Bipolar and Related Disorders

Question 1

Define and list the DSM Criteria for BP I

Answer 1

• Characterised by distinct periods of depression and mania, seperated by symptom-free remission
• Ratio of manic to depressive epsiodes roughly 1:3
• The manic episodes causes impairment or disruption in social or occupational areas of functioning, hospitalization may be necessary to contain acute symptoms and if severe, psychotic symptoms can occur within episodes.
• Might include MDE lasting 2 weeks or more, with periods of mania (extreme elevated mood, elation, hyperactivity) lasting 1 week or more.

DSM-5 Criteria

Criterion A: abnormally & persistently elevated, expansive or irritable mood, and
- increased goal directed activity/energy, present nearly daily

Criterion B:
1. Inflated sense of self-esteem or grandiosity
2. Decreased need for sleep
3. Rapid or pressured speech
4. Flight of ideas or racing thoughts
5. Distractibility
6. Increase in goal directed activity or psychomotor agitation
7. Excessive involvement in activities that have a high potential for negative consequences

• At least 3 or more to a significant degree required to be present & represent a noticeable change from usual behaviour
• Bipolar I diagnosis requires a manic episode and hypomanic can be present (but not necessary)
• MDE can be present but also not necessary

Bipolar 1 is equally likely in men and women but women more likely to have bipolar 2

Question 2

Define and list the DSM Criteria for BP II

Answer 2

MUST include a MDE lasting 2 weeks or more, with periods of hypomania (milder form of mania) lasting 4 days or more.

Question 3

How are bipolar disorders treated?

Answer 3

Depends on phase of illness = Acute stabilization -> Ongoing maintenance -> Relapse Prevention

• Most treatment evidence based on biploar 1 extrapolated to bipolar 2 and others
  Best treatment is Psychological + (adjunct) Psychological interventions

Phase 1: Acute stabilisation - Mania
- Goal is to reduce arousal, agitation, aggression, cognitive disturbance and psychosis (if present)
- Treated medically, often involving hospitalisation
- Pharmacotherapy if the first line treatment for acute stabilisation of mania.

Stabilisation = Mood stabiliser or antipsychotic medication
Rapid containment of behavioural disturbance = Antipsychotic medication or short-term benzodiazepine
Manage cognitive disturbance = Antipsychotic medication
If severe or high risk = Electroconvulsive therapy (ECT)

FOR HYPOMANIA - more moderate dosage of drug and psychotherapy

Phase 1: Acute stabilisation - Depression
- Goal is to achieve complete and functional remission of depressive symptoms
- Manage suicide risk
- Pharmacotherapy commonly used: monotherapy with second generation antipsychotics or mood stabilisers, or combination therapy with adjunct antidepressant therapy
ECT can be used to treat acute mania or sevre depression if medication is not viable, however short term side effects include confusion, disorientation, memory loss
Medication required to maintain mood stability and prevent relapse

Phase 2: Relapse prevention
Essential to preventing future episodes
Includes:
- mood monitoring on daily mood chart
- recognising early warning signs of an episode
- collaborative relapse prevention plan
- coping with stressful events
- preventing manic thinking
- planning hospitalisations in advance when required

Relapse prevention plan!

Take home message:
- A strong therapeutic alliance between clinicians, patients and family members is important to prevent relapse
- Building a system of care around the patient, ensuring psychoeducation for all involved and developing a relapse prevention plan is key to coordinated care

Question 4

Different treatment approaches used?

Answer 4

MEDICAL
-Psychiatric review and management; coordinated care with GP + specialists
- Prophylactic medication to prevent future episodes
Pharmacotherapy
- Mood stabilisers
- Anticonvulsants
- Antipsychotics
- Antidepressants (SSRI/SNRIs)

Lithium discovered as effective treatment for depression and mania in bipolar patients in 1949 - it is a first line pharmacotherapy treatment across international guidelines
- Evidence suggesting Lithium is neuroprotective and anti-suicidal, however there is a narrow therapeutic index, can be toxic at high blood concentrations and requires careful monitoring to prevent toxicity.
Medication monitoring
- Psychiatric review to determine medication regime, based on physical examination, tolerability of side effects and efficacy of pharmacotherapy to manage symptoms.
- Side effects include: weight gain, drowziness, dizziness, stomach upset, dry mouth, constipation
Long term use can affect kidney, renal, thyroid and cardiac functioning
Often involves coordinated care across GP and specialists

PSYCHOLOGICAL
CBT: improve knowledge about managing the condition and prevent relapse
- Improving awareness of illness
- Treatment adherence
- Harm avoidance
- Detecting early warning signs
- Lifestyle regularity

Identifying and challenging automatic thoughts
“Im so dissapointed in myself - this happened again”
“It’s my fault this keeps on happening”
=
“There are things that i did that exacerbated my mania, but i know that its biological so its not always completely my fault when it happens.”

Behavioural experiments
Symptom: increased creativity
Kevin re-evaluates himself using a diary: He found that he had more ideas when he was high, but they were not always the best ideas

Intepersonal and social rythms therapy: aims to improve interpersonal functioning and to reduce disruption to daily routines and sleep wake cycles
- Addressing losses, role transitions and interpersonal problems
Stabilizing social rythms
- Fixing wake time across 7 days of the week.

Family focused therapy
Aim: to enhance caregivers’ illness management and self-care
Involves individual with bipolar disorder and their family members
Psychoeducation
Communication skills
Problem solving

Question 5

Define Cyclothymia

Answer 5

Chronic, less severe form of biploar disorder
- Symtoms need to have lasted 2-years with no less than 2 month period of remission within that 2-year period
Person cycles between hypomania and milder form of depression (doesn’t classify as MDE)

Question 6

What is the DSM-5 criteria for Manic vs Hypomanic?

Answer 6

Mania - At least 1 week of symptoms most of the day, nearly every day (or any duration if hospitalization is necessary)

Hypomania - At least 4 days of symptoms most of the day, nearly everyday
- Less severe than manic episodes
- Change in functioning is uncharacteristic of the individual
- Mood disturbance is noticeable to others
- Shorter in duration compared to mania
- Not severe enough to disrupt functioning, but can impair functioning
- Not severe enough to cause hospitalisation