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Flashcards in Psych - Bipolar Deck (21):
1

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

2

BPD Definition

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!

3

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

Obstetrical complications

Season of Birth! SPRING and WINTER

Traumatic Brain Injuries

Multiple Sclerosis

Epilepsy

Seafood consumption LOWERS RISK!

4

Describe MANIA

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!!!

5

Manic Triggers

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

6

HYPOMANIA

Lasts at least 4 days

Not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, no psychotic features

7

MIXED EPISODES

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

8

Signs and Symptoms of Mania and Hypomania

3 or more:

Distractibility
Increased activity/psychomotor agitation
Gradiosity
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

9

Diagnosing BPD

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

10

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

11

Differential Dx for BPD

Other mood disorders

Primary psychotic disorders (schizophrenia)

Personality Disorders (patients with poor emotional control)

ADHD

Substance intoxication/withdrawal

Neuro conditions

12

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

13

Schizoaffective Disorder

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

14

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

15

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

16

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

17

ECT

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

18

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!

19

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!

20

Maintenance Treatment

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

21

STEP-BD Study

Found that less than 1/3 of symptomatic BPD patients reach recovery and remain well over 2 years!!!

Highly recurrent disorder; recovery achieved only 58.5% of the time

No difference in giving an antidepressant as an adjunct to the mood stabilizer

Drugs just aren't that effective

All intensive therapies (CBT, intrapersonal, social rhythm therapy) were similar, and more successful than superficial care (collaborative care)