BIPOLAR DISORDER BIPOLAR I DISORDER 4/4/14

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1 BIPOLAR DISORDER Jason Tentinger PA-C 1. Bipolar I Disorder 2. Bipolar II Disorder 3. Bipolar vs Unipolar Depression 4. Cyclothymic Disorder 5. Treatment Epidemiology BIPOLAR I DISORDER Affects around 1% of the population Equal in men and women Manic episodes are more frequent in men Major depressive episodes more frequent in women Mean age of onset is 18 Can happen anytime from adolescence to 50 or older Higher than average incidence in higher socioeconomic groups Biggest risk factor is family history Having a parent with Bipolar I Disorder may increase risk by 10X Must have at least one manic episode Which is defined by Criteria A-D in the DSM-V Major depressive episodes typically occur, but not necessary for diagnosis Criterion A: A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary) Criterion B: During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present Must be present to a significant degree and represent a noticeable change from usual behavior Jesse Jackson, Jr. Politician Image: 1

2 1. Inflated self esteem or grandiosity 2. Decreased need for sleep 3. More talkative than usual or pressure to keep talking 4. Flight of ideas or subjective experience that thoughts are racing 5. Distractibility, as reported or observed 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (purposeless non-goal-directed activity) 7. Excessive involvement in activities that have a high potential for painful consequences Inflated self esteem or gradiosity Feelings of being important Physically attractive Successful Unstoppable Decreased need for sleep May sleep only a few hours a night or go days without sleeping Catherine Zeta Jones, Actress Image: More talkative than usual or pressure to keep talking Difficult to interrupt Intrusive Rapid Flight of ideas or subjective experience that thoughts are racing Jump from thing to thing This pen is out of ink. I m from Des Moines. My dad is a firefighter. What time is supper? You re boring. Can I use the phone? I have a pig farm, you know. Distractibility, as reported or observed Difficulty staying on task Lack attention to small details Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (purposeless non-goal-directed activity) Constantly busy If organized, may be very successful Excessive involvement in activities that have a high potential for painful consequences Gambling Sex Spending sprees Hitchhiking Criterion C: Disturbance is sufficiently severe enough to cause marked impairment in social or occupational functioning Or the patient needs to be hospitalized to prevent harm to self or others Or there are psychotic features Criterion D: The episode is not attributable to the effects of a substance or to another medical condition Criteria A-D constitute a manic episode, at least one of which is necessary for a diagnosis of Bipolar I Disorder Image: 2

3 Specifiers With Mixed Features Features of both manic and depressive symptoms present during the majority of the mood episode With Psychosis (up to 75%) Specify mood congruent vs mood incongruent psychosis With rapid cycling (5-15%) Presence of at least 4 mood episode in the previous 12 months With melancholic features With anxious distress With catatonia With seasonal pattern With peripartum onset During pregnancy or in the 4 weeks after delivery Considerations Suicide risk is estimated to be more than 15 times that of the general population Over half of patients have a co-occurring substance use disorder Russel Brand, Actor Virginia Woolf, Author Image: Image: Considerations Up to 60% of people may experience chronic interpersonal or occupational problems between acute episodes 20-30% have residual mood lability or other mood issues BIPOLAR II DISORDER Bipolar II Disorder Average onset is in the mid 20 s Prevalence in the US: 0.8% Like bipolar I disorder, there are strong genetic factors Patients with bipolar II disorder have a higher total number of lifetime episodes than patients with bipolar I disorder or cyclothymic disorder Hypomania does not generally impair function, but major depressive episodes do. Bipolar II Disorder At least one hypomanic episode and one major depressive episode Hypomanic episode: A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week 4 days and present most of the day, nearly every day Same symptoms as listed for manic episode, but Do not cause marked impairment in social or occupational functioning Do not require hospitalization No psychosis 3

4 Major Depressive Episode 5 or more of the following symptoms during a 2 week period 1. Depressed mood most of the day, nearly every day 1. In children may be irritable mood 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day 3. Significant weight loss when not dieting (change in 5% of body weight) or weight gain, or decrease or increase in appetite 4. Insomnia or hypersomnia nearly every day 5. Psychomotor agitation or retardation (observable by others) 6. Fatigue or loss of energy 7. Feelings of worthlessness or excessive or inappropriate guilt 8. Diminished ability to think or concentrate, indecisiveness 9. Recurrent thoughts of death, recurrent suicidal ideation, suicide attempt, or specific plan BIPOLAR VS UNIPOLAR DEPRESSION Bipolar vs Unipolar Depression Up to 40% of patients with a bipolar disorder are initially diagnosed with unipolar depression Depression may come first Patient may not admit to manic symptoms Poor insight More Common in Bipolar Depression Psychotic features Younger age of onset (under 25) Family history Antidepressant induced mania or hypomania Seasonality Atypical features Excessive sleepiness, weight gain, psychomotor retardation ALWAYS SCREEN FOR A HISTORY OF MANIA OR HYPOMANIA Jane Pauley Journalist Image: Cyclothymic Disorder CYCLOTHYMIC DISORDER 2 years Numerous periods of periods with hypomanic symptoms that do not meet criteria for a manic or mixed episode Don t have to meet criteria for a hypomanic episode Numerous periods of depression that don t meet criteria for a major depressive episode After the two years, there may be manic, mixed or MD episodes In which case a diagnosis of bipolar I or II disorder is added 15-50% chance the person will develop bipolar I or II 4

5 Mood Stabilizers TREATMENT Lithium Exact MOA unknown, several theories exist Stabilizes glutamate uptake, enhances serotonin and norepinephrine in CNS Watch for toxicity Dehydration, NSAIDs (Level ) Symptoms: Severe tremor, stupor, confusion, ataxia, GI upset, Eliminated by kidneys BUN/Creatinine at baseline and every 2-3 months X 6 months, then every 6-12 months Hypothyroidism TSH/Free T4 at baseline and again in the first 6 months, then every 6-12 months Tremor Neurotoxicity delirium, encephalopathy Protective against suicide Mood Stabilizers Valproate (Depakote) Loading dose strategy in acute mania Anticonvulsant taper dose when discontinuing Metabolized by liver (Check liver function at baseline and monitor) Reduces irritability and aggression Side effects GI effects (most often at start of treatment and transient) Hair loss (early and treatment and usually transient) Sedation Tremor Weight gain PCOS Leukopenia and thrombocytopenia Teratogenic Rare pancreatitis Mood Stabilizers Lamotrigine (Lamictal) Anticonvulsant Maintenance therapy of Bipolar I Disorder Increases time to next mood episode No acute antimanic activity May help bipolar depression Dose titrated very slowly over 8 weeks due to rare Stevens- Johnson Syndrome Cut dose in half if given with valproate Increase dose if given with carbamazepine or oxcarbazepine Side effects: Rash SJS (0.02%), benign rashes, systemic hypersensitivity If rash develops, stop drug immediately and seek medical attention Headache, nausea, dizziness Weight neutral Second Generation Antipsychotics All are approved for acute mania (except clozapine and lurasidone) and psychosis Lurasidone, quetiapine, and olanzapine indicated for bipolar depression Many can also be used for acute agitation Several available in long acting injectable formulations Side effects EPS Tardive dyskinesia Metabolic side effects Weight gain, diabetes, dyslipidemia Hyperprolactinemia Antidepressants Can be helpful for bipolar depression But may induce manic/mixed episodes olanzapine/fluoxetine (Symbyax) paroxetine and bupropion may be least harmful 5

6 References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Black, M.D, Donald, and Nancy Andreasen, M.D., Ph.D. Introductory Textbook of Psychiatry. 5th Ed. Washington, DC: American Psychiatric Publishing, Inc., Print. Cuellar, Amy, Sheri Johnson, and Ray Winters. "Distinctions Between Bipolar and Unipolar Depression." Clinical Psychology Review. (2005): Print. Julien, Robert, Claire Advokat, and Joseph Comaty. A Primer of Drug Action. 11th Ed. New York, NY.: Worth Publishers, Print. Kaye, Neil. "Is Your Depressed Patient Bipolar?." Journal of the American Board of Family Medicine (2005): Print. Sadock, MD, Benjamin, and Virginia Sadock, MD. Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins, Print. Schatzberg, MD, Alan, and Charles Nemeroff, MD, Ph.D. Essentials of Clinical Psychopharmacology. 3rd Ed. Washington, DC: American Psychiatric Publishing, Inc., Print. Stovall, Jeffrey, Paul Keck, and David Solomon. "Bipolar Disorder in Adults: Pharmacotherapy for Acute Depression." UpToDate. (2014): n. page. Web. 11 Mar

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