Lecture 8 - Bipolar Disorder Flashcards
DSM-5 Diagnosis of Bipolar
- Diagnosed based on the presence of a
manic episode, lasting at least one week
(most of the day, nearly every day) (except if hospitalized (could last less time when treated)) - Must be distinct period– i.e., distinct
change from normal functioning - Manic episode can consist of “elevated,
expansive mood,” or “extreme irritability.” - Persistently increased goal-directed
activity or energy A lot of motivation, engagement with the world, start lots of projects - If only irritable, need to meet more
criteria. - Inflated self-esteem or grandiosity
- Decreased need for sleep:
- Irritability often stems from inability to down-regulate/
slow down. - More talkative than usual:
- Pressured speech
- Flight of ideas/racing thoughts
- Jump from one idea to the next
- Appears similar to loose associations in Schizophrenia. Thoughts still make sense (unlike schizophrenia), but rapidly jump
- Thoughts are racing and they can’t keep up.
- Distractability:
- Reported or Observed
- Can contribute to the flight of ideas
- Sometimes leads to diagnostic difficulties with ADHD
- Increase in goal-directed activities:
- Can also be social
- Talk to strangers, call at all hours of the night,
working on several projects at once (but never finish). - Increased libido (along with impulsivity can contribute to infidelity, risky behaviour, divorce…)
- More active or agitated
- Can’t sit still
- Excessive involvement in pleasurable activities
with a high potential for painful consequences: - Shopping sprees, foolish business investments,
sexual indiscretions. - Not attributable to physiological effects of a
substance (e.g., drugs) or another medical
condition - Overlaps with several other disorders,
making differential diagnosis difficult. - Need MARKED impairment for diagnosis:
- Hospitalization
- Psychotic features
- Extreme impairment in several domains
(work, family, etc.) - Distress NOT a factor in mania– poor
insight and often feel very little pain.
Forms of Bipolar Disorder
Don’t need both mania and depression (can be just mania or both… but not just depression)
- Bipolar I: mania plus episodes of MDD
(but can get diagnosis before experience depression) - Bipolar II: HYPOmania and MDD
- Hypomania same symptoms as mania, milder.
- No hospitalization
- No psychosis
- Mood is out of normal range, but not necessarily
distressing - Often very fun!
- Stimulus-seeking
- Causes some impairment, but not so extreme
- Cyclothymia
- Hypomania and short depressive episodes
- Chronic pattern, less severe
- LOTS of highs and lows
- More extreme than normal mood fluctuations
- M = F
- Often don’t seek treatment
– women more likely - At increased risk for Bipolar I
- Antidepressant meds can be a trigger
-2 or more years of this pattern - Specifier: Rapid Cyclers:
- 4 or more episodes within a year
- Can be either kind of episode
- More likely to be female
- Predicts poor response to treatment
- Mood stabilizers often ineffective
- NOT a stable trait– rather a phase that some will
pass through.
-have earlier onset
-Continuous = no free interval between episodes (idk if it always is continuous though)
Psychotic symptoms of bipolar
- Mood Congruent vs. Mood Incongruent psychotic symptoms
Mood congruent: consistent with someone’s mood state (makes sense with mania or depression)
Mood incongruent: inconsistent with someone’s mood state
Mood congruent in mania: am Jesus, I am a billionaire…
Mood congruent in depression: the world has been destroyed, I have committed a sin
Mood incongruent in mania:
Thought insertion
Mind control
Mood incongruent in depression:
Anything happy
This is rare
Psychotic symptoms raise serious differential diagnosis questions.
Current DSM-5 resolution:
- If psychotic symptoms occur during a manic or depressive episode, then qualifies as a
MOOD DISORDER (w/ psychosis)
- If occur outside mood episode, usually schizoaffective diagnosis
Epidemiology of Bipolar Disorder
Bipolar I and II
Lifetime prevalence between 2-4% for EITHER
BIPOLAR I OR II
Prevalence does not seem to differ as a
function of sex, culture, countries, parts of the
world
- Rates fairly stable
Some evidence prevalence may be higher in
certain subgroups
Used to think high SES = greater prevalence,
- Probably diagnostic bias
- Low SES more likely to be diagnosed with
Schizophrenia
- Rates of Bipolar much higher among artists,
poets, writers
Cyclothymia
* Prevalence closer to 4-5%
* Contrast with MDD, 17%
lifetime prevalence
Unipolar mania (only experiencing mania, not mdd)
* Unipolar mania has been reported in community
studies of mania
* 25% to 33% of bipolar I patients
* 1-2% in general population
* However, if you follow unipolar mania for long
enough, the majority (20/27, or 74%) had at least
one episode of depression during follow-up
* Not clear if unipolar mania is stable over the life
course or whether most bipolar I patients, if
followed long enough, eventually develop a
depressive episode.
Unipolar (MDD)/bipolar distinction
* MDD 10-20 x more common than Bipolar.
* Differ in gender distribution:
- Bipolar: M≈F
- Unipolar: 2F = 1M
* Differ in course:
- Bipolar– earlier onset
- Bipolar– more episodes
- Bipolar– more pernicious course
Course of Bipolar Disorder
- Takes average of 6 to 10 years for an individual
with bipolar disorder to receive correct
diagnosis and appropriate treatment - Misdiagnosed consult an average of four
physicians prior to receiving an accurate
diagnosis - Close to 60% of individuals with bipolar
disorder initially misclassified as having MDD - In general, more likely to seek treatment when
depressed
Treatment response differs:
* Mood stabilizers (lithium) and anticonvulsants for bipolar
* Anti-depressants (e.g., tricyclics,
SSRIs) for unipolar
* Anti-depressants can trigger manic
episodes in bipolar
-explains why a lot of people with bp don’t want to take meds… mania (the fun part) gets stabilized but doesn’t work for the depression part (and anti-depressants can trigger mania)
- Age-of-onset:
- 20-30
- ½ time 1st episode is manic
- ½ time 1st episode is depressed
- 5-10% of people who present with a
history of only depression will
convert to bipolar - Particularly if younger age,
heightened guilt, psychomotor
retardation, and a family history of
bipolar - Episodes typically last about 2 months
- Previously 8 months, prior to effective treatments
- Poor prognostic indicators (indication treatment might not work as well):
- Mixed states
- Rapid cycling
- Relapse rate– 7-9 times over lifetime
Suicide in bipolar
* Risk of death by suicide are 15 X the general population
* 4 X patients with major depressive disorder
* Some estimates of inpatients with bipolar suggest 11% die by suicide
* Risk factors for death by suicide:
- younger age
- recent illness onset
- male gender
- prior suicide attempts (SAs)
- a family history of suicide
- comorbid alcohol or substance abuse
- rapid cycling course
- social isolation
* MOST of these are associated with increased risk for death by suicide across all populations, not specific
Etiology of Bipolar Disorder
Environmental: Stress and Adversity in
Bipolar
* Stress appears to increase in the 1st 6 months prior to
an episode
* Frequently relapse following a stressful experience
* Sheri Johnson (UC Berkeley)
* Particular class of stressors important in mania:
- Goal-attainment events
- Significantly associated with manic episodes.
- When achieve a goal, become very happy;
subsequently dysregulated; spiral into mania.
How does stress get “into” the brain?
* Kindling:
* Graham Goddard (1967)
* stimulate areas of the brain
repeatedly w/ electricity, seizures
develop
* Over time, requires lower doses of
electricity to provoke a seizure
* Eventually happens with no
electricity
* Robert Post (George Washington University)
* Applied this theory to Bipolar Pts.
* 1
st episode of Bipolar requires a lot of stress
* 2
nd episode requires less stress
* 3
rd episode even less
* Eventually, don’t need stressors– episodes occur on
their own.
Sleep disruption
* Sleep deprivation a powerful predictor of
mania
* Less sleep on day N predicts increases in
manic symptoms on day N+1
* Exposure to bright light, which can change
circadian rhythms, can trigger of manic
symptoms
Neurobiology of Bipolar Disorder
Striatum
* Ventral Striatum
* Striatum is a central part of basal
ganglia
- Facilitate voluntary
movement
- Reward processing
* Esp. nucleus accumbens
* Reward & reinforcement
Striatum in Bipolar
* Enlarged in men and women with bipolar
disorder
* Compare first-and multiple episode
bipolar and HC
* Enlargement in both affected and
unaffected monozygotic twins discordant
for bipolar disorder
Reward in Bipolar
* Abnormally elevated activity within the VS during:
- reward anticipation
- reward consumption
- to reward-predictive cues
* A failure of prefrontal regions to effectively down-regulate
VS responses
* Recent evidence:
- Reward consumption-related activation more prominent in BP-I
- Abnormalities in reward anticipation-related activation more
prominent in BP-II
Treatment of Bipolar Disorder
Lithium
* Mid-nineteenth century, lithium was used to treat
many disorders
* Fell out of fashion
* Lobotomies became more common for bipolar
* John Cade, 1949
* Tranquilizing effects
* Began to use on his hospitalized bipolar patients
* For many years no consensus on how it works
* Deactivates an enzyme that interferes with circadian
clock
* Glutamate antagonist
* Recent evidence: appears to interrupt dopamine
signaling in the brain
* Very narrow therapeutic window
* Side effects:
- Thyroid and kidney problems
- Dehydration, weight gain, acne, thinning of hair, hand
tremors
(see slide of lithium levels in drinking water per country and suicide rates by country)
