bipolar basics for mrcpsych year 1
DESCRIPTION
Lecture on the basics of bipolar disorder for MRCPsych course year 1, delivered in Leicester 2010TRANSCRIPT
Bipolar Disorder
MRCPsych MasterclassDr Nick StaffordConsultant Psychiatrist LPT
Lecture Scope
Epidemiology
Aetiology
Clinical findings
Rating scales
Laboratory findings & imaging
Course of illness
Differential diagnoses
Famous men with bipolar
Famous women with bipolar
ICD 10 & DSM IV
ICD-11 & DSM V
Diagnostic Criteria
Mania Hypomania Depression
Degree of symptoms Nature of symptoms Time of symptoms Number of
symptoms
ICD10 / DSMIV Other
Mania / Hypomania ICD10
SYMPTOM DOMAINS
•Elevated
Mood
•Quantity
•Speed
Physical activity
•Quantity
•Speed
Mental activity
SEVERITY
•More persistent and marked than cyclothymia
•Several days on end
Hypomania
•Greater degree of mood elevation
•At least one week
Mania without
psychosis
•Congruous or incongruous
•Severe and sustained increase in activity
Mania with psychosis
DSMIV Hypomania
Elevated mood >=4days
Symptoms (three or more)
Unequivocal change in functioning
Mood and function change observed by others
No marked impairment in social / occupational functioning & no psychosis
Not due to substance misuse or a medical condition
DSMIV Mania
Mood elevate at least 1 week
Symptoms (3 or more)
Not Mixed Episode
Severe impairment of functioning or relationships or need hospitalisation or psychosis
Not due to substances misuse or a medical condition
Depression & Mania – Patient Experience
Beating Bipolar 1 – Symptoms I: Depression 1 – Symptoms II: Hypomania 1 – 4: Mixed and psychosis
Classification
Bipolar type I
Episode of mania
Bipolar type II
Hypomania not mania
Rapid-cycling bipolar
disorder
Four or more
episodes in one year
Cyclothymia (Bipolar
III)
Subsyndromal mood swings
More subtypes of bipolar
Bipolar IV
Hypomania or mania
precipitated by antidepressant
drugs
Bipolar VDepressed
patients with a family history of bipolar disorder
Bipolar VI
Mania without depression
(unipolar mania)
Lifechart
BB 1 – Life chart 5
Epidemiology
Bipolar Depression
Lifetime risk About 1-5% 10-20%
Sex ratio (M:F) 1:1 1:2
First-degree relatives:
Lifetime risk for bipolar About 10% About 2%
Lifetime risk for unipolar depression
20-30% 20-30%
Average age of onset 21 yrs (?earlier)
27 yrs
Suicide 15% 10%
Risk factors
Factor
Expressed Emotion Greater predictor of relapse than schizophrenia
Family history Complex hereditability
Social class High social class cf. other mood disorders
Life events Significant with nature & degree
Personality More maladaptive traits during relapseNeed for reassurance and sensitivity to criticism
Childhood experience
Approx 50% bipolars and leads to more complex cases
Postpartum Marked increases
Menopause Deterioration in perimenopause
Social support Bipolars get less social support
Sleep deprivation Tends to mania, circadian disturbances
Behavioural activation
Excessive activity leads to mania
Aetiology
Bipolar DisorderLife events
Genetics
Neuro-transmitters
Neuroendocrine
Psychosocial
Biological theories
Mood thermostat
Neurotransmitters
Neuroendocrine
effects
Variable neurotransmitters
Depression & mania at
opposite ends of the spectrum
DepressionReduced NA
ManiaIncreased NA
Variable neurotransmitters
Depression & mania at
opposite ends of the spectrum
DepressionReduced NA
ManiaIncreased NA
This simple model has now
been superseded
Mood Thermostat
BB 2 – Mood thermostat 3: I, II, III, IV
Neuroendocrine factors
Mood Thermost
at
Stress
HPA axis
HPT axis
HPA Axis
HPT Axis
Elevated basal plasma concentrations of TSH
Exaggerated TSH response to TRH
Rapid cyclers higher rate of hypothyroidism
Blunted / absent evening surge of plasma TSH
Blunted TSH response to TRH
Presence of antithyroid microsomal and/or anti-thyroglobulin antibodies
Laboratory findings and imaging
HPA axisHPT axis
Sleep EEGBrain
imaging
Psychosocial theories
Bipolar trigger & cycling
Mood thermostat
Psychoanalytic
Psychodynamic
Behavioural
Environmental stress
Kindling model
Kindling model
Increasing age
Hypomania
Depression
Beating Bipolar – 2:IV
CBT in bipolar / Psychoeducation
Improve functioning
Recognise early warning
signs
Prevent relapse
Psychoeducation
Medication understandin
g
Mood charting
Genetics
Beating Bipolar 4 – Nick Craddock onwards
Genetic epidemiology of bipolar
Children of affected parent(s) One parent: 15-30% Both parents: 50-75%
Siblings of affected sibling One sibling: 15-25% MZ concordance 60-70%
Additional genetic loading for depressive disorder, ADHD, OCD or Oppositional Defiant Disorder
Associati0n studies of candidate genes
BDNF gene (Vall66) GAD1 gene (4s2241165) Dopamine transporter
gene (rs41084) Serotonin transporter
gene
Circadian / Clock genes ARNTL (BmaL1) TIMELESS PERIOD3 RORA & RORB
Candidate Genes
Bipolar I DAO, GRM3, GRM4, GRIN2B,
IL2RB, and TUBA8
Overlapping with schizophrenia DPYSL2, DTNBP1, G30/G72,
GRID1, GRM4, and NOS1
BDNF Alpha subunit of the voltage-
dependent calcium channel Glutamate signalling
pathways
Genetic linkage studies
Strongest linkage on chromosomes 10q25, 10p12, 16q24, 16p13, and 16p12
6q25 (suicidal behaviour)
7q21 (panic disorder) 16p12 (psychosis) using
phenotypic subtypes
Bipolar and unipolar differences
Bipolar Unipolar
Substance abuse +++ +
Family history ++++ +
Seasonality ++++ +
Onset before age 25 +++ +
Postpartum onset +++ +
Psychotic depression <age 35 +++ --
Atypical features ++++ +
Rapid on/off pattern ++ --
Recurrent Major Depressive Episodes ++ +
Antidepressants associated with hypomania / mania
++ --
Brief episodes of depression ++++ --
Antidepressant wear-off ++ --
Mixed depression ++ --
Considering Diagnosis
Any mental health history
Recurrent depressive disorder
Any alcohol or substance misuse
Repeated relationship problems
Repeated occupational problems
Family history
Common Difficulties in the Diagnosis of Bipolar
• Functional mental illnessesRecurrent Depression,
Anxiety• Emotionally unstable /
borderline typesPersonality disorder
• Chronic or intermittent useSubstance and alcohol misuse
• Chronic stress & psychosocial problemsNormal human
emotion
Psychiatric Comorbidities
Anxiety disorders
Panic disorderSimple phobia
Social phobia
GAD
OCD
Sleep disorders
PTSD
Substance misuse
Alcohol misuse
Any substance
misuse
Childhood mental
health
Childhood bipolar
Conduct disorder
ADHD
Personality
disorders
Cluster B
Borderline
Emotionally unstable
Physical Comorbidities
Metabolic syndrome
Obesity & Diabetes
CVS
disease
Basic psychopharmacology
Mood stabilsers
Antipsychotics
Antidepressants
Anxiolytics Others
Attitudes to medication
Beating Bipolar 3: Section 3 Get CT1s to discuss each question in 2
groups▪ What they think▪ What they think the patient might thinks▪ Consider pros & Cons
Watch next film of patients (Mark & Jane)
Dr Alison Roberts – on lithium
Mood stabilisers
Lithium
Carbonate
Citrate
Antiepileptics
Carbamazepine
Valproate
Antipsychotics
Olanzapine
Quetiapine
Risperidone
Some examples of other drugs used in bipolar
Antidepressants Quetiapine Lamotrigine Benzodiazepines Typical antipsychotics Folic acid
Metabolic syndrome Maudsley Guidelines
Natural treatments
Exercise
Stress reduction
Diet
RelaxationPleasurable
activitiesSocial activities
Sleep
Cycles & rhythms
Lifestyles
Beating Bipolar Sections▪ 2 – Sleep▪ 3 – Rood & Exercise▪ 5 – Routines
Families and Carers
Beating Bipolar Module 7 General group discussion about what it
might be like to live with someone who has bipolar
Women and bipolar
Pregnancy Childbirth Stress Medication Genetics & children
Course of bipolar
Age of onset
•Average 21 years
Duration of
mania
•Mania
•Hypomania
Duration of
depression
Recovery
Long term
outcome
Mortality and
suicide
Relapse Prevention & Early Intervention
Beating Bipolar 2 – Triggers 3 – Monitoring mood 4 – Nipping episodes in the bud 5 – Dealing with suicidal thoughts
Psychological approaches
Beating Bipolar Module 6 sessions
Rating scales for bipolar
Bipolar Spectrum
Rating Scale
Mood Disorder
Questionnaire
Young Mania Rating Scale
Parent Version of the YMRS
Manic State Rating Scale
Mania Rating Guide
Affective Disorders Evaluation
Altman Mania Self-
Rating Scale
Goldberg Mania Scale
Psychiatric differentials
Axis I Axis II
Delirium Emotionally unstable PD
Dementia Histrionic PD
Substance-related disorder
Schizophrenia
Schizoaffective disorder
Delusional disorders
Psychotic disorder NOS
Cyclothymic disorder
Factitious disorder
Malingering
ADHD
Conduct disorder
Medical Conditions
Medications Substance abuse
Neurological disease
Infectious disease
Neoplasms Metabolic & endocrine disorders
Collagen-vascular
conditions
Miscellaneous
Medications that may cause mania
Isoniazid Corticosteroids and ACTH
Procarbazine Hallucinogens
L-Dopa Cimetidine
Bromide Sympathomimetic amines
Decongestants Disulfiram
Bronchodilators Barbiturates
Procyclidine Anticonvulsants
Calcium replacement Benzodiazepines
Phencyclidine Cocaine
Metoclopramide TCAs
Metabolic disturbances causing mania
Postoperative states
Haemodialysis
Vitamin B12
Addison’s disease
Iatrogenic Cushing’s disease
Post-infection states
Dialysis
Hyperthyroidism
Neurologic Disorders causing mania
Right temporal lobe seizures
Multiple sclerosis
Right hemisphere damage
Seizure disorders
Huntington’s disease
Post-stroke
Infectious diseases causing mania
Neurosyphilis
Herpes simplex encephalitis
Q fever
HIV infection
Management
Group discussion of principles
BeatingBipolar.org