Bipolar DSA Flashcards
What is “Bipolar”?
As a general concept, bipolarity refers to a group of disorders in which a patient has sustained mood episodes in both directions (elevated or depressed).
Any given mood symptom can have a variety of possible etiologies, and is not pathognomonic for a bipolar disorder.
BAD = Bipolar Affective Disorder MDD= Major Depressive Disorder
The Bipolar Disorders
Bipolar d/o, I
Bipolar d/o, II
Cyclothymic d/o
Substance/Medication Induced Bipolar d/o
Mood disorders are based on episode types
- Manic
- Depressed (MDE)
- Hypomanic
- Dysthymic persistence
Bipolar Epidemiology
Lifetime prevalence
- Bipolar I - ~1.5 - 2%
- Bipolar II - ~3%
BAD I has 1:1 gender ratio
Total BAD has a 3:2 ratio in favor of women
Median age of onset: 25 years
- Men have earlier onset than women
Can be quite disabling
Manic Episode
Presence of abnormally elevated, expansive, or irritable mood for at least one week (or less if requiring hospitalization)
And: three of seven characteristic symptoms:
Inflated self esteem or grandiosity
Decreased need for sleep
More talkative or pressured
Flight of ideas/subjective racing thoughts
Distractibility
Increased goal directed activity (more energy)
Excessive involvement in pleasurable activities
affect of manic episode
Mood disturbance causes impairment in occupational, social, relationships, or results in hospitalization to prevent harm to self or others
Not due to direct physiological effects of a substance or general medical condition
If episode is secondary to anti-depressant treatment but continues past expected physiologic effect, then it counts as manic episode
Mania Clinical Findings
Mood either irritable, expansive, or euphoric
“Bigger, faster, better!”
A lot of emotional outpouring
Pressured, tangential speech (and lots of it)
More energy – “Taking care of business!”
Distractible – Everything is highly stimulating
Loss of consideration for consequences
Faster thoughts and flight of ideas
Fundamental truths become all-encompassing
Grandiosity, possibly delusional
Mania Course
Onset usually abrupt
Episodes last a week to months
Usually briefer than depressive episode
Risk of recurrence is significant
Frequently is preceded, or followed, by depressive episode
Complications of marital discord, financial and occupational problem
Heightened risk of suicide in subsequent depressive episode
Hypomanic Episode
Persistently elevated, expansive, or irritable mood, for at least 4 days.
Accompanied by 3 or more manic symptoms but….
Does not markedly impair social/occupational functioning.
- No hospitalization needed
- No psychotic features
The harbinger of a manic episode?
Mood Episodes and Psychosis
Psychosis is a symptom state that can be found in severe Manic or Depressed episodes.
Usually psychotic content is mood congruent in all mood disorders.
Hypomanic episodes, by definition, are without psychotic features.
Peri-Partum mood episodes have high rate of psychotic features
Bipolar I Classification
A history of at least one manic episode moves the diagnosis into Bipolar I
The diagnosis is then specified as to what was the most recent episode: manic, depressed, hypomanic.
Often characterized by recurrent episodes of both mania and depression
- Lifetime ratio of 3 MDEs to each Manic episode
Inter-episode functioning often good to excellent
Manic episode = Bipolar I
Regardless of when an episode occurred in the patient’s history, only one episode of mania is necessary to meet the criteria for Bipolar I
Bipolar II Disorder
Hypomanic episodes and major depressive episodes.
Symptoms do not meet full criteria for a manic episode
Breeds true: relatives of Bipolar II patients have higher rates of Bipolar II disorder than either Bipolar I or MDD
Also has a higher rate of comorbidity with substance abuse disorders
Cyclothymic Disorder
“Chronic, fluctuating disturbance” between (brief) periods of hypomanic symptoms and periods of some depressive symptoms
- Minimum course of 2yrs
- Number of episodes not defined but “numerous”
- No episodes of mania, hypomania, or major depressive episodes
30% of patients have Fam Hx of BAD
1/3 patients eventually have MDD or BAD dx
60% respond very positively to Lithium
Particularly sensitive to AD-induced hypomania
Could you please be more specific?
Current episode specifiers Severity Mild Mod Severe
With or Without psychotic features Mood congruent, or incongruent With mixed features With peripartum onset With catatonia
With anxious distress
Longitudinal course specifiers
With or without inter-episode recovery
With rapid cycling
With seasonal pattern
Example:
Bipolar I D/o, MRE Depressed, severe w/ psychotic features, with peripartum onset
Mixed Features,or “Mixed Episodes, I Once Knew You”
Have Manic or Hypomanic episode with significant depressive symptoms simultaneously.
Mood and symptom picture alternates rapidly
Significantly elevated suicide risk
Likely to have more lifetime episodes
Previously we had “mixed episodes” which met criteria for Mania and MDE at same time.
Bipolar Differential Diagnosis
“Stimulants”
- Amphetamines, PCP, Cocaine, MDMA
- Antidepressants
Exogenous Steroids
- HRT, Testosterone, PEDs
Endogenous Endocrine Disorders
- Hyperthyroidism, Pheochromocytoma
Neurologic
- Fronto-Temporal Dementia, ICM
Other psychiatric disorders
- Schizophrenia, ADHD, BPD, Agitated MDE
