Download Mood Spectrum Disorders

Approach to Bipolar
Spectrum Disorders
M NAJIB M ALWI
MD(USM), Dip IC(UK), MSc(UK), MRCPsych(UK)
Dept of Psychiatry
School of Medical Sciences
Universiti Sains Malaysia
Mania/Hypomania Episode:
DSM-IV Symptoms
•
Persistently elevated, expansive, or irritable mood
below, 4)
•
Inflated self-esteem or grandiosity
•
Decreased need for sleep
•
Talkativeness or pressured speech
•
Flight of ideas or “racing” thoughts
•
Distractibility
•
Increase in goal-directed activity or psychomotor agitation
•
Excessive involvement in pleasurable activities with high potential for
negative consequences
•
DURATION: 1 week / need for hospitalisation (MANIA); 4 days
(HYPOMANIA)
(at least 1 + >3 of
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision Washington, DC. American Psychiatric Association, 2000.
2. Ghaemi SN. Bipolar Disorder and Antidepressants: An Ongoing Controversy. Primary
Psychiatry. 2001;(8):28-34.
Major Depressive Episode:
DSM-IV Symptoms
•
•
•
•
•
•
•
•
•
Depressed mood*
 interest/pleasure*
Weight loss/gain
 or  need for sleep
Psychomotor agitation/retardation
Fatigue/loss of energy
Feelings of worthlessness
 ability to think or concentrate
Suicidal thoughts or thoughts of death
*Either must be present for the diagnosis of a major depressive
episode.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision. Washington, DC. American Psychiatric Association, 2000.
Bipolar Disorder:
Mixed Mania and Rapid Cycling
• Mixed mania
– Simultaneous symptoms of depression and
mania
– Evident in up to 30-40% of all bipolar I patients
– Women >men
• Rapid cycling
– 4 mood episodes yearly
– 3 times women >men
– Ultrarapid cycling: 4 episodes monthly
1. Evans DL. J Clin Psych 2000;61 (Suppl 13):26-31.
2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision. Washington, DC. American Psychiatric Association, 2000.
BIPOLAR DISORDERS (DSM-IV)
• Bipolar I Disorder
– (manic depressive illness with or without psychosis)
• Bipolar II disorder
– (episodes of major depression alternating with episodes
of hypomania which are not severe enough to result in
impairment of function)
• Cyclothymic disorder
– (brief and attenuated episodes of depression and
hypomania sometimes known as minor cyclic mood
disorder)
• Lifetime prevalence: 3% to 4% of general
population
5
Misdiagnosis
2000 National DMDA Bipolar Survey
(n=600)
69%
Misdiagnosis
occurred
Most frequent misdiagnosis:
Unipolar depression
35% were symptomatic for more than
10 years before correct diagnosis
10+ years
NDMDA: National Depressive and Manic-Depressive Association.
Hirschfeld RMA, et al. J Clin Psychiatry. 2003;64:161-174.
6
7
Further Diagnostic Difficulty
• A much larger group of patients
demonstrate milder and/or atypical forms
of episodic mood disturbances
– Frequently resistant to standard
antidepressants
– Some worsened by antidepressants
• Efforts at clinical subtyping the so-called
soft bipolar spectrum are ongoing
– Currently: DSM-IV Bipolar II Disorder, NOS
(not otherwise specified).
• If included: lifetime prevalence of Bipolar
DO - 5% to 8 % of the general population
8
History of Mood Disorders
• Kraepelin (1890s):
– “manic-depressive insanity”
– Included DSM-IV subtypes, mixed and rapid cycling
states, many of the soft bipolar variations and also
episodic depressions
• DSM-I (1960s):
– proposed a differentiation between major depression
and manic-depressive illness
• Later DSMs:
– unipolar - bipolar dichotomy
• Fieve and Dunner (1970s):
– discriminated bipolar I from bipolar II disorder
– a seminal event in the evolution of the soft bipolar
spectrum
11
Further Evolution
• KLERMAN'S BIPOLAR SUBTYPES (1981)
–
–
–
–
Bipolar I: Mania and depression
Bipolar II: Hypomania and depression
Bipolar III: Cyclothymic disorder
Bipolar IV: Hypomania or mania precipitated by
antidepressant drugs
– Bipolar V: Depressed patients with a family
history of bipolar illness
– Bipolar VI: Mania without depression [unipolar
mania]
Psychiatric Annals #17: January 1987
12
Current Thinking
• Hagop Akiskal: nosologic pendulum
is swinging back towards
Kraepelinian original unitary concept
of the bipolar spectrum of mood
disorders
• He added four more subtypes:
according to some unique clinical
features.
13
AKISKAL'S SCHEMA OF BIPOLAR
SUBTYPES
•
•
•
•
•
•
Bipolar I: full-blown mania
Bipolar I ½: depression with protracted hypomania
Bipolar II: depression with hypomanic episodes
Bipolar II ½: cyclothymic disorder
Bipolar III: hypomania due to antidepressant drugs
Bipolar III ½: hypomania and/or depression
associated with substance use
• Bipolar IV: depression associated with hyperthymic
temperament
14
Akiskal & Pinto (1999) Psychiatric Clinics of North America 22:3, 517-534
AKISKAL'S SCHEMA OF BIPOLAR
SUBTYPES
•
•
•
•
•
•
Bipolar I: full-blown mania
Bipolar I ½: depression with protracted hypomania
Bipolar II: depression with hypomanic episodes
Bipolar II ½: cyclothymic disorder
Bipolar III: hypomania due to antidepressant drugs
Bipolar III ½: hypomania and/or depression
associated with substance use
• Bipolar IV: depression associated with hyperthymic
temperament
• Proposed subtypes V and VI have not yet been
characterized:
– presumably will involve:
• episodic anxiety disorders
• seasonal mood states
• mood disorders co morbid with various anxiety disorders of an
episodic nature.
15
Akiskal & Pinto (1999) Psychiatric Clinics of North America 22:3, 517-534
Complicated….?
That’s not all……..
16
Lieber’s “soft” Bipolar
Spectrum Disorders
• Episodic Mood Instability
• Episodic Atypical Depression
• Episodic Dysphoric Hypomania
17
1. Episodic mood instability
• Lifelong episodes of mood swings starting around
adolescence.
• The mood shifts unpredictably among several
distinct mood poles:
–
–
–
–
–
–
brief depressions lasting hours to one or two days
brief euphoria
brief dysphoric or irritable episodes
brief paranoid episodes
brief episodes of rage or intense uncontrollable anger
brief episodic anxiety equivalents (panic attacks, phobias or
obsessive ruminations).
• This multiplicity of mood options: multipolar mood
disorder might be a more accurate designation for it.
18
2. Episodic atypical depression
(EAD)
• shows atypical depressive features:
– eating too much, sleeping too much, feeling
worse towards evening and intense tiredness or
lethargy.
• mood responsive:
– Temporary response to favourable circumstances
(hours to a day or two) before returning to the
depressed state.
• co-existing anxiety and its subtypes
(phobias, panic attacks, OCD )
19
Subtypes of Episodic Atypical
Depression
• (distinguished by special features):
– seasonal affective disorder
• winter-onset atypical depressions
– premenstrual dysphoric disorder
• a/w irritability, mood swings and dysphoria (irritability)
• a week to ten days on either side of the menstrual period
– hysteroid dysphoria
• mainly in women with histrionic personality features
• episodes precipitated by romantic rejection
– abulic depression
• a/w a deficit syndrome (apathy, amotivation, lack of will
power, lack of energy, lack of pleasure in life, emotional
blunting )
20
3. Episodic Dysphoric Hypomania
NB: Hypomania:
• Two types: euphoric and dysphoric (irritable)
• Two durations: episodic and protracted
• Episodic dysphoric hypomania:
– Irritability, emotional discomfiture, impulsiveness, temper
dyscontrol and impaired judgment
– Interfere with interpersonal relationships and to limit
productivity at work
– Sense of inner speeding combined with restless over activity
and racing thoughts, which can lead to a state of desperation.
– Episodes of depression and mood instability almost always
present + sometimes brief euphoric episodes.
– Triad: irritable episodes alternating with rage episodes and
paranoid episodes is characteristic of dysphoric hypomania.
21
A Proposed Definition of Bipolar
Spectrum Disorder
A. At least 1 major depressive episode
B. No spontaneous hypomanic or manic
episodes
C. Either:
•
•
1 of the following plus at least 2 of D;
or 2 of the following, plus 1 item from D:
•
•
Family history of bipolar disorder in 1st degree
relatives
Antidepressant induced mania or hypomania
Ghaemi SN et al (2002) Can J Psychiatry. 47(2):125-134
23
A Proposed Definition of Bipolar
Spectrum Disorder
D.
If no items from C are present, 6 / 9 of below are
needed:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Hyperthymic personality (at baseline, non-depressive
state)
Recurrent major depressive episodes (>3)
Brief major depressive episodes (ave <3 months)
Atypical depressive symptoms
Psychotic major depressive episodes
Early age of onset of major depressive episodes (<age 25)
Postpartum depression
Antidepressant “wear-off” (acute, but not prophylactic
response)
Lack of response to ≥ 3 antidepressants trial
Ghaemi SN et al (2002) Can J Psychiatry. 47(2):125-134
24
COMORBIDITY
• A high percentage of bipolar mood
disorders, perhaps more than 50%, are
comorbid with other medical and/or
psychiatric conditions.
25
Thyroid disorders
• Hyperthyroidism: resembles hypomania/
mania and it can worsen pre-existing mania/
hypomania
• Hypothyroidism: resembles clinical depression
and it can cause pre-existing depression to be
unresponsive to antidepressant medications
• Treatment with lithium can produce
hypothyroidism
• Subtle or subclinical hypothyroidism is often
associated with the development of mixed and
rapid cycling bipolar disorders.
26
Substance misuse
• Psychoactive effects on the brain and can
worsen the bipolar condition
• Interfere with effective treatment
• Can mimic both depression and hypomanic
states
• Unmask a pre- existing depression or bipolar
disorder
• Can be secondary to self-medication of bipolar
disorder
27
ADHD
• ADHD is now known to often persist into adulthood
and symptoms may overlap with bipolar spectrum
disorder
• Overlapping symptoms:
–
–
–
–
–
–
Restlessness
Motor hyperactivity
Easy distractibility
Impulsiveness
Inability to concentrate or focus attention
Temper dyscontrol
• Differentiation: ADHD continuous vs bipolar
conditions episodic
• Incidence of their co morbidity is unknown.
• Stimulants (eg Ritalin), tend to worsen the symptoms of
bipolar spectrum disorder
28
Borderline Personality Disorder (BPD)
• Stormy and unstable lifestyle, overly dramatic, intense
but unstable relationships, and exhibit self-defeating
and often self-destructive behaviours
• Recent years: a high percentage of these patients have
co morbid bipolar spectrum disorders.
• 75 % of these patients will respond to combination
pharmacotherapy using SSRI, a mood stabilizer and an
atypical antipsychotic (e.g. olanzapine).
• Once the mood has become stable, they can then
benefit from competent psychotherapy to deal with
their emotional backwash.
• Better prognosis with this treatment approach?
29
*
*Mood Disorder Questionnaire (MDQ)
Bipolar Spectrum Disorder Scale (BSDS)
30
Hirschfield RM (2002) J Clin Psych. 4: 9-11
31
31
Bipolar Spectrum Disorder Scale (Ghaemi & Pies 2003)
•
Read the following paragraph all the way through first, then follow the instructions
which appear below it.
•
Some individuals noticed that their mood and/or energy levels shift drastically from
time to time ______ . These individuals notice that, at times, their moody and/or energy
level is very low , and at other times, and very high______. During their " low" phases,
these individuals often feel a lack of energy, a need to stay in bed or get extra sleep, and
little or no motivation to do things they need to do______ . They often put on weight
during these periods______ . During their low phases, these individuals often feel
"blue," sad all the time, or depressed______ . Sometimes, during the low phases, they
feel helpless or even suicidal _____ . Their ability to function at work or socially is
impaired ______ . Typically, the low phases last for a few weeks, but sometimes they
last only a few days ______ . Individuals with this type of pattern may experience a
period of "normal" mood in between mood swings, during which their mood and energy
level feels "right" and their ability to function is not disturbed ______ . They may then
noticed they marked shift or "switch" in the way they feel ______ . Their energy
increases above what is normal for them, and they often get many things done they
would not ordinarily be able to do ______ . Sometimes during those "high" periods,
these individuals feel as if they had too much energy or feel "hyper" ______ . Some
individuals, during these high periods, may feel irritable, "on edge," or aggressive
______. Some individuals, during the high periods, take on too many activities at once
______. During the high periods, some individuals may spend money in ways that
cause them trouble______ . They may be more talkative, outgoing or sexual during
these periods ______ . Sometimes, their behavior during the high periods seems strange
or annoying to others ______ . Sometimes, these individuals get into difficulty with coworkers or police during these high periods ______ . Sometimes, they increase their
alcohol or nonprescription drug use during the high periods ______ .
32
Scoring the BSDS
• Add total of check marks from the first 19 sentences. To that total, add
the number in parentheses below for the line you selected:
–
–
–
–
this story fits me very well, or almost perfectly (6)
this story fits me fairly well (4)
this story fits me to some degree, but not in most respects (2)
this story doesn't really describe me at all (0)
• The maximum is 19 plus 6, for 25 points.
• Interpretation:
19 or higher
11-18
6-10
<6
=
=
=
=
bipolar spectrum disorder highly likely
moderate probability of bipolar spectrum disorder.
low probability of bipolar spectrum disorder
bipolar spectrum disorder very unlikely
33
Bipolar Disorder Treatment Strategies
Revisited
34
Treatment of Bipolar Disorder
Treats the highs (mania)
Helps prevent the highs
and lows (maintenance)
Helps manage the lows (depression)
36
Long-term Treatment Goals
•
Facilitating compliance
–
–
•
Tolerability of adverse effects of medications
Denial of illness
Recognizing ‘signal events’ that indicate
1. Patient has returned to baseline functioning
2. Patient is at a risk for relapse
•
Family Involvement
–
–
To pick up early warning signs of patient relapsing
To assess the family’s expectations
37
World Federation of Societies of Biological
Psychiatry (WFSBP) 2003 Guidelines
• Acute bipolar mania, mild to moderate
• Acute bipolar mania, severe
• Bipolar depression
38
Efficacy of Olanzapine in Combination
with Lithium or Valproate
% Probability of Remaining
in Remission
100
OLZ plus Li or VPA, (n=30)
Li or VPA, (n=38)
80
60
40
20
p=.023
0
0
100
200
300
400
500
Time to Recurrence Into Mania or Depression
(Days)
Time to recurrence into either pole following symptomatic remission of mania (YMRS 12) and depression
(HAMD-21 8), was significantly longer for the olanzapine cotherapy group compared to the monotherapy group
(estimated 25th percentile 124 vs 15 days, respectively).
Tohen M, et al. Presented at: 155th APA Annual Meeting; May 18-23, 2002; Philadelphia, Pa.
43
Treatment Strategies for Bipolar
Spectrum Disorder Lieber (2003)?
• Present with predominantly anxiety or
depression symptoms:
– Start initially on an SSRI (e.g. Fluoxetine)
– If symptoms of hypomania occur during the
course of treatment, add a mood stabilizer (e.g.
Sodium Valproate)
– If the patient fails to respond to the SSRI within
four weeks or is unable to tolerate it due to
side effects, I will switch to a dual
neurotransmitter antidepressant (Effexor,
Welbutrin, Remeron, Serzone).
– Once the patient is mood stable and without
symptoms, monitor at one to three-month
intervals. Advise to continue the same dose to
prevent recurrence
44
Treatment Strategies for Bipolar
Spectrum Disorder Lieber (2003)?
• Present with either euphoric or dysphoric
hypomania/ uncontrollable rage/violent
outbursts:
– Start on a mood stabilizer.
– If necessary, an antidepressant drug can be
added later after the mood has been stabilized.
• Patients with mixed or rapid cycling
states:
– Usually respond to combination therapy with
mood stabilizers and antidepressants.
45
Unanswered Questions
• Does bipolar spectrum disorder
routinely require mood stabilisers?
• How safe are antidepressants in bipolar
spectrum?
• What is the optimal duration of
treatment?
46
Conclusion
• Bipolar Spectrum Disorders are only
recently recognized
• May explain difficulties in treating mood
disorder patients
• Treatment strategies need to be
optimized depending on presenting
problems and may need to be revised
from time to time
47
Thank You
48