1 / 36

Bipolar Not

Bipolar Not. Sheila Ward APRN Norton Women’s Counseling Louisville KY Sheila.ward@nortonhealthcare.org. Bipolar. Historically under-diagnosed Historically misdiagnosed Major Depression 10 years to Diagnosis Diagnosis doubling in the last decade among adults

kemal
Download Presentation

Bipolar Not

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Bipolar Not Sheila Ward APRN Norton Women’s Counseling Louisville KY Sheila.ward@nortonhealthcare.org

  2. Bipolar • Historically under-diagnosed • Historically misdiagnosed • Major Depression • 10 years to Diagnosis • Diagnosis doubling in the last decade among adults • 40-fold among children and adolescents • Moreno et al., 2007

  3. Bipolar-- What it is • Manic Episode • Distinct period of abnormally and persistently elevated or irritable mood and abnormally and persistently increased goal-directed activity or energy • With 3 (or 4 for irritable type) • Inflated self-esteem • Decreased need for sleep • Flight of ideas • Distractibility • Increase in activity • Doing stupid things

  4. New in DSM-5 Bipolar 1 Bipolar 2 Psychosis and lifetime experience of Major Depression are not requirements for Bipolar 1 Requires 1 week of mania or hospitalization Episode of Major Depression is required Bipolar (soft bipolar) is no longer considered to be a milder form of bipolar illness

  5. More DSM-5 News • Now include both changes in mood and changes in activity or energy • Mixed Type deleted • Specifiers “with mixed features” and “anxious distress” added

  6. MDQ • A screening tool for bipolar disorder (Hirschfeld 2000) • Positive screen just as likely to have Borderline Personality Disorder (Zimmerman 2010) • In primary care settings, the MDQ could be useful in identifying patients who should be referred for further psychiatric evaluation. • Mark Zimmerman, Janine N. Galione, Camilo J. Ruggero, Iwona Chelminski, Kristy Dalrymple, and Diane Young Comprehensive Psychiatry, 2011-11-01, Volume 52, Issue 6, Pages 600-606

  7. Generalized Anxiety Disorder • Excessive worry about everything • Uncontrollable worry • Three or more • Restless, on edge • Fatigue • Poor concentration (racing mind) • Muscle tension (headache, GI sx, body pain) • Sleep disturbance • Irritable • Impairment in function

  8. PTSD • A qualifying event • Combat • Rape • Childhood Sexual Abuse • Domestic Violence • MVA • Surgical Trauma • Childbirth Trauma • Witness to violence • Vicarious Trauma • Repressed Trauma-Unremembered

  9. PTSD Intrusive Symptoms (1) ___ Bad memories of a traumatic event _____Nightmares _____Flashbacks (re-living the traumatic event) _____Feeling stressed from reminders of the traumatic event _____Panic symptoms (heart racing, shaking, difficulty breathing, choking)

  10. PTSD Hyper-Arousal Symptoms (2) _____Difficulty falling or staying asleep _____Irritability ____ Outbursts of anger ! _____Difficulty concentrating _____Feeling alert or watchful when there is no need to be _____Jump or startle easily, for no reason

  11. PTSD Avoidant Symptoms (3) _____Avoiding thoughts, feelings, or conversations about it _____Avoiding activities, places or people that remind you of it _____Difficulty remembering details of it _____Loss of interest or pleasure in normal activities _____Feeling distant or cut off from others _____Difficulty feeling normal feelings such as love and happiness _____Feeling that the future will be cut short

  12. PTSD • Does what happened to you cause you a lot stress, or damage your relationships, employment, or other important things in your life? _______

  13. Panic Disorder

  14. ADHD • Inattentive • Hyperactive Impulsive • Fidgets • Can’t sit still • Restlessness • Can’t be quiet • Talks excessively • On the go, driven by a motor • Blurts out • Difficulty waiting turn • Interrupts others

  15. Personality DisordersCluster B as in Bad Antisocial Pervasive pattern of disregard Failure to conform Deceitful Impulsivity Irritable and aggressive Reckless Irresponsible Lack Remorse Narcissistic Grandiosity Fantasies of success “Special” Requires Admiration Sense of entitlement Exploitative Lacks empathy Envious Arrogant

  16. Cluster B Girls • Borderline • Abandonment • Unstable relationships • Identity Disturbance • Impulsivity • Recurrent suicidal acts • Mood swings ! • Emptiness • Intense Anger • Paranoia or Dissociation • Histrionic • Persistent pattern of excessive emotionality and attention seeking • Center of Attention • Sexually seductive • Rapidly shifting emotions • Physical appearance to draw attention • Impressionistic Speech • Theatrical • Suggestible • Exaggerates relationships

  17. Schizoaffective Disorder Continue to have psychotic symptoms between episodes of mania and depression

  18. One of my people Candy 18 y.o. Presents with “hx of BP” Aged out of state system Unknown father Raised by MGM, foster home Hx of childhood sexual abuse Fighting, Drugging, D.V. Legal issues Boy Friend incarcerated Wants to know can I write a letter for SSID

  19. Candy Chief Complaint Pertinent History • Bipolar and Bad nerves • Wants Xanax (Mom has bipolar and she gets Xanax) • Works great, makes her feel normal!!! • No clear history of manic episode • Tantrums • Family history ??? • Has nightmares, flashbacks, outbursts, poor concentration, • Sad, low appetite, tired, and can’t keep up with anything anymore.

  20. Differentials for Candy CD PTSD Borderline Personality Disorder ADD Bipolar Disorder

  21. Then what happened? Lost to care Wanted bipolar dx for SSI, angry Wanted Xanax, didn’t get it “I could get this crap from anybody”

  22. Another one of mine Gina • 26 y.0. • Presents with female partner • I cannot take these moods! • I don’t know who will wake up with me, the one I love or the hateful one. • Artist • PCOS

  23. Clinical Course • Dx Bipolar • Discontinued SSRI (weaned) • Mood Stabilizers • Gave up after a year • More history—recurrent depression, no manic but a lot of irritable moods • No trauma—no “qualifying event” • Normal dysfunctional family • PMS • Back to SSRIs, some better

  24. Clinical Course Consideration of personality disorder (Zimmerman 2010) Borderline screening—Bingo! Patient Resistance/Denial No Access to DBT—Partner self studied Partner identifies ADD Stimulant trial—Another Bingo Current therapies Celexa 40/60 Trazodone Ritalin Continuous method OCP Obama Care=Insurance and DBT!!!

  25. DBT • Behavioral Treatment for Borderline and other … • Marcia Lindehan • 100% Validation • Distress Tolerance • Mindfullness • Coping Skills

  26. Keri • 24 y, o. History of recent seizure onset • Opioid abuse • “Episodes” of not myself • Does not sleep or eat • Sort of buzzing feeling • Ideas are out there • Thought are “warp speed” • Pacing a lot • Several day duration • Sometimes not when using

  27. Keri Social Lives with parents Going to college—hx of flunking out, starting over Feels guilty for depending on parents Gets very uncomfortable in class when called upon, palpatations, assumes everyone thinks is a f___up. No girlfriend, ever

  28. Kirk Work up • BDI II 39 with no SI (depressed) • Beck Anxiety Scale 44 • Severe anxiety • Tox Negative • Family confirms manic • Rule out personality Disorders • Rule out PTSD • Rule out ADD • Diagnosis • Opioid Abuse • Bipolar 1 • Social Anxiety Disorder

  29. Treatment so far… • Seroquel IR 200 mg • Seroquel XR 600 mg • Metoprolol for social anxiety • Lithium starting after another manic episode probably triggered by stress of a new job • Referral to Addiction medicine consult in LA.

  30. A Typical Case Starla 40 y.o. at 20 weeks gest Dx bipolar by former psychiatrist On Lamictal 400 and abilify Intention to breastfeed Marital Conflict (understatement) Stayed on meds throughout pregnancy and lactation “Manic” episodes ????

  31. Next chapter 4 years later 2 months postpartum at 44 y.o. CPS requiring psych care Verbal abuse of older child Still on “bipolar meds” Borderline screening +/- Court ordered “psychiatrist” Dxborderline Privately secured second opinion Dx Histrionic Personality DO I fired her for mistreating staff

  32. Do Over Question the Bipolar Dx Screen for personality DO Set limits on behaviors tolerated No special treatment No meds DBT Get a different job!

  33. Case Example Dominique 24 y.o. Army Private Episode in Vehicle Felt trapped Too hot Felt out of body No recall Inappropriate behavior Transferred to psych Diagnosed with Bipolar Disorder

  34. History / Work-up/ Treatment No manic criteria Personality screening neg Has some Cluster B traits (dissociation, mood instability, Center of attention issues) High strung individual Hx of childhood sexual abuse Dose not meet criteria for PTSD Diagnosis = Panic Disorder DBT still advised along with Rx for anxiety

  35. Resources

  36. Upshot Never accept a prior history Dx of Bipolar Assume it is wrong until criteria met Use Depression NOS, or Mood Swings, or Insomnia Never Dx bipolar until all differentials ruled out Always assume you can be wrong Antidepressants could be wrong drug Lamotrigine is never wrong unless it’s wrong Use standardized scales and assessment tools Get an easier job!

More Related