Bipolar Disorder. Manic Episode

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1 Bipolar Disorder Manic Episode A distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least one week and including at least three of the following: inflated self-esteem or grandiosity decreased need for sleep pressure of speech flight of ideas (thoughts racing one after another) distractibility increase in goal-directed activity or psychomotor agitation excessive involvement in pleasurable activities with potential for negative consequences Hypomanic Episode less severe symptoms shorter duration (4 days) no suicidal ideas

2 Features Associated with Hypomania vividness of sensory perceptions increased activation of associational networks clarity of thought facility for rhyming and alliteration seemingly unbounded energy and enthusiasm feelings of wellbeing and expectation increased personal charisma sexual attractiveness dramatic gestures and vocalizations feelings of oneness with the universe feelings of invincibility may rapidly change from magnanimous to angry Mixed Episode Criteria for both mania and depression are met in the same episode (lasting at least one week) May evolve out of either a manic or a depressive episode or may arise de novo Usually includes agitation, insomnia, appetite dysregulation, psychotic features, and suicidal thinking Often requires hospitalization Bipolar I Disorder manic episodes or mixed episodes usually includes depression Bipolar II Disorder hypomanic episodes alternating with depressive episodes (Bipolar sufferers typically have 8-12 mood disturbances over lifetime) Rapid Cycling at least four episodes of mood disturbance within 12 months more common in women (70-90% rapid cyclers are women)

3 Two Possible Subtypes Paranoid/Destructive Primarily mixed episodes cycling with depression Black mania Euphoric/Grandiose Primarily manic episodes cycling with depression White mania Additional Subtypes of Bipolar (Not Recognized by DSM IV) Bipolar III cyclothymia Bipolar IV antidepressant-induced hypomania Bipolar V the individual meets the diagnostic criteria for major depression and there is a family history of Bipolar Disorder Bipolar VI the individual meets diagnostic criteria for manic episodes, but not any of the depressive conditions Leslie E. Packer, PhD, 2006 Bipolar Disorder episodes tend to come closer together over time typical age of onset is but can occur at any time childhood onset may involve hyperactivity, temper tantrums, hypersexuality on average it takes people with bipolar disorder 8 years to get proper diagnosis

4 Genetics and Bipolar Disorder Family Studies 1st degree relative of bipolar proband more likely to have either bipolar or unipolar depression Twin Studies MZ concordance = 69%, DZ concordance = 19% Offspring of twins discordant for bipolar (Bertelson & Gottesman, 1986) MZ affected unaffected 21% BP 25%BP DZ affected unaffected 14% BP 2%BP Adoption Studies higher rate of affective disorder (both Bipolar (24%) and unipolar (12)) in bio parents of probands vs adoptive parents Conclusion: There is a very strong genetic component in bipolar disorder Bipolar Disorder Structural and Functional Findings hyperintensities in periventricular areas (in white matter) abnormalities in basal ganglia involving dopamine transmission higher glucose metabolism in basal ganglia abnormalities in left (DLPFC) involving glutamate increased number of G-proteins in untreated patients

5 Etiology of Bipolar Disorder 1) neurotransmitter dysregulation 2) Calcium channel abnormalities 3) G-protein abnormalities Possible Triggers for Manic Episodes seasonal (summer) sleep deprivation circadian rhythm changes (travel, etc) bright light therapy antidepressant medication stimulant drugs thyroid gland dysfunction Treatments for Bipolar Disorder Mood Stabilizers lithium valproate (Depakote) carbemazepine (Tegretol) Neuroleptics (e.g., haldol) when psychotic symptoms are present Antidepressants (in conjunction with lithium) Omega-3 fatty acids

6 Treatments for Bipolar Disorder Cognitive Behavioral Therapy compliance with medication protocol damage control fear of future episodes self esteem family education Psychosocial factors may contribute 25-30% of outcome variance in BD Bipolar Disorder is a lifetime disease. There is no cure. The risk for suicide is great. In order to survive, those with Bipolar must remain on unpleasant medications. Mania has brought into my life a different level of sensing and feeling and thinking. Even when I have been most psychotic - delusional, hallucinating, frenzied - I have been aware of finding new corners in my mind and heart. Some of those corners were incredible and beautiful and took my breath away and made me feel as though I could die right then and the images would sustain me. Some of them were grotesque and ugly and I never wanted to know they were there or to see them again. But, always, there were those new corners...i cannot imagine becoming jaded to life, because I know of those limitless corners, with their limitless views. Kay Redfield Jamison An Unquiet Mind

7 Suicide Suicide - Some Numbers... More than 30,000 Americans complete suicide each year (1 every 20 minutes) 400,000 uncompleted attempts per year 80% of these are related to an affective disorder Suicide rate for year olds has tripled since 1950 Common methods: (in order of frequency) handguns drug overdose cutting/stabbing jumping inhalation hanging drowning according to Jamison (1999), for men and women (15-44) worldwide: suicide is 2nd most frequent cause of death for women suiced is 4th most frequent cause of death for men Suicide with Different Motives (Schneidman, 1963, 1981, 1993) Death seekers clearly and explicitly seek to end their lives planful impulsive Death initiators clear intention to die but are hastening the inevitable with fatal illness or AIDS Death ignorers intend to end life to go to a better place mass suicides of cults suicide bombers Death darers ambivalent about dying, may enjoy thrill of risk Russian Roulette or take pills then call a friend

8 Types of suicide Euthanasia / Assisted suicide Murder-suicide Suicide bombing Ritual suicide Cult suicide Mass suicide Suicide pact Internet suicide Copycat suicide Forced suicide Suicide by cop Risk Factors Mood disorder Schizophrenia Alcoholism Prior attempt(s) (increases risk 1,500 x) Use of lethal method (gun or hanging) Social isolation, rejection Hopelessness Older white male Modeling Work problems, unemployment Marital, sexual problems Negative life event Anger, impulsivity Physical illness How about SSRIs? The SSRI Debate

9 Protective Factors Large social network Marriage Calm mood state Happy mood state Social supports Father s sociability Mother s sociability Mother s acceptance High ego strength High self-esteem Religiosity Signs to Watch for sudden change in mood life event that would be considered very stressful change in eating or sleeping patterns quits going to classes or out with friends gives away things that are personally meaningful talks about death or suicide talks about celebs that you know have committed suicide washes far more frequently than usual expresses excessive guilt increases use of substances talks of loneliness, rejection, or alienation When a friend is suicidal Take your friend or family member seriously. Don t promise confidentiality. Involve other people. Contact MH professionals working with the person. Listen attentively. Express your concern. Ask direct questions about suicidal intentions. Acknowledge the person s feelings. Reassure them that things will become better. Suicide is a permanent solution to a temporary problem. If possible, don t leave the person alone until the person is safe. guidelines from the National Depressive and Manic Depressive Association (1996)