Flashcards in Psych - Bipolar Deck (21):
Epidemiology of BPD
Affects 4% of the population
1% = BPD 1, 0.4% = BPD 2, 2.4% = BPD spectrum
M = F, Races = Other Races
Suicide Risk is about 20%!!!! Mixed or delusional states are more at risk
Mean Age of Onset = 21 for BPD1; peak symptoms = 15-19, 20-24
Linked to individuals with creative aptitude
Only 27% of people EVER GET TREATMENT
Characterized by alternating periods of MANIA and DEPRESSION
Usually manic episodes exhibit a much more abrupt onset than depressive episodes
Some manic episodes may progress over days or even HOURS, occurring more quickly as the QUANTITY OF EPISODES INCREASES
If left untreated, episodes of mania can PERSIST FOR 4-12 MONTHS --> try to identify the "prodrome" stage in treatment so we can fight it before it occurs!!!
Episods are precipitated by a SPECIFIC ENVIRONMENTAL TRIGGER -- sleep disruption, stress, pregnancy, incomplete remission of previous mania
RECURRENCE IS COMMON - life long treatment!
Risk factors for BPD
Family history -- first degree relative (5-10x more likely for BPD, 2x more likely for MDD)
Substance abuse --> BPD has the HIGHEST LIFETIME RATES --> 46% abuse alcohol (gen pop = 14%), 42% other drugs (gen pop = 6%)
--> confers a WORSE PROGNOSIS
Season of Birth! SPRING and WINTER
Traumatic Brain Injuries
Seafood consumption LOWERS RISK!
Period of abnormally and persistently elevated, expansive or irritable mood
Disturbances last at least one week, any duration if hospitalization is needed
Causes marked impairment in occupational or social function, or has PSYCHOTIC features
Untreated can last 4-12 months
Onset occurs more quickly as the QUANTITY of episodes increases
Episodes tend to be precipitated by a specific trigger!!!
Environmental --> pregnancy, sleep disruption, stressors, incomplete remission of mood elevation symptoms
Medical ---> ****antidepressants**** (critical in differentiating between this and UNIPOLAR depression), steroids, amphetamines
Brain Injury, endocrine disorders, HIV encephalitis, autoimmune disorders, metabolic disorders
Lasts at least 4 days
Not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, no psychotic features
Criteria are met for BOTH MANIA AND MAJOR DEPRESSIVE EPISODES
Often lasts much longer than manic episodes alone
Associated with poor recovery and greater cumulative morbidity
Signs and Symptoms of Mania and Hypomania
3 or more:
Increased activity/psychomotor agitation
Flight of ideas or racing thoughts
Activities that are pleasurable but potentially harmful
SLeep decreased (feel they don't need it!)
Talkative and Pressured Speech
Perception and sensation INCREASE
PSYCHOSIS (MANIA) --> 2/3 of BPD patients experience one psychotic symptom; delusions are 3x as likely as hallucinations, early age of onset cases are more likely to have psychotic features, psychosis is associated with greater severity of illness
All of these increase brain activity
Requires at least ONE period of mood elevation or significant irritability characteristic of a manic, mix, or hypomanic state
Despite common thinking, the presence of depressed periods is NOT REQUIRED FOR DIAGNOSIS
Subtypes of BPD
BPD 1 = HALLMARK is MANIC or MIXED MANIC (does NOT require MDD)
BPD 2 = Involves the presence of one or more MAJOR depressive episodes AND the presence of one hypomanic episode
CYCLOTHYMIA = Characterized by ongoing (2+ years) cycles of HYPOmania and DEPRESSIVE symptoms that aren't MDD --> never reach the same highs and lows but is still severely debilitating
BPD NOS --> seem to have BPD but DONT meet the diagnostic criteria
RAPID CYCLING --> subtype of BPD I/II where patients demonstrate at least FOUR EPISODES of a mood disturbance in a SHORT 12 MONTH SPAN
Manic depressant, manic, mixed, or hypomanic
Differential Dx for BPD
Other mood disorders
Primary psychotic disorders (schizophrenia)
Personality Disorders (patients with poor emotional control)
Genetics in BPD
Proportion of BPD risk attributed to genetics is 60-85%!!!!
Person with relative (1st degree) --> 8.7x more likely
Heritability is 40% for MZ, < 10 % for DZ twins
Experience PSYCHOSIS and are plagued by mood disturbances
Their psychosis DOES NOT HAVE TO BE IN LINE WITH THEIR MANIC EPISODES - in fact, partly defined by "delusions or hallucinations for at least a 2 week span in the ABSENCE of prominent mood symptoms"
This is important to distinguish the psychosis from BPD and Schizoaffective Disorder
Neurobiological Theories of BPD
HPA Axis --> HPA axis and the abnormal stress response is involved in both depression and BPD --> certain endocrine disorders (Cushing's) and steroids can cause mania
----> Additionally, BPD patients have higher cortisol levels than unipolar people
Hypothalamic-Pituitary-THYROID axis --> in some patients with BPD, TSH levels are elevated and giving TRH causes an exaggerated TSH response; leads to an elevated basal rate of TSH
Catecholamine hypothesis of affective disorders --> depression is associated with reduced catecholamines; mania is due to INCREASED CATECHOLAMINES
Signal Transduction pathway --> Many G-proteins use the PIP2 --> DAG and IP3 transduction pathway
Lithium BLOCKS inosital monophosphatase and hence the conversion of inosital monophoshphate to inositol; REDUCES inositol by inhibiting its cycling --> phosphoinositide system must be messed up in BPD
What parts of the brain are messed up in BPD?
Modulation of the anterior limbic (amygdala, striatum, thalamus) are prefrontal circuit is ABNORMAL in BPD
Emotional reactivity (including impulses) is controlled by the prefrontal cortex
Abnormalities in these circuits (between the emotional limbic and controlling/logical prefrontal cortex) contribute to BPD
Drugs for BPD
ACUTE MANIC EPISODES --> MOOD STABILIZERS -- a patient may respond to one med or need multiple/combinations = FIRST LINE TREATMENT
****LITHIUM and VALPROIC ACID --> take a long time to work, but effective*****
Others = Carbamazepine, LAMOTRIGINE (first line for BP DEPRESSION)
NEUROLEPTICS (ATYPICALS) --> indicated for 3 situations:
To treat ACUTE MANIC EPISODES (or mixed)
To treat PSYCHOTIC SYMPTOMS
When patients DO NOT RESPOND TO MOOD STABILIZERS ALONE
Aripiprazole, Olanzapine, Quetiapine, Risperidone, Ziprasidone
COMPLIANCE IS A PROBLEM
SUPERIOR TO LITHIUM in terms of effectiveness, but it is associated with some cognitive side effects, and there is also a negative association with it in general; not first line
Psychotherapy in BPD
NOT FOR ACUTE EPISODES!!!!!
Focuses on maintaining therapeutic alliance, improving insight, monitoring treatment response, psychoeducation for patient and family
As symptoms remit, there is more focus on education, awareness of stressors, sleep hygiene, identifying harbingers of relapse!
How do we treat ACUTE DEPRESSIVE episodes?
Antidepressants can make a depressed Bipolar patient WORSE!!! They can switch a patient into mania/hypomania; basically they DESTABILIZE MOOD and cause more episodes in the long term!!!
MOOD STABILIZERS ARE FIRST LINE FOR ACUTE EPISODES TOO!!! Lithium has an inherent anti-depressant effect
Some atypicals could be useful
Lamotrigine is another mood-stabilizer than can work!
Aside from treating acute manic and acute depression episodes, Bipolar is a RECURRENT, LIFELONG disease --> one episode will NOT be the last and patients NEED to be on long-term treatment
Could be a hard-sell for younger patients!
LITHIUM, VALPROATE, CARBAMAZEPINE, LAMOTRIGINE, QUETIAPINE, ARIPIPRAZOLE, OLANZAPINE