Mood Disorders: Bipolar Disorders !

Question 1

Bipolar disorders

Answer 1

Main focus: periods of mania/hypomania and low mood.
Categorised by two conditions: bipolar 1 and bipolar 2.
Other diagnoses include: cyclothymia.

Question 2

Bipolar: defined by intensity and duration mania vs. hypomania.
Manic episode DSM5

Answer 2

A. abnormally and persistently elevated, expansive, or irritable mood.. persistently increased goal-directed activity or energy, lasting at least 1 week. Present most of the day, nearly every day.
B. .. plus 3 or more of following:
- inflated self esteem or grandiosity.
- decreased need for sleep.
- more talkative that usual or pressure to keep talking.
- flight of ideas/subjective experience that thoughts are racing.
- distractibility.
- increase in goal-directed activity or psychomotor agitation.
- excessive involvement in reckless activities.
C. the mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalisation to prevent harm to self or others, or there are psychotic features.
D. .. not attributable to psychological effects of a substance or another medical condition.

Question 3

Hypomanic episode DSM5

Answer 3

A. Mood similar to manic episode but lasting at least 4 days.
B. … plus 3 (or more; 4 if mood only irritable) of manic episode criteria (category B).
C. Episode associated with unequivocal (uncharacteristic) change in functioning.
D. Disturbance in mood/function change observable by others.
E. Not severe enough to qualify for manic category C.
F. …not attributable to psychological effects of a substance (but can ‘emerge’ during antidepressant treatment).

Question 4

Major depressive episode DSM5

Answer 4

An episode of MDD within any bipolar disorder is diagnosed in the same way as unipolar MDD.

Question 5

Bipolar 1 DSM5

Answer 5

A. manic criteria A-D for at least one manic episode.
- the manic episode may have preceded or be followed by hypomanic or depressive episodes.
B. occurrence of manic and MDD episode(s) not better explained by schizoaffective disorder/schizophrenia.

Question 6

Bipolar 2 DSM5

Answer 6

A. hypomanic criteria A-F for at least one hypomanic episode.
- and there must be current/past MDD episode.
B. there has never been a manic episode.
C. the occurrence of hypomanic and major depressive episode(s) not better

Question 7

Bipolar prevalence

Answer 7

Prevalence bipolar less common than: 
1% for Bipolar 1; 0.5% for Bipolar 2. 
- but more severe- hospitalisation more likely. 
- and more recurrent than MDD. 
No gender difference.

Question 8

Causes?

Answer 8

Mostly biological - especially bipolar 1.
Genetic heritability: bipolar disorder one of the most heritable conditions (Edvardsen et al, 08).
- as high as 93% in some twin studies- also supported in adoption studies.
- but genetics do not explain timing of mood swings.

Question 9

Biological causes

Answer 9

Neurotransmitters:

• facilitate activity between neurons.
• norepinephrine, dopamine, and serotonin strongly implicated- high levels in manic.
• possible explanations relate to dopamine receptors- overly sensitive in bipolar.

Question 10

Psychological explanations

Answer 10

Psychodynamic, behavioural, cognitive explanations are weak for manic symptoms but..
- life events can trigger symptoms.
- other potential triggers: stressful or distressing events; childbirth; relationship breakdown; money problems; abuse.
(may be related to ion activity- Etain et al, 2017).

Question 11

Impact of bipolar disorders

Answer 11

• relationships.
• employment.
• university performance.
• legal or financial consequences.
• side effects from prolonged abuse of drugs or alcohol.
• repetitive self harming behaviours.
• suicide.

Question 12

Bipolar disorders and suicide

Answer 12

Suicide attempts more frequent in bipolar disorder than depression (Kessler, Borges & Walters, 1999).
- although attempts tend not occur during mania.
Supported further evidence:
- patients admitted after suicide attempt: 28% MDD dc; 39% P (Raja & Azzoni, 04).
- BP patients more suicide attempts (27%) than MDD ts (18%).
- risk for death by suicide in BP patients 20-30 times higher than gen pop. (Pompili et al, 2013).

Question 13

Treatments for mania/hypomania

Answer 13

Typical treatments:
- mood stabilisers.
- and/or antipsychotic meds.
Some mood stabilisers only treat mania (and mood cycling):
- but not effective for depression- valproic acid, carbamazepine.
- others can also treat depressive symptoms- lamotrigine, lithium carbonate.
Some atypical antipsychotics also have mood stabilising effects:
- normally used to treat psychoses- but useful in severe depression (including ‘psychotic’ type).
- some of the most common include: clozapine, olanzapine etc.
Lithium carbonate frequently used in bipolar disorder:
- ania associated with irregular ‘protein kinase C (PKC)’ activity- lithium charbonate inhibits PKC activity.
Side effects: discomfort, frequent urination, mild thirst, nausea etc.
Dose must be calculated to body weight: dosage needs to be high enough to work but not too close to toxicity levels.
- blood levels and kidney function should be monitored closely.

Question 14

Effectiveness of bipolar medication

Answer 14

Lithium has better efficacy than several comparator treatments- generally better side effect profiles too.
Considered to be best first line treatment.
Antipsychotics, such as quetiapine, better as second line (Brahm et al, 07):
- although some studies suggest antipsychotics should be added to lithium.- eg. lithium and quetiapine better efficacy than lithium alone (Vieta et al, 08).

Question 15

Psychological therapies

Answer 15

Rend not to work to well for manic states- but CBT and other therapies highly effective depressive states.
CBT also effective for educating BP patients (NICE, 2014):
- monitoring mood cycles and symptoms.
- encouraging treatment compliance.
Peer support can also be powerful: bipolar UK, Mind, Mental Health Foundation.
Some BP therapy works well in group settings:
- group psychoeducation- build up knowledge about bipolar disorder and self-management.
- family-focused therapy.
General management focuses on life style and coping strategies- enhance relapse prevention.
Interpersonal and social rhythm therapy: improves communication, relationship problems, sleep cycle, work-life balance etc.

Long term treatment from talking therapies (Mind):

• understanding BD.
• identifying early warning signs and symptoms.
• developing strategies to cope with triggers and episodes.
• making a crisis plan.
• setting goals and plans for staying well.