Lecture 34: Bipolar Disorder

Question 1

What are the DSM-IV diagnoses of bipolar disorder?

Answer 1

1. Bipolar type 1 (at least 1 manic episode)
2. Bipolar Type II (hypomania and depression; no manic episodes)
3. Bipolar NOS (not otherwise specified…neither I nor II)
4. Related diagnoses
   
   • cyclothymic disorder
   • Schizoaffective disorder
   • Mania secondary to medications or illnesses

Question 2

What are the diagnostic criteria for Mania?

Answer 2

1. Distinct Period of abnormally elated or irritable mood (at least 7 days for first episode)
2. At least 3 of the following
   
   • grandiosity
   • need for sleep
   • pressured speech
   • infatuation (High school love)
   • distractibility
   • increased goal-directed activity or agitation
   • poor judgement/risky behaviors
3. Impairment in occupational and/or social functioning
4. Not attributable to a general medical illness or a drug /medication effect

Question 3

What is the prevalence of psychosis in mania?

Answer 3

58% of patients have at least 1 psychotic symptom
Delusions (typically mood congruent grandiose and paranoid) more common than hallucinations
90% of patients have at least 1 psychotic symptom by self-report

Question 4

What is the distinguishing factor between mania and hypomania?

Answer 4

Mania is MUCH more disabling
-hallucinations, vocalization and social impairment, and hospitalization = mania
People with hypomania don’t seek treatment

Question 5

What is distinguishing feature between bipolar I and II?

Answer 5

Bipolar I = mania

Bipolar 2 = DEPRESSION 37 fold more frequent than mania

Question 6

What is the difference between bipolar I and bipolar II diagnosis?

Answer 6

Bipolar II is heavily dependent on the threshold for hypomania
-when more inclusive criteria are used, up to 50% of people with unipolar depression can be placed within a broader bipolar spectrum
Bipolar II = more depression

Question 7

What is the significance of cycling?

Answer 7

Cycling between Mania and Depression that is characteristic of bipolar disorder

Question 8

How heritable is bipolar disorder?

Answer 8

Highly

Question 9

What are the important subforms of bipolar disorder?

Answer 9

1. Rapid cycling (4+ episodes/year)
   
   • means 1st and 2nd generation doesn’t work as well
2. Mixed features
   
   • mania AND depression, they can co-occur
3. Seasonal pattern
   
   • depression in fall/winter and mania in spring/summer
4. With psychotic features
   
   • 60% in manias
   • 20% in depressions

Question 10

What is cyclothymia?

Answer 10

Periods of up and down that are relatively normal

At risk for bipolar disorder

Question 11

What are Bipolar I disorder comorbidities?

Answer 11

Anxiety
Alcohol dependence
Drug dependence
Adult antisocial behavior

Question 12

What do mood stabilizers do?

Answer 12

Effective in the acute treatment or stabilization of manic/mixed hypomanic, and depressive episodes
Do NOT induce alternate mood symptoms
-prevent against future relapse or recurrence

Question 13

What defines mood stabilizer?

Answer 13

1. treats acute mania and/or depression
2. prevents recurrence of mania and depression
3. Does not increase the risk of mania or depression

Question 14

Do you want to give antidepressants for bipolar I disorder? Significance?

Answer 14

NO YOU DON’T

This is significant because oftentimes, depression is diagnosed vs. bipolar

Question 15

What is age of onset for bipolar disorder?

Answer 15

17.5 years

Question 16

What is the difference between bipolar disorder and unipolar depression?

Answer 16

Bipolar disorder is much MORE disabling

MORE psychotic, MORE comorbid

Question 17

Do bipolar disorder oftentimes get misdiagnosed as unipolar depression? Significance?

Answer 17

Yes, over 50% misdiagnosed
Significance: unipolar depression patients were more likely to have poorer outcomes because anti-depressants don’t work in bipolar disorder

Question 18

What are the pearls in treatment of bipolar disorder

Answer 18

1. Treatment modalities often need to change over time
2. Several weeks are required to assess the effect of new treatment
3. Optimize mood stabilizers (use more than 1)
4. Combination therapy is standard for BPD
5. Antidepressant may WORSEN disease course
6. Select drug regimens that are well-tolerated and promote compliance

Question 19

The average bipolar patient has to take how many medications?

Answer 19

3 medications

- 2 mood stabilizer
- 1 antipsychotic

Question 20

What is the association with completed suicide and bipolar disorder?

Answer 20

Bipolar I disorder have higher rates of completed suicide than unipolar disorder
Needs to be considered for treatment

Question 21

What is the significance of mood disorder questionnaire MDQ?

Answer 21

Used to diagnose bipolar disorder

Used to get history of manias

Question 22

What are examples of mood stabilizers?

Answer 22

Lithium
Valproic acid (anticonvulsant)

Question 23

What are antimanic therapies?

Answer 23

Lithium
Divalproex
Carbamazapine
First and second generation antipsychotics
ECT (rarely)

Question 24

How long does it take to recover from bipolar depression?

Answer 24

Mania take 8 weeks
Depression takes 6 months
Mixed/cycling = one year
That’s why mania was easier to treat