bipolar disorder stephanie b. boyd, ph.d. october 2012
TRANSCRIPT
BIPOLAR DISORDER
Stephanie B. Boyd, Ph.D.
October 2012
What do you think of when you hear a
person has BIPOLAR Disorder?
? ? ? ? ?
Story of Bipolar
http://www.youtube.com/watch?v=Q_XWa0BVcuw
DSM – IV Criteria
Major Depressive Episodes: Persistence of either depressed mood or marked loss of interest in most activities for a period of at least 2 weeks. The episode is associated with at least 5 symptoms that , in addition to depressed mood and loss of pleasure, consist of: Significant weight loss when not dieting, or weight gain (5% in a month), or decrease or increase in
appetite nearly every day Insomnia or hypersomnia nearly every day Psychomotor agitation or retardation nearly every day Fatigue or loss of energy nearly every day Feelings of worthlessness or excessive or inappropriate, guilt nearly every day Persistent diminished ability to think or concentrate, or indecisiveness Recurrent thoughts of death or suicide ideation
Mania: There must be evidence for a distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week. During the period of mood disturbance, 3 (or more) of the following symptoms have persisted and have been present to a significant degree: Inflated self-esteem or grandiosity Decrease need for sleep More talkative than usual and under pressure to keep talking: (
http://www.youtube.com/watch?v=F_YPZt7CuNY ) Flighty ideas or subjective experience that thoughts are racing Distractibility Increase in goal-directed activity (work, school, or sexuality) or psychomotor agitation Excessive involvement in pleasurable activities that have a high potential for painful consequences
Subtypes of Bipolar
Bipolar I : a single manic or mixed episode
Bipolar II : major depressive episodes alternating with hypomanic episodes
Cyclothymia : 2 or more years of alterations between hypomanic and depressive symptoms but not meeting severity criteria
Bipolar Disorder (NOS) : meets criteria of symptoms from DSM, but not duration
Rapid Cycler : 4 or more distinct episodes in 1 year
Secondary Mania: bipolar symptoms induced in association with focal brain injury (usually in right-hemisphere lesions and lesions to the limbic system)
Recurrence / Recovery
Recurrence : 1st year – 37% 2nd year – 60% 5th year – 73% Recurrence has been linked to life stressors;
particularly family negativity and hostility High stress = 4.5x’s increased chance of relapse
Recovery : Within 1st year, only half will fully recover from
the initial manic or mixed episode
Prevalence
General population with Bipolar : >1-4% reported
Broadly depends on criteria being used
Rates are low in children : >1% of high school kids meet DSM criteria for Bipolar I, II or Cyclothymia
Demographics
Age of onset is variable
Median age = 25 years old
25% observe symptoms as early as age 17
Gender Ratio = Equal
Ethnicity/Race = Equal
Clinical Picture
Adults Data from diagnosed manic patients (adults, N = 576)
revealed 7 common descriptive factors: depressive mood, irritable aggression, insomnia, depressive
inhibition, pure manic symptoms, emotional lability/agitation, and psychosis
Children Meta – Analysis from 7 studies (children, ages 5-18)
revealed common descriptive factors: Increased energy, distractibility, and pressure of speech 80% showed irritability and grandiosity 70% had elated mood, decreased need for sleep, or racing
thoughts
Most often diagnosed in older children and adolescents, but can occur in children of any age. Exhibits as mood swings from the highs of hyperactivity or euphoria (mania) to the lows of serious depression. It may be more than just a phase.Common signs and symptoms: Sudden mood swings that may occur several times a day — for example, giddy and talkative one minute, explode in anger the next, and then cry for hours; hyperactive, impulsive, aggressive or inappropriate behavior; sexual promiscuity, alcohol or drug abuse, and reckless behavior in older children and teens
Bipolar Disorder in Children
Comorbid Disorders with Bipolar Disorder
Substance abuse Very common but the reasons for this link are unclear.
Anxiety disorders Post-traumatic stress disorder (PTSD) and social phobia
Attention deficit hyperactivity disorder (ADHD), Has some symptoms that overlap with bipolar disorder, such as
restlessness and being easily distracted. A higher risk for thyroid disease, migraine headaches, heart
disease, diabetes, obesity, and other physical illnesses. These illnesses may cause symptoms of mania or depression. They
may also result from treatment for bipolar disorder. Other illnesses can make it hard to diagnose and treat bipolar
disorder. People with bipolar disorder should monitor their physical and mental
health. If a symptom does not get better with treatment, they should tell their doctor.
Affected Brain Regions
Hyperactive : Amygdala
Emotional sensitivity & reactivity
Smaller-than-average volume in: Prefrontal Cortex
Effective planning, problem solving, and goal pursuit Hippocampus
Learning, memory, initiate behavior reactions Anterior Cingulate
Emotion formation, affect, & social interactions Basal Ganglia
Emotional functions and behavioral switching
Patient with bipolar disorder has enlarged ventricles; bright white spots of hyper-intensity associated with bipolar illness. A structural MRI with functional MRI data superimposed. It shows that the left amygdala, a fear hub, and related structures, activated more in youth with the disorder than in healthy youth. (Credit: Source: NIMH Mood and Anxiety Disorders Program). The left amygdala and related structures (yellow area where lines intersect) are part of an emotion-regulating brain circuit where children with bipolar disorder showed greater activation than controls when rating their fear of neutral faces.
Brain Imaging Credit: Source: NIMH Mood and Anxiety Disorders Program
Chemical Imbalance--Three brain chemicals: Norepinephrine and Serotonin - Involved in psychiatric disorders/mood disorders such as depression and BD. Dopamine - more closely linked to psychotic disorders, such as schizophrenia.
However, since these disorders have a number of symptoms in common, all three chemicals are likely involved in different phases of BD.
Neurochemical Functioning
Neuropsychological Profile
No biological test, must rely on clinical interview Overall Theme : 32% show some cognitive deficits
Intelligence PIQ < VIQ
Speech / Language Depressive state low rate and long pauses Manic state pressured speech, fast rate, and commission errors Variable differences in verbal fluency
Executive Functioning / Attention Impaired cognitive flexibility, concept formulation, decision making, and planning Selective attention intact Sustained attention impaired with impulsive responding
Memory Variable, but deficits seen. Question regarding true memory deficit or more attention challenge
Motor Depressive state slowed Manic state presents hyperactivity and acceleration
Reviews of testing do not suggest one overall profile due to: Dependent on clinical state, small sample sizes, different measures used = difficult comparisons, few
longitudinal studies, medication impact on results
Risk Factors
Genetics Heritability
Estimates range 24 – 87% Monozygotic twins (57%) / Dizygotic twins (14%)
Studies of identical twins have shown that the twin of a person with bipolar illness does not always develop the disorder. Because identical twins share all of the same genes this
suggest factors besides genes are also at work. Many different genes and a person's environment are
involved. How these factors interact to cause bipolar disorder is not well
understood.
Associated Risks
SUICIDE Compared to general population : 15x’s higher Compared to Major Depression : 4x’s higher Approximately 50% of Bipolar clients will attempt
suicide in their lifetime and between 15% - 20% will be successful
Increased risk if the person also presents comorbidity
Psychosocial Impairments
Family : High rates of family or marital distress, separation,
divorce, and adjustment challenges of offspring Employment Challenges
Study of Bipolar I & II patients (N = 253) : 33% worked full time, 9% worked part time, 57% reported being unable to work
Positive: Link with Creativity
Living with Bipolar Disorder
Managing Bipolar Disorder at Work To Tell or Not to Tell
Strategies to Manage Symptoms Manage Stress Make other healthy lifestyle changes Keep side effects at bay Don’t ignore symptoms Maintain concentration Stay organized Develop support systems Maintain connections with people and purpose
Treatments
Optimal = Combination of Pharmacological & Psychosocial Interventions
Pharmacological : Goal is to stabilize existing episodes Most often includes :
Mood Stabilizers (lithium carbonate, divalproex sodium, carbamazepine)
Antipsychotic Medications (olanapine, quetiapine, risperidone, aripiprazole, ziprasidone)
Antidepressants (*however can cause manic switching and acceleration of cycles in some)
Problem is consistency 60% of Bipolar clients will discontinue meds Result = Increased risk for recurrence and suicide
attempts
Medication Side Effects
Common side effects Drowsiness Dizziness Headache Diarrhea Constipation Heartburn Mood swings Stuffed or runny nose, or
other cold-like symptoms
Atypical Antipsychotics Drowsiness Dizziness when changing positions Blurred vision Rapid heartbeat Sensitivity to the sun Skin rashes Menstrual problems for women.
Antidepressants Headache, which usually goes away within
a few days. Nausea (feeling sick to your stomach),
which usually goes away within a few days. Sleep problems, such as sleeplessness or
drowsiness. This may happen during the first few weeks but then go away.
Agitation (feeling jittery). Sexual problems, which can affect both
men and women. These include reduced sex drive and problems having and enjoying sex.
Psychosocial Interventions
Introduced during the post-episode stabilization phase Goal is to minimize residual symptoms, educate, and
prevent recurrences Modalities of beneficial psychotherapy interventions are :
Individual, Family, & Group
Modality Techniques
Individual or Group Educating patients about coping with the disorder and its cycling; Use of emergency services; Setting appropriate life goals
Family Educating members about coping and disorder; Enhancing communication and problem-solving skills
Types of Psychotherapies
Behavioral Therapy Focuses on behaviors that decrease stress.
Cognitive Therapy Involves learning to identify and modify the patterns of
thinking that accompany mood shifts.
Interpersonal Therapy Focuses on relationships and aims to reduce strains that
the illness may place upon them.
Types of Psychotherapies
Social rhythm therapy (Behavior Modification) Establish structure and routines.
Regular sleep, eating, and activity appear to help people with bipolar disorder control their moods.
Education Identify symptoms.
Even though the early warning signs of an approaching episode vary from person to person, together with a psychiatrist you can identify what behavior changes signal the onset of an episode for you. It may be insomnia, shopping sprees, or becoming suddenly involved in religion.
Adapt.
This can help you avoid embarrassing behavior during manic episodes and set realistic goals for treatment. Your doctor can help you prepare for future episodes and manage fear about having more. A key part of adapting is to understand the types of stress that can cause episodes and the lifestyle changes that can reduce them.
Maintain a regular sleep pattern. Go to bed and wake up around the same times each day. Changes in sleep can cause chemical changes in
the brain, potentially triggering mood episodes.
Do not use alcohol or drugs. These substances can trigger mood episodes. They can also interfere with the effectiveness of medication.
Drug and alcohol abuse is a big problem for many people with bipolar disorder.
Managing Sleep
Types of Sleep Abnormalities Insomnia and REM Disturbance
Effects of Sleep Deprivation Be extremely moody Feel sick, tired, depressed, or worried Have trouble concentrating or making decisions Be at higher risk for an accidental death
Get Better Sleep: Eliminate alcohol and caffeine late in the day. Keep the bedroom as dark and quiet as possible and maintain a temperature that is not
too hot or cold. Use fans, heaters, blinds, earplugs, or sleep masks, as needed. Talk with your partner about ways to minimize snoring or other sleep habits that may be
affecting your sleep. Exercise, but not too late in the day. Try visualization and other relaxation techniques
Foods and Bipolar Disorder
There is no specific bipolar diet Fish Oil? A healthy diet is always recommended Some general dietary recommendations:
Only moderate amounts of caffeine and not stopping caffeine use abruptly
Avoiding high fat meals to reduce the risk for obesity Watching salt intake
If you are being prescribed lithium since low salt intake can cause abnormal elevations of blood lithium levels
Stay away from foods that may interact with your specific bipolar medication, if any
Be wary of natural dietary supplements that may cause a drug-herb interaction.
Food and Bipolar Disorder
Which Foods Should I Avoid if I Have Bipolar Disorder?
If you take MAO inhibitors, a certain class of antidepressant that includes Nardil and Parnate Important to avoid tyramine-containing foods. These foods can
increase sympathetic activity and cause severe hypertension. Some foods high in tyramine are
Overly ripe bananas Tap beer Fermented cheese Aged meats Some wines, such as Chianti Soy sauce in high quantities
Your doctor can give you a list of foods to avoid if you take these drugs.
The End
Thank you…