Lecture 4 - Bipolar depression Flashcards by Fran Hodgkins

What is the principle feature of a mood disorder?

Prolonged, intense, pervasive affective disturbance

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What is the difference between unipolar and bipolar depression?

Unipolar = includes only/mainly depressive episodes
Bipolar = includes both manic or hypomanic, & depressive episodes

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Can normal mood states can occur between episodes for both unipolar and bipolar mood disorders?

Yes

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What is the first (main) criteria for a manic episode?

Period of abnormally & persistently elevated/expansive/irritable mood
Abnormally & persistently increased goal-directed activity or energy.
Lasts ≥ 1 week; present most of the day, every day.

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What is the issue with goal-directed behaviour in mania?

This activity is fine but not taking breaks from it is the issue in mania - people go days without sleep sometimes

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What criteria do you need three or more of (four if mood is only irritable) for a manic episode? (7 criteria)

1) Inflated self esteem
2) More talkative
3) Distractibility
4) Excessive involvement in activities with high potential for painful consequences
5) Decreased need for sleep
6) Flight of ideas/ thoughts racing (cannot keep up with their brain - disorienting)
7) Increased goal-directed/ psychomotor activity

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What are criteria C and D for a manic episode?

C. Mood disturbance causes impaired functioning, necessitates hospitalisation, or there are psychotic features.
D. Can’t be explained by, e.g., substance abuse or another medical condition

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What are the differences in criteria for a hypomanic episode vs a manic episode?

Same A and B criteria (mood, goal-directed activity) however lasts ≥ 4 consecutive days and is not necessarily goal-directed behaviour
C. Mood disturbance causes change in functioning
D. Mood disturbance & functional change noticeable by others
E. Is not severe enough to need hospitalisation or markedly impede function
F. Can’t be explained by, e.g., substance abuse or another medical condition

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Can one can cycle rapidly between depressive and manic symptoms within the same episode?

Yes - mixed episodes (not dichotomous)

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Are depressive and manic symptoms the opposite of each other?

The symptoms are NOT the ‘opposite’ of each other e.g., significant functional impairment in both circumstances

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What are the diagnostic criteria for Bipolar 1 disorder?

Criteria have been met for at least one manic episode
Presentation is not better explained by a schizophrenia-spectrum disorder

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Are the specifiers for bipolar 1 and 2 the same as for MDD?

Yes

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Do you have to be diagnosed with depression or experience depression to have bipolar 1?

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For bipolar 2 disorder criteria, what two episodes have to happen, and what one episode has to not happen?

Hypomanic and depressive - at least one major one of each
Manic - there has never been a manic episode

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For bipolar 2 disorder, do the following criteria apply:
Presentation is not better explained by a schizophrenia-spectrum disorder.
Symptoms of depression / unpredictability caused by mood alternation causes clinically significant distress / impairment in functioning.

Yes

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What are key diagnostic differences between bipolar 1 and 2?

In bipolar I, the person typically experiences:
- full-blown mania with very marked functional impairment
- depressive symptoms which may – or may not – meet the threshold for a major depressive episode (i.e., in theory, diagnosis can be made without evidence of major depression)
In bipolar II, the person typically experiences:
- hypomania but symptoms are below the threshold for full-blown mania, with less marked functional impairment
- depressive symptoms which meet criteria for major depression

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What is cyclothymic disorder?

Cyclical mood changes less severe than seen in bipolar disorders

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For how long do periods of depressive then hypomanic symptoms have to occur for a diagnosis of cyclothymic disorder?

At least 2 years

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Is it true that for cyclothymic disorder, there should not be a period of mood stability lasting longer than 1 month?

False
2 months

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Can someone have cyclothymic disorder and have met the criteria for a full manic, hypomanic or depressive episode?

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How are depressive symptoms different during MDD and Bipolar disorder 2?

In bipolar disorder, depressive episodes:
- are more severe and frequent, cause more role impairment
- are shorter
- more frequently have psychotic features & psychomotor difficulties, substance use, and mood lability as associated factors
In MDD, depressive episodes:
- are accompanied by higher levels of anxiety, agitation, insomnia, physical symptoms & weight loss

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What is the 12 month prevalence of BPD 1 and 2 for males?

Male: 0.8% for BP-I, 0.9% for BP-II

2.6% for subthreshold BPD

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What is the 12 month prevalence of BPD 1 and 2 for females?

1.1% for BP-I, 1.3% for BP-II

2.1% for subthreshold BPD

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When is typical BPD onset?

Early 20s

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What is the most common type of BPD?

Subthreshold symptoms

Which has higher prevalence of BPD: Europe or Africa?

Europe Africa: 0.1 to 1.83% (review of 5 studies) Europe: 0.6-6.2% (review of 7 studies)

What is the worldwide prevalence of bipolar 1 and bipolar 2?

Worldwide: 1% for bipolar I and 1.5% for bipolar II (meta-analysis of 25 studies) Significant amount of subclinical symptoms in general population

Does prevalence of bipolar disorder vary with ethnicity?

No, not consistently

What is more common - type 1 or 2 bipolar?

Mixed evidence - probably type 2

How long can episodes of bipolar-related mania last if not treated?

3-6 months

How long can an episode of depression (in bipolar disorder) last if not treated?

6-12 months

How many modes does the distribution of first onset of bipolar disorder have?

Three - trimodal 17, 26 and 42

What are the 4 main prodromal features of bipolar disorder? (Faedda et al., 2015)

- mood lability, - subclinical hypomania/ depression, - other specified bipolar and related disorders - major depression, especially with hypomanic or psychotic symptoms Another review noted specific prodromal neurocognitive impairments in verbal memory, attention, and executive functions but no decrement to general intelligence.

What are the syndromal recovery rates after first episode of mania after 6 months and after 1 year?

Syndromal recovery rates were 77% at 6 months and 84% at 1 year

Outcomes after first episode of mania: is recurrence 26% within 6 months, 41% by 1 year, and 50% by 4 years?

No - 60% by 4 years Others correct

What is younger age at first onset of manic episode associated with a risk of?

Recurrence after 1 year

Is bipolar II characterised by a greater number of total mood episodes than bipolar I?

Yes

Is bipolar II characterised by longer mean duration of episodes than bipolar I?

No - shorter

Is bipolar II characterised by less chance of psychosis and hospitalisation than bipolar I?

Yes

Are there low rates of cross-over between bipolar II and bipolar I?

Yes

Do bipolar I and II patients have symptoms for around half the year?

Yes I = 48% II = 54%

Which is more common in bipolar 1: depressive symptoms or manic symptoms? Is this also true to bipolar II?

Depressive Depressive symptoms (32% of total follow-up) were more common than manic/hypomanic symptoms (9%) or cycling/mixed symptoms (6%). Also true for bipolar II: Depressive symptoms (50% of total follow-up) were more common than manic/hypomanic symptoms (1%) or cycling/mixed symptoms (2%).

Are minor depressive and hypomanic symptoms combined more frequent than major depressive and manic symptoms?

Yes - 30% vs 11%

In bipolar II, are minor depressive, and hypomanic symptoms combined >3 times more frequent than major depressive and manic symptoms?

Yes - 40% vs 13%

What is an explanation of bipolar disorder involving emotional stimuli and the prefrontal cortex?

Not effective suppression of emotional stimuli by the prefrontal cortex

What is the default mode network (DMN)?

Default mode network: brain activity when a person is restfully awake (focused in, not out) Includes contemplation, remembering, thinking of others, and planning for the future… internal narrative. DMN activity inversely correlated with other networks such as attention, & memory performance

Is DMN different in bipolar disorders?

Yes - patterns of hypo and hyper connectivity

Is there lower volume in the anterior cingulate cortex for bipolar?

No - only in unipolar depression

Is there lower volume in the hippocampus and amygdala for bipolar?

Yes

Is there - lower white matter integrity (cortical thinning) in bipolar?

Yes

Is there more activation in the amygdala in unipolar towards negative emotional stimuli compared to bipolar depression?

Yes

Is there more activation in the amygdala in unipolar towards positive emotional stimuli compared to bipolar?

No - less

Is the failure to deactivate the default mode during cognitive tasks greater for bipolar compared to unipolar depression?

Yes

Is there weaker functional connectivity in bipolar for the default mode network? (compared to unipolar?)

No - stronger

Is there stronger functional connectivity in bipolar in prefrontal cortex, anterior cingulate cortex, parietal and temporal regions, and thalamus? (Compared to unipolar)

Yes

Are there impairments in attention, verbal learning and memory, and executive functions in bipolar? Do people experience cognitive decline all the time?

Yes Some people experience cognitive decline across the course but others resume usual levels of functioning between episodes

What is the MZ and first-degree relatives concordance of unipolar and bipolar depressive disorders?

MZ concordance of between 40–70% First-degree relatives have 5–10% risk – 7 times higher than general population.

How does the genetic risk for bipolar and unipolar depression transcend mood disorder diagnostic categories?

Relatives of someone with bipolar are more likely to develop unipolar depression than bipolar themselves

Are there shared genetic risks between diagnoses of bipolar and schizophrenia?

Yes

Is the risk for bipolar polygenic?

Yes: Multiple single nucleotide polymorphisms, which are highly prevalent in the general population and confer a small increased risk individually

What is a polygenic risk score?

An individual’s relative risk of a specific condition based on the collective influence of many genetic variants compared to someone without the variants (a ‘control’) (or someone with only some of the variants)

Do socioeconomic risk factors for bipolar disorder have a large overlap with those for unipolar depression?

Yes

What socioeconomic risk factors may differentially increase risk for bipolar disorder (vs unipolar depression)?

- Childhood trauma and abuse, especially emotional - Childhood adversity and neglect - Childbirth (i.e., giving birth) - Substance misuse (especially opioids) - Cannabis & cocaine use (predict onset of mania) - Some other medical conditions e.g., asthma, IBS (suggests a shared autoimmune pathway?)

What are SNPs in bipolar also involved in? What does this suggest about heritability of bipolar?

Immune function - also put us at risk for auto-immune disorders They suggest that findings of consistent immune-related epigenetic alterations in people with bipolar may demonstrate how immune dysfunction is transmitted across generations

Are mood stabilisers similar for bipolar I and II?

Yes, but order may be slightly different

Can you give an SSRI alone to a manic patient? Why?

NEVER give an SSRI alone to a manic patient - flips them into mania - overcorrect

Why is psychoeducation especially important at first onset?

Patient will likely be very alarmed

Different mood stabilisers are used for the different mood phases of bipolar disorder - this is treatment timing - is lithium used in both phases?

Yes

Is pharmacological and psychological treatment in early illness more effective than later stages in terms of response, relapse rate, time to recurrence, symptomatic relief, remission, psychosocial functioning & employment?

Yes However, first presentation often ≠ first episode due to treatment delays.

What does lithium help with?

Lithium carbonate is used to help with both (hypo)manic and depressed phases as a long-term treatment

What is known about the function of lithium treatment?

We do know that it reduces norepinephrine levels, increases serotonin synthesis, and has some anti-inflammatory actions. Possible routes include changes to levels and properties of glutamate, GABA, dopamine, inositol and neurotrophic factors (help new growth of brain cells).

What is typically used in combination with an SSRI to treat bipolar?

Olanzapine (an antipsychotic) or another antipsychotic on its own is typically used. (Stops someone from getting too high)

Can an SSRI on its own be used for someone with bipolar 2 who shows no evidence of hypomania?

Yes - low dose

What do markers of bipolar include? (To distinguish it from MDD)

- earlier age at onset of illness, more eating - hyperphagia, hypersomnia, and psychosis - a higher frequency of affective episodes, - comorbid substance use disorders, anxiety disorders, binge eating disorders, and migraines - family history of psychopathology, particularly schizophrenia or bipolar

If deciding to prescribe antidepressants to a patient who may have bipolar, what should you watch carefully for?

- insufficient response - amplification of anxiety, dysphoria, and mood instability Start a short course and have to come back to see the doctor

Do psychological treatments for bipolar disorder have a weaker (smaller) evidence base than for MDD?

Yes They have been trialed as adjunctive therapies, i.e., alongside medication.

Do psychological treatments alongside medication reduce episodic recurrence and stabilise depressive symptoms?

Yes, some do (CBT esp stabilises depressive symptoms)

What are three commonly used psychological treatments for BPD?

Cognitive behavioural therapy - helps ppl detect changes in their own mood and helps them to seek help themselves, more empowered to reach out to family and friends Psychoeducation Family therapy - decrease environmental trigger factors, family can look for risk factors Combining psychotherapy and medication can be very beneficial

What are similarities between bipolar and schizophrenia?

Both groups of disorders show prodromal symptoms, before initial onset and also before relapses They share profiles of polygenic risk Both disorders show cognitive, neurological and functional progression (decline) without effective treatment Both feature some of the same symptoms.