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