ch 6 exam review

Chapter 6: Bipolar Disorders and Mood Stabilizers

DSM-5 – Bipolar Disorders

• Primary Diagnoses:

  • Bipolar I Disorder

  • Bipolar II Disorder

  • Cyclothymic Disorder

• Variations Noted in Literature:

  • Bipolar III: Manic or hypomanic symptoms after antidepressants

  • Bipolar IV: Depression with preexisting hyperthymic temperament

  • Bipolar V: Depression with mixed hypomania

  • Bipolar VI: Bipolar with dementia

• Bipolar II Variations:

  • Bipolar II ½: Cyclothymia leading to major depression

  • Bipolar III ½: Bipolar with substance abuse

  • Bipolar ¼: Unstable unipolar depression responding inconsistently to antidepressants

Bipolar I Disorder

• Criteria:

  • Presence/history of one or more manic episodes

  • Elevated mood for at least 1 week with increased energy/activity

  • Along with 3+ symptoms (4 if mood is irritable):

    • Grandiosity or euphoria

    • Decreased need for sleep

    • More talkative

    • Racing thoughts/flight of ideas

    • Distractibility

    • Increased goal-directed activity or agitation

    • High-risk behavior involvement

• Challenges in Recognition:

  • Mood during manic episodes may feel rewarding; impairment often unrecognized.

• Dietary Impact:

  • Mediterranean diet may show benefits; keto diets less effective.

Sleep Hygiene

• Guidelines for Good Sleep Hygiene:

  • Meds usually ineffective long-term; disrupt sleep stages 3 and 4.

  • Consistent wake time daily; limit strenuous activity 2 hours before bed.

  • Avoid screens/eating 1 hour before sleep; bedroom activities limited to sleep/sex.

  • After 15 minutes of sleeplessness, engage in reading until sleepy.

• Sleep Adjustment Period:

  • Expect 3-4 days for improvement; severe cases may take up to 10 days.

Bipolar II Disorder

• Criteria:

  • No manic episodes, only one or more hypomanic episodes (4 days minimum).

  • Must include at least one major depressive episode.

• Specify Recent Episode:

  • Hypomanic or Depressed with severity ratings (mild, moderate, severe).

Cyclothymic Disorder

• Criteria:

  • Numerous episodes of hypomania and depression over 2 years.

  • Symptoms less severe than in Bipolar II; chronic, unremitting pattern without symptom-free intervals longer than 2 months.

  • Specify if with anxious distress.

Bipolar Symptoms and Behavior

• Behavior Patterns:

  • Provocative behaviors more likely to be sexual than aggressive.

  • High prevalence of substance use disorder; approximately 60% lifetime incidence.

Prevalence and Heritability of Bipolar Disorders

• Lifetime Prevalence Rates:

  • 1% for Bipolar I

  • 1.1% for Bipolar II

  • 0.5%-2.4% for Cyclothymic Disorder

• Suicide Risk:

  • Suicide rate around 15%.

• Heritability:

  • Estimated between 80-85%; significant recurrence risk in family history.

Neurobiology of Bipolar Disorder

• Structural Brain Abnormalities:

  • No clear abnormalities; areas involved similar to those seen in depression.

• Orbitofrontal Cortex Role:

  • Associated with impulsivity and decision-making, less activation shown in manic patients.

Calcium Dysregulation and Medications

• Calcium Channels:

  • Voltage-gated calcium channels (VGCC) significant in mood regulation; anticonvulsants can stabilize mood swings in bipolar disorder.

• Brain Changes:

  • Structural changes observed; ventricular enlargement and gray matter reduction noted as disorder progresses.

Bipolar and Metabolic Disorders

• Connection with Metabolic Disorders:

  • Increased risk for obesity, type 2 diabetes; inflammation affects bipolar symptoms.

  • HPA axis dysregulation implicated in the stress response.

A Brief History of Mood Stabilizers

• Historical Context:

  • Early 1900s: Barbiturates primarily used; lithium recognized for antimanic properties in 1949.

• Significant Drug Approvals:

  • 1966: Valproic acid identified for mood swings.

  • Subsequent years saw approvals of multiple medications; notable ones include:

    • 1970: Lithium treatment approval

    • 2000: First second-generation antipsychotic; olanzapine.

• Common Side Effects of Mood Stabilizers:

  • Lithium: Weakness, drowsiness, increased thirst, tremors.

  • Anticonvulsants: Dry mouth, confusion, sun sensitivity.

  • Atypicals: Weight gain, confusion, sedation.

Non-Response Checklist

• Considerations for Non-response:

  • Confirm correct diagnosis; overlap with other disorders can complicate this.

  • Check for co-morbid disorders; ADHD common among bipolar patients.

  • Medical illnesses, substance abuse, medication compliance, psychological factors, dose adequacy, and time for medication efficacy must be evaluated.