Sheila Ward APRN Norton Women s Counseling Louisville KY Sheila.ward@nortonhealthcare.org Bipolar Historically under-diagnosed Historically misdiagnosed Major Depression 10 years to Diagnosis Diagnosis doubling in the last decade among adults 40-fold among children and adolescents Bipolar-- What it is Manic Episode Distinct period of abnormally and persistently elevated or irritable mood and abnormally and persistently increased goal-directed activity or energy With 3 (or 4 for irritable type) Inflated self-esteem Decreased need for sleep Flight of ideas Distractibility Increase in activity Doing stupid things New in DSM-5 Bipolar 1 Bipolar 2 Psychosis and lifetime experience of Major Depression are not requirements for Bipolar 1 Requires 1 week of mania or hospitalization Episode of Major Depression is required Bipolar (soft bipolar) is no longer considered to be a milder form of bipolar illness More DSM-5 News Now include both changes in mood and changes in activity or energy Mixed Type deleted Specifiers with mixed df features and d anxious distress added MDQ A screening tool for bipolar disorder (Hirschfeld 2000) Positive screen just as likely to have Borderline Personality Disorder (Zimmerman 2010) In primary care settings, the MDQ could ldbe useful lin identifying patients who should be referred for further psychiatric evaluation. Mark Zimmerman, Janine N. Galione, Camilo J. Ruggero, Iwona Chelminski, Kristy Dalrymple, and Diane Young Comprehensive Psychiatry, 2011-11-01, Volume 52, Issue 6, Pages 600-606 1
Generalized Anxiety Disorder Excessive worry about everything Uncontrollable worry Three or more Restless, on edge Fatigue Poor concentration (racing mind) Muscle tension (headache, GI sx, body pain) Sleep disturbance Irritable Impairment in function A qualifying event Combat Rape Childhood Sexual Abuse Domestic Violence MVA Surgical Trauma Childbirth Trauma Witness to violence Vicarious Trauma Repressed Trauma-Unremembered Intrusive Symptoms (1) Bad memories of a traumatic event Nightmares Flashbacks (re-living the traumatic event) Feeling stressed from reminders of the traumatic event Panic symptoms (heart racing, shaking, difficulty breathing, choking) Hyper-Arousal Symptoms (2) Difficulty falling or staying asleep Irritability Outbursts of anger! Difficulty concentrating Feeling alert or watchful when there is no need to be Jump or startle easily, for no reason Avoidant Symptoms (3) Avoiding thoughts, feelings, or conversations about it Avoiding activities, places or people that remind you of it Difficulty remembering details of it Loss of interest or pleasure in normal activities Feeling distant or cut off from others Difficulty feeling normal feelings such as love and happiness Feeling that the future will be cut short Does what happened to you cause you a lot stress, or damage your relationships, employment, or other important things in your life? 2
Panic Disorder ADHD Inattentive Hyperactive Impulsive Fidgets Can t sit still Restlessness Can t be quiet Talks excessively On the go, driven by a motor Blurts out Difficulty waiting turn Interrupts others Personality Disorders Cluster B as in Bad Antisocial Pervasive pattern of disregard Fil Failure to conform Deceitful Impulsivity Irritable and aggressive Reckless Irresponsible Lack Remorse Narcissistic Grandiosity Fantasies of success Special Requires Admiration Sense of entitlement Exploitative Lacks empathy Envious Arrogant Cluster B Girls Borderline Abandonment Unstable relationships Identity Disturbance Impulsivity Recurrent suicidal acts Mood swings! Emptiness Intense Anger Paranoia or Dissociation Histrionic Persistent pattern of excessive emotionality and attention seeking Center of Attention Sexually seductive Rapidly shifting emotions Physical appearance to draw attention Impressionistic Speech Theatrical Suggestible Exaggerates relationships Schizoaffective Disorder Continue to have psychotic symptoms between episodes of mania and depression One of my people Candy 18 y.o. Presents with hx of BP Aged out of state system Unknown father Raised by MGM, foster home Hx of childhood sexual abuse Fighting, Drugging, D.V. Legal issues Boy Friend incarcerated Wants to know can I write a letter for SSID 3
Candy Chief Complaint Bipolar and Bad nerves Wants Xanax (Mom has bipolar and she gets Xanax) Works great, makes her feel normal!!! Pertinent History No clear history of manic episode Tantrums Family history??? Has nightmares, flashbacks, outbursts, poor concentration, Sad, low appetite, tired, and can t keep up with anything anymore. Differentials for Candy CD Borderline Personality Disorder ADD Bipolar Disorder Then what happened? Lost to care Wanted bipolar dx for SSI, angry Wanted Xanax, didn t get it I could get this crap from anybody Another one of mine Gina 26 y.0. Presents with female partner I cannot ttake these moods! I don t know who will wake up with me, the one I love or the hateful one. Artist PCOS Clinical Course Dx Bipolar Discontinued SSRI (weaned) Mood Stabilizers Gave up after a year More history recurrent depression, no manic but a lot of irritable moods No trauma no qualifying event Normal dysfunctional family PMS Back to SSRIs, some better Clinical Course Consideration of personality disorder (Zimmerman 2010) Borderline screening Bingo! Patient Resistance/Denial No Access to DBT Partner self studied Partner identifies ADD Stimulant trial Another Bingo Current therapies Celexa 40/60 Trazodone Ritalin Continuous method OCP Obama Care=Insurance and DBT!!! 4
DBT Behavioral Treatment for Borderline and other Marcia Lindehan 100% Validation Distress Tolerance Mindfullness Coping Skills Keri 24 y, o. History of recent seizure onset Opioid abuse Episodes of not myself Does not sleep or eat Sort of buzzing feeling Ideas are out there Thought are warp speed Pacing a lot Several day duration Sometimes not when using Keri Social Lives with parents Going to college hx of flunking out, starting over Feels guilty for depending on parents Gets very uncomfortable in class when called upon, palpatations, assumes everyone thinks is a f up. No girlfriend, ever Kirk Work up BDI II 39 with no SI (depressed) Beck Anxiety Scale 44 Severe anxiety Tox Negative Family confirms manic Rule out personality Disorders Rule out Rule out ADD Diagnosis Opioid Abuse Bipolar 1 Social Anxiety Disorder Treatment so far Seroquel IR 200 mg Seroquel XR 600 mg Metoprolol for social anxiety Lithium starting after another manic episode probably triggered by stress of a new job Referral to Addiction medicine consult in LA. A Typical Case Starla 40 y.o. at 20 weeks gest Dx bipolar by former psychiatrist On Lamictal 400 and abilify Intention to breastfeed Marital Conflict (understatement) Stayed on meds throughout pregnancy and lactation Manic episodes???? 5
Next chapter 4 years later 2 months postpartum at 44 y.o. CPS requiring psych care Verbal abuse of older child Still on bipolar meds Borderline screening +/- Court ordered psychiatrist Dx borderline Privately secured second opinion Dx Histrionic Personality DO I fired her for mistreating staff Do Over Question the Bipolar Dx Screen for personality DO Set limits on behaviors tolerated No special treatment No meds DBT Get a different job! Case Example Dominique 24 y.o. Army Private Episode in Vehicle Fl Felt trapped Too hot Felt out of body No recall Inappropriate behavior Transferred to psych Diagnosed with Bipolar Disorder History / Work-up/ Treatment No manic criteria Personality screening neg Has some Cluster B traits (dissociation, mood instability, Center of attention issues) High strung individual Hx of childhood sexual abuse Dose not meet criteria for Diagnosis = Panic Disorder DBT still advised along with Rx for anxiety Resources Upshot Never accept a prior history Dx of Bipolar Assume it is wrong until criteria met Use Depression NOS, or Mood Swings, or Insomnia Never Dx bipolar until all differentials ruled out Always assume you can be wrong Antidepressants could be wrong drug Lamotrigine is never wrong unless it s wrong Use standardized scales and assessment tools Get an easier job! 6