5.2 Bipolar Disorder Flashcards
What are the 4 basic pathological states in Bipolar Disorder (BPD)?
- Abnormally low mood (depression)
- Abnormally high mood (mania)
- Abnormally irritable mood
- Psychosis
- Associated with difficulties in normal mood recovery
What is the definition of bipolar I disorder?
Manic episodes lasting ≥ 7 days or manic symptoms so severe requiring immediate hospital care + depressive episodes lasting ≥ 2 weeks (mixed episodes are possible)
What is the definition of bipolar II disorder?
Hypomanic episodes (no full-blown mania) + depressive episodes
What is the definition of cyclothymia?
Numerous periods of hypomanic symptoms + numerous periods of depressive symptoms lasting ≥ 2 years (do not meet the diagnostic requirements for hypomanic/depressive episode)
What is rapid cycling?
≥ 4 episodes per year of major mood derangement
What is the criteria of mania?
A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week ( or any duration if hospitalization is necessary.)
During the period of mood disturbance, 3 (or more) of the following symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree:
- 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
- Excessive involvement in pleasurable activities that have a high potential for painful consequences
What is the hypomanic criteria?
A distinct period of persistently elevated, expansive or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual non depressed mood.
During the period of mood disturbance, 3 (or more) of the following symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree:
- 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
- Excessive involvement in pleasurable activities that have a high potential for painful consequences
What is the depression criteria?
≥ 5 of the following symptoms in the same 2 week period representing a change from a previous level of functioning:
• At least 1 of the symptoms is either depressed mood or anhedonia
o Depressed mood most of the day and nearly every day
o Markedly diminished interest/pleasure in all/almost all activities most of day
o Significant weight loss when not dieting/weight gain (> 5%/month) or decrease/increase in appetite nearly every day
o Insomnia/hypersomnia nearly every day
o Psychomotor agitation/retardation nearly every day (retardation more)
o Fatigue/loss of energy nearly every day
o Feelings of worthlessness or excessive/inappropriate guilt nearly every day
o Diminished ability to think/concentrate or indecisiveness nearly every day
o Recurrent thoughts of death/suicidal ideation/attempt/plan
What is this likely a presentation of?
• Inexplicable change in mood pattern
• Feeling happy/charged up: overly energetic, excessively enthusiastic, over-involved, talkative, overfriendly, over-familiar with people → may start writing letters to President, Prime Ministers, politicians, VIPs in high disinhibited states
• Disruptive of usual routines: sleep very little and yet not tired, family members report they are noticeably different in a hyper way, make several phone calls, want to start big projects, spend excessively, may buy unwisely, may suddenly make decisions to travel (disturbed behaviours overseas)
o Loss of weight/appetite due to preoccupation with projects or does not feel the need to eat due to high energy levels → not characteristic
• Increased sexual libido: flirtatious behaviours seen openly, partners may not be able to cope with sexual demands, inappropriate sexual liaisons may occur
• Family members feel strain of coping with someone with abnormally high mood
• Disruptive/disinhibited/disturbed behaviour in public (may be arrested by police
Mania
What is this likely a presentation of?
• Patients recognise change in mood pattern and that it has changed/gone down (quality of change is emotionally painful, troubling, distressing → qualitatively different from sadness)
• Decreased energy levels (patient feels devitalised):
o Loss of interest in previously pleasurable activities & social withdrawal
o Decline in functional capacity/capacity to concentrate, loss of drive to work
o Often stay at home in misery with low appetite and refusing to eat
o May continue to lose weight and have sleep difficulties
o May seek pain release through suicide attempts
• Multiple somatic complaints with no organic basis
• Distorted memory of the past, excessive amounts of guilt → focusing on mistakes and failures rather than successes and achievements
• Hallucinations and delusions
• Seeing no future for themselves (even for offspring if depression is severe enough)
Depression?
What is the criteria for a mixed episode>?
- The criteria are met both for a manic episode and for a major depressive episode (except for duration) nearly every day during at least a 1 week period.
- The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
- The symptoms are not due to the direct physiological effects of a substance or a general medical condition.
What are the 2 genes implicated in BPD?
- ANK3 (ankyrin G) and CACNA1C (alpha 1C subunit of the L-type voltage-gated calcium channel
- ANK3 is an adaptor protein found at axon initial segments that regulates the assembly of voltage-gated sodium channels and both ANK3 and subunits of the calcium channel are down-regulated in mouse brain in response to lithium, indicating a possible therapeutic mechanism of action of one of the most effective treatments for bipolar disorder.
The blood pressure drug __________ , which depletes catecholamines from nerve terminals, was noted incidentally to cause depression. This led to the idea that an increase in epinephrine and norepinephrine causes mania and a decrease in epinephrine and norepinephrine causes depression.
reserpine
Calcium channel blockers have been used to treat mania, which also may result from a disruption of calcium regulation in neurons. The proposed disruption of calcium regulation may be caused by various neurologic insults such as excessive glutaminergic transmission or ischemia. ___________ specifically up-regulates expression of a calcium chaperone protein, GRP 78, which may be one of its chief mechanisms of cellular protection
Valproate
What are the ddx of BPD?
- Neurosyphilis
- Epilepsy
- AIDS
- MS
- Substance abuse
- Medications
