Bipolar disorder Flashcards
Manic episode - DSM V criteria
At Least 1 Week Duration Elevated mood (+3 other sx) or Irritable mood (+4 other sx)
Additional Symptoms:
- Decreased NEED for sleep
- Grandiosity
- Pressured speech
- Increased goal directed activity
- Flight of ideas/racing thoughts
- Distractibility
- Risky behavior
Hypomanic vs. manic episode
- Hypomanic episode: less severe
- Hypomanic episode: shorter duration
- During a manic episode, pt may have psychotic symptoms
- Hypomanic pts do NOT have psychotic symptoms
With mixed features
Patient has symptoms of both a manic or hypomanic episode with concurrent depressive symptoms at the same time
- duration of at least 1 week
Rapid cycling
Rapid cycling refers to a Bipolar I or II disorder in which 4 or more mood episodes occur in a year
- 70-90% of rapid cyclers are female
- More common in bipolar II vs. bipolar I
- May be triggered by antidepressants, or by lithium-induced hypothyroidism
- *60-90% of patients with rapid cycling BPAD have hypothyroidism
- Worse prognosis overall
Things to rule out before diagnosing any mood episode
Substance Abuse
- Acute cocaine intoxication can look like mania or psychosis or an anxiety disorder –> After the high wears off, patients may appear depressed
- Heroin intoxication can look like depression or cognitive deficit
- Heroin withdrawal may look like an anxiety disorder or even hypomania
- ETOH withdrawal can look like an anxiety disorder, mania, hypomania or psychosis
Co-morbid Medical conditions
- Hyperthyroidism
- Complex Partial Seizure
- MS
- SLE
- Any cause of delirium
- Syphilis
- Head trauma
- Cushing’s syndrome
- HIV encephalitis, hypoglycemia, hypoxia…
Medication side effects
- Antidepressants
- Prednisone and other steroids
- Stimulants
- Dopaminergic Agents
- Many More…
Personality disorder
Secondary Gain
Bipolar I disorder - epidemiology
- Lifetime prevalence of BPAD type I in the general population ~0.6%
- Women=Men, but the disorder affects each differently:
- Women are more likely to be rapid cyclers, have mixed states, and have more depressive episodes
- 10-15% of patients with an initial diagnosis of unipolar depression will eventually receive a revised diagnosis of bipolar disorder
- Average age of onset ~18 y.o.
- Rare after 5th decade (be sure you haven’t missed another medical illness as the cause)
BPAD I - clinical course
- 75% of women with bipolar have depressive episodes before their first manic episode
- 67% of men with bipolar have depressive episodes before their first manic episode
- 10-20% of bipolar patients only experience manic episodes
- An untreated manic episode lasts ~3 months
- An untreated bipolar depression lasts ~6-12 months
- Untreated mixed episodes last approx. 6 months
- Patients have a variable number of lifetime mood episodes, with the mean number of 9
- 60% of manic episodes occur directly before a major depressive episode
- 40-50% of bipolar I patients may have a second manic episode within 2 years of the first episode
- 5-15% of bipolar patients are rapid cyclers
- 50-60% of bipolar patients achieve significant control with their symptoms while on lithium
- 36% of patients attempt suicide
- 10-19% suicide completion rate
- 60% of bipolar patients develop a substance problem
- Patients do not usually have insight into their symptoms during an acute manic episode
- Patients tend to have more insight during a depressive episode
Co-morbidities
- 60% have substance use disorders
- 75% have anxiety disorders
- > 50% have alcohol use disorder (which increases their risk for suicide)
BPAD I - genetics
There is a stronger genetic component with bipolar vs. MDD
- 10x increased risk of BPAD in relatives of patients with BPAD I or II
- 50% of all Bipolar patients have at least one parent with a mood disorder (most often MDD)
- If one parent has a bipolar mood disorder, the risk that a child will have unipolar or bipolar disorder is ~25%
- If both parents have mood disorders, the risk is 50-75%
Concordance rates for BPAD
- Monozygotic twins: 33-90%
- Dizygotic twins: 5-25%
Genetic markers have been reported on chromosome 5, 11, 18 and X, among others
Bipolar disorder causes
Several theories
- Not one single cause, but rather several factors that play into illness development
- NE or Dopamine abnormalities ?
- Abnormalities in the second messenger systems ?
- Infectious cause ?
- Amino Acid abnormalities (Glutamate and Glycine) ?
- 10% of patients with BPAD have an abnormal release of TSH in response to TRH infusion
- May be an association between rapid cycling and hypothyroidism
- Somatostatin may be decreased in CSF of depressed patients, but increased in manic patients
- Some association with large ventricles and bipolar
BPAD II - epidemiology
Lifetime prevalence of BPAD type II in the U.S. = 0.8%
Age of onset is ~20 yrs old (LATER than BPAD type I)
BPAD II - clinical course
- 12% of patients originally dx with MDD later develop BPAD type II
- 5-15% of patients eventually develop a full-blown manic episode –> dx becomes BPAD type I
- More lifetime mood episodes than BPAD type I
- Depressive episodes are more frequent than hypomanic episodes, and get more disabling over time
- 5-15% of BPAD type II patients are rapid cyclers
Co-morbidities
- Anxiety disorder (75%)
- Substance use disorder (37%)
- At least one lifetime eating disorder (14%, binge eating > bulimia or anorexia)
Suicide
- 1/3 of patients attempt suicide (similar to BPAD type I patients)
- lethality of suicide attempts is higher in BPAD type II than type I
Cyclothymia
Patients with cyclothymia have hypomanic periods and dysthymic periods, but never have symptoms severe enough to meet criteria for either mania, hypomania, or major depression
Sxs last for >2 yrs, without going for more than 2 months sx-free
- Lifetime prevalence: 0.4-1%
- Prevalence in psych clinics: 3-5%
- Female to male ratio is equal
- Age of onset is adolescence to early adult yrs
15-50% chance that symptoms will evolve into BPAD type I or II
Co-morbidities:
Borderline personality disorder
Substance use disorder
