Bipolar and Manic Spectrum disorders

Bipolar spectrum disorders characterized by…

Abnormally and persistently elevated mood phases lasting for periods of a week or longer (mania)

Frequent periods of dysphoric moods (depression) lasting for two weeks or longer

Four categories

Bipolar 1

• defined by occurrence of at least one manic episode

• can also include depressive and hypomanic episodes

Bipolar 2

• NO manic phases

Cyclothymic

• hypomanic and depressive symptoms not severe enough to warrant a manic or major depressive label

Bipolar disorder not otherwise specified

Bipolar 1 versus Bipolar 2

Bipolar 1:

• includes manic episodes (lasting at least one week)

• more severe

• doesn’t require depression technically

Bipolar 2:

• includes hypomanic episodes (lasting 4 days)

• less severe

• requires depression

Symptoms of manic and hypomanic episodes

• 1. Inflated self-esteem or grandiosity

• 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

• 3. More talkative than usual or pressure to keep talking

• 4. Flight of ideas or subjective experiences that thoughts are racing

• 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed

• 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity

• 7. Excessive involvement in activities that have high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments

How common is cyclothymic and unspecified bipolar compared to bipolar 1 or 2?

3-4x as common

both have a high rate of progression to bipolar 1 or 2

is bipolar 1 more common among one gender or cultural group?

Equal between men and women

higher among native americans

peak age of onset for bipolar 1?

20-30

specifically 22 in the us

rapid cycling in bipolar 1

Those with bipolar I disorder with 4 or more mood episodes (major depressive, manic, or hypomanic) occurring in the prior 12 months

• Associated with poorer outcomes

Environmental risks of bipolar 1

• Childhood adversity

  • A known risk factor for bipolar disorder

    • This includes early emotional trauma, parental psychopathology, and family conflict

    • Also appears to predispose to early onset of bipolar disorder

    • Associated with poorer prognosis and worse clinical picture

• Recent life stress and other negative life effects

  • Increase depressive relapse risk in individuals diagnosed with bipolar disorder

• Manic relapse

  • Specifically linked to goal-attainment life events e.g., getting married, completing a degree, et

• Cannabis and other substance use

  • Associated with exacerbation of manic symptoms among individuals diagnosed with bipolar disorder

  • Associated with first onset of manic symptoms in the general population

Genetics of bipolar 1

• Monozygotic concordance of 40-70% in most twin studies

  • some as high as 90

• Lifetime risk in first-degree relatives is 5-10%

  • General pop is around 1%

• Relatives of patients with bipolar are more likely to develop unipolar depression than bipolar themselves

• There is a shared genetic risk between bipolar, schizophrenia, and autism spectrum disorder

Bipolar 2 associated features

• Impulsivity

  • Contributes to suicide attempts and substance use

• Creativity

  • Heightened levels of creativity during hypomanic phases

  • Relationship may be non-linear

    • Greater lifetime accomplishments associated with milder forms of bipolar disorder

  • Individuals attachment to prospect of heightened creativity in hypomanic episodes contributes to ambivalence about seeking treatment and losing that creativity

  • ex. Kanye

Bipolar 2 avg age of onset?

• Average age of onset is mid-20s (later than bipolar 1 but earlier than MDD)

Cyclothymia

• For at least 2 years (at least 1 year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode

Cognitive processes in bipolar disorder - beck cognitive model

• Mania typically viewed as opposite of depression

  • Theoretically linked to overly positive cognitive styles

  • e.g. people with bipolar disorder have higher senses of “hyper-positive self”

  • People with bipolar disorder who had higher “sense of hyper-positive self” were more likely to relapse because they viewed the emerging symptoms as desirable

Cognitive processes of bipolar - goal dysregulation

• Theory states that the behavioral activation system (which controls reward and goal-related events) is overly sensitive in bipolar disorder

  • Oversensitivity: Means that people with bipolar disorder find it difficult to regulate response to reward and goal-related events

  • Goal-relevant cognitive styles have been linked to bipolar disorder

• These include

  • Extreme aspirations for the future (particularly popular fame and financial success)

  • Greater expectation of success

Cognitive processes of bipolar - Integrative Cognitive Model of mood dysregulation

• Proposes that positive and negative appraisals of internal experiences are central to the mood dysregulation characteristic of bipolar disorder

  • These appraisals of changes to internal state are extreme, with personally significant meaning

  •  e.g., “I have the energy to do anything I want”

• In ICM

  • The appraisals of high mood are not always positive

  • The appraisals of low mood may not necessarily be negative

what % of individuals who have a single manic episode go on to have recurrent mood episodes

More than 90% of individuals who have a single manic episode go on to have recurrent mood episodes

what percent of manic episodes occur right before a depressive one?

60%

Bipolar 2 is often misdiagnosed as …

depression before occurrence of hypomanic episode

Rapid cycling in bipolar 2

• Approximately 5-15% have four or more mood episodes (hypomanic or major depressive) in the past year

• This is more common in women

• May reflect an overall worsening of the bipolar disorder

Risk of bipolar 2 is highest among

relatives of individuals with bipolar 2

what percent of individuals with bipolar 2 experience a second hypomanic episode within a year after the first

50

cyclothymia prevalence?

Equal prevalence in men and women in general pop but in clinical settings more likely in women than men

3-4x more common than bipolar 1 or 2

when do suicides typically occur for bipolar people?

in transition from mania to depression or vice versa