Bipolar Disorder Flashcards
Cyclothymia (or Cyclothymic Disorder), general
Cycle for 2 years in adults, or 1 year in children, between hypomania and PDD
Pattern is irregular and unpredictable
Low and high mood swings never reach the severity of major depression or full mania.
Hypomania or depression can last for days or weeks. In between up and down moods, a person might have normal moods for more than a month – or may cycle continuously from hypomanic to depressed, with no normal period in between
Manic Episode, Sign vs Symptom
Sign = what can be seen
e.g. flight of ideas
Symptom = what is reported
May include delusions and hallucinations, racing thoughts
Manic Episode
DSM-5 Criteria
A:
A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting AT LEAST 1 WEEK and present most of the day, nearly every day
*If hospitalization is necessary, duration is irrelevant
B:
During period of mood disturbance,3 or more of the following (4 if mood is only irritable):
- 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 (reported or observed)
- Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (purposeless non-goal-directed activity)
- Excessive involvement in activities that have a high potential for painful consequences
* e.g. unrestrained buying sprees; sexual indiscretion; foolish business investments
Bipolar with psychotic features vs. schizophrenia (SZ)
In SZ, delusions/hallucinations occur in the absence of mood symptoms for more than 2 weeks
Anxious Distress Specifier
DSM 5
High levels of anxiety have been associated with higher suicide risk, longer duration of illness, and greater likelihood of treatment nonresponse
Intended to identify patients with anxiety symptoms that are not part of the bipolar diagnostic criteria
- Feeling keyed up or tense
- Feeling unusually restless
- Difficulty concentrating because of worry
- Fear that something awful might happen
- Feeling that the individual might lose control of himself or herself
Bipolar II Disorder
At least one episode of hypomania: must last 4 days min.
At least one episode of major depression
Dx :
Individual must never have experienced a full manic episode
~25% of all bipolar cases
Rapid cycling pattern is associated with a poorer prognosis
Hypomania
Sustained state of elevated or irritable mood
Less severe than mania
Does not significantly impact quality of life
Unlike mania, hypomania is not associated with psychosis
Bipolar I vs. Bipolar II
Depressive Episodes
Bipolar II:
*More common in females
(BP-I 50/50)
- More frequent depressive episodes and shorter intervals of well-being than BP-I
- More chronic and consists of more frequent cycling than the course of bipolar I
- Associated with a greater risk of suicidal thoughts and behaviors than bipolar I or unipolar depression
- Although bipolar II is commonly perceived to be a milder form of Type I, this is not the case.
- Types I and II present equally severe burdens
Pharmacotherapy: Tricyclics
Effective as SSRIs but with more side effects
anticholinergic effects = blurred vision, constipation, weight gain
toxic in high quantities
dangerous with suicidal patients, easy to overdose
Pharmacotherapy: SSRIs effectiveness
No more effective than tricyclics
~30% success rate
Pharmacotherapy: Lithium
The lethal and therapeutic dosage are not that different: risk of toxicity
Pharmacotherapy: Anticonvulsants
Depakote – most commonly prescribed anticonvulsant for bipolar disorder
• Prescribed if an individual does not respond well to lithium
Lamictal is also commonly prescribed, but may cause Steven-Johnson syndrome (A lethal rash)
Pharmacotherapy: Antipsychotics
Typically, a second-line of defense
Used to balance mood
These drugs work well, but are accompanied by a range of side effects
Mayberg: research predictive pharmacotherapy efficacy
Bromin’s area 25
More activation, medication leads to a better outcome
Less activation, CBT works better than meds
ECT
Electroconvulsive Therapy
Typically used in elderly, non-responsive, populations
Seizure is therapeutic
Applied to the non-dominant hemisphere
Treatment should be apparent in 2-4 weeks
Side effects:
- transient amnesia
- general confusion
ECT Most effective Course
Meds before ECT
CBT or drugs after
• Helps decrease relapse rate of depression
May help promote neurogenesis and increase serotonin
Transcranial Magnetic Stimulation (TMS)
Not as effective as ECT in treating depression with psychotic features
Treatment focuses on the dorsolateral prefrontal cortex
Vagus Nerve Stimulation
Involves sending small electric pulses to the neck
Bipolar Spectrum: Onset
Early 20s
Earlier onset than typical for depression (mid to late 20s)
Bipolar Spectrum: Duration mania vs depression
For ALL bipolar diagnoses:
depression lasts 3x longer than mania
Applies to both genders
Bipolar Spectrum: Genetics
Bigger role than in depression
MZ twins:
Depression, 4x greater chance
Bipolar, 80% chance
Bipolar Spectrum: Neurotransmitters
Interaction and combination of:
serotonin
dopamine
norepinephrine
Transmitters linked with MOTIVATION AND CONCENTRATION
Bipolar Spectrum: Permissive Hypothesis
Decrease in serotonin leads to the deregulation of norepinephrine and dopamine
Bipolar Spectrum: Disruption of Sodium Ions
Malfunctioning ion channels due to faulty proteins:
Decrease of Na+ ions leads to sluggish behavior
Increase of Na+ ions leads to mania
*potentially resolved via regulation of potassium
Bipolar Spectrum: Thyroid
Thyroid Deregulation
Greater link to bipolar than unipolar
Hypomania
DSM-5 Criteria
- Episode is not severe enough to cause marked impairment in social or occupational functioning
- If psychotic features, the episode is by definition manic
A:
A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, LASTING AT LEAST 4 CONSECUTIVE DAYS and present most of the day, nearly every day
B:
During period of mood disturbance,3 or more of the following (4 if mood is only irritable):
- 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 (reported or observed)
- Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (purposeless non-goal-directed activity)
- Excessive involvement in activities that have a high potential for painful consequences
* e.g. unrestrained buying sprees; sexual indiscretion; foolish business investments
Bipolar II
DSM-5 Criteria
Hypomanic Episode (current or past–at least 4 days)
AND
Major Depressive Episode (current or past–at least 2 weeks)
Cyclothymic Disorder
DSM-5 Criteria
A:
At least 2 years (1 year children/adolescents)
Numerous periods with hypomanic symptoms that do not meet criteria for hypomanic episode
AND
Numerous periods with depressive symptoms that do not meet criteria for a major depressive episode
B:
Hypomanic and depressive periods have been present for at least 1/2 the time
Individual has not been without the symptoms for more than 2 months at a time
- criteria for a major depressive, manic, or hypomanic episode have never been met
- most children with cyclothymic disorder are more likely to have comorbid ADHD
Bipolar Spectrum: Neuroanatomical Correlates
Asymmetrical hemispheric blood flow in bipolar disorder
Decreased gray matter
Altered activation patterns
Alterations to: PFC ACC Hippocampus Amygdala
Bipolar Spectrum: Suicidality
Biggest risk: when depression just starts to alleviate
• Individuals are still depressed but have more energy
Loss of abstract thinking
Lack of cognitive flexibility
Concrete thinking only
Mixed states
In a mixed state, the individual has co-occurring manic and depressive features, which can occur either simultaneously or in very short succession.
Dysphoric mania is primarily manic
Agitated depression is primarily depressed
The mixed state can put a patient at greater suicide risk
Depression \+ Increased energy \+ Agitation \+ Impulsivity = higher risk of dangerous behavior, self-injury or suicide.
Cyclothymia: Prevalence
Lifetime: 0.4% – 1%
equal male/female
In Mood disorder clinics: 3%–5%
Females more commonly present for tx
Usually
A diagnosis of Cyclothymia increases the chance of later being diagnosed with bipolar disorder
More difficult to discover Cyclothymia than bipolar
Individuals with Cyclothymia can still function in daily lives
Cyclothymia: Course
15%–50% risk of developing Bipolar I or II later in life
Bipolar Spectrum: Cortisol
Cortisol is elevated during both mania and depression phases, similar to unipolar
DSM-5 Changes
Emphasis on changes in activity and energy as well as mood for hypomanic and manic episodes
Anxious to stress specifier
