Bipolar Disorder

Question 1

Cyclothymia (or Cyclothymic Disorder), general

Answer 1

Cycle for 2 years in adults, or 1 year in children, between hypomania and PDD

Pattern is irregular and unpredictable

Low and high mood swings never reach the severity of major depression or full mania.

Hypomania or depression can last for days or weeks. In between up and down moods, a person might have normal moods for more than a month – or may cycle continuously from hypomanic to depressed, with no normal period in between

Question 2

Manic Episode, Sign vs Symptom

Answer 2

Sign = what can be seen
e.g. flight of ideas

Symptom = what is reported
May include delusions and hallucinations, racing thoughts

Question 3

Manic Episode

DSM-5 Criteria

Answer 3

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

*If hospitalization is necessary, duration is irrelevant

B:
During period of mood disturbance,3 or more of the following (4 if mood is only irritable):

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 (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
   * e.g. unrestrained buying sprees; sexual indiscretion; foolish business investments

Question 4

Bipolar with psychotic features vs. schizophrenia (SZ)

Answer 4

In SZ, delusions/hallucinations occur in the absence of mood symptoms for more than 2 weeks

Question 5

Anxious Distress Specifier

DSM 5

Answer 5

High levels of anxiety have been associated with higher suicide risk, longer duration of illness, and greater likelihood of treatment nonresponse

Intended to identify patients with anxiety symptoms that are not part of the bipolar diagnostic criteria

1. Feeling keyed up or tense
2. Feeling unusually restless
3. Difficulty concentrating because of worry
4. Fear that something awful might happen
5. Feeling that the individual might lose control of himself or herself

Question 6

Bipolar II Disorder

Answer 6

At least one episode of hypomania: must last 4 days min.

At least one episode of major depression

Dx :
Individual must never have experienced a full manic episode

~25% of all bipolar cases

Rapid cycling pattern is associated with a poorer prognosis

Question 7

Hypomania

Answer 7

Sustained state of elevated or irritable mood

Less severe than mania

Does not significantly impact quality of life

Unlike mania, hypomania is not associated with psychosis

Question 8

Bipolar I vs. Bipolar II

Depressive Episodes

Answer 8

Bipolar II:
*More common in females
(BP-I 50/50)

• More frequent depressive episodes and shorter intervals of well-being than BP-I
• More chronic and consists of more frequent cycling than the course of bipolar I
• Associated with a greater risk of suicidal thoughts and behaviors than bipolar I or unipolar depression
• Although bipolar II is commonly perceived to be a milder form of Type I, this is not the case.
• Types I and II present equally severe burdens

Question 9

Pharmacotherapy: Tricyclics

Answer 9

Effective as SSRIs but with more side effects

anticholinergic effects = blurred vision, constipation, weight gain

toxic in high quantities

dangerous with suicidal patients, easy to overdose

Question 10

Pharmacotherapy: SSRIs effectiveness

Answer 10

No more effective than tricyclics

~30% success rate

Question 11

Pharmacotherapy: Lithium

Answer 11

The lethal and therapeutic dosage are not that different: risk of toxicity

Question 12

Pharmacotherapy: Anticonvulsants

Answer 12

Depakote – most commonly prescribed anticonvulsant for bipolar disorder
• Prescribed if an individual does not respond well to lithium

Lamictal is also commonly prescribed, but may cause Steven-Johnson syndrome (A lethal rash)

Question 13

Pharmacotherapy: Antipsychotics

Answer 13

Typically, a second-line of defense

Used to balance mood

These drugs work well, but are accompanied by a range of side effects

Question 14

Mayberg: research predictive pharmacotherapy efficacy

Answer 14

Bromin’s area 25

More activation, medication leads to a better outcome

Less activation, CBT works better than meds

Question 15

ECT

Answer 15

Electroconvulsive Therapy

Typically used in elderly, non-responsive, populations

Seizure is therapeutic

Applied to the non-dominant hemisphere

Treatment should be apparent in 2-4 weeks

Side effects:

• transient amnesia
• general confusion

Question 16

ECT Most effective Course

Answer 16

Meds before ECT

CBT or drugs after
• Helps decrease relapse rate of depression

May help promote neurogenesis and increase serotonin

Question 17

Transcranial Magnetic Stimulation (TMS)

Answer 17

Not as effective as ECT in treating depression with psychotic features

Treatment focuses on the dorsolateral prefrontal cortex

Question 18

Vagus Nerve Stimulation

Answer 18

Involves sending small electric pulses to the neck

Question 19

Bipolar Spectrum: Onset

Answer 19

Early 20s

Earlier onset than typical for depression (mid to late 20s)

Question 20

Bipolar Spectrum: Duration mania vs depression

Answer 20

For ALL bipolar diagnoses:
depression lasts 3x longer than mania

Applies to both genders

Question 21

Bipolar Spectrum: Genetics

Answer 21

Bigger role than in depression

MZ twins:

Depression, 4x greater chance

Bipolar, 80% chance

Question 22

Bipolar Spectrum: Neurotransmitters

Answer 22

Interaction and combination of:
serotonin
dopamine
norepinephrine

Transmitters linked with MOTIVATION AND CONCENTRATION

Question 23

Bipolar Spectrum: Permissive Hypothesis

Answer 23

Decrease in serotonin leads to the deregulation of norepinephrine and dopamine

Question 24

Bipolar Spectrum: Disruption of Sodium Ions

Answer 24

Malfunctioning ion channels due to faulty proteins:

Decrease of Na+ ions leads to sluggish behavior

Increase of Na+ ions leads to mania

*potentially resolved via regulation of potassium

Question 25

Bipolar Spectrum: Thyroid

Answer 25

Thyroid Deregulation Greater link to bipolar than unipolar

Question 26

Hypomania | DSM-5 Criteria

Answer 26

* Episode is not severe enough to cause marked impairment in social or occupational functioning * If psychotic features, the episode is by definition manic A: A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, LASTING AT LEAST 4 CONSECUTIVE DAYS and present most of the day, nearly every day B: During period of mood disturbance,3 or more of the following (4 if mood is only irritable): 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 (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 * e.g. unrestrained buying sprees; sexual indiscretion; foolish business investments

Question 27

Bipolar II | DSM-5 Criteria

Answer 27

Hypomanic Episode (current or past--at least 4 days) AND Major Depressive Episode (current or past--at least 2 weeks)

Question 28

Cyclothymic Disorder | DSM-5 Criteria

Answer 28

A: At least 2 years (1 year children/adolescents) Numerous periods with hypomanic symptoms that do not meet criteria for hypomanic episode AND Numerous periods with depressive symptoms that do not meet criteria for a major depressive episode B: Hypomanic and depressive periods have been present for at least 1/2 the time Individual has not been without the symptoms for more than 2 months at a time * criteria for a major depressive, manic, or hypomanic episode have never been met * most children with cyclothymic disorder are more likely to have comorbid ADHD

Question 29

Bipolar Spectrum: Neuroanatomical Correlates

Answer 29

Asymmetrical hemispheric blood flow in bipolar disorder Decreased gray matter Altered activation patterns ``` Alterations to: PFC ACC Hippocampus Amygdala ```

Question 30

Bipolar Spectrum: Suicidality

Answer 30

Biggest risk: when depression just starts to alleviate • Individuals are still depressed but have more energy Loss of abstract thinking Lack of cognitive flexibility Concrete thinking only

Question 31

Mixed states

Answer 31

In a mixed state, the individual has co-occurring manic and depressive features, which can occur either simultaneously or in very short succession. Dysphoric mania is primarily manic Agitated depression is primarily depressed The mixed state can put a patient at greater suicide risk ``` Depression + Increased energy + Agitation + Impulsivity = higher risk of dangerous behavior, self-injury or suicide. ```

Question 32

Cyclothymia: Prevalence

Answer 32

Lifetime: 0.4% -- 1% equal male/female In Mood disorder clinics: 3%--5% Females more commonly present for tx Usually A diagnosis of Cyclothymia increases the chance of later being diagnosed with bipolar disorder More difficult to discover Cyclothymia than bipolar Individuals with Cyclothymia can still function in daily lives

Question 33

Cyclothymia: Course

Answer 33

15%--50% risk of developing Bipolar I or II later in life

Question 34

Bipolar Spectrum: Cortisol

Answer 34

Cortisol is elevated during both mania and depression phases, similar to unipolar

Question 35

DSM-5 Changes

Answer 35

Emphasis on changes in activity and energy as well as mood for hypomanic and manic episodes Anxious to stress specifier