Bipolar Disorder Flashcards
Bipolar disorder: epidemiology
o Lifetime prevalence = 4% (does not vary by ethnicity)
o Only 1/3 patients get diagnosed & only 1/3 of these get treatment
o 3:2 more likely female than male
o Median age of onset = 25 years (men have earlier onset)
o Highly co-morbid with substance use (60%) and anxiety disorders (50%)
o Most have depression and SI
Bipolar disorder: pathophysiology
o Unclear etiology
o Clear genetic component (but not identified)
Imaging:
• Enlarged ventricles
• Increased deep white matter lesions (especially in frontal lobes)
• Decreased gray matter in parts of limbic system
• Increased metabolism in anterior cingulated cortex
• Decreased metabolism in neuropil volume (low levels of N-acetylaspartate in PFC, anterior cingulated cortex, hippocampus)
o Dysfunction of HPA axis = impaired central glucocorticoid signaling → elevated cortisol levels
o Inflammatory state (higher pro-inflammatory cytokines: IL-6, IL-8, TNF)
Bipolar disorder: risk factors
o Sleep deprivation and travel-related changes = onset of mania
Psychosocial factors:
• From families with high expressed emotion = higher relapse
• Negative life events = longer recovery times, more likely to have new episodes
o Medical conditions
o Substances
Bipolar disorder: clinical presentation
Manic episode
• Abrupt change in mood = elevated or euphoric, expansive, irritable
• Labile affect
• Inflated self-esteem (self-confidence, grandiosity, delusional)
• Psychosis = loss of reality testing:
• Religious
• Grandiose
• Auditory or visual hallucinations
• Decreased need for sleep (only 2-3 hours needed)
• Pressured speech
• Racing thoughts
• Disorganized thoughts (flight of ideas)
• High energy and increased goal-directed activity
• Impulsivity
Symptoms of major depressive episodes
Bipolar disorder: prognosis
o Rapid cycling: 4 or more episodes per year
• Associated with: younger age of onset, more frequent depressive episodes, greater risk suicide attempts
o Classic bipolar disorder: averages 4 episodes every 10 years
Bipolar disorder: mixed features
- Meet criteria for manic episode and also have symptoms of major depressive episode
- Dangerous because combines hopelessness and suicidality of depression with impulsivity and increased activity of mania
Recognize the substance- and medication-induced and other medical etiologies of mania.
Medical (bipolar disorder due to another medical condition)
o Endocrine disorders: hyperthyroidism
o Neurological disorders: MS, Huntington’s
o Neoplasia: tumors in frontal lobe
o Cerebrovascular disease: strokes in right frontal lobe
Substances (substance/medication-induced bipolar disorder)
o Psychostimulants: cocaine, amphetamines
o Anti-depressants
o Glucocorticoids
o Antibiotics
• Acute treatment for manic episodes
o Need rapid mood stabilization = Lithium (gold standard)
Also effective:
• Anticonvulsants (Valproic acid, Oxcarbazepine)
• Atypical antipschotics (risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole) especially if also have psychotic symptoms
• Benzodiazepines (lorazepam) added if anxiety, agitation, insomnia
Psychotherapy usually not effective
• Acute treatment for depressive episodes
o Antidepressants may lead to manic episode or increased cycling
o Do NOT give antidepressant without a mood-stabilizer (lithium, anticonvulsant, antipsychotic)
o Lithium, antipsychotics, lamotrigine (anticonvulsant) = antidepressant properties; effective bipolar depression treatment without destabilizing mood
o Psychotherapy = may be effective
o Electroconvulsive therapy = for sever or refractory depression or mania
Maintenance treatment for bipolar disorder
Goal = prevent recurrence
• Note: substance abuse may destabilize mood → mood episode
o Lithium = good at preventing hypomania and mania episodes
o Lamotrigine = good at preventing depressive episodes
o Other maintenance agents:
• Valproic acid
• Atypical antipsychotics
o Challenge = adherence!
Psychosocial interventions
o Interpersonal and social rhythm therapy = keep track of times/regulate daily life
o Vocation rehabilitation or credit counseling
Define psychostimulant.
Effects include: o Mood elevation o Locomotor stimulation o Alertness o Increased ability to concentrate o Decreased appetite o Decreased fatigue
List the psychostimulant drugs
Amphetamine Atomoxetine Cocaine Methamphetamine Methylphenidate Modafinil
Describe how cocaine and amphetamine differ in their effects at the monoamine uptake transporters.
• Cocaine
o Inhibits NE, DA, and 5-HT transporters
• Amphetamine
o Indirect-acting sympathomimetic (agonist)
o Inhibits NE, DA, and 5-HT uptake transporters
o Evokes monoamine release
Describe the mechanisms of action and clinical uses of psychostimulant drugs.
Two effects:
o Inhibit uptake via monoamine transporters (5-HT, NE) = compete for substrate binding
o Evoke transporter-mediated monoamine release
Some can do both
Clinical uses: o ADHD o Narcolepsy o Prevention and reversal of fatigue (ex: shift workers) o Appetite suppression
Describe the pharmacology of modafinil and how it differs from other psychostimulants.
- Non-amphetamine stimulant
- Uses: promote wakefulness for narcolepsy, shift-related sleep disorder, and obstructive sleep apnea; may be useful treatment for cocaine dependence
- MOA: unclear; but binds to DAT and NET to inhibit DA and NE uptake; increases glutamate levels in medial preoptic area and posterior hypothalamus
- Effects NOT antagonized by haloperidol = not a D2 receptor MOA
