7)bipolar

DSM-5 diagnosis of bipolar (4)

diagnosed based on the presence of a manic episode, lasting at least one week—most of the day, nearly every day

much be distinct period—i.e. distinct change (diff) from normal funcitoning

*Catastrophic shift in ability to sleep, etc bc of ecstatic state

*manic episode may 1st feel good -- but then not so much as more episodes happen, but depends on the person

*Lithium as treatment for manic episode

DSM-5 diagnosis of bipolar—criterion A (2 symptoms)

manic episodes can consist of “elevated, expansive mood” OR “extreme irritability” (A)

persistent increased in goal directed activity/energy

if only irritable, need more criteria

*Can be bipolar even if only experienced one manic episode; Don't need to have experienced depression episode for bipolar diagnosis

*Expansive mood: happy about a bunch of diff things all over the place

DSM-5 diagnosis of bipolar—criterion B (7 possible symptoms)

3 of the following criterion B symptoms must also be present—4 symptoms need to be present in mood is only irritbale

1)inflated self-esteem/grandiosity—* thinking your status/or that you're more imp in the world than anything else

2)decreased need for sleep: irritability often stems from inabiltiy to down-regulate/slow down *ex. sleep 4 hrs per night but 'still feels great'

3)more talkative than usual—pressured speech: *how ppl in manic episode report what is feels like to be talking -- they feel words are pushing out of them, they can slow them down, they have no ability to regulate them

4)flight of ideas/racing thoughts: jump from one idea to the next — thoughts are racing and they can’t keep up, may appears similar to loose associations in schizophrenia *There may be logical connection from one thought to the next -- but they jump very fast form one to another

5)reckless & impulsive behvaiour

6)increased energy—more active or agitated (can’t sit still)

7)distractibility

more on distractibility & goal-directed activities

(extreme) distractibility *Ex. Ppl start one doing one thing, (ex. cooking), then go fold laundry, then go play on playground, but then see ice cream truck so then wants ice cream, etc.—it’s really hard to stay on one task

— reported or observed *Ppl w/ bipolar during manic episodes lacks insight

can contribute to the flight of ideas, sometimes leads to diagnositc difficutlies with ADHD

increase in goal directed activites:

can be social—talk to strangers, call at all hours of the night, working on several projects at once (but never finish)

*can also be making things: cooking, backing, making dress

bipolar, increased libido & infidelity (3)

increased libido may be symptom of bipolar

*Ex. Flirty guy that was very distractable, with increased libido

when distractability is coupled with impulsivity—this leads to distressing consequences like infidelity

Increased libido + impulsive = more likely to engage in sexual activities they wouldn't otherwise if not in manic state like infidelity (cheating on partner)

this contributes to high divorce rate in ppl with bipolar

overlap with order disorders VS what makes bipolar distinct from other disorders

bipolar symptoms overlaps with several other disorders making differential diagnosis difficult

need marked impairment for diagnosis of bipolar: (3 *signs of marked impairment)

—hospitalization,

—psychotic features

—extreme impariment in several domains (work, fam, etc.)

distress is NOT a factor in mania—ppl in manic episodes have poor insight & often feel very little pain *ex. bc even tho patient blowing up they're life, they feel great about it *euphoria

high activity & its consequences in ppl with bipolar ($)

more active or agitated—can’t sit still *full of energy

excessive involvement in pleasurable activities with high potential for painful consequences:

—shopping sprees, foolish buisness investments, sexual indiscretions *excessive shopping with extreme financial consequences: ex. Bought rolex, new tesla -- going into life savings bc of shopping etc. 

(ONLY applied to bipolar IF) not attributable to phsyiological effects of a substance (e.g. drugs) or another medical condition

Jamison & ‘An Unquiet Mind”

Kay Redfield Jamison — PH.D. in clinical psyc from UCLA, prof of psychiatry at Johns Hopkinds

author of 100+ published aritcles, six published books, MacArthur Genuis Winner (2001)

*in her works disproves perception that mania is 'fun'— while person in manic episode feel like 'fun', it is emotionally, financially, romantically devastating

she was diagnoised with bipolar disorder 3 months into her 1st job ~1977

treated with lithium but then attempted suicide by lithium overdose

forms of bipolar (3)

bipolar I: mania plus episodes of MDD

bipolar II: hypomania & depression

cyclomania: hypomania & short depressive episodes

hypomania (3)

*only in bipolar II & cyclomania

hypomania has same symptoms as mania, but milder *lasts min. 4 days

no hospitalization, no psychosis *if presence of psychosis, that makes it bipolar II

mood is out of normal range but not necessarily distressing

often very fun! stimlus seeking, causes some impairment but not so extreme *as bipolar

*although there are change in behaviour: not same lvl of functional impairment as for bipolar 1

manic episodes/mania (criteria) (3)

RE: increase in goal-directed activity or energy

evidence of functional impairment (if meets criteria for symptoms lasting at least one week)

OR if lasts less than 1 week, the need for hospitalization or emegency treatment

*key difference btwn mania VS hypomania

1)Duration

2)Degree of impairment

*if have psychosis CANNOT be bipolar 2 -- this makes you bipolar 1

cyclomania (4)

RE cyclomania: BOTH hypomania and short depressive epsiode symptoms

chronic pattern, less severe *in symptoms compared to bipolar 1

*2 yrs or more of switching btwn hypomanic and depressive symptoms—doesn’t quite meet criteria for full hypomanic episode or full depressive episode

lots of high highs and low lows — more extreme than normal mood fluctuations

prev of cylomania (5)

m=f *men & women are at equal risk for hypomania

often don’t seek treatment—but women more likely to see treatment (than men)

at increased risk for bipolar 1

antidepressant meds can be a trigger *for episodes, importance of looking at psychiatric history before giving medications

*earlier onset before age 17 (than bipolar 1 or 2 at age 20)

rapid cyclers *specifier (3)

*Imp specifier: rapidity with which ppl cycle through diff mood states—ppl with bipolar change form manic state to depressive states

4 or more episodes within a year

can be either kind of episode *at least 4 depressive or 4 manic episode

*just that these episodes have a period of remittance btwn them; so ppl are not continuously in a manic or depressive stat

*2 types of rapid cyclers (3)

Cycling can be continuous; in which there are no free intervals btwn episodes—In that case you would need to see switching btwn the two poles (change form manic state to depressive states)

Ultra rapid: moods shifting really sharply/rapidly within the same day or even the same hour

Regular rapid cycling: 2 or more complete cycles of a manic and major depressive episode that succeeded each other without a period of remission within a year

*regular span from several days to months

characteristics/prognosis of rapid cyclers (4)

more likely to be female

predicts poor response to treatment

mood stabilizers often ineffective *Mood stabilizers not effective for ppl with rapid cuycling

NOT a stable trait — rather a phase that s/o w/ bipolar will pass through

*But doesn’t mean that if they experience a period of rapid cycling that they will always be stuck in rapid cycling subtype

mood congruent VS mood incongruent psyhoctic symptoms

*Psychosis: loss of contact of reality (when ppl have trouble with differentiating btwn what's real and not real) — there are symptoms of psychosis (psychotic symptoms) in bipolar disorder and MDD

mood congruent: symptoms that are consistent with the affective mood state the person is during episode of disorder

mood incongruent: symptoms that are inconsistent with the affective mood state the person is during episode of disorder

mood congruent VS mood incongruent symptoms in bipolar (3)

mood congruent: psychotic symptoms in mania that are consistent with the affective mood state the person is in when they're in a manic episode

Ex. Usually grandiose themes, like you’re a prince, a billionaire or jesus—delusions of grandeur *in line with mood state of grandiosity

mood incongruent: Symptoms in mania that are NOT congruent/consistent with the mood state

1)Thought insertion; belief that ppl are inserting thought directly in your head

2)Themes of mind control; you're being controlled by an outside force

mood congruent VS mood incongruent symptoms in depression (4)

mood congruent: Psychotic experiences consistent with sad low mood

Psychotic delusion or guilt or sins —Ppl may be confessing to crimes they didn't commit or things that they relaly didn't do 

A lot of themes of disease and also

nihilistic delusions: the delusion that everything including the self doesn't exist or is unreal or had been destr

mood incongruent: Anything happy/positive; this is rare in depression

if you have mood incongruent symptoms in a depression state you might be seeing things like delusions of grandeur -- but this is pretty unusual for s/o in profound depressive state

psychotic symptoms & differential diagnosis (3)

psychotic symptoms raise serious differntial diagnosis questions

current DSM-5 resolution: if psychotic symptoms occur (only) during a manic or depresive episode, then qualifies as a MOOD DISORDER w/ psychosis

if psychotic symptoms occurs outside of mood episodes, then given schizoaffective diagnosis *or schizophrenia

prevalence of bipolar I and bipolar II (4)

lifetime prev btwn 2-4% for EITHER BIPOLAR I OR II *bipolar 1 & 2 are pretty rare

prevalence does NOT seem to differ as a function of sex, culture, countries, parts of the world

some evidence prevalence may be higher in certain subgroups—used to think high SES = greater prevalence — BUT prob diagnositc bias *bc ppl w/ low SES (even fitting the same symptom profile) were more likely diagnoses with schizophrenia than bipolar

rates of bipolar much higher among artists, poets, writers *Maria Bamford (comedian with bipolar 1),

*Kay Redfield Jameson (Touched with fire; book)  ppl have thought that manic episodes might contribute to a more creative view/way of being of the world

prev of cyclomania

prevalence closer to 4-5% *cyclo as more common than bipolar 1 and 2

contrasts with MDD, 17% lifttime prev *but compared to MDD, cyclo is less common

*most to least common: MDD, anx, bipolar 1 and 2, cyclomania

unipolar mania (4)

*unipolar mania mood disorder (bipolar): ppl who only ever experince mania/manic episodes (and NOT depression/depressive episodes at all)

unipolar mania has been reported in community studies of mania

—25-33% bipolar I patients, 1-2% of general pop *unipolar mania more common in bipolar pop, than gen pop

however, if you follow unipolar mania for long enough, the majority (20/27 or 74%) had at least one episode of depression during follow-up *If you follow unipolar mania for long enough, majority have at least depressive episode

not clear if unipolar mania is stable over the life course or whether most bipolar I patients, if followed long enough, eventually develop a depressive disorder

unipolar/bipolar prevalence distinction

MDD is 10-20x more common than bipolar *MDD much more common than bipolar

diff in gender distribution: bipolar—m=f, unipolar 2f=1m *MDD is 2x more common in women

differ in course: bipolar— earlier onset, more episodes & more pernicious course—*treatments are less effective, ppl tend to stay ill for longer, more sever outcomes associated with illness

problems w/ bipolar diagnosis (4)

takes average of 6 to 10 yrs of a person w/ bipolar to recieve correct diagnosis & appropriate treatment

misdiagnosed consult an average of 4 physicans beofre receiving an accurate diagnoiss *This likely contributes to the course of bipolar disorder being more pernicious

close of 60% of ppl with bipolar disorder initially misclassified as having MDD *Often misclassified as having MDD (most ppl with bipolar that don't receive bipolar diagnosis at first, tend to be diagnosed with MDD)

in general, more likely to seek treatment when depressed *Ppl are more likey to seek treatment when depressed compared to when in a manic episode -- may also be less likely to report on manic episodes when in a manic state

unipolar/bipolar treatment distinction (3)

treatment response differs based on unipolar or bipolar

bipolar: mood stabilizer like lithium (*most common) and anticonvulsants *both mania & depression to treat

unipolar: antidepressants like SSRIs, tricyclics *only depression to treat

caution: if antidepressant are given to s/o w/ bipolar or cyclomania this can trigger manic episodes

age of onset of bipolar and liklihood of conveting from MDD to bipolar (3)

age of onset: 20-30 yrs

½ time 1st episode is manic, ½ 1st episode is depression *eqally likely of having episode of depression or mania as 1st episode

5-10% of ppl who present with a history of only depression will convert to bipolar—*they will have manic episodes

risk factors for converting from MDD to bipolar (4)

—particularly (likely to convert to bipolar) if younger in age,

report heighened guilt during depressive epsiodes,

psychomotor retardation and a

fam hist of bipolar *risk factors for converting to bipolar from depression

course of bipolar episodes

bipolar episodes typically lasts about 2 months

previously 8 months, prior to effective treatments

*Used to last 8 months, but treatments have gotten better so ppl see faster resolution of symptoms with more appropriate treatment

relapse rate & poor prognosis indicators (3)

poor prognosis indicators (2):

—mixesd states *If they have the appearance of both mania and depressed mood

—rapid cycling (refer to flashcard) *transitioning btwn states faster

relapse rate—7-9 times over liftime

*Over course of the illness, the average relapse rate is 7-9 over lifetime which is relatively high

prevalence of suicide in bipolar (3)

risk of death by suicide are 15X higher in bipolar than the general population

—this risk of death by suicide in ppl w/ bipolar is 4X higher than that of MDD

some estimates of inpatients with bipolar suggest 11% die by suicide

*inpatients=ppl that are/have been hospitalized due to bipolar

(8) risk factors for death by suicide

Risk factors *things that are associated with suicide attempts and death by suicide

1)younger age, 2)recent illness onset,

3)male gender 4)prior suicide attempts (SAs)

5)fam hist of suicide 6)comorbid alcohol or subtance abuse

7)rapid cycling course 8)social isolation

most of these are assocaetd with increased risk for death by suicide across all populations, not specific to bipolar

stress & bipolar (2)

stress increases in the first 6 months prior to a bipolar episode

frequently bipolar relapse following a stressful experince *Ppl w/ bipolar often relapse after a stressful experiences

*Stress exposure associated with risk for lots of diff disorders

imp class of stressors in bipolar — Sheri Johnson (3)

*she tries to understand the types of stress exposure that might be particularly dangerous for ppl with bipolar or at risk for bipolar disorder

found class of stressors especially imp in mania -- goal attainment events: experience where you've had smth that you've been for a rlly rlly long time actually happens

*Ex. You get a promotion at work, start w new relationship you've always wanted, you get rlly good grades ina class—These are examples of goal attainment events that can trigger manic episode)

goal attainment events are significantly associated with manic episodes

when achieve a goal, become very happy; subsequently dysrgualted; and sprial into mania *

*when ppl reach a goal they often go out to celebrate: drink a lot, their sleep might get disrupted and they might stay out later

*they may not engage in the self care that they might have to and they get dysregulated as a result. If they get affectively emotionally dysregulated, and the more dysregulated they get the less sleep they sleep, they may drink more coffee than usual or take more stimulants and eventually ppl could spiral into mania from this happy event

Graham Goddard — kindling theory *for stress (4)

*in both depression and mania questions about how stress 'gets into' the brain

Goddard did a series of experiments where he electrically stimulated various regions of the rats brains to observe the effects of electrical stimulation on their ability to learn tasks

he found that if you stimulated areas of the brain reputedly w/ electricity, then ultimately rats would starts to develop seizures

Also noticed that over time the rates would required lower doses of electricity to provoke the seizures to the point that eventually seizures would happen with no electricity

*Ex. To provoke the first seizures, would need a high dose of electricity. Over time, the next time you'd wanna provoke a seizure, you would require lower and lower doses of electivity. At some point, the seizures would happen spontaneously without electricity

*Kindling theory as metaphor in the ways in which stress can affect psychological outcomes: evidence shows that for some disorders, the 1st episode requires a high degree of stress (pretty severe stressor), but then s/o has become ill over time, it requires less stress to provoke a 2nd, 3rd or 4th episode

Robert Post — Kindling Theory for bipolar (5)

Post applied Kindling Theory to bipolar pts

1st bipolar episode: requires a lot of stress *required a pretty severe stressor

2nd episode: requires even less stress

3rd episode: even less stress

eventually don’t need stressors—bipolar episodes happen on their own

*caveat to Post’s Kindling Theory for bipolar

bc Post worked with ppl that were hospitalised, he might've also just identified a subset of patients with really severe affective illness that got worse over time

So these patients are just going to become more severely ill the more amount of time they spend cycling btwn illness states

 But also possible that having one episodes damages or leaves a mark in some way that would cause ppl to be more vulnerable to a second episode

Idea that an episode causes damage so hen there's culminative damage with multiple episodes --therefore episodes begin to beget episodes

sleep disruption & mania (3)

sleep depreviation is a powerful predictor of mania *Sleep disruption also a common trigger for manic episodes

less sleep on day N predicts incrases in manic symptoms on day N+1 If I have a predisposition to mania and then I sleep badly tn, I'm going to have more manic symptoms tmrw —so strong association btwn poor sleep and mania

*lack of sleep on day can predisposed you to manic symptoms the next day

exposure to bright light, which can change circadian rhythms  (which govern our sleep wake schedule), so can trigger manic symptoms *Ex. Season change