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Psych Week 3 > ICL 9.7: Bipolar > Flashcards

ICL 9.7: Bipolar Flashcards

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1
Q

what is the range of mood variation seen in someone with bipolar disorder?

A

temperament/personality

personality Disorders

m (hyperthymic)

d (dysthymic/depressive)

dm (cyclothymic)

D (Major Depression)

M (Mania)

Md (predominantly manic)

Dm (BPII, predominantly depressed)

MD (BPI)

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2
Q

what are the phases of mood swings of a bipolar person?

A

euthymia –> depression –> mania –> subsyndromal depression –> depression –> hypomania

slide 7

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3
Q

what is the DSM5 criteria for a manic episode?

A

a distinct period of abnormally and persistently elevated, expansive or irritable mood lasting at least 1 week duration (or any duration if hospitalization is required)

during the period of mood disturbance 3 or more of the following symptoms have persisted to a significant degree:

  1. inflated self esteem or grandiosity
  2. decreased need for sleep
  3. more talkative or pressured speech
  4. flight of ideas or racing thoughts
  5. distractibility
  6. increased goal directed activity or agitation
  7. excessive involvement in pleasurable activities that have a high potential for painful consequences
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4
Q

what is a hypomanic episode?

A

a distinct period of persistently elevated, expansive or irritable mood lasting at least 4 days that is clearly different from the usual non-depressed mood

during the period of disturbed mood 3 or more of the following symptoms have persisted ( 4 if the mood is only irritable) and have been present to a significant degree:

  1. inflated self esteem or grandiosity
  2. decreased need for sleep
  3. more talkative than usual or pressured speech
  4. distractibility
  5. increase in goal directed activity or agitation
  6. excessive involvement in pleasurable activities that have a high potential for painful consequences
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5
Q

what are the 2 types of manias?

A
  1. euphoric = high energy, grandiose ideas, high self esteem, happy
  2. dysphoric = irritability, anxiety + high energy
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6
Q

what is mixed state/dysphoric mania?

A

the criteria for a Manic episode and a Major Depressive Episode are simultaneously present nearly every day for at least a week

it causes marked social and occupational impairment or is severe enough to necessitate hospitalization to prevent harm

not substance induced nor due to a general medical condition

again antidepressant induced mixed states do not count towards making the diagnosis

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7
Q

what is bipolar NOS/NEC?

A

People have symptoms of mania or hypomania that are too few in number or too short in duration to meet current criteria for the syndrome or an episode of mania/hypomania

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8
Q

how does the epidemiology of unipolar depression vs. bipolar disorder differ?

A

MDD
lifetime prevalence: 16.2%

mean age of onset is older

BIPOLAR
lifetime prevalence: 1.3-1.6%

mean age of onset younger

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9
Q

how does the genetics of unipolar depression vs. bipolar disorder differ?

A

MDD
low rate of occurrence of bipolar disorder and depression in family members

prevalence is 1/10 men and 2/10 women

10-13% risk for 1st degree relatives

BIPOLAR
increased familial occurrence of depression and bipolar disorder

no difference in prevalence between men and women

20-25% risk for 1st degree relatives

child with 1 parent 25% risk; child with 2 parents 50%-75% risk

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10
Q

how does the phenomenology of unipolar depression vs. bipolar disorder differ?

A

MDD

  1. anxiety
  2. somatic complaints
  3. appetite loss
  4. weight loss
  5. insomnia
  6. increased pain sensitivity
  7. rate of recurrence carries from 0%-constant

BIPOLAR

  1. atypical depression
  2. mixed states
  3. symptomatic variability
  4. mood lability
  5. irritability/agitation
  6. decreased need to sleep
  7. postpartum episodes
  8. weight gain
  9. psychotic features
  10. comorbid substance abuse
  11. 90% recurrence
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11
Q

how does the patient’s personality of unipolar depression vs. bipolar disorder differ?

A

MDD
1. role of personality is unclear but probably has a role

  1. less hyperthymic temperament
  2. less cyclothymia

BIPOLAR
1. temperament and personality have been linked to mood disorders for ages e.g. “melancholic, sanguine, choleric, phlegmatic”…

  1. personality disorders may be 3 times more common
  2. more hyperthymic temperament

4, more cyclothymia

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12
Q

how does the longitudinal course of unipolar depression vs. bipolar disorder differ?

A

MDD
1. middle age

  1. fewer episodes
  2. longer cycle length
  3. long prodromal period of several months to 2 years
  4. fewer interepisode mood shifts

BIPOLAR
1. adolescence or childhood

  1. more episodes
  2. shorter cycle length
  3. seasonal pattern more common
  4. more interepisode mood shifts
  5. comorbid with anxiety disorders
  6. more substance abuse
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13
Q

how does the pharmacological response of unipolar depression vs. bipolar disorder differ?

A

MDD
1. 50-70% acute response to AD

  1. less rapid response to AD?
  2. more tolerant to AD montherapy
  3. less mood switch to AD
  4. good prophylactic response to AD montherapy

BIPOLAR
1. only 20-40% have an acute response to AD

  1. more rapid response to AD?
  2. more intolerant to AD monotherapy; they’ll lose the benefit of AD over time
  3. more mood switch to AD
  4. poor prophylactic response to AD monotherapy
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14
Q

what is the hallmark difference between bipolar I and bipolar II?

A

bipolar I patients have full-blown manic episodes and they may or may not have episodes of depression (but they usually do) – so the hallmark of bipolar I is the mania

the hallmark of bipolar II is they don’t have mania, they have hypomania and their predominant mood state is depressed; they spend a lot of time in the depressed phase

then with unipolar major depression has no hypomania or mania, it’s just depression

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15
Q

what are the causes for concern when making a bipolar diagnosis?

A

only 9% of patients have adequate insight into their high periods well enough to recognize them as such during their initial interview

having a family member present increases accurate diagnosis only to 26%

pts undergo 3-4 evaluations before the proper diagnosis is made

the delay in making the proper diagnosis has been estimated to range from 9 to 18 years – so it’s not easy to diagnose BPD by looking at polarity or the cycling of symptoms….

depressed patients are especially poor at recalling previous episodes of hypomania

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16
Q

what is kindling?

A

the theory of “kindling” is used to explain the highly recurrent nature of bipolar disorders

“kindling” refers to the likelihood that a nerve cell will fire more frequently when it has fired before

“kindling” appears to be a driving mechanism for addiction, craving, epilepsy and recurrent mood episodes

kindling could explain how in the absence of genetic risk factors bipolar disorder and major depression can become highly recurrent.

it implies that the greatest predictive factor determining whether or not an individual will suffer a major mood swing is whether or not they have had a previous major mood swing or subsyndromal mood swing

so if we could find some anti-kindling drugs then we could treat bipolar disorder more effectively!

17
Q

how is unipolar depression linked to bipolar depression?

A

people with highly recurrent episodes of unipolar depression were likely to end up with a diagnosis of bipolar II than patients with low recurrent episodes of unipolar depression

18
Q

according to Goodwin and Jamison, what is the best way to diagnose bipolar disorder?

A

the best way is to identify and characterize the cycle in which it occurs as the disorder evolves over a patient’s lifetime

bipolar disorders are defined by both their polarity and cycling nature

they appear to exist on a spectrum from fluctuating temperament to frank psychotic disorders of mood and thinking

recognizing BOTH their polar and cycling nature allows for better diagnosis and treatment

it’s important to be able to recognize that someone has bipolar disorder and not unipolar depression because they don’t respond well to antidepressants like MDD and need mood stabilizers!

19
Q

how do we make the diagnosis of bipolar disorder?

A
  1. take a biographical history
  2. look for evidence of a manic or hypomanic episode
  3. look for evidence of mood cycling > 5x
  4. ask about family history
  5. determine age of onset of affective illness (usually early onset)
  6. recognize clusters of comorbidity (OCD, GAD, substance use, PTSD)
  7. ask about response to treatment; BPD pts. have antidepressant wear-off effects
  8. show patients how to do prospective daily mood charting to help establish the diagnosis (so you can see the mood cycling)
  9. interview significant other
20
Q

what are the clues that suggest mania?

A

DIGFAST

Ⓓistractibility: poorly focused multitasking

Ⓘnsomnia: decreased need to sleep

Ⓖrandiosity: inflated self-esteem

Ⓕlight of Ideas: complaints of racing thoughts

Ⓐctivities: increased goal directed activities

Ⓢpeech: pressured or more talkative

Ⓣhoughtlessness: “risk taking” behaviors (sexual, travel, financial, driving)

21
Q

what questions do you ask during a suspected interview for bipolar disorder?

A

Have you ever had a period of time when you were feeling up or high or so full of energy, full of yourself that you got into trouble or that other people thought you were not your usual self? (Do not consider times when you were intoxicated on drugs or alcohol)

If the patient is puzzled or unclear about what you mean by up or high clarify as follows: By up or high I mean having elated mood, increased energy, needing less sleep, having rapid thoughts, being full of ideas; having an increase in productivity, motivation, creativity, or impulsive behavior. (euphoric mania)

Are you currently feeling up or high or full of energy?
Have you ever been persistently irritable for several days so that you had arguments or verbal or physical fights, or shouted at people outside
your family? (dysphoric mania)

Have you or others noticed that you have been more irritable or overreacted compared to other people even in situations that you felt were justified?

During the times when you felt high, full of energy, or irritable did you:

  1. feel that you could do things others couldn’t do, or that you were an especially important person?
  2. need less sleep (for example feel rested after only a few hours sleep)?
  3. Talk too much without stopping, or so fast that people had difficulty understanding?
  4. Have racing thoughts?
  5. Becoming easily distracted so that any little interruption could distract you?
  6. Becomes so active or physically restless that others were worried about you?
  7. Want so much to engage in pleasurable activities that you ignored the risks or consequences (for example, spending sprees, reckless driving, or sexual indiscretions)?

Did these symptoms last at least a week and cause significant problems at home, at work, socially, or at school, or were you hospitalized for these problems?

22
Q

what are the clinical clues that could point you towards thinking someone has bipolar disorder?

A
  1. brief major-depressive episodes <3 mo
  2. psychotic MDEs
  3. postpartum depression
  4. antidepressant induced mania or hypomania
  5. antidepressant “wear off” (acute but not prophylactic response)
  6. lack of response to >3 adequate AD trials
  7. darly age of onset of MDE (<25)
  8. family history of BPD in 1st degree relative
  9. hyperthymic personality in non-depressed state

these are not in the DSM5 criteria but we recognize them clinically as clues to the fact that someone might have bipolar disorder

23
Q

what is the bipolar spectrum disorder?

A

A. at least one major depressive episode (MDE)

B. no spontaneous hypomanic or manic episodes

C. either of the following, plus at least 2 items from criterion D, or both of the following plus 1 item from criterion D

  1. a family history of BPD in a 1st degree relative
  2. AD induced mania or hypomania
24
Q

what are personality disorders?

A

no autonomous mood cycling

no diurnal variation of mood

mood is subject to abrupt changes secondary to cognitive associations triggered by external experiences thus there appears to be reverse diurnal variation of mood.

mood is dominated by cognitive beliefs and are not autonomously generated

beliefs are in general conflict with cultural norms but serve to reduce anxiety so in part are experienced as adaptive to the individual

effective treatments are exclusively psychosocial interventions and outcomes are not significantly effected by medications

25
Q

what’s the difference between a personality disorder and mood disorders?

A

personality disorders don’t have cycling!! their moods are constant!!

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