Download Bi Polar Affective Disorder

BiPolar Affective Disorder
Ratna Ghosh
ST6, GA Psychiatry
Cambridgeshire & Peterborough Foundation NHS Trust
20.8.09
What I am going to talk about
• History
• Epidemiology
• Aetiology
• Diagnosis
• Treatment
• Prognosis
• ISQs
History(1)
• Hippocratic school: described melancholia and mania
• Galen: black bile=melancholia; yellow bile=mania
• In the middle ages, more theological and religious
explanations for mental illness
• Nineteenth century: French Psychiatrists: “la folie
circulaire”
• Kahlbaum : circular disorder characterised by episodes
of both excitement and depression which did not end in
dementia (cyclothymia)
History(2)
• Emil Kraeplin : separated manic-depressive
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illness from dementia praecox by episodic
course, benign outcome, family history;
“Kraeplinian Dichotomy”
Eugen Bleuler: Spectrum disorder; mood
symptoms are non specific
Kasanin : schizo-affective disorders
Freud: mourning & melancholia
History (3)
• Current nosology is neo-krepaelinian
• Validity of the diagnosis is derived from
research on phenomenology, genetics,
course, treatment response
• Diagnostic subtypes (DSM-IV &ICD-10)
Major Depressive (Unipolar) Disorder
Bipolar Disorder( BPI , BPII, BPIII,? BPIV)
Dysthymia; Cylcothymia ;( Hyperthymia )
Fig. 1 Two-dimensional mood/affective spectrum (does not include schizoaffective
disorder, as a transition to the schizophrenic spectrum). The precise relationship of
personality disorders to the disease spectra is uncertain and an unsolved general problem
of psychiatric classification. BP-I (-II), bipolar-I disorder type I (II); D, major depression, d,
minor depression; M, mania; m, hypomania; MDD, major depressive disorder; RBD,
recurrent brief depression; sx, symptoms
Angst, J. Br J Psychiatry 2007;190:189-191
Copyright © 2008 The Royal College of Psychiatrists
Acute Mania
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Elevated mood
Irritable mood
Increased self esteem or grandiosity
Decreased need for sleep
Increased talkativeness
Flight of ideas
Distractibility
Increased social activities
Psychomotor agitation
Risk taking behaviour
Increased sexual activites
Clinical Features :Acute Mania (3 stages of
acute mania in untreated patients*)
• Hypomania: increased well being/ irritability, sufficient control over the
condition; elevated mood (4/7)+psychomotor symptoms+ expansive; but able to
function in social & occupational setting
• Mania without psychotic features: elevated/ irritable mood
(1/52), decreased need for sleep , psychomotor agitation, distractibility, increased
social activities, increased talkativeness, flight of ideas, increased self esteem, risk
taking behaviour, increased sexual activities. There is marked impairment in social &
occupational functioning and hospital admission is often needed
• Mania with psychotic features: emotional lability, extreme
anger, hostility, severe agitation, no need for sleep, flight of ideas, grandiose
delusions, sexually very preoccupied. Mood congruent/incongruent psychotic
symptoms
*Carlson& Goodwin, Arch of Gen Psych,28,221-8
Bipolar Disorder: recurrent episodes
• BP I : episodes of mania+ episodes of major depression. 5-10% only
recurrent mania
• BP II: episodes of hypomania + episodes of major depression
• BP III: cyclothymia (DSM-IV-TR)
• ? BP IV: episodes of mania following treatment with antidepressant
• ? BP V: episodes of depression with family history of BAD
• ? BP VI : only episodes of mania or hypomania
Bipolar Disorder
• Rapid Cycling Disorder: at least 4 episodes
of mania, depression, hypomania, mixed
state in the past 12 months
• Mixed Affective State: presence of manic
and depressive symptoms in the same
episode; duration at least 2 /52
Bipolar Disorder: chronic
• Chronic mania: rare
• Chronic bipolar major depression : major
depression continuously for at least 2
years in a patient with a previous manic or
hypomanic episode
• Cyclothymia: sub-syndromal mood swings;
persistent fluctuating mood disturbances
Bipolar Depression
• Family history of any bipolar disorder in first-degree
relatives
• Early age at onset
• High frequency of depressive episodes
• Psychotic features
• Hypersomnia (atypical symptoms)
• psychomotor retardation, anergia
• Irritability & anger
Epidemiology(1)
• Data from USA National Institute of Mental
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Health Epidemiologic Catchment Area Study
(ECA)& National Co-morbidity survey
National Psychiatric Morbidity Survey of GB
Lifetime prevalence is 0.3-1.5%
Bipolar Spectrum disorder: prevalence up to
6.4%
Mean age of Onset : 17-27 years (not normally
distributed with a peak in late teenage)
Similar prevalence in males and females
Epidemiology(2)
• High co-morbidity: anxiety disorders
(90%), alcohol(40%)& drug
abuse/dependence(60%), conduct
disorder, ADHD
• Significant increase in lifetime health
service utilisation
• Greater marital disruption
• 10% of patients commit suicide. Up to
40% patients have attempted suicide
Aetiology
• Genetic Factors
• Organic factors
• Iatrogenic
• Life Events : childbirth
• seasonal variation
• Childhood factors +/-
Genetic Aetiology of Bipolar
Disorder
• Family studies :Family studies of bipolar disorder, have shown
increased familial risks of bipolar disorder, schizoaffective disorder,
and unipolar depression.
• Adoption studies : support familial aggregation(17% risk in
biological parent vs 7% in adopted parent)
• Twin studies :increased risk of bipolar disorder in monozygotic
(identical) co-twins (50%)as compared to dizygotic (fraternal) cotwins (10%) of a proband with bipolar-I disorder
• Molecular Genetics
Molecular Genetics
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Chromosomes 8,9,10,13,14,22,18
Small positive effect size
Often negative on replication
Meta analysis have provided some support for
polymorphism in genes involved in MAO,COMT,5HT
metabolism; ? Genes for ion channelopathy
• some of the regions identified in linkage studies of
bipolar disorder overlap with regions implicated in
schizophrenia
• DISC1,neuregulin,BDNF (rapid cycling) genes could be
involved (? Psychosis gene)
• ANTICIPATION
Neural correlates (affective
disorder)
• Neuropsychology
• Neuro imaging
• Neuropathology (PM) studies
• Lesion studies implicate disturbances in the frontal lobe, basal
ganglia, striatum and anterior temporal cortex.
• Amygdala hyperactivation
• Methodological issues
• State/trait/effects of medication
Psychosocial Aetiology
• Life Events
• Child birth
• Social relationships
• Dysfunctional cognition
• Temperament & personality variables
Course & Prognosis
• Onset 15-19 years
• Considerable time lag between first
symptom(15),diagnosis(19),treatment(22)
• Median length of episode 4-6 months
• Chronic in 10% (over 24 months)
• ?Kindling effect in recurrence
• More episodes in bipolar illness (10 vs 4 in
22 year follow up)
Course & Prognosis (2)
• Higher recurrence if mixed/cycling feature
• Remission is frequently incomplete
• Residual symptoms are a strong risk
factor(x3) for further recurrence
• Longer term : recovery in 16%,chronic
course in 11%
• Co morbidity : 30% alcoholism
• Mortality:15%
Treatment
• NICE Guidelines
• BAP Guidelines
Treatment of acute mania(not
on anti manic)
• Second generation antipsychotic :
Olanzapine, quetiapine, risperidone
• If no response, add Li or valproate
• Consider Valproate or Lithium if previous
good response and compliance (avoid
valproate in women of child bearing age
group)
• Avoid CBZ
Acute Mania ( patient on anti
manic)
• Optimise treatment dose (Li: 0.8-1.0)
• Add olanzapine/quetiapine/risperidone
Acute depression
• SSRI + antimanic
• Consider quetiapine
• Consider Lamotrigine (BP II)
Longer term treatment
• If more than 2 episodes in BP I
• If significant risk/functional
impairment/frequent episodes in BP II
• Lithium/valproate/olanzapine
monotherapy
• If no response in 6 months, consider
combination of 2 of the above
• If no response, add lamotrigine, CBZ
• Antidepressants not routinely prescribed
ISQs…
1. In bipolar affective disorder, mania &
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3.
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depression may correlate with activation of
distinct parts of the pre-frontal cortex
Lithium may provide protection against some
structural changes in the brain
In bipolar affective disorder, amygdala is not
affected
The manic prodrome is idiosyncratic to each
patient with bipolar affective disorder
ANS: 1T.2T.3F.4T.
1. Patients with bipolar disorder have more minor/sub
syndromal depressive symptoms than depressive
episodes
2. Patients with bipolar disorder are symptomatic for up to
50% of the time
3. Lithium is equally effective in preventing manic and
depressive relapses
4. Antidepressants may be less effective in the treatment
of major depression than bipolar depression
ANS
1T.2T.3F.4F.
ISQ(3)
1. Bipolar disorder patients are less likely than
2.
patients with major depressive disorder to
experience psychosis during depressive
episodes
Antidepressants are associated with higher
rates of depressive relapse on discontinuation
in patients with bipolar disorder than in those
with major depression
Ans 1F 2T
• Any Questions?
• Thank You