Bipolar and related disorders

Bipolar and related disorders

1. BIPOLAR AND RELATED DISORDERS Muhammad Musawar Ali MPHIL, ICAP [email protected]

2. BIPOLAR DISORDERS Bipolar disorder, also known as manic depression, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated mood clinically referred to as mania or, if milder, hypomania. Individuals who experience manic episodes also commonly experience depressive episodes or symptoms, or mixed episodes in which features of both mania and depression are present at the same time.

3. Bipolar and related disorders are separated as a distinct chapter in DSM-5 and include: Bipolar I disorder Bipolar II disorder Cyclothymic disorder Substance/medication induced bipolar and related disorder Bipolar and related disorder due to another medical condition Other specified bipolar and related disorder Unspecified bipolar and related disorder

4. Symptoms There are several types of bipolar and related disorders. For each type, the exact symptoms of bipolar disorder can vary from person to person. Bipolar I and bipolar II disorders also have additional specific features that can be added to the diagnosis based on your particular signs and symptoms.

5. COMORBIDITY Comorbidity - Anxiety Bipolar type I Bipolar type II OCD Panic Disorder GAD Phobia 14-30% 18-33% 42% 42-66% 28% 5% Comorbidity -Substance abuse Bipolar Unipolar Alcohol Drugs 46% 41% 21% 18%

6. Risk for Bipolar and Related Disorders Most people are in their teens or early 20s when symptoms of bipolar disorder first appear. Nearly everyone with bipolar disorder develops it before age 50. People with an immediate family member who has bipolar are at higher risk.

7. DIAGNOSTIC CRITERIA Diagnostic criteria for bipolar and related disorders are based on the specific type of disorder: Bipolar I disorder.  You've had at least one manic episode. The manic episode may be preceded by or followed by hypomanic or major depressive episodes. Mania symptoms cause significant impairment in your life and may require hospitalization or trigger a break from reality (psychosis). Bipolar II disorder.  You've had at least one major depressive episode lasting at least two weeks and at least one hypomanic episode lasting at least four days, but you've never had a manic episode. Major depressive episodes or the unpredictable changes in mood and behavior can cause distress or difficulty in areas of your life.

8. DIAGNOSTIC CRITERIA Cyclothymic disorder.  You've had at least two years — or one year in children and teenagers — of numerous periods of hypomania symptoms (less severe than a hypomanic episode) and periods of depressive symptoms (less severe than a major depressive episode). During that time, symptoms occur at least half the time and never go away for more than two months. Symptoms cause significant distress in important areas of your life. Other types.  These include, for example, bipolar and related disorder due to another medical condition, such as Cushing's disease, multiple sclerosis or stroke. Another type is called substance and medication-induced bipolar and related disorder. Bipolar II disorder is not a milder form of bipolar I disorder, but a separate diagnosis. While the manic episodes of bipolar I disorder can be severe and dangerous, individuals with bipolar II disorder can be depressed for longer periods, which can cause significant impairment.

9. BIPOLAR I

10. MANIC EPISODE

11. Criteria for a Manic Episode A distinct period of abnormally and persistently elevated, expansive or irritable mood that lasts at least one week (or less than a week if hospitalization is necessary). The episode includes persistently increased goal-directed activity or energy. During the period of disturbed mood and increased energy, three or more of the following symptoms (four if the mood is only irritable) must be present and represent a noticeable change from your usual behavior:

12. Inflated self-esteem or grandiosity Decreased need for sleep (for example, you feel rested after only three hours of sleep) Unusual talkativeness Racing thoughts Distractibility Increased goal-directed activity (either socially, at work or school, or sexually) or agitation Doing things that are unusual and that have a high potential for painful consequences — for example, unrestrained buying sprees, sexual indiscretions or foolish business investments .

13. C. The mood disturbance must be severe enough to cause noticeable difficulty at work, at school or in social activities or relationships; or to require hospitalization to prevent harm to yourself or others; or to trigger a break from reality (psychosis). D. Symptoms are not due to the direct effects of something else, such as alcohol or drug use; a medication; or a medical condition.

14. HYPOMANIC EPISODE

15. CRITERIA OF HYPOMANIC EPISODE A distinct period of abnormally and persistently elevated, expansive or irritable mood that lasts at least four consecutive days. During the period of disturbed mood and increased energy, three or more of the following symptoms (four if the mood is only irritable) must be present and represent a noticeable change from your usual behavior: Inflated self-esteem or grandiosity Decreased need for sleep (for example, you feel rested after only three hours of sleep) Unusual talkativeness

16. CRITERIA OF HYPOMANIC EPISODE Racing thoughts Distractibility Increased goal-directed activity (either socially, at work or school, or sexually) or agitation Doing things that are unusual and that have a high potential for painful consequences — for example, unrestrained buying sprees, sexual indiscretions or foolish business investments

17. CRITERIA OF HYPOMANIC EPISODE C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. D. The episode is a distinct change in mood and functioning that is not characteristic of you when the symptoms are not present, and enough of a change that other people notice. E. The episode isn't severe enough to cause significant difficulty at work, at school or in social activities or relationships, and it doesn't require hospitalization or trigger a break from reality. F. Symptoms are not due to the direct effects of something else, such as alcohol or drug use; a medication; or a medical condition.

18. MAJOR DEPRESSIVE EPISODE

19. CRITERIA OF MAJOR DEPRESSIVE EPISODE A. Five or more of the symptoms below over a two-week period that represent a change from previous mood and functioning. At least one of the symptoms is either depressed mood or loss of interest or pleasure: Depressed mood most of the day, nearly every day, such as feeling sad, empty, hopeless or tearful (in children and teens, depressed mood can appear as irritability) Markedly reduced interest or feeling no pleasure in all — or almost all — activities most of the day, nearly every day Significant weight loss when not dieting, weight gain, or decrease or increase in appetite nearly every day (in children, failure to gain weight as expected can be a sign of depression) Either insomnia or sleeping excessively nearly every day

20. CRITERIA OF MAJOR DEPRESSIVE EPISODE Either restlessness or slowed behavior that can be observed by others Fatigue or loss of energy nearly every day Feelings of worthlessness or excessive or inappropriate guilt, such as believing things that are not true, nearly every day Decreased ability to think or concentrate, or indecisiveness, nearly every day Recurrent thoughts of death or suicide, or suicide planning or attempt.

21. CRITERIA OF MAJOR DEPRESSIVE EPISODE B. Symptoms must be severe enough to cause noticeable difficulty in day-to-day activities, such as work, school, social activities or relationships C. Symptoms are not due to the direct effects of something else, such as alcohol or drug use, a medication or a medical condition

22. BIPOLAR I DISORDER Criteria have been met for at least one manic episode (Criteria A-D under “Manic Episode”). The occurrence of manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

23. Specify If With anxious distress With mixed features With rapid cycling With melancholic features With atypical features With mood congruent psychotic features With mood-incongruent psychotic features With catatonia With peripartum onset With seasonal pattern

24. PREVALENCE The 12-month prevalence estimate in the continental united states was 0.6% for bipolar 1 disorders as defined as DSM-IV. 12-month prevalence of bipolar 1 disorder across 11 countries ranged from 0.0% to 0.6%. The lifetime male-to-female prevalence is approximately 1.1:1.

25. BIPOLAR II

26. HYPOMANIC EPISODE A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally persistently increased activity of energy, lasting at least 4 consecutive days and present most of the day, nearly everyday day. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms have persisted (four if the mood is only irritable), represent a noticeable change from usual behavior, and have been present to a significant degree: Inflated self-esteem or grandiosity. Decreased need for sleep (e.g. feels rested only after 3 hours of sleep). More talkative than usual or pressure to keep talking. Flight of ideas or subjective experiences that thoughts are racing.

27. HYPOMANIC EPISODE Distractibility (i.e. attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation. Excessive involvement in activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

28. HYPOMANIC EPISODE C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others. E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. F. The episode is not attributable to the psychological effects of a substance (e.g. a drug of abuse, a medication or other treatment).

29. MAJOR DEPRESSIVE EPISODE A. Five or more of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either 1) depressed mood or 2) loss of interest or pleasure. Depressed mood most of the day , nearly every day, as indicated either by subjective report (e.g. feels empty sad or hopeless) or observation made by others (e.g. appears tearful). Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly everyday. Significant weight loss when not dieting or weight gain (e.g. a change of more than 5% of body weight in a month), or decreased or an increase in appetite nearly everyday. Insomnia or hypersomnia nearly everyday. psychomotor agitation or retardation nearly everyday (observable by others; not merely subjective feelings or restlessness or being slowed down).

30. MAJOR DEPRESSIVE EPISODE Fatigue or loss of energy nearly everyday. Feelings of worthlessness or excessive inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). Diminished ability to think or concentrate, or indecisiveness, nearly everyday (either by subjective account or as observed by others). Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, a suicide attempt, or a specific plan for committing suicide. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The episode is not attributable to the psychological effects of a substance or another medical condition.

31. BIPOLAR II DISORDER Criteria have been met for at least one hypomanic episode (Criteria A-F under “hypomanic episode”) and at least one major depressive episode (Criteria A-C under “major depressive episode”). There has never been a manic episode. The occurrence of hypomanic episode(s) or major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

32. Specify current or most recent episode: Hypomanic Depressed Specify if: With anxious distress With mixed features With rapid cycling With mood congruent psychotic features With mood-incongruent psychotic features With catatonia With peripartum onset With seasonal pattern

33. Specify course if full criteria for mood episode are not currently met: In partial remission In full remission Specify severity if full criteria for mood episode are currently met: Mild Moderate Severe

34. PREVALENCE The 12-month prevalence of bipolar II disorder, internationally, is 0.3%. In the United States, 12-month prevalence is 0.8%.

35. CYCLOTHYMIC DISORDER

36. CYCLOTHYMIC DISORDER 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. During the above 2 year period (1 year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time. Criteria for a major depressive, manic, or hypomanic episode have never been met.

37. CYCLOTHYMIC DISORDER D. The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. E. The symptoms are not attributable to the psychological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify If With anxious distress

38. PREVALENCE The lifetime prevalence of cyclothymic disorder is approximately 0.4%-1%. Prevalence in mood disorders clinics may range from 3% to 5%. In the general population, cyclothymic disorder is apparently equally common in males and females. In clinical settings, females with cyclothymic disorder may be more likely to present for treatment than males.

39. SUBSTANCE/MEDICATION-INDUCED BIPOLAR AND RELATED DISORDER

40. SUBSTANCE/MEDICATION-INDUCED BIPOLAR AND RELATED DISORDER A. A prominent and persistent disturbance in mood that predominates in the clinical picture and is characterized by elevated, expansive or irritable mood, with or without depressed mood, or markedly diminished interest or pleasure in all, or almost all, activities. B. There is evidence from the history, physical examination, or laboratory findings or both (1) or (2): The symptoms in criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medicine. The involved substance/medication is capable of producing the symptoms in Criterion A.

41. SUBSTANCE/MEDICATION-INDUCED BIPOLAR AND RELATED DISORDER C. The disturbance is not better explained by a bipolar or related disorder that is not substance/medication-induced. Such evidence of an independent bipolar or related disorder include the following: The symptoms precede the onset of the substance/medication use; the symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication; or there is other evidence suggesting the existence of an independence non-substance/medication-induced bipolar and related disorder (e.g., a history of recurrent non-substance/medication-related episodes).

42. SUBSTANCE/MEDICATION-INDUCED BIPOLAR AND RELATED DISORDER The disturbance does not occur exclusively during the course of delirium. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

43. PREVALENCE There are no epidemiological studies of substance/medication-induces mania or bipolar disorder. Each etiological substance may have its own individual risk of inducing a bipolar (manic/hypomanic) disorder.

44. BIPOLAR AND RELATED DISORDER DUE TO ANOTHER MEDICAL CONDITION

45. BIPOLAR AND RELATED DISORDER DUE TO ANOTHER MEDICAL CONDITION A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally persistently increased activity of energy that predominates in the clinical picture. There is evidence from history, physical examination, or laboratory findings that the disturbance is the direct pathopsychological consequence of another medical condition. The disturbance is not better explained by another medical condition. The disturbance does not occur exclusively during the course of a delirium. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, or necessitates hospitalization to prevent harm to self or others, or there are psychotic features.

46. Specify if With manic features: Full criteria are not met for a manic or hypomanic episode. With manic-or hypomanic-like episode: Full criteria are met except Criterion D for a manic episode or except Criterion F for a hypomanic episode. With mixed features: Symptoms of depression are also present but do not predominate in the clinical picture.

47. Causes of Bipolar Disorders Psychodynamic Approach Freud: looked at the self-depreciation of people with depression and attributed that self-reproach to anger turned inward related to either real or perceived loss. Feeling abandoned by this loss, people become angry while both loving and hating the lost object.

48. Existential Theory Existential theorist believed that behavioral deviations result when a person is out of touch with himself or the environment. The person who is self-alienated is lonely, sad and feels hopeless. Lack of self awareness, coupled with harsh criticism, prevents the person from participating in satisfying relationships. The person is not free to choose from all possible alternatives because of self imposed restrictions. The person is avoiding personal responsibilities and giving it to the wishes or demands of others.

49. Biogenic Amine Theory states that depression is caused by a deficiency of monoamines, particularly noradrenaline and serotonin serotonin plays an important role as a neurotransmitter in the modulation of anger, aggression, body temperature, mood, sleep, sexuality, appetite, and metabolism, as well as stimulating vomiting. norepinephrine as a stress hormone, affects parts of the brain where attention and responding actions are controlled.

50. The Kindling Theory This theory asserts that people who are genetically predisposed toward bipolar disorder can experience a series of stressful events, each of which lowers the threshold at which mood changes occur. Eventually, a mood episode can start (and becomes recurrent) by itself. Not all individuals experience subsequent mood episodes in the absence of positive or negative life events, however.

51. Cognitive-Behavioral Approach Aaron T. Beck's cognitive theory proposes that individuals who have a biological vulnerability to bipolar disorder and who hold problematic beliefs about themselves (e.g., the belief that they are worthless) can, when those vulnerabilities and beliefs are activated by life stressors, experience symptoms of bipolar disorder. Symptoms, in the cognitive-behavioral model, are made up of emotions (e.g., depression or elation), thoughts ( e.g , "I'm worthless," or "I'm amazingly talented") and behaviors (e.g., passivity or excessive activity).

52. Neuroendocrine influence Elevated glucocorticoid activity is associated with the stress response, and evidence of increased cortisol secretion is apparent in about 40% of clients with depression with the highest rates found among older clients. About 5%-10% of people with depression have thyroid hormone dysfunction, notably an elevated TSH.

53. Variations in Brain Structure and Impaired Functions in Bipolar Disorder Structural variation/abnormality Functional Impairment (all decreased) - diencephalon (thalamus, mamillothalasmic tract and medullary lamina) -prefrontal cortex -frontal subcortical -brain lesions -midsagittal Areas reduction -Abnormal white brain matter( increase with age) -Medial temporal lobe (hippocampus, parahippocampal and periphinal cortices- episodes of depression and mania may result in hypercortisolemia, producing damage) -Basal ganglia -memory performance -verbal memory (recall of a story or single word) -attention dysfunction -verbal learning -verbal fluency -Psychomotor speed -declarative memory (conscious recollection of facts and events)

54. Treatments Electroconvulsive therapy (ECT) Antidepressant Mood stabilizer Antipsychotic Agents Psychotherapy

55. Electroconvulsive therapy (ECT) Used only in extreme cases Patients need to be admitted in hospital Quick action 5 to 10 ECT sessions are required Medication along with ECT is still required

56. Mood stabilizer Mood Stabilizer Common Adverse Effects Special Concerns Lithium carbonate ( Eskalith CR, Lithobid ) Lethargy, weight gain, chances of developing hypothroidism in 5-10% of patients To be avoided in cases of Hypothyroidism and diabetes. Sodium valproate ( Epival ) Sedation, liver disease, weight gain liver diseases Carbamazepine ( Tegrol ) Drowsiness, Skin rashes and hair fall bone marrow suppression Lamotrigine ( Lamictal ) Sedation, headache, skin rash Stevens-Johnson syndrome

57. Psychotherapy Cognitive behavior therapy Psycho-education Interpersonal therapy Multifamily support groups

58. Cognitive behavior therapy More effective with the depressive part of bipolar disorder “…Involves identifying irrational thought patterns and altering [them] to better reflect reality” ***Activities such as “daily mood logs” can help (Wilkinson 2002)

59. Psycho-education Learning signs and symptoms of his/her disorder; what triggers mood alteration More useful for mania ---Being able to identify signs and symptoms of mania is helpful in the prevention of a “full blown manic episode” (Wilkinson 2002).

60. Interpersonal therapy Helps to improve social skills and thereby provides patients with more stability in interacting with others Activities include: Role playing Modeling

61. Multifamily support groups Parent involvement in a child with BD by teaching the child: relaxation techniques anger management decision-making skills communication/listening skills seeing that children don’t become “victims of their illnesses” (Wilkinson 2002)

62. THANK YOU