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Transcript
Adult Bipolar Disorder
Anthony Norelli, M.D.
Northwestern Mutual
WAHLU Presentation
4/16/15
1
Goals
• Visit history of BPD
• Address epidemiology of BPD
• Briefly address diagnostic criteria
• Address why BPD is so difficult to diagnose
• Address why BPD is so difficult to treat
• Address what is in the underwriter’s armamentarium
• Time for Q&A
2
BPD History
• Earliest mentions of BPD symptoms are found in
Egyptian Papyri dating to approximately 2000 B.C.
• Aretaeus of Cappadocia – (practiced somewhere
between 70-150 A.D.?) Gave early descriptions of
diabetes, asthma, tetanus, diphtheria, and epilepsy
among others. Also identified mania and depression as
two separate forms found within the same illness.
3
Cappadocia? (=Anatolia)
4
5
Aretaeus of Cappadocia
• Aretaeus described a group of patients who ‘laugh, play,
dance night and day, and sometimes go openly to the
market crowned, as if victors in some contest of skill’ only
to be ‘torpid, dull, and sorrowful’ at other times. Though
he suggested that both patterns of behavior resulted from
one and the same disorder, this idea did not gain
currency until the modern era (e.g. mid-19th century)
6
Ancient Greece/Rome Forward
• Mania and Melancholy
• Lithium baths were thought to be helpful
• 300-500 A.D. – manic individuals thought to be
possessed, were executed
• 500-1600 – equally crummy care
• Burton, 1621 – Anatomy of Melancholy
• Baillarger, Falret 1854: folie a double forme, folie
circulaire
7
20th Century
• Emil Kraeplin
a. Broke with Freud (e.g. societal cause of mental
illness)
b. Studied course of illness: delineated between
démence précoce (dementia praecox; aka
schizophrenia) and manic-depressive psychosis
c. DSM-V suggests Kraeplin had the right idea, and took
BPD out of the mood disorders chapter and gave it its
own chapter between mood disorders and psychosis.
8
20th Century
• Treatment: lobotomy, ECT, etc.
• Dr. John Cade – Guinea pig experiments led to 1949
paper on Lithium Salts – fear of excess toxicity led to
Lithium being banned in the US until 1970.
• 1950’s-60’s – BPD felt to be less stigmatizing than manicdepressive psychosis
9
BPD Fiction
• Some have maintained that BPD is strictly a construct of
“Western Medicine,” or even a “celebrity fashion
statement.”
• Just how “Western” is Cappadocia?, or Ancient Egypt?
Remember, these areas were trade centers back in that
time, where people exchanged not only good but also
ideas.
• 1583: Gao Lian published his “Eight Treatises on the
Nurturing of Life” which discusses BPD-type symptoms
(in detail) over centuries in his native China.
10
BPD Nonfiction
• A number of well-known individuals have admitted to
having BPD (and others were outed by confidants). A
short list includes:
Ernest Hemingway, Marilyn Monroe, Britney Spears,
Robert Schumann, Mel Gibson, Vivian Leigh, Jim Carey,
Rosemary Clooney, Russell Brand, Ted Turner, Demi
Lovato, Dick Cavett, Patricia Cornwell, Edward Elgar, Brian
Wilson, Kurt Cobain, Robin Williams, and many more.
11
Sylvia Plath
“It’s as if my life was run by two electric currents: joyous
positive and despairing negative – whichever is running
at the moment dominates my life, floods it.”
12
BPD and Creativity
• It has been suggested that many of the renowned artists
in history (think composers, painters, sculptors, etc.) were
bipolar
• Some have asked if the availability of medication to
control BPD has actually decreased overall creativity…
• Is there an evolutionary advantage of BPD?
13
BPD Epidemiology
• Prevalence estimates range from 1% to 4.5% (can rise to
10% depending upon inclusion criteria). Closer to 4% is
likely most accurate.
• Overall prevalence is equal in males and females.
However:
a. Women tend to have more depressive presentations
b. Women tend to have more rapid cycling (3:1 ratio)
c. Men tend to have more psychosis (e.g.
schizophrenia)
d. So when misdiagnosed, guess what the
“misdiagnoses” are…
14
BPD Epidemiology
• Average age of onset is 25
a. “Usual” is later teens to early 20’s
b. From teens through 5th decade is considered more
typical
c. Pre-pubertal onset portends more aggressive course,
and likely at least 1 parent with BPD
d. Onset ≥50’s – think underlying systemic disease first,
and psych disorder second
15
BPD Heritability
• Falret recognized that BPD seemed to run in families, and
felt it was thus heritable
• A number of genes have been isolated that contribute to
BPD development but none make development of BPD a
given (e.g. ANK3, which codes for ankyrin, has strongest
correlation of any gene with BPD – determines synaptic
behavior)
• 1 parent with BPD confers 15-30% chance for their
offspring to have BPD
• 2 parents with BPD confers 50-75% chance for their
offspring to have BPD
16
BPD Heritability
• Twin studies: Historically flawed and small
• One often-quoted study out of Denmark showed the
following:
Probandwise Concordance Rate
Bipolar-Bipolar
Monozygotic
Twins
Dizygotic Twins
62%
8%
BipolarBipolar/Unipolar
79%
19%
17
BPD Triggers
• So if genetics helps “load the gun”, what helps “pull the
trigger?”
a. Stressful life events (good or bad): loss of job, birth of
baby, promotion, etc.
b. Disruption of sleep patterns – chronic sleep
deprivation could theoretically lead to mania or hypomania;
chronic excess sleep could lead to depression
c. Disruption to routine – studies have shown those who
have regular sleep/wake schedules are less likely to
develop (or have recurrence of) BPD
d. Excess external stimulation – clutter, traffic, noise,
light, crowds, work deadlines, social activities
18
BPD Triggers – Continued
• So if genetics helps “load the gun”, what helps “pull the
trigger?”
e. Too much internal stimulation – overstimulation from
excessive activity/excitement while trying to achieve
challenging goals, or ingesting stimulants (caffeine,
nicotine)
f. AODA – can trigger BPD; BPD patients are also more
likely to abuse AODA
g. Excessive conflict/stress – think PTSD
h. Untreated/undiagnosed medical illness
19
BPD Numbers
• According to WHO, BPD is the #6 cause of disability in
the world
• BPD estimated cost to US economy $75 Billion in 2008
• BPD diagnosis translates to an average decrease of
estimated lifespan by 9.2 years:
a. Treated appropriately, BPD mortality approaches
general population mortality
b. 2007 study (Goodwin and Jamison) found untreated
BPD mortality was 230% greater than general population
• Up to 20% of those with BPD complete suicide
20
BPD Definition
• There are 4 main types of BPD:
a. Bipolar Type I (BPI)
b. Bipolar Type II (BPII) – greatest association with
suicide risk
c. Cyclothymia – about 15% have rapid cycling
d. Bipolar disorder with atypia
Please also see handouts for DSM-V definitions
21
22
Why BPD is so Challenging
• The definitions!
• BPI does not require a depressive episode
• BPII does not require a manic episode (and good luck
nailing that hypomanic thingy)
• Cyclothymia – symptoms present >2 years and
hypomania/depression has persisted for at least 1 year,
and not more than 2 months have gone by without
symptoms (and spouse has not tried to air mail patient to
Siberia in their sleep)
23
BPD – Points Worth Noting
• Typical BPD patient averages 8-10 manic or depressive
episodes over a lifetime, though some may have many
more or fewer episodes
• Even when optimally treated, the BPD symptoms may
wax and wane significantly
• BPD diagnoses can change (i.e. patients with one type of
bipolar diagnosis and go on to develop another, different
bipolar diagnosis due to change in symptoms – which is
another reason some experts believe different types of
BPD are actually distinct from each other…)
• BPD is a lifelong disorder, but in any given year up to half
of BPD patients may be off treatment (their choice, not
the MD’s).
24
BPD – Screening
Screening tests for BPD include:
a. Depression – any of the validated depression
screening tests: Hamilton, Beck, PHQ-9, Major Depression
Inventory, Zung scale, etc.)
b. Mania – either of
i. Mood Disorder Questionnaire (MDQ) – 13
questions
ii. (WHO) Composite International Diagnostic
Interview (aka CIDI 3.0) – 12 questions
25
BPD – Screening; A Few Parting Thoughts
• Screening for and treating depression and/or anxiety can
be adequately performed in a primary care setting
• Screening for BPD can be adequately performed in a
primary care setting
• However, confirmation of BPD diagnosis and formal BPD
treatment should be the province of a specialist
(psychiatrist and allied health professionals). Once an
individual has been appropriately diagnosed and is stable
on treatment it is not unreasonable for much of the
maintenance care to happen in a primary care setting
(med refills, blood testing, etc.) but the psych experts
should stay involved at some level.
26
BPD – Screening and Underwriting
• So, if the medical records indicate that screening tests
were done – especially the MDQ or CIDI 3.0 – and the
screen was determined to be positive, it is hard to argue
with the diagnosis of BPD.
• If the records do not record how the diagnosis was made,
look for these to increase likelihood of BPD Dx:
a. Positive family history (parent, sib, child)
b. Lithium use
c. Nonmedical evidence: multiple driving citations,
OUI’s, arrests, bankruptcies, etc. (though this might carry a
little less weight than a and b above in my mind)
27
28
Why BPD is so Challenging
• The presentation
A. Mood – in descending order: irritability, euphoria,
expansiveness, lability, depression
B. Cognitive – in descending order: racing
thoughts/flight of ideas, distractibility/poor concentration,
grandiosity/overconfidence,
confusion/disorientation/impaired memory
29
Why BPD is so Challenging
C. Activity and Behavior – in descending order of
frequency: hyperactivity, increased speech output,
rapid/pressured speech, decreased need for sleep,
increased libido, violent/assaultive behavior, religiosity,
extravagant spending sprees, nudity/sexual exposure,
pronounced regression, catatonia
30
31
Why BPD is so Challenging
Long differential:
Must first rule out
a. Thyroid disease
b. Seizure disorder
c. Multiple sclerosis
d. CVA
e. AODA
f. Hyperparathyroidism
g. Personality disorder
h. Schizophrenia
i. Infection (syphilis)
j. Traumatic Brain Injury (TBI)
k. Schizoaffective disorder
32
Why BPD is so Challenging
Difficult to diagnose:
33
Why BPD is so Challenging
• Inconsistent course:
34
Why BPD is so Challenging
• The company it keeps:
a. Lifetime prevalence of at least one comorbid psychiatric
disorder was 2x that of gen pop (92% vs. 46%)
b. Prevalence of anxiety was 2.5x gen pop
c. Prevalence of AODA in US
i. BPI – 4x gen pop
ii. BPII – 2.5x gen pop
d. Prevalence of ADHD is 4x gen pop
35
Why BPD is so Challenging
e. Prevalence of eating disorders 3-5x gen pop
f. Prevalence of intermittent explosive disorder is 6x gen
pop
g. Prevalence of comorbid personality disorder
i. Cluster A (paranoid, schizoid, schizotypal) was 2x
gen pop
ii. Cluster B (antisocial, borderline, histrionic and
narcissistic) was 7.5x gen pop
iii. Cluster C (avoidant, dependent, OCD, passiveaggressive) was 3.5x gen pop
36
Why BPD is so Challenging
• Comorbids in general are associated with:
a. Earlier age of onset
b. More severe clinical course
c. More suicide attempts
d. Poorer psychosocial functioning
e. Greater potential for cognitive impairment
37
Why BPD is so Challenging
• PATIENTS OFTEN LACK INSIGHT!
• Also, if I can get all my stuff done, have all the energy in
the world and feel great, am I really interested in doing
something that’s going to take that away?
• Similar to overtreated hypothyroidism
38
Disclaimer
• I am not in any way saying that the individual in the next
slide has BPD, diagnosed or otherwise. I am simply
showing their response to a very appropriate question
given their behavior at that time. You may remember
parts of this…
• But for illustrative purposes this response would
represent a classic lack of insight
39
40
Why BPD is so Challenging
• Social Stigma
This individual has exhibited courage by blogging publicly
about their BPD:
• https://www.youtube.com/watch?v=6zTw-TCBAL4
Note the flight of ideas, grandiosity, desire for AODA,
rapidity of speech, questionable plausibility of some of their
plans, etc.
I’m exhausted just listening to him.
41
Same Individual, Depressed
• https://www.youtube.com/watch?v=PQWp4gsu9mQ
• Depressed entry preceded manic entry
• Posting dates were only 3 days apart = rapid cycling
42
An Example of Good Insight…
43
Current BPD Treatment Arsenal*
Generic Name
Trade Name
Manic
Mixed
Valproate
Depakote
X
Carbamazepine (ER)
Equetro
X
Lamotrigine
Lamictal
Lithium
Eskalith
X
Aripiprazole
Abilify
X
X
Risperidone
Risperdal
X
X
Asenapine
Saphris
X
X
Quetiapine
Seroquel
X
Chlorpromazine
Thorazine
X
Olanzapine
Zyprexa
X
Olanzapine/fluoxetine
Symbyax
Maintenance
Depression
X
X
X
X
X
X
X
X
*FDA-Approved
44
Benefits of Being an Underwriter
• Access to medical information psych and otherwise – or
at least a single, rather terse paragraph – hopefully
including appropriate screening tests
• Access to medication list (+/- Rx report)
• Access to driving records
• Access to criminal records
• Can re-contact proposed to clarify or develop more
information
45
Disadvantages of Being an Underwriter
• Summary Statements that state next to nothing
• Physicians contradicting one another
a. IS the patient bipolar?
b. Is the patient in remission?
c. Was initial diagnosis incorrect?
• Patient disagrees with diagnosis – Googled this; eyeopener
• Blank pharmacy report
• Documented noncompliance but the proposed looks like
a rose
46
Cause for Optimism?
• Regular followup
• Engaged with medication and CBT
• Family or other support system in place
• Symptom stability
• Stability both in home and at work
47
Things to Remember
• Even though the symptoms may wax and wane, the
disorder is lifelong
• Plugged into regular care = best prognosis both in life and
in Life Underwriting
• Compliance with MD-directed management is key
• Underwriter is in a unique position – in clinic MD does not
always have access to info about driving, financial
indiscretions, etc.
48
Questions?
49