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Bipolar Disorder -- diagnosis, symptoms, etc… Kurt Weber, PhD Mental Health America – Brown County Bemis International Center St Norbert College May 13, 2008 no definitive test… and… there are a number of physical conditions and quite a few psychiatric disorders which present symptoms that can be confused with those of bipolar disorder even more… many psychiatric disorders can occur in tandem therefore… a psychiatrist will usually conduct the following complete medical history and physical exam to rule out other physical or organic concerns complete psychiatric history family history of medical and psychiatric concerns possibility of other mental disorders should be considered previous mood swings (perhaps of less severity or duration) may come to light Current research indicates that mood disorders have genetic underpinnings evaluation of current symptoms symptoms dramatic mood swings overly high and/or irritable to sad and hopeless, and then back again, often with periods of normal mood in between severe changes in energy and behavior go along with these changes in mood manic phase three stages of mania 1) hypomania - energetic, extroverted, assertive, hypersexual, self-confident, rapid speech 2) mania - loss of judgment, euphoria, grandiose, paranoid, irritable, hyperactive, ideas of reference, pressured, manipulative, demanding, hyper-religious 3) psychotic - paranoid, hyperactive, assaultive, delusional, labile, depressed, circumstantial, distractible, confused. delusions most frequent psychotic symptoms in mania (50%) hallucinations are present in 15% 70% of manic clients show severe thought pathology equal to or greater than the severity of formal thought disorders in acute schizophrenia differential diagnosis no symptom or cluster of symptoms reliably distinguishes bipolar mania from schizophrenia signs and symptoms of a manic episode Increased energy, activity, and restlessness Excessively high, overly good, euphoric mood Extreme irritability Racing thoughts and talking very fast, jumping from one idea to another Distractibility, can t concentrate well Little sleep needed Unrealistic beliefs in one s abilities and powers Poor judgment Spending sprees A lasting period of behavior that is different from usual Increased sexual drive Abuse of drugs, particularly cocaine, alcohol, and sleeping medications Provocative, intrusive, or aggressive behavior Denial that anything is wrong red flags (about.com) 1. Make note of changes in sleeping patterns, especially if your friend or loved one has lots of energy on just a few hours of sleep. 2. Is he restlessly searching for ways to work off extra energy? Washing the car every day? Make note of this. 3. Be alert to increased talkativeness. If her mouth runneth over, this could be another symptom, especially if the talk seems pressured. 4. Be aware if someone starts making "clang" associations, i.e., gets distracted by the sounds of words - such as going on about microphones, xylophones and ice cream cones. 5. If your spouse/partner is suddenly more sexually demanding, it could be a symptom. more 6. Check your phone bill for calls to 900 sex numbers. This, unfortunately, is another symptom of bipolar hypersexuality. 7. Study your credit card bills diligently! Mania can cause disastrous spending sprees. Consider taking the cards and checkbook away. 8. Notice if he complains that his thoughts are racing uncontrollably. 9. Be on the alert if she starts having delusions of grandeur for example, making exaggerated plans like "I'm going to quit my job and write a novel" or "Let's move to Yemen this weekend!“ 10. Watch out for unreasonable irritability and/or hostility. This is not just a symptom - it can be dangerous. Be cautious! even more… 11. Increased religious zeal or involvement can be another sign of mania. Make note of this if you see it. 12. If she describes auditory or visual hallucinations or shows paranoid behavior, contact her psychiatrist immediately. These are serious symptoms. 13. During a manic episode, a person is likely to wear brightly colored or flamboyant clothing. Note this if it occurs with other symptoms. 14. If manic symptoms occur following a change in medications, contact the prescribing doctor promptly. one may consider… 1. Make a pact with your friend that if you bring these behaviors to his attention, he will contact his doctor. 2. If your spouse/partner has a pattern of manic spending sprees, keep money in your name only. A manic episode is diagnosed if elevated mood occurs with other symptoms most of the day, nearly every day, for 1 week or longer. If the mood is irritable, 4 additional symptoms must be present. Subjective experience -- mania “The fast ideas become too fast and there are far too many… “overwhelming confusion replaces clarity... “you stop keeping up with it and memory goes. “Infectious humor ceases to amuse. “Your friends become frightened...everything is now against the grain… “you are irritable, angry, frightened, uncontrollable, and trapped…” anatomy of a manic upswing Mania can also be secondary to… Drugs CNS disorders amphetamines, alprazolam, antidepressants, baclofen, bromide, bronchodilators, calcium, cocaine, corticosteroids, cyclobenzaprine, cyclosporine, decongestants, digitalis, flutamide, isoniazid, levodopa, methylphenidate, metoclopromide, niridazole, phenocyclidine, procarbazine, procyclidine, reserpine withdrawal, thyroid, tolmetin, antidepressants. brain tumors, cerebrovascular disorder, trauma, epilepsy, Huntington's, multiple sclerosis, Pick's, postencephalitic, Parkinson's, spinocerebellar atrophy, Wilson's Disease. Toxic/ Metabolic AIDS, calcium, Cushing's, hemodialysis, hyperthyroidism, influenza, neurosyphilis, postoperative, post St. Louis type A encephalitis, Q fever, lupus, vitamin B12 deficiency. bipolar depressive episodes quite difficult to treat and prevent nearly all classes of antidepressants have been linked to mania, mixed states, and rapid cycling, they should be avoided without also using a mood stabilizer signs and symptoms A depressive episode is diagnosed if 5 or more of these symptoms last most of the day, nearly every day, for a period of 2 weeks or longer. Lasting sad, anxious, or empty mood Feelings of hopelessness or pessimism Feelings of guilt, worthlessness, or helplessness Loss of interest or pleasure in activities once enjoyed, including sex Decreased energy, a feeling of fatigue or of being slowed down Difficulty concentrating, remembering, making decisions Restlessness or irritability Sleeping too much, or can’t sleep Change in appetite and/or unintended weight loss or gain Chronic pain or other persistent bodily symptoms that are not caused by physical illness or injury Thoughts of death or suicide, or suicide attempts Subjective experience – depression I doubt completely my ability to do anything well It seems as though my mind has slowed down and burned out to the point of being virtually useless. All I can experience is the total, the desperate hopelessness of it all Others say, "It's only temporary, it will pass, you will get over it," but of course they haven't any idea of how I feel, although they are certain they do If I can't feel, move, think or care, then what on earth is the point? red flags for depression 1. If you start having trouble getting to sleep or staying asleep, keep a record and watch for other symptoms. 2. Be on the alert if someone starts sleeping excessively. Seriously depressed persons can sleep as much as 20 hours a day in some cases. 3. Be concerned if someone begins cancelling social engagements and staring at television programs he otherwise wouldn't watch. 4. Notice if mail - even bills - is piling up unopened, or other common tasks such as laundry, taking out garbage, etc., are not being done. 5. Marked change in appetite (increase or decrease), or significant weight gain or loss, can signify many conditions, including depression; consider it in light of other depressive symptoms. 6. Keep track of episodes of unexplained and uncontrolled crying. 7. Document feelings of sadness, guilt, worthlessness or despair that last most or all day for several days. 8. Be alert if you or your loved one exhibits signs of unusual worry, anger, negativity, helplessness or hopelessness. 9. Pay attention if you or a loved one begins to have difficulty making even simple decisions. This is a very common warning sign of depression. 10. Be sensitive to behavioral changes such as disorganization, inability to concentrate, or indifference to everyday necessary tasks. 11. Notice if actions and thoughts seem to be slowing down (psychomotor retardation) or speeding up jerkily (psychomotor agitation). 12. Watch your loved one for physical signs of depression such as slumped posture, frowning, decreased eye contact, frequent sighing, inattentive speech, or decreased sexual desires. 13. Contact the doctor quickly if you experience or someone reports recurrent thoughts of death and suicide. 14. If depressive symptoms appear after a change in medication, contact the prescribing doctor promptly. it might be a good idea to… 1. Depression can creep up slowly or descend quickly. If slowly, it can be harder to notice, especially in yourself. Get in the habit of observing yourself if you have depressive episodes. 2. Make a pact with your friend or loved one (or yourself) that if one of you sees anger signals in the other (or in yourself), the affected person will take appropriate action such as contacting a doctor hypomania mild to moderate level of manic symptoms may feel good to the person who experiences it and may even be associated with good functioning and enhanced productivity the person may deny that anything is wrong without proper treatment, however, hypomania can become severe mania in some people or can switch into depression. subjective experience -- hypomania at first when I'm high, it's tremendous... ideas are fast... like shooting stars you follow until brighter ones appear All shyness disappears, the right words and gestures are suddenly there... uninteresting people, things become intensely interesting Sensuality is pervasive, the desire to seduce and be seduced is irresistible Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria... you can do anything... but, somewhere this changes. psychosis severe episodes of mania or depression can include psychotic symptoms hallucinations (hearing, seeing, or otherwise sensing the presence of things not actually there) delusions (false, strongly held beliefs not influenced by logical reasoning or explained by a person s usual cultural concepts). Paranoia - believing that a person or group is actively working to harm you, without any basis in fact Psychotic symptoms in bipolar disorder tend to reflect the extreme mood state at the time delusions of grandiosity, such as believing one is the President or has special powers or wealth, may occur during mania delusions of guilt or worthlessness, such as believing that one is ruined and penniless or has committed some terrible crime, may appear during depression People with bipolar disorder who have these symptoms are sometimes incorrectly diagnosed as having schizophrenia continuum…? may be helpful to think of the various mood states in bipolar disorder as a spectrum or continuous range at one end severe depression moderate depression mild low mood (if chronic, known as dysthymia) then normal or balanced mood then hypomania then severe mania at other end mixed mania and depression may occur together symptoms of a mixed state often include agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking someone may have a very sad, hopeless mood while at the same time feeling extremely energized – not a good mix... diagnostic concerns BD may appear to be a problem other than mental illness e.g., alcohol or drug abuse, poor school or work performance, strained interpersonal relationships. these concerns may be signs of an underlying mood disorder more on this later in the dual diagnosis section WHIPLASHED Pies (Tufts) – mnemonic device no data to support the use of this tool could serve as a starting point or a reminder for doctors to consider the possibility of bipolar disorder when evaluating a patient WHIPLASHED Worse or "wired" when taking antidepressants Hypomania in the patient's history Irritable Psychomotor retardation or agitation Loaded family history Abrupt onset or termination of depressive bouts Seasonal or postpartum pattern Hyperphagia and hypersomnia Early age at depression onset Delusions, hallucinations or other psychotic features Bipolar III Just to confuse things even more… Bipolar III Disorder – Cyclothymia long-term condition where the person's moods cycle between hypomania - a "high" that can be mild to fairly severe but does not include delusions, hallucinations or other psychotic features - and depression, also mild to fairly severe but not incapacitating or suicidal suicide… of course, some people with bipolar disorder become suicidal Anyone who is thinking about committing suicide needs immediate attention, preferably from a mental health professional or a physician Anyone who talks about suicide should be taken seriously Risk for suicide appears to be higher earlier in the course of the illness recognizing bipolar disorder early and learning how best to manage it may decrease the risk of death by suicide suicide signs and symptoms talking about feeling suicidal or wanting to die feeling hopeless, that nothing will ever change or get better feeling helpless, that nothing one does makes any difference feeling like a burden to family and friends abusing alcohol or drugs putting affairs in order (e.g., organizing finances or giving away possessions to prepare for one s death) writing a suicide note putting oneself in harm’s way, or in situations where there is a danger of being killed If you are feeling suicidal or know someone who is… call a doctor, emergency room, or 911 right away to get immediate help make sure you, or the suicidal person, are not left alone make sure that access is prevented to large amounts of medication, weapons, or other items that could be used for self-harm some suicide attempts are carefully planned over time others are impulsive acts that have not been well thought out; important to understand that suicidal feelings and actions are symptoms of an illness that can be treated withproper treatment, suicidal feelings can be overcome please consider… learning QPR… and promoting its use and dissemination… potential new understanding – may become new assessment tool five key items as predictors for BD Co-morbid anxiety Feelings of people being unfriendly Family history of bipolar disorder Recent diagnosis of depression Legal problems predictors identified in this study may help physicians and patients identify depression associated with bipolar disorder rather than unipolar mood disorder