Bipolar Disease and Mood Disorders - Josh Corwin



Bipolar Disease and Mood Disorders

I. Bipolar I Disorder- mood disorder in which feelings, thoughts, behaviors, and perceptions are altered within the context of episodes of mania and depression.

a. Epidemiology

i. Overall prevalence of bipolar I disorder in US adolescents 1% in children 2-4%

ii. Most cases of bipolar disorder present in early adulthood in persons aged 20-30 years; second most common peak 15-19 years old

iii. Approximately 20% of youths in whom a major depressive disorder has been previously diagnosed develop symptoms consistent with a manic state at a later age

iv. Childhood onset of bipolar symptoms: more severe, more chronic, and has a refractory course (not treated with mood stabilizers as effectively)

b. Etiology and Risk Factors

i. Genetic and familial factors have profound influence

1. Risk for offspring of a couple in which 1 parent has bipolar disorder is 30-35%; if both parents have bipolar disorder- 70-75%

2. Approximately 90% of children who have bipolar disorder have ADHD

3. Early onset bipolar disease: associated psychotic symptoms, such as aggression, mood shifts, or attention difficulties; poor or ineffective response to lithium therapy, increased risk of alcohol-related disorders

c. Cognitive and neurodevelopmental factors: neurodevelopmental delays are high incidence in early-onset bipolar disorders-

i. Patients with more severe bipolar disorder had an average lower IQ than those with mild-to-moderate forms of the disorder

ii. Neurodevelopmental delays are high incidence in early onset BD- social skills, language delays, and motor delays

d. Environmental factors: behavioral, educational, family-related, toxic, or substance abuse

i. Increase the risk of suicide in adolescents compared to their healthy peers

ii. Physical, emotional, or sexual abuse with exponentially increase the risk

iii. Incarcerated youths also have an inordinately high number of mental illness

e. Biological and biochemical factors

i. Sleep disturbances- decrease need for sleep or hypersomnolence (increased need)

ii. Several neurotransmitters act in unison but with dynamic balance as modulators of mood states. In particular, serotonin (mood), dopamine (pleasure), norepinephrine (alertness, energy level), acetylcholine (memory, cognition)

iii. Pharmacotherapy is based on the use of medications that facilitate the regulation of these and perhaps other neurochemicals to restore normal mood and cognitive state

1. Recurrent episodes of mania and depression may be associated with seizure activity in the limbic area of the brain

II. According to the DSM-IV TR, the criteria for a manic episode are as follows:

a. Individual experiences a distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week or any hospitalization if necessary

i. Elevated and elated mood may transform into a state of dysphoria, during which agitated and irritable behaviors may develop

1. At baseline most operate at a high level of productivity mainly in creative environments

2. It becomes a problem if too much time is invested in the action and loses the capacity to conform to social expectations and norms

ii. Most patients experience cyclic episodes of mania ( depression ( mania

iii. When mood elevation is of milder nature, either in severity or in duration, and is not associated with a marked impairement in function, an assessment of hypomania rather than mania is made, resulting in a bipolar II disorder. It is not known whether these disorders are distinct in their etiology or exist on a continuum

iv. Hypomania- no hospitalization has ever been necessary, no delusions, psychosis

b. During the period of mood disturbance, 3 or more of the following symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree:

i. Inflated self-esteem to levels of grandiosity (delusions of grandeur)- frequently center around sense of self and is far beyond narcissism

ii. Decreased need for sleep

iii. More talkative, often with pressured speech and sense of necessity to keep talking

iv. Flight of ideas or subjective feeling that thoughts are racing or “out of control”

v. Distractibility

vi. Increase in goal directed activity or psychomotor agitation

vii. Excessive involvement in pleasurable activity that has a high potential for painful consequences (hypersexuality, excessive spending, impetuous traveling)- reckless, risky

1. Complications- STD, financial burden, job loss, legal problems, friend loss

c. The symptoms do not meet criteria for a mixed episode

d. The mood disturbance is sufficiently severe to cause marked social impairement in occupational functioning, social activities, or relationships with others. Hospitalization may be necessary to prevent harm to self or others or if psychotic features are present

e. Symptoms are not due to direct physiologic effects of a substance or medical condition- R/O substance abuse, brain trauma, CNS insult, seizures, delirium, medication-induced

i. Though rare, bipolar patients may exhibit social aggression, hallucinations, delusions, anxiety, paranoia- complicates diagnosis

The DSM-IV TR uses universal symptoms to define the diagnostic criteria for mood episodes, including major depressive and manic episodes

One true manic episode, with or without psychotic features, is necessary and sufficient criterion by which bipolar disorder is defined as type I. A depressive episode is insufficient for making diagnosis, even in presence of a strong family history of bipolar disorder

Type II bipolar disorder is diagnosed based on presence of at least one hypomanic episode

III. Laboratory Tests/Imaging

a. Substance abuse, alcohol levels, head trauma, CNS insults, thyroid disease, hypoglycemia must be ruled out

IV. Treatment: Team approach used in clinical setting because multiple factors need to be addressed, including medication, family issues, social and school functioning, substance abuse

a. Evaluation and diagnosis of presenting symptoms

b. Acute care and crisis stabilization for psychosis or suicidal or homicidal ideas or acts

c. Movement toward full recovery from a depressed or manic state

d. Attainment and maintenance of euthymia

e. Mood stabilizers (lithium carbonate, sodium divalproex, carbamazepine)

i. Mainstay of treatment for bipolar disorder and are the initial therapy

ii. 10-14 days may be required before full effect is achieved

iii. Favorable response- 65-75% have favorable response

iv. Complications are infrequent- rebound depression (suicide)

f. Antipsychotic agent (risperidone or haloperidol)

i. Used if psychotic features or aggressive agitation is present

g. Psychosocial therapy- some form of psychosocial intervention is almost always indicated

i. Dependent on family and financial situation, cognitive-behavioral psychotherapy

Hospitalization is necessary for most patients in whom psychotic features are present and in almost all patients in whom suicidal or homicidal ideations or plans are present

h. Electroconvulsive therapy- not first line intervention, usually administered on an inpatient basis because it most frequently is used in severe or refractory cases; rapid onset therapeutic response versus medications; drawback= memory loss around events of treatment

V. Cyclothymic Disorder

a. Characterized by hypomanic and depressive states not of sufficient severity or duration to meet the criteria for either bipolar disorder or major depression

b. Symptoms must persist for 2 years and have no psychotic component

c. Age at onset if symptoms of early to late adolescence

d. It is more common in women, and there is apt to be a family history or mood disorder and “mood spectrum” problems such as alcohol abuse and antisocial personality

e. About a third of patients will experience an intensification of symptoms during a 2-year follow-up, sufficient to meet the criteria for mania, hypomania, or major depression

f. About 60% of patients improve when treated with a mood stabilizer and antidepressants

Studies of behavioral characteristics of these patients show that they are extroverted sociable individuals who appear self-assured, energetic, and often impulsive. They are frequently described as “stimulus seeking”, a characteristic that leads them to become involved I daring hobbies. In spite of this, patients often achieve substantial success and status in society. Cheerful exuberance changing to increased sensitivity to rejection or loss

VI. Dysthymic disorder

a. Characterized by chronic feeling if inadequacy, low self confidence and self criticism

b. Age of onset very early in childhood or adolescence, lifetime prevalence is about 6%

c. Express feelings in dramatic manner and overact to stressors of life in an overdramatic mood

d. Morbidity associated with major depression, such as suicide, is less common

e. Can be quite demanding and complaining, blaming others for their failures as much as they blame themselves- obsessional traits are common

f. Loss of interest or pleasure in most activities of daily life but do not have symptoms severe enough to meet the criteria for major depressive episode

g. Unstable relationships with others and few friends may affect job performance

h. Abuse of alcohol and other drugs is common

i. Treatment: psychotherapy is the principal treatment resource (individual and group therapy), significant number of patients may benefit from a trial of an antidepressant

VII. Seasonal Affective Disorder

a. Depressive symptoms caused by dysfunction of circadian rhythms, that occurs most often in the winter months and is believed to be due to: decreased exposure to full spectrum light; abnormal melanin metabolism

b. In addition to feeling of sadness and anxiety, symptoms include hypersomnia, lethargy, carbohydrate craving and weight gain. Diagnosis usually requires a 2-3 year mood disturbance pattern, with the onset occurring in the autumn, and a remission in the spring. It occurs more commonly in women and among individuals living in the northern latitudes

VIII. Adjustment Disorder

a. Diagnostic and statistical manual of mental disorders (DSM-IV): “the development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within three months of the onset of the stressor

i. The reaction may take the form of either “marked distress in excess of what would be expected” or “significant impairement in social or occupational functioning”

ii. Onset frequently in adolescence; clinicians overuse category

iii. Etiology: stress related disorders are a disruption of the normal process of a adaptation to stressful life events; individual sustained a level of psychological strain that exceeded their ability to cope

b. Contributing factors: several models have been developed to explain why some people can handle stress and even grow as a result, whereas others develop distress of psychopathological proportions

i. Stressor: time limited shock type stressors versus continuous stressors (more commonly cited as precipitating causes of psychological disorder)

1. Adults- family or marriage, job, money, school

2. Adolescents- problems with school, parental rejection, parents’ marriage

3. The degree of undesirable change a stressor causes is the most significant aspect of its ability to cause strain; whether the event was sudden or anticipated, central or peripheral to the life of the individual, and culturally shared or experienced in social isolation

ii. Situational context: presence of material and social supports or handicaps

1. Economic, occupational, and recreational opportunities

2. Family, friends, neighbors, and cultural or religious support groups

iii. Intrapersonal factors: most crucial in determine whether response to stress; vulnerability to stressful life experiences may be general or specific

1. Wide range of coping strategies, intelligence, social skills, and flexibility

2. Chronic medical, psychological or cognitive disorders

3. Relevant life experiences or traumas, unresolved conflicts, developmental issues

c. Diagnosis is not used when symptoms conform to the specific criteria for another mental disorder, or when current distress represents but one instance of a general pattern of overreaction to stressors; for this reason it is a diagnosis of exclusion

d. Four major decisions are involved in the diagnosis:

i. Establishing a relationship to a psychosocial stressor- DSM-IV diagnostic criteria require that the dysfunction be evident within 3 months after the onset of the stressor and persist for no longer than 6 months after the termination of the stressor

ii. Evaluating the level and duration of disturbance- patient’s symptoms are more severe than would be expected in absence of mental disorder, disturbance leads to significant impairement in social or occupational functioning, symptoms do not meet criteria for other mental disorder, and duration does not exceed 6 months

iii. Ruling out other mental disorders

iv. Evaluating the context of the patient’s total personality

e. Treatment: controversial

i. Defined as being associated with exaggerated symptoms and social or occupational impairement. Symptoms must be brought within manageable limits before the patient can begin to cope with the stress

ii. Crisis intervention theory maintains that a crisis offers an ideal opportunity for treatment that will act as a catalyst for positive change in coping strategies

iii. When used, medications are generally considered adjuncts to treatment, to bring distress within tolerable limits

IX. Impulse Control Disorders

a. 1838- “Conditions in which persons performed acts that they did not want to do in response to irresistible impulses”. Voluntary control is profoundly compromised: patients is constrained to perform acts which are dictated neither by his reason nor by his emotions, acts which his conscience disapproves of, but over which he no longer has willful control

b. The actions are involuntary, instinctive, irresistible, and associate with anxiety, compulsion and other unpleasant affective states

c. Current research shows that serotonergic systems are the mediators of impulse control

d. No established psychological or medical treatment for any impulse-control disorder

i. Accurate recognition and identification of particular impulse-control disorder, characterization of its specific phenomenological features, psychiatric comorbidity

e. Intermittent Explosive Disorder

i. Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property. The aggressive acts are grossly out of proportion to any precipitating psychosocial stressors and not better accounted for by another mental disorder, a substance, or a medical condition

ii. Although presumed to be rare, may be more common than realized

iii. More common in men, begins in adolescence, follows episode or chronic course

iv. Often co-occurs with other psychiatric disorders, especially mood, anxiety, and substance use disorders, including bipolar, obsessive-compulsive, and panic disorders

v. May be less responsive to psychoanalytic and insight-oriented psychotherapies and more responsive to cognitive-behavioral and addiction-based therapies (stress anger management techniques)

vi. Medications: mood stabilizers, SSRIs, antiepileptics, and B-blockers

f. Kleptomania

i. Impulsive, compulsive, addictive, or abnormal stealing of unneeded object or the irresistible urge to appropriate things- recurrently fail to resist the urge to steal objects which are not needed for personal use or monetary value

ii. Person feels an increasing sense of tension immediately before committing the theft and pleasure, gratification, or relief at the time of committing the theft

iii. More common in women, may begin in childhood, adolescence, or adulthood

iv. Often co-occurs with other psychiatric disorders, especially mood, anxiety, substance use, eating, and other impulse control disorders (OCD, bulimia)

v. Treatment- psychotherapy and SSRIs

g. Pyromania

i. Irresistible impulse or compulsive urge to burn or set fires; deliberate and purposeful fire setting on more than one occasion

ii. Associated with tension or affective arousal before the act; fascination with, interest in, curiosity about, or attraction to fire and its situational contexts; and pleasure, gratification, or relief when setting fires or when witnessing or participation in their aftermath

1. Diagnosis can not made if they set fires for money or homicide

iii. More common in men, most commonly beginning in childhood/adolescents

iv. Associated mood, obsessive-compulsive, eating, and possibly psychotic disorders and high rates of mood, substance use, intermittent explosive disorder, cruelty to animals

v. Treatment- behavioral therapy

h. Pathological Gambling

i. Impulsive, compulsive, problematic, and/or addictive gambling that results in personal distress, impairement in vocational or social functioning, and/or legal or financial problems

ii. Defined as a substance abuse disorder

iii. Incidence is 1.2%-2.3% of the general adult population, more common in men

iv. High rates of comorbid mood, substance use, and anxiety disorders, including depressive and bipolar disorders, women may have high rates of eating disorders

v. Treatment- Gambler’s anonymous, psychotherapy, antidepressants, mood stabilizers

i. Trichotillomania

i. Impulsive, compulsive, or automatic hair pulling that results in noticeable hair loss and is associated with an increasing sense of tension before hair pulling and pleasure, gratification, or relief during hair pulling (argument of hair-pulling, twisting as habit)

ii. More common in women

iii. Hair is most often pulled from the scalp but also from the eyelashes, eyebrows, face, axilla, arms, legs, abdomen, and pubis- extracted hair may be chewed or swallowed

iv. Complications- trichobezoar (hair ball), obstruction or perforation of stomach or bowel

v. Co-occurs with mood anxiety and other eating disorders

vi. Treatment- behavioral therapy, SSRIs, and mood stabilizers

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