* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download The many faces of Bipolar Spectrum disorders
Personality disorder wikipedia , lookup
Rumination syndrome wikipedia , lookup
Obsessive–compulsive personality disorder wikipedia , lookup
Mental status examination wikipedia , lookup
History of psychiatric institutions wikipedia , lookup
Antipsychotic wikipedia , lookup
Obsessive–compulsive disorder wikipedia , lookup
Emergency psychiatry wikipedia , lookup
Postpartum depression wikipedia , lookup
Excoriation disorder wikipedia , lookup
Autism spectrum wikipedia , lookup
Anxiety disorder wikipedia , lookup
Antisocial personality disorder wikipedia , lookup
Depersonalization disorder wikipedia , lookup
Major depressive disorder wikipedia , lookup
Controversy surrounding psychiatry wikipedia , lookup
Panic disorder wikipedia , lookup
Conduct disorder wikipedia , lookup
Causes of mental disorders wikipedia , lookup
Mental disorder wikipedia , lookup
Pyotr Gannushkin wikipedia , lookup
Conversion disorder wikipedia , lookup
Separation anxiety disorder wikipedia , lookup
Dissociative identity disorder wikipedia , lookup
Diagnostic and Statistical Manual of Mental Disorders wikipedia , lookup
Classification of mental disorders wikipedia , lookup
Asperger syndrome wikipedia , lookup
Schizoaffective disorder wikipedia , lookup
Abnormal psychology wikipedia , lookup
Narcissistic personality disorder wikipedia , lookup
History of mental disorders wikipedia , lookup
Child psychopathology wikipedia , lookup
Generalized anxiety disorder wikipedia , lookup
History of psychiatry wikipedia , lookup
Depression in childhood and adolescence wikipedia , lookup
Spectrum disorder wikipedia , lookup
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. [email protected] 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 [email protected] 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! [email protected] 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 [email protected] Life-time prevalence of social phobia in patients with bipolar I og II disorders (National Comorbidty Survey Replication: CIDI; Merikangas et al, 2007) ½! [email protected] Life-time co-morbidity in pts with bipolar I og II disorders (National Comorbidty Survey Replication: CIDI; Merikangas et al, 2007) Alcohol Benzodiazepines [email protected] 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) [email protected] 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. [email protected] 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. [email protected] 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). [email protected] 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 [email protected] 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 [email protected] The burned out chief executive officer [email protected] Markus Bittermann 2007 Bipolar IV disorder [email protected] 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! [email protected] 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) [email protected] Somatic morbidity in pts with bipolar disorders Migraine Increased BMI Diabetes type II Metabolic syndrome National Epidemiologic Survey on Alcohol and related conditions – NESARC 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) [email protected] [email protected] 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 [email protected] 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?