bipolar lecture
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Nirvana’s LithiumI'm so happy 'cause today I've found my friends
They're in my head I'm so ugly, but that's okay, 'cause so are you...We've broken our mirrors
Sunday morning is everyday for all I care...And I'm not scared
Light my candles in a daze...'Cause I've found god - yeah, yeah, yeah
I'm so lonely but that's okay I shaved my head...And I'm not sad
And just maybe I'm to blame for all I've heard...But I'm not sure I'm so excited, I can't wait to meet you there...
But I don't care I'm so horny but that's okay...My will is good - yeah, yeah, yeah I like it - I'm not gonna crack
I miss youI'm not gonna crack
I love youI'm not gonna crack
I kill youI'm not gonna crack
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Bipolar Disorder Also known as manic depression, a mental
illness that causes a person’s moods to swing from extremely happy and energized (mania) to extremely sad (depression)
Chronic illness; can be life-threatening Most often diagnosed in adolescence
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Mood Disorders
AKA: Affective Disorders
Affect – “emotion” or “mood”
Unipolar & Bipolar Depression
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Unipolar Bipolar
Depressive Disorder, NOSDysthymiaMajor Depression
-Single Episode-Recurrent
- - -Seasonal Affective
Disorder (SAD)Postpartum Depression
Mood Disorder, NOSCyclothymiaBipolar II DisorderBipolar I DisorderBipolar Disorder, NOS
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Mania/Hypomania
-Extreme euphoria
-Lack of need for sleep
-Inflated Ego and Self-Esteem
-Loose Associations/Flight of Ideas
(from topic to topic)
-May become psychotic when in episode
(in mania only)
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Continuum of Causes of Affective Disorders
Biological Bipolar
Major Depression
Environmental Dysthymia
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Genetics
30-70% Identical twins 75% Both parents bipolar
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Mood Disorders
Growing consensus that Bipolar is organically based with a notable genetic factor
Like Major Depression, Bipolar Disorder linked to low serotonin activity
Theory: low serotonin dysregulation of other important neurotransmitters, e.g., norepinephrine
Etiology of Bipolar Disorder
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Mood Disorders“Defective Membrane” Theory of
Bipolar Disorder
1. Nerve impulse moves along neuron electro-chemically
2. Impulse carried via exchange of Na & K ions across neural membrane
NaK
3. Defect in process impulse carried too quickly or too slowly
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GRK3 regulates sensitivity to neurotransmitters
Decreases the sensitivity of neurons to neurotransmitters
Acts as a brake to stress Maintains balance in the brain
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GRK3 is a Gene For Bipolar Disorder GRK3 is inherited with bipolar disorder GRK3 is turned on by amphetamine A mutation in GRK3 increases risk to
bipolar disorder 3 fold
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Mood Disorders
Genetic studies, especially of twins, indicate a genetic predisposition for bipolar disorder
40% of identical twins concordant, vs. 5 to 10% of fraternal twins
Etiology of Bipolar Disorder
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Epidemiology of Bipolar Disorder
Prevalence: 1% of population Adults = Adolescents
Males = Females 2-3 million American adults are diagnosed
with bipolar disorder NIMH estimates that one in very one
hundred people will develop the disorder
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Controversy Severity and duration Onset before puberty is estimated to be
rare Developmental variability Retrospective study of adults
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Vincent Van Gogh“It isn’t possible to get
values and color. You can’t be at the pole and the equator at the same time. You must choose your own line, as I hope to do, and it will probably be color.”
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Assessment/Diagnosis of Bipolar Disorder
Often very complicated; it mimics many other disorders and has comorbidity (presents with other disorders)
Alphabet soup diagnosis Half of bipolar children have
relatives with bipolar disorder
It is important to first rule out the possibility of any other organic diagnosis:
Thyroid disorder Seizure disorder Multiple sclerosis Infectious, toxic, and drug-
induced disorders
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Mood history Mania
Giddy, goofy, laughing fits, class clown
Explosive (how often, how long, how destructive and aggressive)
Irritable, cranky, angry, disrespectful, threatening
Grandiosity may present as EXTREME defiance and oppositionality
Depression Low frustration tolerance, self-
destructive, no pleasure, lower level of irritability
DSM Criteria :A distinct period of abnormally and persistently elevated, expansive, or irritable mood
DIGFAST acronym (at least 3 of 7 symptoms)
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DIGFAST – Mental Status Exam Distractible Increased activity/psychomotor agitation Grandiosity/Super-hero mentality Flight of ideas or racing thoughts Activities that are dangerous or
hypersexual Sleep decreased Talkative or pressured speech
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Bipolar Disorder Significant functional impairment Bipolar I people go through cycles of major
depression and mania Bipolar II similar to Bipolar I except that
people have hypomanic episodes, a milder form of mania
Rapid cyclers
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Suicide Risk Factors 22% of adolescents with completed
suicides had bipolar disorder Family history of suicide Substance abuse i.e. adolescent with
impulse control disorder, depression, suicidality, substance use and access to a weapon is potential for lethality
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Major depression often presents first (estimated that 20 - 40% of children presenting with major depression within 5 years will be bipolar)
Comorbidity 70 - 90 % of adolescents have other
disorders ADHD, Conduct Disorder, Substance
abuse
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Pediatric-Onset Bipolar Disorder
Geller (American Journal of Psychiatry, 2001) followed up 72 depressed prepubertal children into adulthood
48.6% (N=35) developed bipolar disorder by mean age 20.7 years
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Atypical presentation in juveniles-exacerbation of disruptive behavior, moodiness, low frustration tolerance, explosive anger and difficulty sleeping at night
Comorbidity of ADHD/BPD more severe presentation, often severe affect dysregulation, marked impairment, violent temper outbursts
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Pediatric-Onset Bipolar Disorder: Differential Diagnosis with ADHD
ADHD confusion although identifying presence of mood disorder helpful in guiding treatment
Talkativeness
Physicalhyperactivity
Distractibility
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Time Magazine, August 19, 2002
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Time Magazine, August 19, 2002
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Prioritizing Target Symptoms
1. Treat mania and/or psychosis
2. Treat depression
3. Anxiety and ADHD
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Medications Mood Stabilizers Lithium Divalproex Sodium
(Depakote) Carbamezapine
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Improvement is seen when mood stabilizers are used
Kowatch et al (JAACAP 2000) Response rates:
53% depakote 38% lithium 38% carbamazepine
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Geller et al. High relapse rate Geller longitudinal study
1 year f/u recovery rate 37% Relapse rate 38%
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Newer Agents Neurontin Lamictal Topamax Gabatril Atypical antipsychotics
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Atypical Antipsychotics Risperidol Olanzapine (Zyprexa) Quetiapine (Seroquel) Abilify Geodon
Increasingly used because they can cause rapid patient stabilization
Zyprexa can help with depression, mania and psychosis
Weight gain
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Key Point Just because a child improves on a mood
stabilizer does not prove the diagnosis. Mood stabilizers have been used for a long time to help with aggression in children.
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Multiple Modalities Psychotherapy Psychoeducation/Support School Support/Consultation Residential Placement, Acute Hospitalization Mood Charting Teach Good Sleep Hygiene Legal intervention Hope