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Part V: Other Psychological Disorders. Bipolar Disorder. Chapter 19 Joseph C. Blader and Gabrielle A. Carlson. HISTORICAL CONTEXT. Emil Kraepelin (1921) coined manic-depressive insanity as a cyclical disturbance of depression and manic excitement .
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Bipolar Disorder Chapter 19 Joseph C. Blader and Gabrielle A. Carlson
HISTORICAL CONTEXT • Emil Kraepelin (1921) coined manic-depressive insanity as a cyclical disturbance of depression and manic excitement. • 1920s and 1930s concluded that Kraepelin' s conception of manic-depression occurred among youth but was rare. • 1950s Lithium's efficacy for the treatment of acute mania was established. • Past 20 years recognition of frequent onset of BPD in mid- to late-adolescence, with possible prodromal signs evident even earlier.
Diagnostic Criteria and Clinical Presentation • In most formal definitions, BPD comprises: • Episodes of depression; interspersed to greater or lesser degree • Episodes of manic (or mixed) symptoms • Intervals between episodes during which mood state and functioning may vary widely both across patients and for the same person over time • An overall course of illness that is chronic (American Psychiatric Association, 2000; Goodwin & Jamison, 2007; World Health Organization, 2010)
Diagnostic Criteria and Clinical Presentation • Bipolar I Disorder • BPDI is the diagnosis applied to either: • A person experiencing an episode of mania or a mixed episode. • One who is experiencing an episode of major depressive disorder or of hypomania but has had a manic or mixed episode in the past.
Diagnostic Criteria and Clinical Presentation • Other Forms of BPD: Bipolar II Disorder and Cyclothymic Disorder • BPDII and cyclothymia involve episodes of hypomania. Hypomania differs from mania chiefly in terms of severity and level of impairment. • Cyclothymic disorder is a still milder form of BPD. • BPDII is the diagnosis applied for an individual who is experiencing either: • An episode of hypomania. • An episode of major depression but who also had a prior episode of hypomania but never had a full manic episode.
PREVALENCE • BPD among adults in the United States is generally agreed to be about 1% to 1.5%, with lifetime prevalence of disorders in the BPD spectrum around 4.5% (Kessler et al., 2006; Merikangas et al., 2007). • Lifetime prevalence among adolescents for bipolar I or II disorder combined of 2.9%. Prevalence increases with age during adolescence and 89.7% of adolescents with these disorders were classified as manifesting “severe” impairment.
DEVELOPMENTAL PROGRESSION • Adolescent-Onset BPD: • High rates of serial hospitalizations • Substance-abuse • Suicide attempts or actual suicides • Less robust response to lithium and divalproex • Generally worse interepisode functioning than adult-onset BPD • Risk for adverse outcomes rises with earlier onset, presence of psychotic features, mixed features, and low socioeconomic resources (Birmaher, et al., 2006).
Course and Outcomes of Bipolar Disorder in Adulthood • With age depressive episodes become more frequent and longer. • In the best of cases, functioning between episodes of mood disturbance can be quite good and a stable, tolerant family and a social milieu can act as a buffer. • A less fortunate outcomes can lead to: • A downward drift socially as interpersonal and occupational functioning become increasingly erratic and inadequate • Interepisode recovery is less successful • Sources of social support may become alienated • Legal entanglements • Criminal activity • Alcohol and drug abuse
CONCEPTUAL AND PRACTICAL ISSUES IN THE DIAGNOSIS OF BIPOLAR DISORDER AMONG YOUTH • Symptom Differences and Confounding Comorbidities • An elevated or euphoric mood • Extreme irritability • Grandiosity • Decreased need for sleep • Increased talkativeness • Distractibility • Increases in goal-directed activity • Psychomotor agitation • Excessive involvement in pleasurable activities • Psychotic symptoms
CONCEPTUAL AND PRACTICAL ISSUES IN THE DIAGNOSIS OF BIPOLAR DISORDER AMONG YOUTH • Distinct Periods of Mood Symptoms or Exacerbation • Rapid cycling: Is defined by at least four episodes in a year. • Episodicity: Implies an onset with a significant change from ordinary functioning. • Periods of remission that occur spontaneously are very uncommon among children, which is yet another deviation from BPD’s episodic nature.
Alternative Approaches to Emotional Volatility in Youth • Persistence Versus Transience of Mood Disturbance • A number of children do show persistent negative mood that changes only minimally with positive events. • Children who manifest with significant irritability are, in fact, highly overreactiveto events. • Ultradiancycling: Cyclesappear many times within a single day.
Distinguishing Narrow, Intermediate, and Broad Phenotypes • Narrow phenotype: Has a symptom presentation, course, and episodicity fully aligned with current criteria for (adult) BPD, with the additional requirement that the mood abnormality be euphoria or signs of pathological grandiosity. • One intermediate phenotype encompasses manic episodes that last from 1 to 3 days. Current nomenclature would classify a number of these situations as bipolar disorder not otherwise specified (NOS). • The other intermediate phenotype allows irritability to be the main mood aberration, so long as there is also evidence of well-demarcated episodes. • Broad phenotype: Denoted as severely disturbed behavior and mood dysregulation, which essentially describes chronic negative emotional reactivity and impulsivity.
RISK FACTORS AND ETIOLOGICAL FORMULATIONS • Depression • Patients who develop BPD often experience depression as their first episode • Biological Susceptibility Factors • Heritability and genetic markers • Neurodevelopmental antecedents • Disturbances of the sleep-wake cycle • Cognitive Factors and Other Potential Markers • Impaired response inhibitions and other executive functions • Deficits related to attention and inhibitory controls • Tendency to exaggerate and dwell on misfortunes
RISK FACTORS AND ETIOLOGICAL FORMULATIONS • Neuroanatomical and Neurophysiological Factors • Reduced amygdala volumes • Increased amygdala activity elicited by emotion relevant stimuli • Reductions in volume of the anterior cingulate • Experiential and Environmental Susceptibility Factors • Childhood maltreatment • Stress • Childhood truama • Psychotropic medications
COMORBIDITY, SEX DIFFERENCES & CULTURAL FACTORS • ADHD is the leading comorbidity among BPD children. • Substance abuse is common among adolescents and adults with BPD. • Prevalence estimates of comorbid anxiety disorders vary considerably in child BPD. • Similar rates of BPD in adolescents but higher rates of males in child samples. • May be cultural differences in the use of diagnoses in clinical settings.
THEORETICAL SYNTHESIS AND FUTURE DIRECTIONS • Forms of very early onset, chronic, and unremitting affective and behavioral volatility have been postulated to constitute a variant of BPD among youth. • At this time, it remains uncertain whether these forms of impairment are: • Developmentalversions of the same disease processes that underlie later-onset BPD. • Separate types of illness that might involve perturbations of the same mechanisms of self-control and mood that are implicated in BPD. • Fundamentally different problems, such as severe ADHD with ODD, which demonstrate some phenotypic overlap with BPD.