Bipolar disorders ch 14 Flashcards
Bipolar I
characterize by one or more manic episodes or mixed episodes usually accompanied by major depressive episodes Criteria sets: 1. single manic episode 2. most recent episode hypomanic 3. most recent episode manic 4. MRE mixed, 5. MRE depressed 6. MRE unspecified.
Specifiers:
- Describe severity (milkd, moderate, severe with or without psychotic features.
- with catatonic features
- with pp onset.
with or without inter episode revoery,
with seasonal pattern,
with rapid cycling.
Bipolar II
Characterized by one or more major depressive episodes accompanied by at least one hypomanic episode and the absence of a manic episode or mixed episode.
Specifiers:
- severity
- with catatonic features
- with atypical features
- with pp onset
If hypomanic or depressive episode do not meet full criteria, then bipolar disorder can be specified by :
in partial remission
full remission, chronic, with catatonic fears
with melancholic features,
with atypical features
with pp onset
Cyclothymia
Fluctuating mood disturbance characterized by numerous periods of hypomanic symptoms that do not meet manic episode criteria, and numbers periods of depressive symptoms that do not meet criteria for major depressive episode.
Adults - numerous periods of hypomanic and depressive symptoms for at least 2 years and 1 year for children and adults.
Must cause significant distress or impairment of social, vocational, or other functioning et depressive episodes do not meet criteria for major depressive episodes.
Epi
Depressive symptom occur 80% of time.Mania 20%.
HIgh rate of suicide attempts over schizophrenia.
4% of popn.
HIgher among single or alone people.
Age of onset 15-19 yrs of age.
Anticipation (earlier onset, greater severity, and more frequent occurrence in those with relative with bipolar) has been observed.
Late onset after age 50. and is more common n females, more der\pressive episodes. Usually due to medical do or stimulant use or psychothropics.
Mania episodes more common in men. Hihger risk of pp onset. Rapid cycling more in women. Women more likely to develop manic switches when taking antidepressant.
Risk; family history of mood do, instability of circadian rhythms, changes in social rhythms. lack of attachment, child abuse.
ETIO
genetic influence 80-90%,
Kindling theory,
stress theory,
stressful life events,
goal deregulation ( increased sensitivity to reward such as public recognition and wealth),
disruption of social rhythms due to stress.
Bio - dysfunction of interaction between PFC network and limbic network. Degreased try matter density in PFC. Abnormal autonomic responses to emotional experiences, decreased ability to experience emotions related to concepts that evoke emotion and inability to adjust to social behavior. Glia cell deficits lead to lack of modulation of glutamate >overexcitement of neuronal cells.
Reduced activity of PF and AC cortexes. Higher rate of soft neurological signs. Abnormalities in mental processing such as intelligence, psychomotor speed, at ten, memory, visual spatial skills, executive functioning.
Reduced dopamine during acute mania. ?
Hypothyroid
Clinical presentation
Prodromal phase -
a. mania, reduced sleep, ^ activity, ^ talkativeness, euphoria, racing thoughts, irritability or sensitivity, speeding of money, promiscuous sexual behavior.
b. depression - decline in energy, interest in activities and people, diff concentration, sadness, ^need for sleep, rumination about fears, and worries.
Acute phase - signs of depression, impulsivity, irritability, agitation, substance use, insomnia, and problems with relationships.
Depressive episodes (bipolar I and II) presentation:
Likely to begin with depression.
Sadness
Anhedonia
Plus at least 5 other symptoms nearly daily for 2 weeks (hopelessness, negativity, SI, poor concentration, sleep disturbances, loos of energy, decreased self esteem, guilt, feelers of worthlessness, thought blocking, fogetfulness, obsessional thoughts).
High levels of distress, disability and functional impairment
Different from MDD as bipolar depression has earlier onset of mood symptoms, more episodes, higher rate of melancholic type depression, and more psychotic symptoms than MDD>
Less likely to be associated with anxiety, tearfulness, but more likely with worthlessness, anhedoia, leaden paralysis, hypersomnia.
Mania Bipolar I
Characterized by one or more mania episodes. Sudden onset, changes in mood, cognition, speech, appearance, behaviors.
a. Mood - euphoria, irritably, angry, hostile, aggressive, tearfulness and good humor.
b. Cognition grandiose, expansive, racing thoughts, flight of ideas, lack of insight, delusions.
c. Speech, increased output, pressured, rapid, circumstantially, inflated view of themselves, abilities, wealth, status.
d. Somatic symtoms - decreased need for sleep, decreased appetite, excessive energy, significant wt loss,
e. Appearnce - untidy and neglected.
f. Behavior - increased goal-directed activity, excessive involvement in pleasurable activities with risk for adverse results.
g. Psychotic symptoms - grandios ides, hallucinations, dleusions.
Mixed Episodes (Bipolar I)
Meet criteria for both depressive and manic episode nearly daily for at least one week.
Depressive symptoms occur more often early in the day and manic symptoms later in the day.
Must cause significant impairment or require hospitalization. There may be rapidly alternating moods. Maylast for weeks or months.
Hypomania (Bipolar II)
Characterized by one or more major depressive episodes and at least ne hypomanic episode.
Hypomania differs from mania by degree of functional impairment and are usually able to continue to function at work and socially. do not require hospitlzlaiton and durant is 4 days not 7.
Characterized by lively, happily euphoria mood, carefree, unrealistic thinking, witty,joking attitude, unaware or uncaring for others feelings,full of energy BUT not able to pursue ideas to goal directed ends. Anger or irritation if others criticize their plans.
Racing thoughts and poor concentration, no insight into behaviors, increase in smoking alcohol, superficial relationships, talking, joking, teasing, meddling.
Comorbidities
Axis I - anixety do (90%), affective do. SA do.
Axis II - narcissistic, BPD, anisoical, OCD.
Medical d/o
Suicide
Higher than any other psychiatric d/o.
Equally high for I and II.
Attempts more common in younger pts, early phases, during depressive phase, and hx of fx member suicide.
Risk factors : prior attempts symptoms of pervasive insomnia, agitation, and impulsivity. severe depression with hopelessness, selfblame and hopelessness during depressive episode ^ # of stressful life events disruption of social and occupational functioning social isolation recentl loss or losses poor response to tx early age of onset high rate of depressive episodes hx of antidepressant induced mania co-occurng personality disorders co-occuring panic disorder, anxiety do, and psychosis, fx hx of suicide comorbid SA do
Protective fx moral objection to suicide fear of social disapproval sense of responsibility for the family presence of plans for the future a reason for living.
Assessment -
male, alone, younger or older, white, occupation (docs, dentists, nurses, social workers)
Tx - Mood disorder questionnaire . Likely to have poor response to antidepressant medications. Irritability, anxiety, restlessness, agitation, or insomnia.
case formulation
5R’s
Repsonse - 50% greater reduction of symptoms following intervention.
Remission- absence of symptom following intervention for 2 months.
Recovery - absence of symptoms more than 2 months
Relapse - episode returns after response or remission
Recurrence - new episode that emerges after recovery.
Features of bipolar;
with seasonal patter
with rapid cycling (54 or more mood episodes in a year, any combination).
Tx
Prodromal phase - valproate, quetiapine, omega 3 fatty acids, family focused therapy.
Acute mania is medical emergency. Use mood stabilizers, antipsychotics, benzos.
1st line of tx in acute mania or mixed episodes is mood stabilizer in combo with atypical antipsychotic.
Anticonvolsants - Carbameazepine, oxcarbazepine, valproate.
Lamotrigine, topiramate, tiagabine.
Antispychotics - chlorpromazine, haloperidol, olanzapine, riperidone, quetiapine, ziprasidone, aripiprazole.
Continuatio phase - lithium, lamotrigine, olanzapien, aripiprazole. quetianpine as adjuntive.
Maintenance phase - lsame as a divlaporiex also.
Symbyax approved for relapse prevention.
Also ECT, brain stimulation, omega 3 fatty acids
Psychotherapy, IP, CT, CBT, FFT,
Bipolar in children
Have higher rates of mixed episodes, rapid cycling, and co-occurring ADHD.
Etio - 90% of children with bipolar have family hx of mood disorder or substance abuse disorders.
Prenatal or perinatal factors such as drugs or adverse events. ]
Bio - frontolimbic circuity may have exaggerated emotion responses and difficulty regulating emotional responses.
Symptoms in young children - increased energy, bold or demanding behavior, cognitive problems, anxious, fearful, worried mood, shyness or dimity, and hick temper.
7-12 years - irritable mood, quick temper, oversensitivity, decreased nervy or feeling tired, labile mood, mood disturbances, sleep problems, agitation, belligerence, hostility, impulsivity.
Children with mania seldom show a euphoria mood but present with predominantly irritably mood mixed with symptom of depression and psychotic symptoms. the irritability cane severe, persistent, and aggressive.
In deprssion, may complain of headaches, muscle aches, tiredness, miss school.
Adolescents- irritable decreased energy, crying guilt, self reproach, withdrawn. decreased sleep, anger, bold and demanding actions, hypomania, hyperactivity, agitation, panic attacks, irritability,hostility aggression, impulsivity, anxiety.
comorbidiy - SIB, academic problems, CD, SA do, psych do, suicidie.
Tx - lithium in adolescents, risperidone, aripiprazoke alone or in conduction with lithium or valproate in ages 10-17.
No beta blockers, trycicly antidepressants, sudafed.
