Download The many faces of Bipolar Spectrum disorders

The many faces of Bipolar
Spectrum disorders
Ulrik Fredrik Malt, MD
Dept of Neuropsychiatry and Psychosomatic Medicine
Division of Surgery and Clinical Neuroscience
Oslo University Hospital – Rikshospitalet
&
Institute of Clinical Medicine, University of Oslo
&
Norwegian research network on mood disorders
(NORMOOD)
[email protected]
"All that we see
or seem
Is but a dream
within a dream"
Edgar Allan Poe
( 1809-1849 )
TABLE 2. Lifetime Prevalence Estimates (%) of the Bipolar disorder in the
National Comorbidity Survey Replication (N=5,692): traditional definitions
Major depressive disorder
with history of mania
= Bip I
0.7
2%
Major depressive disorder
with history of hypomania
= BIP II
1.6
Major depressive disorder
16.9
17 %
Angst J, et al. Am J Psychiatry 2010; 167:1194-1201
TABLE Lifetime Prevalence Estimates (%) of the Bipolar Spectrum Groups in the
National Comorbidity Survey Replication (N=5,692)
Bipolar spect
classification
Major depressive disorder
with history of mania
0.7
Major depressive disorder
with history of hypomania
1.6
Major depressive disorder
with history of
subthreshold hypomania
6.7
Major depressive disorder
only
10.2 %
Traditional ICD-10 /DSMIV classification
9%
2%
10 %
17 %
Angst J, et al. Am J Psychiatry 2010; 167:1194-1201
About 40% of pts treated for ”major depression” in primary care
belong to the bipolar spectrum if double depression and diurnal
variation of mood (melancholia) is considered indicators of bipolar
spectrum
Data from: Malt et al, BMJ 1999
(Malt et al. BMJ 1999; 318: 1180-4)
Overlooking bipolar disorders

A consecutive sample of 1000 patients
attending a specialist depression clinic
for diagnostic and management
considerations. Of those assessed, 34%
were evaluated as having a bipolar
disorder, with this condition having been
diagnosed for the first time in threequarters of those patients.
Parker G, et al. Nerv Ment Dis. 2011;199(6):419-22.
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Bipolar II patients over 13 years:
Time spent ill
Mixed / cycling 2 %
Depression
51%
Hypomania 1%
Asymptomatic
46%
Judd et al, Arch. Gen. Psychiatry 2003
Cognition
Neurobiology
Anxiety
Illness behaviour
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The woman with yellow belt in Judo who ended
up in a wheelchair







43 yrs old; disability pension
Previous healthy
except hypothyreoidism
Gradual development of
paresis & feeling of choking
No neurological explanation
D: Dissociative disorder
with motoric symptoms
(conversion disorder)
Psychotherapy no effect
Another neurological +
respiratory assessment
negative
Drs became desperate
The woman with yellow belt in Judo who ended
up in a wheelchair
Bipolar I
disorder
Life-time prevalence of panic attacks in pts with
bipolar disorders
(National Comorbidty Survey Replication: CIDI; Merikangas et al, 2007)
¾!
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Symptoms of panic attacks
Autonomic sxs
 Palpitations
 Sweating
 Trembling
 Dry mouth
Sxs related to respiration
 Difficulty breathing
 Feeling of choking
 Chest pain / discomfort
Sxs related to abdomen
 Nausea
 Churning in stomach
 IBS- symptoms
Sxs related to CNS
 Dizzy, unsteady, faint
 Derealization,
depersonalitzation
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Life-time prevalence of social phobia in patients with
bipolar I og II disorders (National Comorbidty Survey Replication: CIDI;
Merikangas et al, 2007)
½!
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Life-time co-morbidity in pts with bipolar I og II disorders
(National Comorbidty Survey Replication: CIDI; Merikangas et al, 2007)
Alcohol
Benzodiazepines
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The executive
with vision
impairment
Previous healthy
Extreme workload
Workaholic
Increasing fatigue
No depr or anx emotions
Progressive vision loss
Bio.assessments negative
D: Somatization
No effect of therapy
Increasing benzodiazepine use
Admitted to a special hospital
No effect.of treatment
Another biological assessment
Referral to C-L
Francis Bacon
Bipolar
II
disorder
Francis Bacon
The alcoholics who lost
his leg
57 yrs
 Episodic alcohol abuse
 Marriage problems
 Hospitalized due to dysphoria
 Transferred to a drug abuse clinic
 Eights week later discharged from a
general hospital without one leg due to
amputation

[email protected]
The alcoholics who lost
his leg

Bipolar II disorder
(with psychotic depressive episodes)
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Mood Disorders as Predictors of Alcohol, Cannabis, and Benzodiazepine Use, Abuse, and
Dependencea
Merikangas, K. R. et al. Arch Gen Psychiatry 2008;65:47-52.
Copyright restrictions may apply.
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The man with excruciating
abdominal pain
Francis Bacon
Previous healthy; no sickleave;
Challenging job; «loves it»
”Prostatitis” (?) > abdominal
pain
Gastrointestinal work-up
negative
GP: depressed? Patient: No
Sertralin 50 mg; no effect;
Increasing pain, anxiety,
progressive insomnia
Hospitalized: no findings
Intense pain; death anxiety;
National hospital
No findings;
>C – L psychiatry
The man with excruciating
abdominal pain
Francis Bacon
Bipolar
Disorder
NOS
(subthreshold)
PAIN
From:
Enck et al, Neuron 2008; 59: 195-206
Nocebo suggestions induce anticipatory
anxiety, which activates two independent
pathways, the hypothalamus-pituitary-adrenal
(HPA) axis on the one hand and a CCK-ergic
pro-nociceptive system on the other hand.
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Functional dyspepsia in women:
Life-time prevalence of mood disorders related to the
bipolar spectrum
[email protected]
Eva Malt et al.
J Psychosom Res 2000; 285-89
Content analysis of verbal behaviour in pts
with functional gastrointestinal pain
problems
59% of
gastrointestinal
symptoms were
predicted by
Intense, existential
death anxiety
(Eva Malt et al,
J Psychosom Res 2003).
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Depression and immunology
Cytokines may lead to sicknessbehaviour
(lethargia, anorexia, paresthesia, irritability, social
withdrawal, impaired concentration, sleep problems,
decreased libido; particularly TNF-alfa and IL-6 may
induce depression, anxiety and memory impairment)
CHRONIC FATIGUE SYNDOME
Schwarz . Dialogues in Clin Neurosciences 2003; 5: 139-153
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Compared to controls, BD II patients performance was
significantly impaired on all neuropsychological
measures, except for phonemic verbal fluency, with
moderate to strong effect sizes ranging from 0.62 to
1.34.
The ERP results indicate dysfunctions in early stages
of information processing, showing a significant MMN
latency increase and attenuated frontal amplitudes in
BD II patients.
Cognitive impairment
Andersson S et al, Bipolar disorders 2008; 10: 888-899
The psychologist referred for
chronic fatigue syndrome
Highly regarded by her peers
 Active, dynamic
 Creative
 Charming, (seductive)
 Successful

Bipolar II disorder
[email protected]
The professor of
immunology who
was afraid of
having HIV
No findings
 CBT; recurrence; CBT;
recurrence; CBT;
recurrence….

[email protected]
Bipolar melancholia + high anxiety + premorbid high function
= somatic symptomatology or hypochondria
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The burned out chief executive officer
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Markus Bittermann 2007
Bipolar IV disorder
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Markus Bittermann 2007
The woman with bladder pain







Extreme bladder pain; gynecol /urology: negative
Psychiatrist: Somatoform disorder (F45.34 with sec pain
F45.4); mianserin 60 mg: OK
3 yrs later: new episode; mianserin no effect; thinking about
suicide due to pain; Gynecology / urology: neg
Somatoform disorder.
CBT and citalopram no effect
Internal med: neg
C-L: Anorexia at 14;
OCD at 20
Eating disorder; OCD and
Bipolar spectrum disorders
Anorexia / eating disorders occur among
6-15 % of pts with bipolar disorder
 If patients with anorexia nervosa /
bulimina subsequently develop OCD,
consider bipolar disorder!

Malt 8.5.2010
The woman with bladder
pain: reassessment





Episodic social anxiety
Episodes of increased energy / drive
Episodes of decreased need for sleep
Episodes of increased sociability
Husband: «confirmed»
Bipolar II
disorder
The physician who
got stuck measuring
blood pressure
- a tragic story
Derealisasjon
Bipolar II
disorder
[email protected]
Francis Bacon
Life-time prevalence of OCD in pts with bipolar disorders
(National Comorbidty Survey Replication: CIDI; Merikangas et al, 2007)
1/5!
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Bipolar spectrum disorders:
Pathophysiology

Hypothalamic dysfunction (increased ACTH and
cortisol release, pathological DST)

Autonomic (e.g. Heart Rate Variability, gastrointestinal
function, sensoric dysfunctions)
Circadian rhythms (e.g. temperature, REM)
 Hormones (e.g. dexametason supp test)
 Immunology (e.g. acute phase response
proinflammatory cytines)
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Somatic morbidity in pts with
bipolar disorders
Migraine
 Increased BMI

Diabetes type II
 Metabolic syndrome

National Epidemiologic Survey on Alcohol
and related conditions – NESARC




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
Non-cirrhotic liver disase (OR 1.69)
tachycardia (OR 1.68)
Peptic ulcers (OR 1.66)
Gastritis (OR 1.49)
Hypertension (OR 1.42)
Arthritis (OR 1.40)
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Charmaine Dragun case illustrates:




Prolonged failure to make the diagnosis
No disorder-specific management implemented
Limitations of non-specific diagnoses such as
“major depression” and “anxiety”, as practitioners
making such diagnoses then risk providing nonspecific treatments.
GPs view the diagnosis of a bipolar disorder as
intrinsically difficult.
Parker G. Med J Aust. 2011;195(2):81-3.
[email protected]
Why do
(scandinavian)
psychiatrists
overlook bipolar
spectrum disorders
?
•
Longitudinal perspective
Bipolar II:
the more sxs;
the earlier diagnosis
Skjelstad et al.
J Affect Disord
2011;132(3):333-43.
[email protected]
Why do
(scandinavian)
psychiatrists
overlook bipolar
spectrum disorders
?
Longitudinal perspective
• Attachment pattern
• They act like psychologists
• Phenomenology !
•
B
I
P
O
L
A
R
?
Arnold Böcklin: self portrait

Have you during the last two weeks felt
depressed or irritable?
Bipolar patients
: NO !
Have you during the last two weeks felt
lack of emotional reactions to events or
activities that normally produce an
emotional response («inability to feel»)?
 Have you during the last two weeks felt
an unexplainable inner tension or worry
with an existential quality («anxiety») ?

Bipolar patients
: YES !
Essential meaning structure in the experience of
postpartum depression (PPD)
Non-bipolar depression: the mother is
thrown into a looming, dangerous
world, coupled with a restricted,
heavy body that hinders her
attunement to her baby. Tormented by
anxiety, guilt and shame, she tries to
deal with her pain by analytical
reflection and social isolation.
Røseth et al, J Phenomenological Psychology 2011; 42: 174–194
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Essential meaning structure in the experience of
postpartum depression (PPD)
Bipolar depression: sudden lapses
into intense feelings of alienation from
the self, the baby, and from the social
and material world. With a distorted
primordial self-awareness, the mother
no longer felt that she existed as
herself in the world.
Røseth et al, J Phenomenological Psychology 2011; 42: 174–194
[email protected]
Why do
(scandinavian)
psychiatrists
overlook bipolar
spectrum disorders
?
Longitudinal perspective
• Attachment pattern
• Phenomenology
• Uncritical use of DSM-IV
/ ICD- 10 based
interviews
•
Hypomania?
 Have
you ever experienced a distinct
period of persistently elevated, expansive
or irritable mood, lasting throughout at
least 4 days, that is clearly different from
the usual nondepressed mood.
 Most pts with bipolar spectrum disorders
will answer
NO !
YES
Have you ever experienced a distinct period
of
 increased activity
 decreased need for sleep
 increased sexual energy
 mild over-spending
 increased sociability
The limitations of only obtaining info from the patient
http://b5studio.blogspot.com/2010_06_01_archive.html
The many faces of bipolar spectrum disorders

Behavioural sxs








Panic attacks
Social phobia
GAD
Alcohol abuse
OCD
Bulimia
Anorexia
Hypochondria

Somatic sxs
•
Fatigue
Gastrointestinal
Hearing
Migraine
Muscle weakness
Pain
Respiration sxs
Paresthesia
•
•
•
•
•
•
•
Somatic disease
"All that we see
or seem
Is but a dream
within a dream"
or perhaps a
bipolar spectrum
disorder?