Bipolar/DMDD-ODD

Bipolar Depression

Criteria same as Major Depressive Episode but increased likely to have

• With psychotic features

• With catatonia

• With mixed manic/depressive features

• Increased suicidality

Manic and Hypomanic Episodes: What is SAME

• Increased mood or irritable and Increased Activity/Energy

• Need 3 Sxs but if mood is irritable need 4Sxs

• Not due to substance, ECT, or med (if caused by ECT or Med to count Sx)

Manic and Hypomanic Episodes: What is DIFFERENT

• Duration

  • Manic → 1 week (any duration if hospitalization is needed)

  • Hypomanic → 4 days (clear change in functioning; disturbance observable by others) 

• Functional Impairment 

  • Manic: mood disturbance leads to

    • Functional impairment OR

    • Psychotic features OR

    • Hospitalization 

  • Hypomanic: mood disturbance does NOT lead to

    • Functional impairment OR

    • Psychotic features OR

    • Hospitalization

Bipolar I

• Required: ≥ 1 Manic episode

• Misc.: Can be mania ONLY

• Impairment: Can be due to mania OR depression (if depression is present)

• Psychosis: can come from mania OR depression 

  • ~75% of manic episodes have psychotic Sxs

Bipolar II

• ≥ 1 hypomanic episode and ≥ 1 depressive episode

• Misc: No manic episode

• Impairment: Due to depression OR unpredictability of mood swings 

• Psychosis: Can occur during depression

Cyclothymia

• ≥ 2 years subclinical Sxs of hypomania and depression

• Misc: No → has Major depressive, Manic, OR Hypomanic episodes 

• Timing: Sxs present ≥1/2 time AND not >2 months without Sxs

• Impairment: due to mood lability

• Psychosis: not present 

• Children and Adolescents: 

  • Duration: 1 year

  • Depression = Irritability

Bipolar Specifiers

• Cyclothymia

  • Only apply with Anxious Distressed

• Mania & Hypomania

  • Severity

    • Mild/Moderate/Severe

    • Moderate: increase in activity OR impaired judgement 

    • Severe: need supervision to prevent harm

  • Remission: full/partial 

  • With seasonal affective: onset spring; offset fall

  • With psychotic features

    • Mood congruent vs mood incongruent

  • Rapid cycling 

    • 4 mood episodes in 12 months 

      • Mood episode: ≥ 2 months baseline OR a polarity switch 

    • Associated with

      • BP-II and decreased treatment outcome

• Mixed Features

  • Apply to both BP-I and BP-II

  • Depressive, with Mixed Features

    • Need ≥ 3 Sxs related to Mania 

  • Manic OR Hypomanic, with Mixed Features 

    • Need ≥ 3 Sxs related to Depression

  • Sxs NOT due to a substance 

  • If meet criteria for BOTH Depression and Mania

    • DSM says Dx Mania with Mixed Features 

  • Increased with younger individuals 

    • Irritability aspect 

Kindling

over time takes decreased stress to set off mood episodes

Types of Meds for Bipolar Dx

Antipsychotics, Anti-depressants, Lithium, AED

Lithium

• Very effective for all 3 phrases 

• Side effects: hand tremor, thirst, weight gain, hypothyroidism, potential kidney damage 

• Toxic range right next to therapeutic range 

  • Hard for teens → metabolism changes (faster)

  • Mid-life → metabolism changes, pregnancy (slower) 

• Appears to have some degree of anti-suicidal effect 

AED

Side effects: Steven’s Johnson’s Syndrome (possible fatal rash)

Polarity Index

• Better for bipolar II for depression

  • Latuda- Anti-psychotic

  • Lamictal- AED’s 

    • If you have time to titrate up 

• Lithium

  • No one wanted to invest in it 

    • Companies couldn’t make money 

• Better for bipolar I for mania

  • Zyprexa- Anti-psychotic

If current episode is Mania or hypomanic

• Acute mania → very uncomfortable for the person

• Most common treatment 

  • Atypical antipsychotic + Lithium OR

  • Atypical antipsychotic + AED 

• If treatment resistant to meds → bifrontal ECT has been found to be efficacious 

If current episode is depressed

• No medical clearly rises to the top as best

• Anti-psychotics 

  • Latuda 

• AED’s 

  • Lamictal 

  • If you have time to titrate up 

• Anti-depressants 

  • Have the potential to spiral people up into mania (especially BP-I)

  • Their use if controversial 

• If resistant to med → ECT has been used with efficacy

If current episode is maintenance

• Lithium- effective prophylaxis for preventing mania 

• Lamictal- effective prophylactic for depressive pole

Disruptive Mood Dysregulation Disorder (DMDD)

• Main purpose of DMDD was to pull kids out of the Bipolar Dx

  • Did not work

    • DMDD Dx

      • Increased meds and anti-psychotics (most common med)

ODD

Opposition Defiant Disorder