MOOD DISORDERS PART II BIPOLAR AFFECTIVE DISORDER (BAD) Todd Stull, M.D. James Sorrell, M.D.

BIPOLAR AFFECTIVE DISORDER (BAD) General Assessment is challenging Input important Change in level of functioning Communication Std diagnosis Limitations ID function at different developmental stage Diagnostic equivalents

BAD DX Often missed Depressed Years to figure out Associated with other medical problems Communication skills Psychosocial masking Cognitive limitations More medical comorbidity

BIPOLAR AFFECTIVE DISORDER Demographics Male = Female 2% of population 10-12% spectrum Average age onset 21 (15-24) childhood to 50 Runs in families 7X to develop Triggers

BAD Criteria for Manic Episode (DSM-IV, p. 332) A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). B. 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: inflated self-esteem or grandiosity decreased need for sleep (e.g., feels rested after only 3 hours of sleep) more talkative than usual or pressure to keep talking flight of ideas or subjective experience that thoughts are racing distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

BAD-MANIA increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) C. The symptoms do not meet criteria for a Mixed Episode. D. 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. E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatments) or a general medical condition (e.g., hyperthyroidism). Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.

BAD-MIXED Criteria for Mixed Episode (DSM-IV, p. 335) A. 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. B. 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. C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

PHASES OF BIPOLAR DISORDER

BAD-CLASSIC PRESENTATION A state of increase energy or drive Psychomotor agitation (hyperactivity) Irritable, elevated or grandiose mood Impulsivity Mood lability-wide range/quick shifts Racing of fast thoughts/jumping topics cluttered thoughts

BAD-CLASSIC PRESENTATION Driven or perseverative thoughts can look like obsessive thoughts or compulsive behaviors Pressured speech- increases rate, volume, quantity or frequency of speech Amplified anxiety/worry/panic/excitability Increase in reactivity to stressors Increased smiling and laughter Hypersexuality, hyper other states

BAD-MANIA IN INDIVIDUALS WITH ID Presenting Symptoms (most common) Irritable mood Labile affect Mood swings Overactivity (rapid cycling) Distractible Decreased sleep Vocalization/gesture changes

BAD-MANIC ID Presentation As ID becomes more severe, symptoms are less classic Cognitive sx less common in Severe/Profound ID Grandiosity Inflated self esteem

BAD-MANIA Rule out. Medical Problems Substance Induced Drugs Medications Induced Side effects disinhibition Other Psychiatric Dx Antipsychotic withdrawal syndrome Task/situation related anxiety

BAD IN ID Other features More psychotic sx in ID More functionally impaired Aggression SIB Disruptive behaviors Behaviors more severe with severe and profound ID Somatic complaints

REMEMBER Partial syndromes are more common Mixed states are more prevalent that pure Observation important Tracking BAD

STANDARD MEDICATIONS Lithium Valproate/Depakote Carbamazepine/Tegretol Lamotrigine/Lamictal OTHER MEDICATIONS Oxcarbamazepine/Trileptal Gabapentin/Neurontin Keppra Topirmate/Topamax Zonegran Lyrica TREATMENT MOOD STABILIZERS

LITHIUM SIDE EFFECTS Loss of coordination Excessive thirst Frequent urination Blackouts and Seizures Slurred speech Fast, slow, irregular, or pounding heartbeat Hallucinations Changes in vision Itching, rash Thyroid Problems

VALPROIC ACID (DEPAKOTE) SIDE EFFECTS Changes in weight Nausea Stomach pain Vomiting Anorexia Loss of appetite Valproic acid may cause damage to the liver or pancreas and lower platelets

COMMON Dizziness Drowsiness Unsteadiness Nausea Vomiting RARE BUT MORE SERIOUS Liver impairment Anemia Low sodium TEGRETOL SIDE EFFECTS

ANTIPSYCHOTICS OR SEROTONIN DOPAMINE ANTAGONISTS = ATYPICALS Olanzapine (Zyprexa) Aripiprazole (Abilify) Risperidone (Risperdal) & Paliperidone (Invega) Ziprasidone (Geodon) Clozapine (Clorazil) Quetiapine (Seroquel) 1 st generation = Typicals Haldol, Thorazine, Mellaril

ANTIPSYCHOTIC SIDE EFFECTS Drowsiness Dizziness and Blurred vision Rapid heartbeat Sensitivity to the sun and Skin rashes Menstrual problems for women Atypical antipsychotic medications can the METABOLIC SYNDROME Typical antipsychotic medications can cause side effects related to physical movement, such as: Rigidity Muscle spasms Tremors Restlessness

ANTIDEPRESSANTS Fluoxetine (Prozac) Citalopram (Celexa & Lexapro) Sertraline (Zoloft) Paroxetine (Paxil) Venlafaxine (Effexor & Pristiq) Duloxetine (Cymbalta) Bupropion (Wellbutrin) TCA: Elavil, Tofranil

ANTIDEPRESSANT SIDE EFFECTS Headache-usually goes away in a few days. Nausea which usually goes away in a few days. Sleeplessness or drowsiness Agitation - jittery Sexual problems

BENZODIAZEPINES = ANTIANXIETY Clonazepam (Klonopin) Lorazepam (Ativan) Alprazolam (Xanax) Diazepam (Valium)

BENZODIAZEPINES SIDE EFFECTS Upset stomach Blurred vision Headache Confusion Grogginess Nightmares

MEDICATION TENETS Mood stabilizer is backbone of treatment Benzodiazepines often added early for mania Antipsychotics and antidepressants often used but controversial

RATE OF IMPROVEMENT Days to weeks TARGET SYMPTOMS TO MONITOR Mood/irritability Speech Aggression Activity Sleep Movement patterns Task attention span MEDICATION TARGETS

BACKBONE TO PSYCHOSOCIAL TREATMENT Monitoring Symptoms Response to treatment Triggers Psychotherapy family-focused therapy, which required the participation and input of patients family members and focused on enhancing family coping, communication and problem-solving; cognitive behavioral therapy, which focused on helping the patient understand distortions in thinking and activity, and learn new ways of coping with the illness; and interpersonal and social rhythm therapy, which focused on helping the patient stabilize his or her daily routines and sleep/wake cycles, and solve key relationship problems