*Lecture 10 - Bipolar Disorder Flashcards
What should we be able to do by the end of the lecture?
- Describe features of depressive, hypomanic & manic episodes
- Define Bipolar Disorders (I, II and Cyclothymia)
- Describe:
* Epidemiology of Bipolar Disorder
* Aetiological Factors
* Pharmacological Interventions
* Psychological Interventions
+ make notes from CHP 3 of textbook
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How has the classification of bipolar changed between the DSM-IV and DSM-5?
No longer in Mood Disorders (DSM-IV), instead in its own chapter:
Bipolar and Related Disorders (DSM-5)
What 7 disorders are in the Bipolar and Related Disorders chapter of DSM-5?
1 Bipolar I Disorder
2 Bipolar II Disorder
3 Cyclothymic Disorder
4 Substance/Medication-Induced Bipolar & Related Disorder
5 Bipolar & Related Disorder due to another Medical Condition
6 Other Specified Bipolar & Related Disorder
7 Unspecified Bipolar & Related Disorder
What are the symptoms of a Major Depressive Episode?
A. At least 5 + symptoms during 2 week period (need #1 or # 2)
- Depressed mood most of the day, nearly every day
- Markedly diminished pleasure/interest in activities
- Significant weight loss or weight gain
- Insomnia or hypersomnia nearly every day
- Psychomotor Agitation
- Fatigue/Loss of energy nearly every day
- Feelings of worthlessness, excessive guilt nearly every day
- Diminished ability to concentrate nearly every day
- Recurrent thoughts of death, suicide, suicide attempts
B. Clinically significant distress or impairment
C. Not attributed to substance use or other medical condition
Bipolar I (BPI): Manic Episode CRITERION A:
At least one week of:
Ø abnormally & persistently elevated, expansive or
irritable mood, and
Ø increased goal directed activity/energy, present
nearly daily
• Manic episodes typically evolve over several weeks from heightened wellbeing to euphoria
• Episodes move quickly from an elated mood to an irritable mood or can fluctuate between elation & irritability
Bipolar I (BPI): Manic Episode CRITERION B:
Ø At least 3 or more present to a significant degree & noticeable change from usual behaviour:
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- Rapid or pressured speech
- Flight of ideas or racing thoughts
- Distractibility
- Increase in goal-directed activity or psychomotor agitation
- Excessive involvement in activities that have a high potential for negative consequences
Bipolar I (BPI): Manic Episode CRITERION C.
The mood disturbance is:
• sufficiently severe to cause marked impairment in occupational functioning or in usual social activities,
• or to necessitate hospitalisation to prevent harm to self or others,
• or there are psychotic features (e.g., delusions or hallucinations)
Bipolar I (BPI): Manic Episode CRITERION D
The symptoms are not due to the direct physiological effects of a substance (e.g. drug or medication) or a general medical condition (e.g. hypothyroidism)
Bipolar II (BPII): Hypomanic Episode CRITERION A
A.
At least 4 days of:
Ø abnormally & persistently elevated, expansive or irritable mood, and
Ø increased goal directed activity/energy, present nearly daily
Bipolar II (BPII): Hypomanic Episode CRITERION B
3 or more:
- Inflated self esteem or grandiosity
- Decreased need for sleep
- More talkative/pressured speech
- Flight of Ideas; racing thoughts
- Distractibility
- Increased goal directed activity or psychomotor agitation
- Excessive involvement in pleasurable activities which have a potential for negative consequences
Bipolar II (BPII): Hypomanic Episode CRITERION C
Change that is uncharacteristic of the individual
Bipolar II (BPII): Hypomanic Episode CRITERION D
Disturbance & changes are observable by others
Bipolar II (BPII): Hypomanic Episode CRITERION E
Not severe enough to cause marked impairment, or hospitalisation, and no psychotic features
Bipolar II (BPII): Hypomanic Episode CRITERION F
Not due to substances/medical condition
Which bipolar is hypomanic and which is manic?
I: Manic
II: Hypomanic
True or False?
A major depressive disorder needs to be present for a diagnosis of Bipolar I?
False: can be present but not necessary for diagnosis.
It IS however required for a diagnosis of bipolar II.
True or False?
A manic episode needs to be present for a diagnosis of Bipolar I?
True: but not for Bipolar II
True or False?
A hypomanic episode needs to be present for a diagnosis of Bipolar I?
False: can be present but not necessary for diagnosis.
It IS however required for a diagnosis of bipolar II.
Describe Cyclothymic Disorder.
- Chronic, less severe form of Bipolar Disorder
- Numerous cycles of hypomania symptoms and depression symptoms that are not severe enough to meet criteria for manic or MDD
- Symptoms for at least 2 years but no more than 2 months without symptoms
- Symptoms cause distress or impairment in functioning
What disorder does this describe?
• Chronic, less severe form of Bipolar Disorder
• Numerous cycles of hypomania symptoms and depression symptoms that are not severe enough to meet criteria for manic or MDD
• Symptoms for at least 2 years but no more than 2 months without symptoms
• Symptoms cause distress or impairment in functioning
Cyclothymic Disorder.
What are some diagnostic issues with bipolar?
Bipolar Disorders are often:
• Undetected/Undiagnosed
• Over-diagnosed (i.e. Borderline Personality Disorder)
• Misdiagnosed as Schizophrenia or Unipolar Depression
Note: Diagnostic problems have implications for pharmacological & psychological interventions
What is the lifetime prevalence of Bipolar I in Australia?
up to 1%
What is the lifetime prevalence of Bipolar II in Australia?
~5%
What is the 12-month prevalence of Bipolar in Australia?
1.3%
True or False?
There are significant gender differences in the epidemiology of bipolar?
False, although the rapid cycle effect women a bit more
When is the main onset for bipolar?
Onset: peak at 15-25 years (for both genders)
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What is the course of bipolar like?
The Course: 10-20 years delay in seeking treatment
• 90% have recurrent episodes
• Untreated: 8-10 lifetime episodes of mania & depression
• Treated: 40% relapsing within 1-year; 73% within 5-years
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Epidemiology
Ø The course - predominantly depressive
• Bipolar I: 32% of time depressed; 9% Manic
• Bipolar II: 50% of time depressed; 1%Hypomanic
• Rapid cycling: 5-15% of sufferers have 4+ episodes per year
What are the main co-morbidities of bipolar?
High rates of co-morbidity!
• 50% Anxiety Disorders (panic, GAD, social phobia)
• 39% Substance misuse (‘self-medication’)
What are the main aetiological factors for Bipolar Disorder?
1 Genetic/Biological Factors
2 Environmental & Life Stressors
3 Psychological Factors
What are two genetic factors affecting the aetiology of bipolar?
What are two biological factors affecting the aetiology of bipolar?
Genetic Factors
- Lifetime risk for family members of BP patients: 10% (versus 1% in the general population)
- Twin studies: BP heritability rate of ~80-85%
Biological Factors
- BP is a neurobiological disorder, largely due to a malfunction of three neurotransmitters: serotonin, dopamine and noradrenaline.
- BP may lie dormant and be either activated spontaneously or be triggered by (e.g. environmental and life) stressors (OR drugs)
What are some environmental factors affecting the aetiology of bipolar?
Stressful Life Events
Ø An association between stressful life events and both manic & depressive episodes
Ø Manic episodes likely preceded by:
• Disruption to routines & sleep-wake cycles
• Excessive focus on goal attainment
Ø Depressive episodes likely preceded by:
• Low social support
• Low self-esteem
What is the rate of suicide attempt and success with suicide for bipolar?
- At least 25% will attempt suicide;
* 10-20% will complete suicide
What are some psychological factors affecting the aetiology of bipolar?
Psychological Factors
§ A negative cognitive style enhances vulnerability to manic & depressive episodes when paired with stressful events
§ Mania may be a defense to counter the negative thoughts & feelings relating to an underlying negative self-esteem
§ Temperament factors: perfectionism & sociotropy (over-investment in social relationships)
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Diathesis-Stress Model (Lam et al., 1999)
What is the best way to treat bipolar?
Best treatment = Pharmacological + (adjunct) Psychological interventions
What are two things that deciding on a bipolar treatment depend on?
- illness stage (acute, maintenance)
2. predominant polarity (depressive, hypo/manic)
Name 5 pharmacotherapy treatments for bipolar.
- Lithium
- Anticonvulsants
- Atypical Antipsychotics
- Sedative Hypnotics
- Antidepressants
Discuss lithium in relation to the treatment of bipolar.
It is very important and effective.
• A mood stabiliser & main component of standard care (mainly BPI)
• John Cade–Au 1940s: not used regularly in treatment until 1960s
• Treatment of manic episodes & for preventing future episodes
• 50% patients relapse within 5months of ceasing Lithium
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Antidepressants
- doses lower & duration shorter than for unipolar depression
- combined with mood stabiliser to prevent inducing mania
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Sedative Hypnotics
Sedative Hypnotics (Benzodiazepines) Sedatives help with sleep
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Atypical Antipsychotics
(e.g. Olanzapine) – (mainly BPI)
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Anticonvulsants
(e.g. Lamotrigine) – also for mood stabilisation
often used for rapid cycling
and highly irritable
Discuss ECT in relation to bipolar treatment
Electro-Convulsive Therapy (ECT)
• Used when medication is not viable
• Effective for treating both manic & depressive episodes
• Short-term side effects: confusion, disorientation, memory loss
• Pharmacotherapy required to maintain mood stability & prevent relapse
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Are medication and therapy around as effective as one another?
Yeh
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Psycho-education
Ø Most commonly in a group setting (includes peer support) (e.g. The REACH Program at BDI, “Moodswings”)
Ø Providing information about:
• Symptoms of BP disorder => Identifying early warning signs of relapse
• Strategies to cope with stressors (need for routines & sleep-wake cycles)
• Diathesis-stress model of BP disorder
• The rationale/importance of medication compliance
Ø Delays recurrence + reduces frequency of future episodes:
• 6-months Psycho-education program: over 5 year FU, time to any recurrence
significantly longer for psycho-education group than controls
• Significantly fewer recurrences with psycho-education (3.9 vs. 8.4) (Colom et al., 2009)
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Cognitive Behavioural Therapy (CBT)
•
• •
Aim: to manage symptoms & prevent relapse
- more effective for depressive episodes and for people with less severe illness
(i.e. fewer past episodes)
Key technique: cognitive restructuring
Patients encouraged to:
• Monitor symptoms (includes psycho-education)
• Challenge/change unhelpful thinking, emotions behaviours
• Improve medication adherence
• Foster self-efficacy
Effective in reducing episodes & hospitalisations, improving medication compliance,
esp. within 6-months post-treatment (Gonzalez-Pinto et al, 2003)
Recent studies show benefits of Mindfulness-based Cognitive Therapy (e.g. Williams et al, 2008; Ives-Deliperi et al, 2013)
Aim: to teach people to become more aware of thoughts and feelings, to relate to them as “mental events’ rather than as aspects of self/reflection of reality
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Bipolar Disorder & Creativity
Bipolar disorder: associated with creative groups
• 17% of a sample of British poets received treatment for
manic episodes
• Enhanced creativity likely linked to manic/hypomanic states & accompanying suprasensory changes (Parker, 2014)
