Lecture 9 Bipolar Flashcards
phases of bipolar
acute stabilisation
ongoing maintenance
relapse prevention
treatment differs based on
phase, severity, polarity
DSM-5 criterion A for manic episode
-abnormally & persistently elevated expansive or irritable mood
AND
-increased goal directed activity/energy, present nearly daily
Manic:
>= 1 week, present most of the day, nearly every day
OR
any duration if needs hospitalisation
Hypomanic:
>=4 consecutive days, present most of the day, nearly every day
DSM-5 criterion B for manic episode
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- Rapid or pressured speech
- Flight of ideas or racing thoughts
- Distractibility
- Increase in goal-directed activity or psychomotor agitation
- Excessive involvement in activities that have a high potential for negative consequences
3 or more needed, 4 if mood is only irritable, present to a significant degree & represent noticeable change from usual behaviour
Other criteria for manic vs hypomanic episodes
Manic:
C. mood disturbance sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalisation, or psychotic features
D. episode not attributed to physiological effects of substance or other medical condition
Hypomanic:
C. episode associated with an unequivocal change in functioning that is uncharacteristic of the individual
D. disturbance in mood and change in functioning observable by others
E. episode not severe enough to cause C in manic
F. same as D of manic
Diagnosis of bipolar I vs II
Bipolar I:
- must manic episode
- hypomanic and major depressive episode not necessary
Bipolar II:
- must not manic episode
- both hypomanic and depressive episode
manic to depressive episode ratio in bipolar I
manic to depressive 1:3, remission in between
hypomania
Less severe than manic episodes:
- Change in functioning is uncharacteristic of the individual
- Mood disturbance is noticeable to others
Shorter duration than manic episodes
Not severe enough to disrupt functioning, but can impairfunctioning
Not severe enough to result in hospitalisation
Cyclothymic disorder
Chronic, less severe form of bipolar disorder
Numerous cycles of hypomanic and depressive symptoms that are not severe enough to meet criteria for manic or major depressive episodes
Symptoms for at least 2 years, no more than 2 months without symptoms
Symptoms cause distress or impairment in functioning
best treatment for bipolar
pharmacological + adjunct psychological interventions
Goal of acute stabilisation
reduce arousal, agitation, aggression, behavioural/cognitive disturbance and psychosis
acute stabilisation for mania
pharmacotherapy as first line treatment:
1) stabilisation of manic mood->mood stabiliser or antipsychotic mediaction
2) rapid containment of behavioural disturbance ->antipsychotic, short-term benzodiazepine
3) manage cognitive disturbance ->antipsychotic
4) severe or high risk ->ECT
acute stabilisation for hypomania
follows general principles of mania
responds to modest doses of pharmacotherapy and psychosocial interventions
acute stabilisation for depression
goal: to achieve complete and functional remission of depressive symptoms
contain suicidal risk
pharmacotherapy:
- monotherapy with 2nd-generation antipsychotics or mood stabiliser
- combined therapy, the above with antidepressant
treatment emergent affective switch into mania from antidepressant
ECT
when medication not viable
effective for acute mania, severe or treatment-resistant depression
confusion, disorientation, memory loss
pharmacotherapy required to maintain mood stability and prevent relapse
components of ongoing maintenance
medical: medication monitoring, prophylactic medication to prevent relapse
psychological: CBT, Interpersonal Social Rhythm Therapy, psychoeducation, family-focused therapy
social and lifestyle: support groups, healthy eating, regular exercise
Pharmacotherapy maintenance
mood stabiliser: lithium
anticonvulsants: lamotrigine
antipsychotics: atypical antipsychotics
antidepressants: SSRI, SNRI
medication monitoring
Psychiatric review to determine medication regimen, based on
- Physical examination
- Tolerability of side effects
- Efficacy of pharmacotherapy
Monitoring of medication tolerability and toxicity
- Side effects include weight gain, drowsiness, dizziness, stomach upset, dry mouth and constipation.
- Long term use can affect kidney, renal, thyroid and cardiac functioning.
Often involves coordinated care across GP and specialists
pros and cons of lithium
lithium carbonate as first-line treatment for mania and depression
neuroprotective and anti-suicidal properties
toxicity:
narrow theraputic index
toxic at high blood conc.
requires regular monitoring
psychological maintenance: CBT
more effective for depressive episodes and for people with less severe illness (i.e. fewer past episodes)
Key technique: cognitive restructuring
Patients encouraged to:
- Monitor symptoms
- Challenge/change unhelpful thinking
- Improve medication adherence
- Foster self-efficacy
Effective in reducing episodes and hospitalisations, improving medication compliance
Mindfulness-based Cognitive Therapy to teach people to become more aware of thoughts and feelings, to relate to them as “mental events’ rather than aspect of self/reflection of reality
treatment phases of CBT
1) Socialization into cognitive therapy model and development of individualized formulation and treatment goals
- Includes psychoeducation and exploration of interpersonal functioning
- Identifying and challenging negative automatic thoughts
- Developing behavioural experiments
- Cognitive and behavioural approaches to symptom management and dysfunctional automatic thoughts
- Self-monitoring and self-regulation techniques
3.Dealing with cognitive and behavioural barriers to treatment adherence and modifying maladaptive beliefs
- Anti-relapse techniques and belief modification
- Relapse prevention
Interpersonal and Social Rhythms Therapy
aim: improve interpersonal functioning and to reduce disruption to daily routine and sleep-wake cycles
interpersonal: Addressing losses, role transitions and interpersonal problems
stabilising social rhythms: Fixing wake time across 7 days of the week
Psychoeducation
aim: improve knowledge about managing the condition and preventing relapse
- Improving awareness of illness
- Treatment adherence
- Harm avoidance
- Detecting early warning signs
- Lifestyle regularity
Family-focused Therapy
aim: to enhance caregivers’ illness management and self-care. Involves individual with bipolar disorder and their family members
Psychoeducation
- Addresses symptoms, causes, and treatment of bipolar disorder
- Medication compliance
- Coping mechanisms, stigma and emotional impact of bipolar disorder are explored
- Collaborative relapse-prevention plan
Communication skills
- Improving active listening
- Delivering positive/negative feedback
Problem-solving
-Medication non-compliance, social-occupational impairment, previous episodes
