4.1 bipolar disorder lifespan perspective Flashcards
bipolar I disorder DSM criteria
at least 1 lifetime manic episode is required - no need for depressive episode
criteria for manic episode:
A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy
- lasting at least 1 week
- present most of the day, nearly every day
During the period of mood disturbance and increased energy or activity, 3 (or more) of the following symptoms (4 if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- More talkative than usual or pressure to keep talking
- Flight of ideas or subjective experience that thoughts are racing
- Distractibility
- Increase in goal-directed activity or psychomotor agitation
- Excessive involvement in activities that have a high potential for painful consequences
mood disturbance causes marked impairement
bipolar II disorder DSM criteria
Criteria have been met for at least one hypomanic episode and at least one major depressive episode
There has never been a manic episode
hypomanic episode:
- at least 4 days
- same as manic episode but episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization
- less severe symptoms than manic episode
The diagnosis requires 1 or more hypomanic episodes (of at least 4 days), and 1 or more major depressive episodes (of at least 2 weeks)
bipolar I vs II
Bipolar disorder (Carvalho, 2020)
bipolar I:
- mostly manic episodes
bipolar II:
- mainly episodes of depression
- alternates with hypomanic episodes
cyclothymic disorder
Bipolar disorder (Carvalho, 2020)
Characterized by chronic, fluctuating mood disturbance that lasts for a distinct period of time
Patients must have exhibited subthreshold symptoms of hypomania and of depression
Adults must have had these symptoms for 2 years, and pediatric patients for 1 year
Patients cannot have been without symptoms for more than 2 months
Genetic and neurobiological features
heritability
Bipolar disorder (Carvalho, 2020)
Estimates of heritability for bipolar disorder range from 70-90% - many genes with small effect sizes are considered to contribute to the group of disorders
common genetic variants are thought to interact with environmental risk factors - but the latter are also not well established
Genetic and neurobiological features
kindling hypothesis
Bipolar disorder (Carvalho, 2020)
Has been suggested as a model to explain gradual stress sensitization that leads to recurring affective episodes
The first episode occurs after exposure to a stressors, and subsequent episodes can occur without exposure to an identifiable stressor
The mechanisms underlying this hypothesis may be strengthened if:
- The illness is not treated
- The person is exposed to substances
- They have lifestyle risks like smoking or sedentary behavior
Genetic and neurobiological features
neuroprogression
Bipolar disorder (Carvalho, 2020)
Progressive changes in brain structure and cellular function (neuroprogression) have been observed
A long duration of illness has been associated with reduced cortical thickness of such brain regions like the PFC - may play a role in stress regulation
Neuroprogression may account for worsening cognitive and functional impairments
treatment of acute episodes
Bipolar disorder (Carvalho, 2020)
acute mania:
- Pharmacological treatment with antispychotics or mood stabilizers
- Combination of antipsychitc and mood stabilizing agents for severe mania is more efficacious than either alone
- Bifrontal electroconvulsive therapy (ECT) in treatment-resistent cases
acute depression:
- During these episodes, patients have a greater number of unacceptable side effects of pharmacological treatments than they do during a manic episode = a low initial dose with gradual upward is generally used
- There is controversy regarding the efficacy and risks of antidepressant agents in managing bipolar depression
maintenance treatment
Bipolar disorder (Carvalho, 2020)
Aimed at preventing the emergence of affective episodes and burdensome affective symptoms - often requires a combination of pharmacological, psychological, and lifestyle interventions
Lithium remains one of the most effective drugs for the prevention of both depressive and manic recurrences in bipolar disorder
Maintenance ECT may be considered with those with bipolar disorder who do not respond to pharmacotherapy
differential diagnosis of ADHD & BD
(Marangoni, 2015)
Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions
The differential diagnosis between ADHD and BD offers several challenges - e.g.:
- The young age of onset of both
- Extensive symptomatic overlap
- Similar psychiatric comorbidities
general differentiation:
- In most uncomplicated cases, the discrete appearance of prominent mood, sleep and aggressive behaviors = BD
- On the other hand, fidgeting and restlessness and inefficient and disorganized performances steeming from inattentiveness, distractability and foregetlness = ADHD
Biggest challenge: occurs when ADHD is comorbid with CD and/or ODD - as their presentation (temper tantrums, aggressive behavior) can overlap with symptoms of manic or mixed state
epidemiology BD vs ADHD
(Marangoni, 2015)
Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions
prevalence:
- ADHD: range from 1.7-16% in school-age youths, and 1-5% of adults
- BD: 2.1% in adults and 1.8% in children
- Both disorders are more prevalent in males (at least BD-I and ADHD with hyperactivity), but ADHD inattentive type might be more common in girls
both typically begin in childhood (especially ADHD) or adolesence
comorbidities:
- BD youths tend to suffer from comorbid disorders like anxiety, ADHD, disruptive behavior, and substance use disorders
- Comorbidity between adolescent ADHD and CD, ODD, anxiety disorders, or SUD significantly increases the odds of developing later BD
3 approaches to the clinical differentiation of ADHD from BD
(Marangoni, 2015)
Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions
- Eliminating overlapping symptoms to compare and contrast both disorders
- Chronological appearance of symptoms on a developmental continuum in children with clinical or structured diagnosis of BD and ADHD
- Child Behavior Checklist (CBCI) scores in children with either BD or ADHD were compared to assess how well CBCI could differentiate the two
Differences in specfic symptoms
hyperactivity
(Marangoni, 2015)
Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions
The temporal distribution of hyperactivity can be helpful in differentiating both
BD: circadian rhythms are altered → greater fluctuations of energy and activity, from very high to very low, as well as improved mood and energy in the later part of the day, interfering with sleeping
ADHD: the levels of locomotor activities are high but relatively stable
Differences in specfic symptoms
disturbances of sleep & circadian rhythms
(Marangoni, 2015)
Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions
Early insomnia and sleep resistance have been reported in both ADHD and BD → differentiating value is limited
Middle and late insomnia are more useful, which are commonly observed among mood-disordered children than in ADHD ones
Differences in specfic symptoms
aggressive & hypersexual behavior
(Marangoni, 2015)
Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions
Aggression is common in BD → can be present in severe temper tantrums, or as deliberate aggression sometimes with lack of remorse
In ADHD, verbal and physical aggression can result from irritability, but the actions tend to be accidental, related to inattention, impulsivity, and poor coordination or impaired motor skills
Differences in specfic symptoms
academic functioning
(Marangoni, 2015)
Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions
ADHD: difficulties with inattention, resistance to completing the homework, and poor concentration often interfere with academic achievement consistently over time
Children with BD: more likely to have more variable, uneven performances, at times doing very well and others not
family history
(Marangoni, 2015)
Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions
The most significant risk factor for developing BD is a positive family history
- Studies suggest that the recurrence risk for BD in first-degree relatives of BD patients is approx. 90% (almost 10x that of the general population)
Adoption and twin studies estimate that 60-80% of the risk for ADHD is heritable
treatment response
(Marangoni, 2015)
Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions
Stimulants: prevent the reuptake of dopaminergic and noradrenergic systems implicated in cognitive deficits - are helpful in reducing the impact of these deficits on academic performance and social interaction, improve classroom behavior, and increase time on task
Therapeutic approaches are often quite different depending on the primary diagnosis
When BD and ADHD are comorbid → a combination of treatment is often required
Stimulants have been shown to be ineffective in the treatment of BD, can cause disruption of sleep and circadian rhythms, etc
conclusion
(Marangoni, 2015)
Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions
BD and ADHD share more than overlapping symptoms:
- Similar ages of onset and comorbidities
- Chronic lifelong course of illness that disrupts educational, vocational, and especially developmental milestones → sets the stage for significant morbidity and mortality
- For both disorders there is evidence of diagnostic error
method
(Uchida, 2015)
Can unipolar and bipolar pediatric major depression be differentiated from each other?
Problem in the diagnosis and management of pediatric MDD is distinguishing children affected with bipolar forms of MDD and those with unipolar forms
Uchida et al. (2014) - found that manic switches in pediatric depression can be predicted by several risk factors:
- Positive family history of mood disorders
- Emotional and behavioral dysregulation
- Subthreshold mania
- Psychosis
Method: systematic literature search was conducted on studies assessing the clinical characteristics and correlates of unipolar MDD and bipolar MDD in youth - 4 studies total
results
Clinical differences between bipolar & unipolar MDD
(Uchida, 2015)
Can unipolar and bipolar pediatric major depression be differentiated from each other?
4 significant distinguishing clinical factors were found to be overrepresented in children with bipolar MDD compared to those with unipolar:
- High rates of psychiatric comorbidities
- High rates of family history of psychiatric illness
- Higher severity of depression
- Higher level of impairment
results
Psychiatric comorbidity
(Uchida, 2015)
Can unipolar and bipolar pediatric major depression be differentiated from each other?
3 studies found significant associations between high levels of comorbidity and bipolar MDD
Reported that children with bipolar MDD had higher rates of ODD, CD, and anxiety disorders
results
family history of psychiatric illness
(Uchida, 2015)
Can unipolar and bipolar pediatric major depression be differentiated from each other?
3 studies found significant associations between higher levels of family history of psychiatric disorders in children and teens with bipolar MDD as compared to those with unipolar
results
severity of depression
(Uchida, 2015)
Can unipolar and bipolar pediatric major depression be differentiated from each other?
Studies found significant associations between a greater number of symptoms and higher severity in children with bipolar compared to those with unipolar
Accordingly, children with bipolar MDD experienced greater levels of sadness; irritability; hopelessness; and suicidal or self-injurous behaviors
