Lecture 6.2 - Bipolar Disorders Flashcards
What are bipolar disorders?
Corresponds to periods of extreme euphoria and depression; including some euthymic periods
What percent of people with bipolar disorder have at least one close relative with the illness?
67% or more than two thirds
70% dual incidence in twin studies
How does a manic episode affect insight and judgement?
It impairs both.
Can a manic episode have psychotic features?
Yes, hallucinations and delusions can occur.
How does a state of mania progress?
It starts with a rapid slow of ideas and euphoria, often increased creativity.
As it progresses an inflated self-worth, incoherent thoughts, disorientation, and risk taking behaviours can increase.
Underlying irritability.
What are the kinds of bipolar disorders?
Bipolar I, II
Cyclothymic disorder
What is bipolar I?
One or more manic episodes with a major depressive occurrence
What is bipolar II
Periods of major depression accompanied by at least one incidence of hypomania
What is hypomania?
Manic behavioural patterns that do not result risk taking behaviours, personal, and professional consequences.
No psychotic features.
What is cyclothymia?
A milder form of bipolar disorder. No overt manic episodes or profound depression, but a cycling of hypomania and depression.
Why might people with bipolar disorders have comorbidities such as substance misuse?
Desire to return to manic state (use of stimulants and amphetamines)?
What kinds of factors contribute to the etiology of bipolar disorders?
Biological:
–> Genetic
–> Neuroendocrine
–> Changes in brain structure
Psychosocial:
–> Mania as a defense mechanism against loss of attachment
What neuroendocrine factors might contribute to bipolar disorders?
Changes in Hypothalamic-pituitary-thyroid-adrenal axis leads to change in NT release (NE, dopamine, serotonin)
What is the clinical course of bipolar disorders? Describe the onset age and trajectory.
Chronic and cyclic disorder that emerges between 21-30 years old.
Sometimes occurs with mild depression and an acute onset of mania, acute psychosis, or several episodes of depression prior to the first manic episode.
The frequency of episodes tends to accelerate over time.
How do bipolar disorders present in children?
Initial presentation is usually depression and associated with intense rage (up to 3 hours).
May be mistaken for ADHD or conduct disorders, difficult to diagnose
How does bipolar disorder affect men and women differently?
Bipolar II is more common in women and they experience more depression, whereas men experience more mania.
What is lithium carbonate used to treat? What is the onset? What is the therapeutic index and when does toxicity occur?
Used to treat bipolar disorder.
Onset: 10-21 days
–> Has narrow therapeutic index (0.6-1.2) and toxicity above 1.5. Monitor blood work.
What are symptoms of lithium toxicity?
N/V/D, thirst, tremors, incoordination, confusion, cardiac arrhythmias, stupor, blurred vision (halos), weakness, blackouts, tremors, seizures.
What kind of patient teaching is necessary for someone taking lithium?
Encourage water and sodium intake to ensure lithium is excreted appropriately by the kidneys and does not damage them.
For this reason, we also monitor kidney and thyroid function at the onset of treatment.
Lithium only starts benefitting people with bipolar disorder 10-21 days after onset of taking it. What can we do for someone who presents with an acute manic episode?
Atypical antipsychotic (often olanzapine) with lithium carbonate.
The antipsychotic has mood stabilizing properties that will help the patient while we wait for lithium to start working. After about 10 days, the antipsychotic will be titrated down.
What kinds of medications are helpful for people with bipolar disorder to decompensate quickly?
Anticonvulsants such as…
Carbamazepine
–> Often combines with antipsychotic and used for people who experience aggression
–> Necessary liver enzyme tests and CBC
Lamotrigine
–> Risk of Stevens-Johnson Syndrome
Valproic Acid
–> Narrow therapeutic range (50-150); signs of toxicity include confusion, fatigue, hallucinations, ataxia. Liver function tests necessary.
–> S/E: Drowsiness, dizziness, increased suicidal ideations.
Which bipolar medication can result in Stephen-Johnson syndrome?
Lamotrigine - anticonvulsant
What bipolar medication is used for patients who are aggressive? What additional assessments are needed for patients on this medication?
Carbamazepine - anticonvulsant
*Liver function tests and CBC necessary
What medication for bipolar has a narrow therapeutic range and increases risk of suicidal ideations and hallucinations?
Valproic Acid / Divalproex Sodium
–> Range of 50-150mcg/ml
What kind of bipolar presentations can benefit from ECT?
Treatment resistant mania or rapid cycling BP disorder
What kind of psychotherapy can benefit people with bipolar disorder?
Interpersonal
–> Stabilize relationships
Family Focused
–> Improve communication with family to they are aware of signs of decompensation
CBT
–> In adjunct to pharmacotherapy for focus on maladaptive thoughts, med adherence, identification of symptoms, lifestyle management.
What do we want to assess for a person with bipolar disorder (or for whom we expect it)?
MSE
–> Focus on mood, cognition, perceptual and thought content disturbance
–> Harm risk assessment
Evaluate anxiety and coping skills
Evaluate physiological symptoms like sleep pattern, diet, and weight.
Labs: BW for lytes, WBC, thyroid
Sexual health
Med Adherence
Can antidepressants precipitate a manic episode?
Yes, when an increase in serotonin in the brain may trigger the onset of a manic episode.
This is why SSRIs and SNRIs are not given to people with bipolar
What should we be aware for ADL care of those with bipolar?
Encourage hydrations and quick high calorie foods.
Encourage sleep hygiene.
What are the priorities of the acute phase of a manic episode?
Medical stabilization, maintaining safety, meeting self-care needs
What are the priorities of the continuation phase of a manic episode?
Maintain medication adherence, psychoeducational teaching, and referrals to specialists
What are the priorities of the maintenance phase of a manic episode?
Preventing relapse in the outpatient setting
–> Strong social network to support individual and identify decompensation when insight is diminished
What is meant by depression with atypical features?
Dominant vegetative symptoms (overeating, oversleeping). Has younger onset, includes slowed psychomotor activities and anxiety accompanying problem.
*different than catatonic features, with are marked by non-responsiveness and extreme psychomotor retardation
What might cause Seasonal Affective Disorder?
Reduced cerebral metabolic activity, accompanied often by hypersomnia, overeating, craving carbohydrates.
What is disruptive mood dysregulated disorder?
Characterized by severe and recurrent temper outburst that are inconsistent with developmental level - created in response to alarming number of children and adolescents diagnosed with bipolar (though most children diagnosed with it went on to be diagnosed with MDD or an anxiety disorder)
What is substance/medication-induces depressive disorder?
Depressive symptoms that occur as a result of use of or withdrawal from drugs and alcohol and last longer than the expected length d/t the effects of the substance.
What is the bereavement exclusions and it is in place now?
Until recently, clinicians were advised against diagnosing depression in a person in the first two months following a significant loss because the diagnosis could:
1. be a normal part of mourning and not be pathological
2. The diagnosis could result in lifelong label
3. Unnecessary medication might be prescribed
It is no longer in pace because mourning could be a stressor that results in depression and waiting two months for a diagnosis and treatment might adversely affect prognosis.
Symptoms of depression in older population can result in memory issues that can be eliminated upon treating the depression. What is the clinical term for this phenomenon?
Pseudodementia
What is Beck’s cognitive triad?
A triad of thought processes seen in MDD:
1. A negative, self-deprecating view of self
2. A pessimistic view of the world
3. The belief that negative reinforcement will continue in the future.
What is the learned helplessness theory?
The idea that although anxiety is the initial response to a stressful situation, it is replaced by depression if the person feels they have no control over the situation.
What is the relation between spirituality and depression?
Spiritual instability and disappointment in a higher power are predictors of depression.
What are the three phases of treatment and recovery from MDD?
- Acute: reducing depressive symptoms and restoration of function (6-12 weeks)
- The continuation phase: Preventing relapse through pharmacotherapy, education, and depression specific psychotherapy (4-9 months)
- Maintenance: Preventing reoccurances (12+ months)
About 75% of people with bipolar I/II also have which comorbidity?
An anxiety disorder of some kind.
