Lecture 6 - Natural history and differential diagnosis of bipolar disorder

Question 1

Regarding bipolar and its clinical characteristics:

a) When does it typically start
b) Estimate lifetime prevalence
c) In a year how many patients will have a severe mood episode

Answer 1

a) Often < 25 years
b) Varies around 1% for BD I & BD II
c) Bipolar II - 68% will have a severe mood episode, Bipolar I - 74.5% will have a severe episode

Question 2

In Bipolar disorder are patients typically euthymic, manic or depressed?

Answer 2

Most common is for patients to have periods of euthymia and depression > mania
True for BD I & II

Some distinguishing features may be BD II patients tend to have more mood episodes and more depressed episodes than BD I

Question 3

Name some features identified in the BRIDGE study identifying characteristics of Bipolar in those with current depression?

Answer 3

Equal or more than two prior mood episodes
Symptoms beginning before aged 30
Substance abuse
Borderline personality disorder
Psychotic features
Mixed states
FHx of hypomania/mania
Previous manic/hypomanic switch or mood lability on antidepressants

Question 4

Which areas activated in emotional pain are similar to those activated in physical pain?

Answer 4

PAG (periaqueductal gray)
Accumbens
Thalamus

Question 5

How many patients with bipolar II have a co-morbid personality disorder diagnosis?

Answer 5

1 in 3 - EUPD (BPD) is most common

Data from Vieta 1999

Question 6

In the study by Juruena, Young, Clare how did BPD and Bipolar differentiate with regards to psychoneuroendocrine measures?

Answer 6

BPD:

• Those with high CTQ for physical abuse -decreasing cortisol
• As cortisol decreased BHS (hopelessness) increased
• Those with high CTQ for sexual abuse - increase cortisol
• In Bipolar high CTQ for sexual abuse - lower cortisol levels

Question 7

How did Cleare and Markopoulou distinguish treatment resistant bipolar and treatment resistance depression with regards to cortisol levels?

Answer 7

Bipolar disorder was shown to have have lower cortisol levels than healthy controls and TRD

Question 8

Name some features of the natural history of bipolar disorder

Answer 8

Early onset
Lifelong recurrence risk
High rates of incomplete remission
Low rates of sustained recovery
Suicide risk 
Frequent mixed symptomatology

Question 9

Define some challenges treating Bipolar disorder

Answer 9

• Under-diagnosed / detected
• Depression can present first impacting above
• Co-morbidity common and can affect detection and treatment
• Treating both manic, depressive and mixed states
• Several subtypes requiring individualised treatment plans

Question 10

Describe different treatment stages of bipolar disorder

Answer 10

• Acute treatment - from symptoms to remission (maybe 6-12 weeks)
• Continuation treatment - from point where symptoms first improve to where remission expected if left untreated. Deals with tail of vulnerability at first remission where recurrence risk may be high. Includes possible post-mania depression
• Maintenance treatment - Prevents or attenuates future mood episodes

Question 11

Describe/define the following terms - if possible with scoring systems and/or time frames:

• Response
• Remission
• Recovery
• Relapse
• Recurrence

Answer 11

Response - 50% or more in reduction of core symptoms

Remission:
• mania: YMRD < 8 or < 5
• depression: HMDS < 7 or BDRS ≤8

Recovery - 8 weeks without mania/depressed symptoms

Relapse - return of symptoms within 8 weeks - may be to same or opposite pole

Recurrence - new episode - will occur > 8 weeks after remission

Question 12

Which are the goals of Cognitive behavioural therapy for bipolar disorder?

Answer 12

1) Medication adherence
2) Early detection/intervention
3) Stress and lifestyle management
4) Treat co-morbidities
5) Treat Bipolar disorder

Question 13

First symptoms to appear in a manic episode:

Answer 13

• More suspicious (paranoid)
• Anxious/worried (fear)
• Irritable, grumpy, angry
• Racing thoughts (feeling that you can’t control the way you think)

Question 14

First symptoms to appear in depression:

Answer 14

Less:
• Sleep
• Energy or motivation
• Socialising
• Level of activity
• Concentration / remembering

Also changes in appetite

Question 15

What is the impact of BD in cognition?

Answer 15

Oscillation between episodes could impact brain areas such as the hippocampus and amygdala. Thus, there is a progressive decrease in cognition in these patients.

Question 16

Which are some social consequences of BD?

Answer 16

• Reduced quality of life
• Impaired physical and social functioning
• Reduced employment and work productivity
• Large healthcare utilization and costs

Question 17

Could lithium impact cognition in BD, and how?

Answer 17

• Impaired short- and long-term memory
• Slowed reaction time
• Diminished associative fluency

Question 18

Could divalproex impact cognition in BD, and how?

Answer 18

• Mild attention impairment
• Mild short- and long-term memory impairment
• Delayed decision time
• Diminished cognitive flexibility

Question 19

Could carbamazepine impact cognition in BD, and how?

Answer 19

Mild short- and long-term memory impairment

Question 20

Could lamotrigine impact cognition in BD, and how?

Answer 20

none reported -yet

Question 21

Could antidepressants impact cognition in BD, and how?

Answer 21

Anticholinergic effects of tricyclic agents: cognitive dulling

Question 22

Could atypical antipsychotics impact cognition in BD, and how?

Answer 22

Noncontrolled studies report poorer executive function, and other studies report improvements from baseline cognitive function in schizophrenia (but this could reflect disease state differences relative to BD)