - Red flags in children - Differential diagnosis (ADHD,ODD, anxiety, FAS)

Diagnosis BD II | Kowatch (2016)

MDD episode that last at least 2 weeks. Hypomanic episode that last at least 4 days

Other specified bipolar related disorders | Kowatch (2016)

Given to pedriatic pat's who have bipolar symptoms that do not meet the full criteria for any BD, but that do cause distress or impairment. Symptoms last 2 or 3 days per week

Cycle | Kowatch (2016)

Shift from mood and energy from one extreme to another

Episode | Kowatch (2016)

Longer period of mood dysregulation that also includes multiple cycles in polarity most of the time.

Rapid cycling | Kowatch (2016)

4 or more episodes in 1 year

Adolescents experience more: | Kowatch (2016)

Depressive symptoms than manic or hypomanic

What is diagnosis of most children under 13? | Kowatch (2016)

Other specified bipolar and related disorders, due to lack of symptoms

Red flags in pedriatic pat's | Kowatch (2016)

1. Aggression several times a dat (parents walking on egg shells) 2. Decreased need for sleep 3. Spontaneous mood shifts 4. High risk behaviour 5. Family history of mood disorders

# Differential diagnosis ODD | Kowatch (2016)

Pattern of angry and irritable mood with defiant behaviour (lasts for 6 months). Chronic disorder People with ODD do'nt have manic symptoms

# Differential diagnosis Anxiety disorders | Kowatch (2016)

Can cause mood swings and irritability. Also no manic behaviour.

# Differential diagnosis FAS | Kowatch (2016)

Prenatal alcohol exposure Symptoms of poor impulse control, deficits in school performance, mood dysregulation