Bipolar and Related Disorders Flashcards
Bipolar Disorder
No longer in Mood Disorders (DSM-IV), instead:
Bipolar and Related Disorders (DSM-5)
• Bipolar I Disorder
• Bipolar II Disorder
• Cyclothymic Disorder
• Substance/Medication-Induced Bipolar & Related Disorder
• Bipolar & Related Disorder due to another Medical Condition
• Other Specified Bipolar & Related Disorder
• Unspecified Bipolar & Related Disorder
Major Depressive Episode
A. At least 5 + symptoms during 2 week period (need #1 or # 2)
1. Depressed mood most of the day, nearly every day
2. Markedly diminished pleasure/interest in activities
3. Significant weight loss or weight gain
4. Insomnia or hypersomnia nearly every day
5. Psychomotor Agitation
6. Fatigue/Loss of energy nearly every day
7. Feelings of worthlessness, excessive guilt nearly every day
8. Diminished ability to concentrate nearly every day
9. Recurrent thoughts of death, suicide, suicide attempts
B. Clinically significant distress or impairment
C. Not attributed to substance use or other medical condition
Bipolar I (BPI): Manic Episode
A: At least one week of:
- abnormally & persistently elevated, expansive or irritable mood, and increased goal directed activity/energy, present nearly daily
B. At least 3 or more present to a significant degree &
noticeable change from usual behaviour:
(Inflated self-esteem or grandiosity, Decreased need for sleep, Rapid or pressured speech, Flight of ideas or racing thoughts, Distractibility, Increase in goal-directed activity or psychomotor agitation, Excessive involvement in activities that have a high potential for negative consequences) –> psychomotor agitation, restlessness
C. The mood disturbance is: sufficiently severe to cause marked impairment in occupational functioning or in usual social activities, or to necessitate hospitalisation to prevent harm to self or others, or there are psychotic features (e.g., delusions or hallucinations)
D. The symptoms are not due to the direct
physiological effects of a substance (e.g. drug or
medication) or a general medical condition (e.g.
hypothyroidism)
Bipolar II (BPII): Hypomanic Episode
A. At least 4 days of: abnormally & persistently elevated, expansive or irritable mood, and increased goal directed activity/energy, present nearly daily
B. 3 or more: Inflated self esteem or grandiosity, Decreased need for sleep, More talkative/pressured speech, Flight of Ideas; racing thoughts, Distractibility, Increased goal directed activity or psychomotor agitation, Excessive involvement in pleasurable activities which have a potential for negative consequences
(Hypomanic shorter time duration, often goes undiagnosed as not a large change, still uncharacteristic but not as intense as manic, no hospitalisation)
A. Change that is uncharacteristic of the individual
B. Disturbance & changes are observable by others
C. Not severe enough to cause marked impairment, or
hospitalisation, and no psychotic features
D. Not due to substances/medical condition
Diagnostic Differences between Bipolar Disorders
Bipolar I - Manic episode necessary, depressive episode or hypomanic episode can be present but not necessary for diagnosis
Bipolar II - Hypomanic episode necessary, depressive episode or manic episode can be present but not necessary –> ‘bipolar lite’ not true, burden equal
Cyclothymic disorder
Chronic, less severe form of Bipolar Disorder
• Numerous cycles of hypomania symptoms and depression
symptoms that are not severe enough to meet criteria for
manic or major depressive episodes
• Symptoms present for at least 2 years, with no more
than 2 months without symptoms
• Symptoms cause distress/impairment in functioning
BDI & BDII: Diagnostic Issues
Both undiagnosed/undetected and overdiagnosed (lots of women borderline personality disorder)
Misdiagnosed –> psychotic features for schizophrenia or unipolar depression
–> rapid cycling more prominent for women
Epidemiology
Lifetime prevalence (Australia):
• Bipolar I: up to 1%
• Bipolar II: ~5%
• 12-month prevalence: 1.3%
• No gender differences
• Onset: peak at 15-25 years (for both genders)
• The Course: 10-20 years delay in seeking treatment
• 90% have recurrent episodes
• Untreated: 8-10 lifetime episodes of mania & depression
• Treated: 40% relapsing within 1-year; 73% within 5-years
Ø The course - predominantly depressive
• Bipolar I: 32% of time depressed; 9% Manic
• Bipolar II: 50% of time depressed; 1% Hypomanic
• 5-15% of sufferers have 4+ episodes per year
(rapid cycling)
Comorbidity
50% Anxiety Disorders (panic, GAD, social phobia) & 39% Substance misuse (‘self-medication’)
- At least 25% will attempt suicide; 10-20% will completed suicide
Aetiology - Genetic Factors
- Lifetime risk for family members of BP patients: 10%
(vs. 1% in the general population) - If both parents have BP, increases to 40&
- Twin studies: BP heritability rate of about 85%
- role of serotonin & excessive dopamine?
Aetiology - Stressful Life Events
An association between stressful life events and both manic & depressive
episodes
Ø Manic episodes likely preceded by:
• Disruption to routines & sleep-wake cycles
• Excessive focus on goal attainment
Ø Depressive episodes likely preceded by:
• Low social support & low self-esteem
Aetiology - Psychological Factors
- A negative cognitive style enhances vulnerability
to manic & depressive episodes when paired with
stressful events - Mania may be a defense to counter the negative
thoughts & feelings relating to an underlying negative
self-esteem - Temperament factors: perfectionism & sociotropy (high need for social approval)
Diathesis-Stress Model (Lam et al., 1999)
Biological Vulnerability, i.e. Circadian rhythm instability –> Prodromal Stage (Early symptoms of mood disturbance) –> poor coping strategies –> Episode (Manic, Hypomanic, or Depressive), –> Stigma & Relationship problems, –> Life Stressors causing poor social routines and/or sleep deprivation
Bipolar disorder: TREATMENT
- Best treatment = pharmacological + (adjunct) psychological interventions
- Depends on:
• illness stage (acute, maintenance)
• predominant polarity (depressive, hypo/manic) - Most treatment evidence based on BPI
• extrapolated to BPII & others.
Considering patient treatment preferences
- “Treatment guidelines… need to be used flexibly alongside consideration of the person, their sociocultural context and availability of resources”
- Treatment adherence depends on the value patients place on treatment efficacy versus side-effect burden
- Patient value the different features of treatment options
differently - effect of medication on creativity etc, drive out the devils and the angels
TREATMENT: Pharmacotherapy
Lithium
• A mood stabiliser & main component of standard care
• Not used regularly in treatment until 1960s
• Treatment of manic episodes & for preventing future episodes
• 50% patients relapse within 5 months of ceasing Lithium
(especially for BI)
- Anticonvulsants (Valproate; Lamotrigine)
- Atypical Antipsychotics (Quetiapine; Olanzapine)
- Sedative Hypnotics (Benzodiazepines)
- Antidepressants
• doses lower & duration shorter than for unipolar depression
• combined with mood stabiliser to prevent inducing mania
Electro-Convulsive Therapy (ECT)
Used when medication is not viable
- Can be used as firstline treatment, effective in up to 75% of patients
• Effective for treating both manic & depressive episodes
• Short-term side effects: confusion, disorientation,
memory loss
• Pharmacotherapy required to maintain mood stability
& prevent relapse
Psychological Interventions
Psychological interventions never studied alone, only effective when used additionally to medication
Aim: to reduce symptoms, prevent relapse, improve quality of life, improve medication adherence & provide support
Psycho-education
Cognitive Behaviour Therapy (CBT)
Interpersonal & Social Rhythm Therapy
Family-focused Therapy
Appear similarly effective - most effective during maintenance stage (when mood has stabilised)
- Important to form therapeutic alliance between the patient, therapist and the family!
Psycho-education
- Most commonly in a group setting
- Providing information about: Symptoms of BP disorder, Diathesis-stress model of BP disorder, Identifying early warning signs of relapse, The rationale/importance of medication compliance, Strategies to cope with stressors, Need for routines & sleep-wake cycles
- Justification of medication
- Importance of family to identify early warning signs
- Delays recurrence + reduces frequency of future episodes:
• Over 5 year FU, time to any recurrence significantly longer for psycho-education group than controls
• Significantly fewer recurrences with psycho-education (3.9 vs. 8.4)
Cognitive Behavioural Therapy (CBT)
- More effective for more depressive patients & patients with lower frequency of episodes
Aim: to manage acute symptoms & prevent relapse
• Key technique: cognitive restructuring
• Patients encouraged to:
• Monitor symptoms
• Challenge hyper-positive cognitions
“I can do no wrong; I am fine, I don’t need medication”
• Improve medication adherence
• Foster self-efficacy
• CBT effective in reducing episodes and hospitalisations,
improving medication compliance, especially within 6-months
post-treatment (Gonzalez-Pinto et al., 2003)
• Recent studies showing benefits of Mindfulness-based Cognitive Therapy (Williams et al, 2008; Ives-Deliperi et al, 2013)
- Each person has unique relapse time
Interpersonal & Social Rhythm Therapy
- very rigid & regiments, not okay for everyone –> therapy by boredom
Aim: to improve interpersonal functioning and to
reduce disruption to routines & sleep-wake cycles - Patients helped to:
• Identify unstable rhythms
• Identify realistic goals for change
• Establish and maintain new routines - Particularly effective in reducing relapse
Family-focused Therapy
Aims to improve:
• knowledge about Bipolar disorder
• family communication and problem solving skills
• family functioning; reducing any criticism or hostility
- Support for family interventions found in reducing
relapse rates, hospitalisations & time to relapse
Relapse Prevention (Sorenson et al., 2007)
Key factors for risk of relapse:
• Biological/genetic vulnerability
• Medication non-adherence
• Dysfunctional attitudes & beliefs
• Disrupted routines (& sleep-wake routine)
(All impact sleep disruption, triggering (hypo)mania or depression)
Four sessions addressing:
• Reduced feelings of hopelessness
• Greater perceived control over internal states
Bipolar & Creativity
- Bipolar disorder: associated with creative groups
• 17% of a sample of British poets received treatment for
manic episodes
• Enhanced creativity likely linked to manic/hypomanic states
& accompanying suprasensory changes (Parker, 2014) - Famous people with Bipolar Disorder
• Artists: Gauguin; Van Gough; Pollack
• Writers: Lord Byron; Virginia Woolf; Hemingway
• Composers: Handel; Schumann
