Bipolar Disorder, Adults/Children

1. Bipolar Disorder, Adults/Children LUBNA KHURSHID, LMSW

2. WHAT IS BIPOLAR DISORDER • Bipolar disorder, known as manic-depressive illness, is a brain disorder that causes unusual mood changes, energy, activity levels, and ability to carry out day-to-day tasks. • Characterized by the occurrence of at least one manic or mixed- manic episode during patient’s lifetime. • Patients may have one or more depressive episodes • May return to their normal state of well- being during intervals between these episodes • Symptoms are different from the normal ups and downs that everyone goes through from time to time. • http://www.nimh.nih.gov/health/publications/bipolar-disorder/index.shtml

3. Bipolar Onset • Symptoms may occur in early childhood, early teens, 40 or 50 years of age, as late as seventies or eighties (very rare) • Any race, ethnic group, or social class can develop features of bipolar. • Recently, children have been diagnosed as young as toddlerhood.  . http://www.bipolarcentral.com/articles/articles-931-1-Age-of-Onset-Influences-Bipolar-Prognosis.html http://bipolarsymptoms.org/bipolar-statistics/

4. Facts about bipolar Disorder According to National Institute of Mental Health: • 5.7 million/ 2.6% the adult population in the United States is diagnosed with bipolar disorder. • According to World Health Organization, bipolar disorder is the sixth leading cause of disability in the world. • Bipolar disorder is the most expensive behavioral health care diagnosis, costing more than twice as much as depression per affected individual ( CDC) http://www.cdc.gov/mentalhealth/data-stats.htm • Women tend to have more depressive episodes and more mixed episodes than men. • Women are three times more likely to experience rapid cycling of bipolar disorder than men. • One in five people with bipolar disorder will commit suicide • http://bipolarsymptoms.org/bipolar-statistics/#IN2.dpuf /bipolarsymptoms.org/bipolar-statistics

5. Genetics/ Cause • Bipolar disorder runs in families. Research suggests people with such genes are more likely to develop bipolar disorder than others. • Children with a parent or sibling who has bipolar disorder are much more likely to develop the illness, compared to children who do not have a family history of bipolar disorder. • Not all children with family history of bipolar disorder develop the illness. • Many factors, rather than just a single cause, may act together to produce the illness or increase risk for Bipolar disorder.http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

6. Bipolar I • According to DSM IV- TR “ Bipolar 1 is characterized by one or more Manic or Mixed Episodes, usually accompanied by Major Depressive episodes,”

7. Mania According to DSM IV-TR “Manic Episode is defined as an abnormally and persistently elevated, expansive and irritable mood lasting at least 1 week or less (if hospitalization is required)” Mood disturbance should accompanied by at least three additional symptoms such as: • Inflated self- esteem or grandiosity • Decreased need for sleep • Pressured speech • Flight of Ideas, or racing thoughts • Distractibility • Increased involvement in activities with painful consequences ( drugs, indiscriminate sexual encounters with strangers, gambling, spending sprees, reckless driving, foolish business investments, trouble with law • If mood is irritable rather than elevated four of the above symptoms must be present. (DSM IV- TR)

8. Mania cont. • Grandiose delusions • Religious delusions are very common, may think they are prophets, elected by God, for a hidden, purpose. • Prosecutorydelusions are quite common • Irritable mood, may get into furious rage of screaming, swearing, and assaultivebehavior. • May become dangerously, hostile. • Are regretful when no more manic • Mood may shift to anger or depression

9. Bipolar depression According to DSM IV TR: • Five or more of the following symptoms must be present during the last 2 weeks period and present a change from previous functioning level. • Depressed Mood, most of the day, every day ( feeling sad, or empty, tearful). • Diminished interest in activities that were once enjoyed. • Significant weight gain or loss. • Insomnia or hypersomnia almost everyday. • Psychomotor agitation.

10. BP depression Cont. • Loss of energy and feeling fatigued. • Feeling of worthlessness and excessive guilt. • Unable to concentrate or indecisiveness. • Recurrent thoughts of death and thoughts of self harm without a specific plan or suicide attempt. • Depressive symptoms may last moments, hours, or more rarely days.

11. Mixed Episode “Lasting at least 1 week in which the criteria are met both for a Manic Episode and for a Major Depressive Episode nearly every day” ( DSM IV –TR) • Rapid alternating moods • Sadness • Irritable • Euphoric • Agitation • Insomnia • Appetite decreased/ increased • Psychotic features • Suicidal ideations • Mood disturbance must cause marked impairment in social or occupational functioning or • Need for hospitalization (DSM IV- TR)

12. Bipolar II “Characterized by one or more major depressive episodes accompanied by at least one Hypomanic episode”. (DSM IV TR)

13. Hypomania A distinct period of an abnormal, persistently elevated, expansive or irritable mood at least last for 4 days. The period of abnormal mood must accompanied by at least three or more of the following symptoms: • Inflated self- esteem ( uncritical self confidence) • Grandiosity ( non- delusional) • Decreased need for sleep • More talkative than normal, pressure to continue talking • Flight of ideas or racing thoughts • Distractibility

14. Hypomania cont. • Psychomotor agitation • Excessive involvement of pleasurable activities that lead to painful consequences • Delusion and hallucinations are not present • Hypomanic episodes are not severe enough to cause marked impairment in social and occupational functioning • Does not require hospitalization • Increased efficiency or creativity for some people

15. Cyclothymic Disorder “Characterized by at least 2 years of numerous periods of hypomanic symptoms that do not meat criteria for Manic episode and numerous periods of depressive symptoms that do not meet criteria for Major Depressive Episode”(DSM IV- TR) • Usually begins in adolescence or early adult life • Equally common in men and in women • 15% - 50% people will subsequently develop bipolar 1 or II disorder http://www.ncbi.nlm.nih.gov/pubmedhealth

16. Disruptive Mood Dysregulation Disorder • A relatively new diagnosis in the mental health field, recently added in DSM V addition. • According to (Zepf FD, Holtmann 2012) Diagnostic criteria for disruptive mood dysregulation disorder, proposed for DSM-5 • A severe recurrent temper outbursts in response to common stressors, which are: • Manifest verbally or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property. • Grossly out of proportion in intensity or duration to the situation or provocation. • Inconsistent with the child’s developmental level. • B Temper outbursts occur, on average, three or more times per week. • C Mood between temper outbursts is persistently negative (irritable, angry, and/or sad) nearly every day

17. Disruptive Mood Dysregulation Disorder • D Criteria A-C have been present for at least 12 months and symptoms have been absent for less than 3 months at a time • E Symptoms exists at least two settings (at home, at school, or with peers) and must be severe at least in one setting. • F Aged 6 years or older • G Onset before 10 years of age • H & I Does not meet criteria for another mental disorder (e.g., bipolar, major depression, psychosis) but it can coexist with oppositional defiant disorder ADHD, conduct disorder or substance use disorder”(Zepf FD Holtmann 2012)

18. Treatment Bipolar disorder requires ongoing treatment even when the patient feels better. The treatments for bipolar disorder may consist of: • Hospitalization • Medications • Individual, group or family therapy • Psychoeducation • participation in support groups • Substance abuse treatment http://www.mayoclinic.com/health/bipolar-disorder

19. Medications • Medications may consist of Mood Stabilizers, Antipsychotics and Antidepressants.

20. Treatment Anticonvulsants (mood-stabilizers) Mood stabilizers are the cornerstone of treatment and work for both depressive and manic symptoms. • (Lithobid) Lithium, is effective in stabilizing mood and preventing extreme highs and lows • Has been used for many years • Periodic blood tests are required (lithium can cause thyroid and kidney problems) • Common side effects • Restlessness, dry mouth and digestive issues

21. Mood stabilizers cont. Abilify (Apriprazole)antipsychotic Side Effects: Nausea,Vomiting,Constipation,Headache,Dizziness,Akathisa,Anxiety,insomnia Depakote ( Divalproex) • Side Effects: Drowsiness, Diarrhea, Constipation,Changesin menstrual periods, Tremor, Hair loss, Weight gain, Unpleasant taste • Depakene Syrup ( Valproate) (oral syrup) • Diarrhea, Dizziness, Drowsiness, Hair loss, Blurred vision, Ringing in ears, Suicidal thoughts

22. Mood stabilizers cont. • Tegretol ( Carbamazepine) Side effects: • Drowsiness,Dizziness,Unsteadiness,Nausea,Vomiting,Headache,Anxiety • Memory problems, Diarrhea, Heartburn,Dry mouth, Back pain • Geodon (Ziprasidone) Antipsychotic • Side effects: • Tiredness, Nausea, Upset stomach, Dizziness,Restlessness, Abnormal muscle movements,Increasedcough

23. Mood stabilizers cont. • Lamictal ( Lamotrigine)treats depression Side effects: Severe skin rash, Dizziness,Drowsiness,Blurred vision • Neurontin ( Gabapentin) Side Effects: Back pain, clumsiness, constipation, dizziness, impaired muscular coordination, fever, hostility, nausea, vomiting, tremor, sleepiness, • Risperidal ( Risperidone) antipsychotic Side effects: fever, stiff mscles, confusion, sweating, uneven hartbeats, drooling , tremors, seizures, • Seroquel ( Quetiapine) Antipsychotic, treats mania, depressive episodes Side effects: low blood pressure, dry mouth, indigestion, drowsiness, dizziness, trouble sleeping, weight gain, sluggishness, weakness

24. Mood stabilizers cont. • Thorazine ( Chlorpromazine) Antipsychotic treats mania Side effects: Dizziness drowsiness, anxiety, sleep problems, breast swelling , weight gain, swelling hand/ feet, blurred vision, sexual dysfunction, • Trileptal (Oxcarbazepine) Side effects: Headaches, dizziness, nausea, fatigue, drowsiness, vomiting, viral infections, anxiety, loss of coordination, heart burn, loss of appetite, low sodium levels in blood, memory loss, urinary tract infections, • Topamax ( Topiramate) Side effects: double vision, involuntary eye movement, painful, irregular periods, drowsiness, water retention, weight loss, dry mouth, decreased white blood cells, • Zyprexa ( Olanzapine) antipsychotic Side effects: weight gain, increased appetite, headache, dizziness, drowsiness, memory problems, loss of bladder control, back pain, numbness,

25. Antipsychotics Antipsychotics are used as a short-term treatment to control psychotic symptoms such as hallucinations or delusions or mania symptoms. They treat bipolar depression, along with demonstrating long-term value in preventing future episodes of mania or depression.

26. Antipsychotics • Antipsychotics: • Abilify (aripiprazole) • Clozaril (clozapine) requires weekly or biweekly blood test monitoring. • Geodon(ziprasidone) • Risperdal (risperidone) • Saphris(asenapine) • Seroquel (quetiapine)(specifically approved by (FDA) for treating bipolar disorder) • Zyprexa (olanzapine)

27. side effects of antipsychotic medications Common side effects of antipsychotic medications include: • Weight gain • Sleepiness • Tremors • Blurred vision • Rapid heartbeat • Involuntary facial or body movements • High cholesterol levels • Increased risk of diabetes • Blurred vision • Dry mouth • Drowsiness • Muscle spasms or tremors

28. Antidepressants • Common SSRIs are used • Prozac (fluoxetine) • Zoloft (sertaline) • Paxil (paroxetine) • Luvox (fluvoxamine) • Celexa (citalopram) • Symbyax(Seroquel and olanzapine-fluoxetine combination) FDA-approved to treat bipolar depression http://www.webmd.com/bipolar-disorder/antidepressants-for-bipolar

29. Antidepressants Wellbutrin( Buproprion) • Sometimes used first-line treatment for bipolar disorder with mood stabilizer • Effective for combating depressive episodes, • Less risk of precipitating manic episodes (compared to SSRI antidepressants) • Side effects: dry mouth, constipation, headaches, and insomnia. http://www.mentalhelp.net

30. Side effects of Antidepressants Side effects from SSRIs are relatively mild: • Nausea • Headache • Insomnia • Sleepiness • Nervousness • Tremors • Increased sweating • Dry mouth • Sexual dysfunction

31. Therapies • Cognitive Behavior Therapy : Cognitive behavioral therapy helps identify unhealthy, negative thoughts, beliefs and behaviors by replacing them with healthy, and positive ones. Teaches effective strategies to manage stress, and coping skills to deal with upsetting situations.

32. Therapies • Family-focused therapy: • Helps enhance family coping strategies • Teaches how to recognize early signs and symptoms of new episodes • Deals with patient’s feelings of anger frustration. • Improves patient’s communication among family members, • Teaches problem-solving skills. • Interpersonal and social rhythm therapy Helps improve relationships with others, manage daily routines, and sleep schedules to protect against manic episodes.

33. Psychoeducation • Psychoeducation: • Provides awareness about illness and treatment. • Helps recognize signs of mood swings and other signs of illness. • Teaches when to seek early treatment in order to avoid full-blown episodes in both group or individual settings. • Group therapy. • Provides a forum to communicate with others, • patients learn from others in similar situations as theirs. • Helps build better relationships.

34. Therapies • Electroconvulsive therapy (ECT) Highly effective treatment for severely depressive, manic, or mixed episodes.Suggested for patients who do not see improvements in their symptoms despite other treatment. Sometimes used when other medical conditions, including pregnancy, make the use of medications risky. Can cause temporary memory loss and confusion. http://nimh.nih.gov/health/topics/bipolar-disorder/index.shtml • Dialectical Behavior Therapy(DBT) Form of CBT developed by Marsha Linehan, Ph.D. Developed to treat people with suicidal thoughts and actionswith bipolar disorder.

35. challenges Pregnancy and bipolar can be difficult to manage: • Research found lithium/ Lamotriginepreferred mood stabilizers during pregnancy • Women should stay hydrated to prevent lithium toxicity in themselves and the fetus. • Careful monitoring of lithium levels, during delivery and after birth is recommended • Breastfeeding should be avoided since Lithium/ lamotrigineare secreted in breast milk. • http://www.healthyplace.com/bipolar-disorder/bipolar-women/pregnancy-and-bipolar-disorder-treatmentmanagement-issues

36. References: http://www.seroquelxr.com http://nimh.nih.gov/health/topics/bipolar-disorder/index.shtml http://www.familyaware.org/expertprofiles/187-s-nassir-ghaemi-md-mph-bipolar-disorder-expert.html http://www.mdjunction.com/forums/bipolar-type-ii-discussions/medicine-treatments/27119-use-of-antidepressants-in-treating-bipolar-disorde http://www.mentalhelp.net http://www.webmd.com/bipolar-disorder/antidepressants-for-bipolar http://www.mayoclinic.com/health/bipolar-disorder http://www.ncbi.nlm.nih.gov/pubmedhealth http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml http://bipolarsymptoms.org/bipolar-statistics/#IN2.dpuf /bipolarsymptoms.org/bipolar-statistics http://www.bipolarcentral.com/articles/articles-931-1-Age-of-Onset-Influences-Bipolar-Prognosis.html http://bipolarsymptoms.org/bipolar-statistics/ http://www.cdc.gov/mentalhealth/data-stats.htm http://www.dbsalliance.org/site/PageServer?pagename=home http://ajp.psychiatryonline.org/article.aspx?articleid=1722061 • http://www.mayoclinic.com/health/bipolar-disorder/DS00356/DSECTION=treatments-and-drugs