Mood Disorders - Bipolar I & II Flashcards
menmonic for bipolar symptoms
DIGFAST
Distractibility Insomnia Grandiosity Flight of ideas Activities Speech Thoughtlessness
DSM IV criteria for manic episode
A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
The symptoms do not meet criteria for a Mixed Episode.
The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
The symptoms are not due to the direct physiological effects of a substance or a general medical condition.
DSM iV crtieria for a mixed episode
The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.
The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
The symptoms are not due to the direct physiological effects of a substance or a general medical condition.
DSM IV crtieria for hypomanic episdoe
A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.
During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
The disturbance in mood and the change in functioning are observable by others.
The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
The symptoms are not due to the direct physiological effects of a substance or a general medical condition.
DSM crtieria for BP I
Presence of at least one Manic or Mixed Episode
Manic/Mixed Episode(s) are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder NOS
DSM IV certeria for BP II
Presence (or history) of one or more Major Depressive Episodes.
Presence (or history) of at least one Hypomanic Episode.
There has never been a Manic Episode or a Mixed Episode.
The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
not due to substamce or GM
DSM criteria for cyclothymia
For at least 2 years, the presence of numerous periods with hypomanic symptoms and numerous periods with depressive symptoms that do not meet criteria for a Major Depressive Episode.
During the above 2-year period (1 year in children and adolescents), the person has not been without the symptoms in Criterion A for more than 2 months at a time.
No Major Depressive Episode, Manic Episode, or Mixed Episode has been present during the first 2 years of the disturbance.
The symptoms in Criterion A are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
not substance or GMC
clinically sig distress or impairment
Note: In children and adolescents, the duration must be at least 1 year.
differential diagnosis with BP
MDD – carefull assessment for manic symptoms (collateral information, second opinion)
Substance-related mood d/o
mood d/o due to GMC
sz/szaffective d/o (chronic vs. episodic)
personality d/o (chronic vs. episodic)
ADHD (chronic vs. episodic; AAO, ADHD is typically earlier than BP)
variations of BP D/o
Bipolar I Disorder: 1 or more manic/mixed episode
- Single Manic Episode
- Most Recent Episode: Hypomanic, Manic, Mixed, Depressed, Unspecified
Bipolar II Disorder: 1 or more MDE, 1 or more hypomanic, no mania/mixed episodes
-Most Recent Episode: Hypomanic, Depressed
Cyclothymia: 2 or more years, periods of hypomanic & depressive sxs, no full criteria for MDE, Manic, Mixed episode
lifetime prev rates for BP I
.4-1.6%
difference in prev rates based on race?
no
difference in prev rates based on gender?
no
though onset and course for women is characteried by more MDEs than men
what proportion of Px’s with BP commit suicide?
10-15%
can aggressive and violent bx occur during a manic or mixed episode?
yes
what percentage of Px’s with BP experience more than one manic episode?
90%
if untreated, on average, how many manic episodes does an individual have in 10 yer?
4
regarding relapse, for Px’s who comply with med tx…
1/3 relapse within 3 years
regarding relapse, in naturlistic studies with varying levels of tx compliance…
2/3 relapse within 2 years
BP is the ____ leading cause of disability (both physical and psych)
6th
in 1999, estimated fiscal cost for americans with BP
45 million
where does the info on the last four cards come from?
Johnson et al., 2000
describe the etiology of BP
Evidence for genetic component from adoption and twin studies – 50 to 80%
Neurotransmitter dysfunction
- Dopamine dysregulation (and serotonin)
- Don’t fully understand the mechanisms here
Brain regions
- Elevated activity in amygdala
- Diminished activity in prefrontal cortex
Milkowitz and Johnson, 2006
Broadly, what does the research say about LE’s and BP
Research has found that stressful life events play a role in the onset of and recovery from episodes of depression and mania
Hlastala, et al., 2000
What are some findings from cross section research on LE’s (gen) and BP; what are the limitations
LE’s more common before bipolar episodes than they are in general population
–56% of px’s with BP report a major role loss before a major episode
LE’s more likely to occur before a bipolar relapse (i.e., new episode) than after
Severe LE’s 4X as common in the month before relapse and 2X as common in the 2 months before relapse compared with control periods
Limitations: causal inferences (temporal precedence); self-report (longterm/emotional recall, emotionally laden material, social desirability)
What are some findings from prospective studies on BP and LE’s (gen)
Severe, negative, independent LE’s found to predict a 4-fold increase in risk of relapse and a 3-fold increase in time to recovery
LE’s appear to be equally common before bipolar and unipolar depressive episodes
What are the findings around neg LE’s (specifically) and mania?
don’t have the evidence to make confident inferences either way
Few cross-sectional studies find a link between negative LE’s and mania
No prospective study has found that negative LE’s directly predict manic symptoms
Johnson, et al. 2004 found that people who were already mildly hypomanic before a negative LE were more likely to become manic after it
What are some findings about other specific kinds of LE’s and BP
LE’s that involve sleep disruptions appear to occur before manic episodes
-E.g. shift work, travel, generally accepted
LE’s involving goal attainment predict increases in manic symptoms
- When someone attains a goal their rewrd sensitiveiy is likely increased. And peple with Bp are elvetated to start with
- At least two prospective studies: goal attn. LE predicted manic episode w/ 2 mos.
name two different models for BP
Gray’s BIS/BAS model (johnson et al. 2000)
CT model (Newman et al., 2002)
Describe the BIS
Sensitive to environmental cues of punishment
Regulates inhibition/avoidance of these cues
Related to anxiety
describe the BAS
Sensitive to environmental cues of reward
Regulates approach behaviors
Related to feelings of hope, elation, and happiness
The main idea of Johnson’s BIS/BAS model of BP & supporting evidence from research on goal attainment and BP
Goal-attainment positive events predict mania, but not depression in bipolar disorder
Supports previous studies that have found that broadly defined positive events are not related to mania
Bipolar individuals do not differ from “normals” in terms of the nature of their goal-attainment events but in their ability to regulate motivation and affect following these events
Clinical implication of this model/research?
Therapy is about goal attainment, careful balance between treatment progress and triggering a manic episode
CT conceptualization
Schemas develop from negative experiences early in childhood
Schemas are activated by significant life events which result in affective changes
Schemas influence information processing by “mental filtering” (e.g. attentional biases)
Schemas contribute to people using faulty compensatory strategies that reinforce and perpetuate the problems that support the formation of the schemas
Bipolar patients seem to maintain consistent maladaptive schemas that shift polarity
A negatively valenced schema is activated during the depressed phase
A positively valenced schema is activated during the manic phase
I’m worthless to I’m worth more than one could imagine
CBT is an effective adjunctive treatment (treatment frontline tx) – but doesn’t mean the mdoel based on this thoery is correct
med treatments for BP
Lithium: control acute episode, prevent future episodes
Anticonvulsants: onset of action is faster
Antipsychotics: tx associated symptoms
Benzodiazepines: behavioral control, sleep
Psychosocial tx’s for BP
Family Focused Treatment
- Focus on expressed emotion within family
- amount of criticalness expressed
- some families are overly intrusive
- these things are risk factors for relaspe
- include psyched, communication training, etc.
Interpersonal and Social Rhythm Therapy
- Focus on life events that may trigger episodes
- tends to focus on the LE’s
- psychoedu (gaining insight into own trigggers),
- also behaviorally focused at minimizing disruptions (e.g. in sleep cycle)
- show to be effective for increasing the time until the next episode
CBT
- Focus on beliefs & cognitions related to medication compliance
- focus on cogs that activate depression/mania
- focus on med compliance (experiences)
- some support, not all that impressive, better for people in earlier stages of the disorder
How do you choose between treatment options?
Thorough hx, individual characteristics, past successful treatment,
-can always provide multiple options and allow for client to choose between them – my increase engagement in treatment
