Download Bipolar Affective Disorder

Psychiatry III
1
Clinical Impression
2
3
Bipolar I Disorder
4
• Also known as Bipolar Affective Disorder
• A psychiatric diagnosis that describes a category of mood
disorders defined by the presence of one or more
episodes of abnormally elevated mood clinically referred
to as mania or hypomania
• A condition in which people experience abnormally
elevated (manic or hypomanic) and abnormally
depressed states for a period of time in a way that
interferes with functioning.
http://en.wikipedia.org/wiki/Bipolar_disorder
Bipolar I Disorder
5
DSM IV-TR Diagnostic Criteria for Bipolar I
Disorder, Most Recent Episode Manic
A. Currently or mostly in a manic episode.
B. There has previously been at least one major depressive
episode, manic episode, or mixed episode.
C. The mood episodes in Criteria A and are not better accounted
for by schizoaffective disorder and are not superimposed on
schizophrenia, schizophreniform disorder, delusional disorder,
or psychotic disorder not otherwise specified.
Page 546
DSM IV-TR Criteria for Manic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable
mood, lasting at least 1 week (or any duration if hospitalization is necessary).
B. During the period of mood disturbance, three or more of the following symptoms
have persisted (four if the mood is only irritable) and have been present to a
significant degree:
1. inflated self-esteem or grandiosity
2. decreased need for sleep (feels rested after only 3 hours of sleep)
3. more talkative than usual or pressure to keep talking
4. flight of ideas or subjective experience that thoughts are racing
5. distractibility (attention too easily drawn to unimportant or irrelevant external
stimuli, impulsive)
6. increase in goal directed activity (either socially, at work or school, or sexually)
or psychomotor agitation
7. excessive involvement in pleasurable activities that have a high potential for
painful consequences (unrestrained buying sprees, sexual indescretions, etc)
C. The symptoms do not meet criteria for a mixed episode.
D. The mood disturbance is sufficiently severe to cause marked impairment…
E. The symptoms are not due to direct physiological effects of a substance…
Previous Manic Episode
7
1993
• Impulsive: grabbed the car’s steering wheel while mother
was driving
• Very talkative in class because or numerous running ideas
in her mind
April 2002 • Spend recklessly, buying a lot of things from the mall
maxing out her 2 credit cards
2008
• October: Observed to be very talkative while on the way to
the cemetery, spent 14,000 for shopping
• December: episodes of hyperactivity, spent most of the
time at the gym to lose weight
Bipolar I Disorder
DSM IV-TR Diagnostic Criteria for Secerity/ Psychotic/ Remission
Specifiers for Current or Most Recent Manic Episode
Severe With Psychotic Features
Presence of Delusions or Hallucinations
Specify:
Mood Congruent Psychotic Features
Delusions or hallucinations whose
content is consistent with the typical
depressive themes of personal
inadequacy, guilt, disease, death,
nihilism, or deserved punishment.
Page 544
Mood-Incongruent Psychotic Features
Delusions or hallucinations whose
content does not involve typical
depressive themes of personal
inadequacy, guilt, disease, death,
nihilism, or deserved punishment.
Included are such symptoms as
persecutory delusions (not directly
related to depressive themes), thought
insertion, thought broadcasting, and
delusions of control.
Psychotic Features
9
• Thought that her co-workers
at the library were talking
about her of the thesis that
she was doing.
April 2002
PERSECUTORY DELUSIONS 
MOOD – INCONGRUENT
PSYCHOSIS
• Got out and ran
October 31, 2008
away from
the car because she thought
there was a coup d’etat going
on.
Clinical Impression: DSM IV
10
• Bipolar I Disorder with Recent Manic
Episode and Mood Incongruent Psychotic
Axis I Symptoms
• No Personality Traits/ Disorders
• No Mental Retardation
Axis II
Axis III
•No Physical Disorders
•No Medical Conditions
Clinical Impression: DSM IV
11
Axis IV
• Pyschosocial and Environmental Factors
contributing to her disorder
• Previous history of ADHD
• Pressures from growing up years to
excel academically
• Moving to the Philippines
91-100 Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought
out by others because of his or her many qualities. No symptoms.
81-90 Absent or minimal symptoms, good functioning in all areas, interested and involved in a wide range of
activities, socially effective, generally satisfied with life, no more than everyday problems or concerns.
71-80 If symptoms are present they are transient and expectable reactions to psychosocial stresses; no more
than slight impairment in social, occupational, or school functioning.
61-70 Some mild symptoms OR some difficulty in social, occupational, or school functioning, but generally
functioning pretty well, has some meaningful interpersonal relationships.
51-60 Moderate symptoms OR any moderate difficulty in social, occupational, or school functioning.
41-50 Serious symptoms OR any serious impairment in social, occupational, or school functioning.
31-40 Some impairment in reality testing or communication OR major impairment in several areas, such as
work or school, family relations, judgment, thinking, or mood.
21-30 Behavior is considerably influenced by delusions or hallucinations OR serious impairment in
communications or judgment OR inability to function in all areas.
11-20 Some danger of hurting self or others OR occasionally fails to maintain minimal personal hygiene OR
gross impairment in communication.
1-10 Persistent danger of severely hurting self or others OR persistent inability to maintain minimum personal
hygiene OR serious suicidal act with clear expectation of death.
0 Not enough information available to provide GAF.
12
Clinical Impression: DSM IV
13
Axis
V
• Global Assessment of Functioning Score of
31-40
• Some impairment in reality testing or
communication OR major impairment
in several areas, such as work or
school, family relations, judgment,
thinking, or mood.
Review DSM IV
DSM IV Diagnosis of EB
Axis I
Bipolar I Disorder with Recent Manic Episode and Mood Incongruent
Psychotic Symptoms
Axis II
• No Personality Traits/ Disorders
• No Mental Retardation
Axis III
• No Physical Disorders
• No Medical Conditions
Axis IV
• Pyschosocial and Environmental Factors contributing to her disorder
• Previous history of ADHD
• Pressures from growing up years to excel academically
• Moving to the Philippines
Axis V
• Global Assessment of Functioning Score of 31-40
• Some impairment in reality testing or communication OR major
impairment in several areas, such as work or school, family
relations, judgment, thinking, or mood.
14
Clinical Impression: ICD 10
• Mood (Affective) Disorder
F30-39
• Bipolar
AffectiveAffective
Disorder, Current
F31.2.21
Bipolar
Episode Manic with Psychotic Symptoms
F31.2
Disorder, Current Episode Manic
With mood
incongruent psychotic
with •Mood
Incongruent
symptoms
.21
Psychotic Symptoms
15
http://priory.com/psych/ICD.htm
Differential Diagnosis
16
1. BIPOLAR II DISORDER
2. SCHIZOAFFECTIVE DISORDER
3. BORDERLINE PERSONALITY DISORDER
Bipolar II Disorder
17
 Involves
 Major Depressive Episodes and
 Hypomanic Episodes
Bipolar II
(Hypomanic + MDD)
vs
Bipolar I
(Manic + MDD)
Bipolar II Disorder
18
•
Bipolar II is often a first step to Bipolar I.
•
Over 5 years, between 5% and 15% of those will Bipolar II will
change diagnosis to Bipolar I.
•
Approximately 0.5% of people will develop Bipolar II in their
lifetimes.
http://www.a-silver-lining.org/BPNDepth/dsmiv.html
DSM-IV-TR Diagnostic Criteria for
Bipolar II Disorder
19
 A) Presence (or history) of one or more Major Depressive Episodes
 B) Presence (or history) or at least one Hypomanic Episode
 C) There has never been a Manic Episode or a Mixed Episode
 D) The mood symptoms in Criteria A and B not better accounted for by
Schizoaffective Disorder and is not superimposed on Schizophrenia,
Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not
Otherwise Specified.
 E) The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
 Specifiers:
Hypomanic. used if the current (or most recent) episode is a
Hypomanic
Episode.
Depressed. used if the current (or most recent) episode is a Major
Depressive Episode.
Hypomanic Episode
20
•
•
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.
During the period of mood disturbance, three (or more) of the following symptoms have
persisted (four if the mood is only irritable) and have been present to a significant degree:
–
–
–
–
–
–
–
•
•
•
•
inflated self-esteem or grandiosity
decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
more talkative than usual or pressure to keep talking
flight of ideas or subjective experience that thoughts are racing
distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in
unrestrained buying sprees, sexual indiscretions, or foolish business investments)
The episode is associated with an unequivocal change in functioning that is
uncharacteristic of the person when not symptomatic.
The disturbance in mood and the change in functioning are observable by others.
The episode is not severe enough to cause marked impairment in social or occupational
functioning, or to necessitate hospitalization, and there are no psychotic features.
The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication, or other treatment) or a general medical condition (e.g.,
hyperthyroidism).
NOTE: Hypomanic-like episodes that are clearly caused by somatic antidepressant
treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count
toward a diagnosis of Bipolar II Disorder.
Schizoaffective Disorder
21
A. An uninterrupted period of illness during which, at
some time, there is either a Major Depressive
Episode, a Manic Episode, or a Mixed Episode
concurrent with symptoms that meet Criterion A
for Schizophrenia.
Note: The Major Depressive Episode must include
Criterion A1: depressed mood.
Schizoaffective Disorder
22
B. During the same period of illness, there have been
delusions or hallucinations for at least 2 weeks in the
absence of prominent mood symptoms.
C. Symptoms that meet criteria for a mood episode are
present for a substantial portion of the total duration
of the active and residual periods of the illness.
Schizoaffective Disorder
23
D. The disturbance is not due to the direct
physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition.
Borderline Personality Disorder
24
 DSM IV Diagnostic Criteria

A pervasive pattern of instability of interpersonal
relationships, self- image and affects and marked
impulsivity beginning by early adulthood and present in a
variety of contexts, as indicated by 5 (or more) of the
following:
Frantic efforts to avoid real or imagined abandonment
 A pattern of unstable and intense interpersonal relationships
characterized by alternating between extremes of idealization and
devaluation
 Identity disturbance: markedly and persistently unstable selfimage or sense of self
 Impulsivity in at least two areas that are potentially self-damaging
(e.g., spending, sex, substance abuse, reckless driving, binge
eating).

Borderline Personality Disorder
25
 Recurrent suicidal behavior, gestures, or threats, or selfmutilating behavior.
 Affective instability due to a marked reactivity of mood
(e.g., intense episodic dysphoria, irritability, or anxiety
usually lasting a few hours and only rarely more than a few
days).
 Chronic feelings of emptiness.
 Inappropriate, intense anger or difficulty controlling anger
(e.g., frequent displays of temper, constant anger, recurrent
physical fights).
 Transient, stress-related paranoid ideation or severe
dissociative
symptoms.
Why Consider Borderline Personality Disorder?
26
 Impulsivity in at least two areas that are potentially
self-damaging
Shops for clothes and jewelries, maxing out her 2 credit
cards
 Went to SM mall of asia and spent at least 14,000 for
shopping
 Tendency to shoplift things

 Chronic feelings of emptiness
 She was approached by a man who told her she looks
miserable and sick (2002)
Why Consider Borderline Personality Disorder?
27
 Transient, stress-related paranoid ideation
 When they got stuck on traffic, she got out of the car and ran
away because she thought there was a coup d’etat going on
Why It Is Not Borderline Personality Disorder?
28
 Only 3 out of the required 5 or more criteria
Treatment
29
Therapeutic Goals
30
 Relief of immediate symptoms
 Improvement of patient’s well-being
 Elimination of stressors
 Combined pharmacotherapy and psychotherapy
Improved medication compliance
Better monitoring of clinical status
Decreased number and length of hospitalizations
Decreased risk of relapse
Improved social and occupational functioning
Pharmacotherapy
31
DIVISION
Acute Phase
 Maintenance Phase

Treatment of Acute Mania
• Lithium Carbonate
–
–



32
the prototypical “mood stabilizer
Therapeutic lithium levels are between 0.6 and 1.2 mEq/L
Controls acute mania and prevents relapse in about 80% of persons with
bipolar I disorder
Has a relatively slow onset of action when used and exerts its antimanic
effects over 1-3 weeks
Thus a benzodiazepine, dopamine receptor antagonist, serotonindopamine antagonist, or valproic acid is usually administered for the first
few weeks.
Caution:
 Nephrotoxic (request Creatinine/BUN, monitor Blood levels)
 Teratogen (Pregnancy Test)
 Hypothyroidism
Treatment of Acute Mania
33
 Valproate


only indicated for acute mania; has prophylactic effects
Typical dose levels of valproic acid are 750 to 2,500 mg per
day, achieving blood levels between 50 and 120 µg/mL
 Carbamazepine and Oxcarbazepine

Typical doses of carbamazepine to treat acute mania range
between 600 and 1,800 mg per day associated with blood
levels of between 4 and 12 µg/mL
Treatment of Acute Mania
34
• Clonazepam and Lorazepam
–
–
effective and are widely used for adjunctive treatment of acute manic
agitation, insomnia, aggression, and dysphoria, as well as panic
Adjuvant to Lithium, may result in an increased time between cycles
and fewer depressive episodes
• Lamotrigine
–
Prevent recurrences of manic episodes
• ECT
–
–
Effective in acute mania
Reserved for rare refractory mania or with medical complications
Treatment of Acute Bipolar Depression
35
 Combination of Antidepressants and Mood Stabilizer
 Olanzepine and Fluoxetine
 Electroconvulsive Therapy
 Calcium Channel Blocker
 Verapamil
 Has acute antimanic efficacy
Table 15.1-37 US Food and Drug Administration
(FDA)-Approved Medications for the Treatment of
Bipolar Disorders
Mania
Maintenance
Aripiprazole (Abilify)
Yes (2004) No
Carbamazepine XR
Yes (2004) No
(Equetro)
Divalproex (Depakote)
Yes (1996) No
Lamotrigine (Lamictal)
No
Yes (2003)
Lithium (Lithobid)
Yes (1970) Yes (1974)
Olanzapine (Zyprexa)
Yes (2000) Yes (2004)
Risperidone (Risperdal)
Yes (2003) No
Quetiapine (Seroquel)
Yes (2004) No
Ziprasidone (Geodon)
Yes (2004) No
36
Maintenace Treatment of Bipolar Disorder
37
MOOD STABILIZERS
–
–
–
Lamotrigine
Lithium
Olanzapine
• Ameliorate affective and psychotic symptoms during
acute manic episodes
• Improve depression episodes during acute bipolar
depressive episodes
• Prevent future mood episodes with sustained
treatment at therapeutic levels (prophylactic benefit)
Psychotherapy
38
• Patients taking lithium or other treatments for
bipolar I disorder are usually medicated for an
indefinite period of time to prevent episodes of
mania or depression
• Most psychotherapists insist that patients with
bipolar I disorder be medicated before starting any
insight-oriented
therapy.
Without
such
premedication, most patients with bipolar I disorder
are unable to make the necessary therapeutic
alliance.
Psychotherapy
39
• When those patients are depressed, their abulia
seriously disrupts their flow of thoughts, and the
sessions are nonproductive.
• When they are manic, their flow of associations can
be rapid, and their speech can be so pressured that
the therapist may be flooded with material and may
be unable to make appropriate interpretations or to
assimilate the material into the patient's disrupted
cognitive framework.
Psychotherapy
40
 American Psychiatric Association (APA) practice
guideline for bipolar disorder


Recommends combined therapy as the best approach
It increases compliance, decreases relapse, and reduces the
need for hospitalization
Thank you.
41
Major Depressive Episode
42
• Five (or more) of the following symptoms have been
present during the same 2-week period and
represent a change from previous functioning; at
least one of the symptoms is either (1) depressed
mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to
a general medical condition, or mood-incongruent
delusions or hallucinations.
Major Depressive Episode
43
depressed mood most of the day, nearly every day,
as indicated by either subjective report (e.g., feels
sad or empty) or observation made by others (e.g.,
appears tearful). Note: In children and
adolescents, can be irritable mood.
2. markedly diminished interest or pleasure in all, or
almost all, activities most of the day, nearly every
day (as indicated by either subjective account or
observation made by others)
1.
Major Depressive Episode
44
3. significant weight loss when not dieting or weight
gain (e.g., a change of more than 5% of body weight
in a month), or decrease or increase in appetite
nearly every day. Note: In children, consider failure
to make expected weight gains.
4. insomnia or hypersomnia nearly every day
5. psychomotor agitation or retardation nearly every
day (observable by others, not merely subjective
feelings of restlessness or being slowed down)
Major Depressive Episode
45
6. fatigue or loss of energy nearly every day
7. feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional) nearly
every day (not merely self-reproach or guilt about
being sick)
8. diminished ability to think or concentrate, or
indecisiveness, nearly every day (either by subjective
account or as observed by others)
Major Depressive Episode
46
9. recurrent thoughts of death (not just fear of dying),
recurrent suicidal ideation without a specific plan, or
a suicide attempt or a specific plan for committing
suicide
• The symptoms do not meet criteria for a Mixed
Episode
• The symptoms cause clinically significant distress or
impairment in social, occupational, or other
important areas of functioning.
Major Depressive Episode
47
• The symptoms are not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition (e.g.,
hypothyroidism).
• The symptoms are not better accounted for by
Bereavement, i.e., after the loss of a loved one, the
symptoms persist for longer than 2 months or are
characterized by marked functional impairment,
morbid preoccupation with worthlessness, suicidal
ideation, psychotic symptoms, or psychomotor
retardation.
Manic Episode
48
 A distinct period of abnormally and persistently
elevated, expansive, or irritable mood, lasting at least
1 week (or any duration if hospitalization is
necessary).
 During the period of mood disturbance, three (or
more) of the following symptoms have persisted
(four if the mood is only irritable) and have been
present to a significant degree:
Manic Episode
49
1.
2.
3.
4.
5.
inflated self-esteem or grandiosity
decreased need for sleep (e.g., feels rested after
only 3 hours of sleep)
more talkative than usual or pressure to keep
talking
flight of ideas or subjective experience that
thoughts are racing
distractibility (i.e., attention too easily drawn to
unimportant or irrelevant external stimuli)
Manic Episode
50
6. increase in goal-directed activity (either socially, at
work or school, or sexually) or psychomotor agitation
7. excessive involvement in pleasurable activities that
have a high potential for painful consequences (e.g.,
engaging in unrestrained buying sprees, sexual
indiscretions, or foolish business investments)
Manic Episode
51
• The symptoms do not meet criteria for a Mixed
Episode
• The mood disturbance is sufficiently severe to cause
marked impairment in occupational functioning or
in usual social activities or relationships with others,
or to necessitate hospitalization to prevent harm to
self or others, or there are psychotic features.
• The symptoms are not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a
medication, or other treatment) or a general medical
condition (e.g., hyperthyroidism).
Mixed Episode
52
• The criteria are met both for a Manic Episode and for a
Major Depressive Episode (except for duration) nearly
every day during at least a 1-week period.
• The mood disturbance is sufficiently severe to cause
marked impairment in occupational functioning or in
usual social activities or relationships with others, or to
necessitate hospitalization to prevent harm to self or
others, or there are psychotic features.
• The symptoms are not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a medication,
or other treatment) or a general medical condition (e.g.,
hyperthyroidism).
Schizophrenia – Criterion A
53
• Two (or more) of the following, each present for a
significant portion of time during a 1-month period
(or less if successfully treated):
- delusions
- hallucinations
- disorganized speech
- frequent derailment or incoherence
- grossly disorganized or catatonic behavior
- negative symptoms
- affective flattening, alogia, or avolition
Schizophrenia – Criterion A
54
 Only one symptom is required if delusions are
bizarre or hallucinations consist of a voice keeping
up a running commentary on the person's behavior
or thoughts, or two or more voices conversing with
each other.