Bipolar Disorder

1. Bipolar Disorder All questions, unless otherwise indicated, are from “Practice Guideline for the Treatment of Patients with Bipolar Disorder, Second Edition, AJP, April 2003 Supplement. Or from Goodwin and Jamison’s MANIC-DEPRESSIVE ILLNESS, 2ND Edition, 2007 As of 12January2012

2. Bipolar - DSM • Q. What are the four major DSM-IV-TR types of bipolar disorders? [Don’t spend time on this one, it is just to get us started.]

3. Bipolar disorder, types • Ans. • -- Bipolar I disorder [with subtypes of most recent episode: hypomanic, manic, mixed, depressed, or unspecified] • -- Bipolar II disorder [with subtypes of most recent episode hypomanic or depressed] • -- Cyclothymic disorder • -- Bipolar, NOS • DSM-IV-TR, p 20.

4. Bipolar – DSM criteria for manic episode • Q. What are the symptoms of a manic episode? List the required one, then list the seven of which 3 or 4 are required.

5. Manic episode criteria • Criteria: • A. At least one week of abnormally elevated, expansive, or irritable mood. • B. In addition to “A” during that week or more: 3 of the those listed on the next slide [4 if “irritability” is all of “A”] • C. Not part of another disorder or illness. • Continued on next slide

6. Manic episode criteria - 2 • Elements of “B”: • -- grandiose • -- decrease need for sleep • -- talkative • -- flight of ideas • -- distractibility • -- increase in goal-directed activity or psychomotor agitation • -- excessive involvement in activity is likely to have untoward results [e.g., buying sprees] DSM-IV-TR, 362

7. Criteria for depressive episode • Q. What are nine symptoms that form the criteria for depressive episode?

8. Depressive episode criteria - 1 • Criteria, two weeks or more of five or more of the following -- and not part of another disorder: • 1. sad [irritable counts in children] • 2. diminished interest in activities. • 3. weight loss or gain • 4. insomnia or hypersomnia • continued

9. Depressive episodecriteria - 2 • 5. psychomotor agitation or retardation. • 6. anergy • 7. feelings of worthlessness or guilt • 8. difficulty concentration • 9. recurrent thoughts of death or suicidal DSM-IV-TR, P 356

10. Dx criteria for hypomania • Q. What is the criteria for hypomania?

11. Criteria for hypomania • Ans. • Same as manic episode except • Only has to be for 4 days • Is not severe enough to cause social or occupational/educational impairment. • Others have observed the symptoms, i.e., can’t be based on pt’s word alone [often a forgotten point by Board candidates]. DSM-IV-TR, P 368

12. Criteria for mixed episode • Q. What is criteria for mixed episode?

13. Criteria for mixed episode • Ans. At least one week of meeting both the signs of depressive episode and manic episode. DSM-IV-TR, 365

14. Criteria for cyclothymic disorder • Q. What is the criteria for cyclothymic disorder?

15. Criteria for cyclothymia • Ans. • 1. At least two years of numerous hypomanic episodes and numerous depressive episodes not severe enough to meet criteria of depressive episode [one year for kids]. • 2. Not part of another disorder. DSM-IV-TR, 400

16. Criteria for catatonic specifier • Q. What are the criteria for the catatonic specifier?

17. Criteria for catatonic specifier • At least two of the following: • 1. motoric immobility • 2. excessive motor activity • 3. negativism • 4. stereotyped behaviors • 5. echolalia or echopraxia [same as when “catatonia” is applied to schizophrenia] DSM-IV-TR, 418

18. Criteria for Melancholia • Q. What are criteria for melancholia?

19. Criteria for melancholia - 1 • Ans. Two sets of signs: • 1. Either loss of please in almost all activities or does not feel pleasure even when something good happens • 2. Three or more of the six signs on the next slide

20. Criteria for melancholia - 2 • Continued, 3 or more of 6: • 1. Sadness is distinctly different than sadness associated with tragic events of the past. • 2. Sadness worse in the morning • 3. Early morning awaking • 4. Psychomotor retardation or agitation • 5. Anorexia or weight loss • 6. Excessive guilt DSM-IV-TR, 420

21. Criteria for Atypical • Q. What is the criteria for the Atypical specifier?

22. Criteria for atypical • Ans. • 1. Mood brightens with positive events. • 2. At least two of the following: • Weight gain • Hypersomnia • Laden paralysis • Hyper rejection sensitivity DSM-IV-TR, 422

23. Criteria for postpartum specifier • Q. What is the criteria for the postpartum specifier?

24. Criteria for postpartumspecifier • Ans. Onset of episode within 4 weeks of delivery. DSM-IV-TR, 423

25. Criteria for seasonal pattern • Q. What is criteria for seasonal pattern specifier?

26. Criteria for seasonal patternspecifier • Ans. For at least two years: • 1. onset of mood episode has a temporal relationship, e.g., each October. • 2. no episodes other than those with a temporal episode. DSN-IV-TR, 427

27. “Chronic” • Q. With mood disorders, “chronic” means?

28. “Chronic” • Ans. Criteria have been met continuously for at least two years. • [Two years is also the way “chronic” is used in schizophrenia, although not part of DSM-IV-TR, “chronic” is part of the current ICD-9-CM for schizophrenia. For adjustment disorders, “chronic” is for 6 months. For PTSD, “chronic” is for 3 months.} DSM-IV-TR, 417

29. Co-morbidity Q. Most common co-morbid psychiatric disorder?

30. Co-morbidity Ans. Alcohol abuse. G&R [=Goodwin and Jamison], p 225

31. gender • Q. Gender breakdown of bipolar disorder? • Give general breakdown, then which episode do men tend to have first? Which do women? Which has more rapid cycling?

32. Gender • Ans. -- about equal generally, but some differences. -- men more likely to have a first episode of mania. -- women more likely have a first episode be depression. -- women more likely to rapid cycle. DSM-IV-TR, p 385

33. Quality of life • Q. Does manic episodes or depressive episodes have the greatest impact on quality of life and duration of symptoms?

34. Quality of life • Ans. Depressive episodes have the greatest negative impact on quality of life and have the longer duration. • Source: APA Watch on bipolar.

35. Suicide • Q. Suicide rate among bipolar I disordered?

36. Suicide • Ans. 10-15%

37. Suicide • Q. What two phases of bipolar disorder have the high suicide rates -- manic, depressed or mixed?

38. Suicide • Ans. • 1] depressive episodes • 2] mixed episodes

39. Suicide risk factors • Q. List symptoms/signs that are associated with increased risk of suicide in bipolar I pts?

40. Suicide risks • Ans. Practice Guideline lists: • -- agitation • -- pervasive insomnia • -- impulsiveness • -- psychosis [especially command hallucinations]* [Despite research that questions the lethality of command hallucinations, this wording is in the Guideline.]

41. Suicide risks • Q. What co-morbid psychiatric disorders increase the risk of suicide in bipolars?

42. Suicide risks • Ans. Practice Guideline lists: • -- Substance-related disorders • -- Personality disorders

43. Med associated with suicide reduction • Q. What med has the clearest evidence of reducing suicides?

44. Med associated withsuicide reduction • Ans. Li. • [Some 2011 studies challenged this, but facing a multiple choice question, this is likely to be the answer.]

45. Secondary manianeurological disorders • Q. What neurological disorders are associated with secondary mania?

46. Secondary manianeurological disorders • Ans. Practice guidelines mentions: • -- MS • -- lesions involving right-side subcortical areas. • -- lesions close to limbic system,

47. Secondary maniasubstances • Q. What meds are associated with secondary mania [not asking about antidepressants]?

48. Secondary maniasubstances • Ans. Practice guideline lists: • -- L-Dopa • -- corticosteroids

49. Hospitalization • Q. Under what conditions should a person with bipolar disorder be hospitalized?

50. Hospitalization • Ans. • 1. A threat to harm self or others • 2. Severely ill and lack social support • 3. Severely ill and significantly impaired judgment. • 4. Has another complicating medical [including psychiatric] illness. • 5. Has not responded to outpt treatment.