Psychiatry III1

Clinical Impression

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Bipolar I Disorder

• Also known as Bipolar Affective Disorder

• A psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated mood clinically referred to as mania or hypomania

• A condition in which people experience abnormally elevated (manic or hypomanic) and abnormally depressed states for a period of time in a way that interferes with functioning.

http://en.wikipedia.org/wiki/Bipolar_disorder

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Bipolar I Disorder

DSM IV-TR Diagnostic Criteria for Bipolar I Disorder, Most Recent Episode ManicA. Currently or mostly in a manic episode.

B. There has previously been at least one major depressive episode, manic episode, or mixed episode.

C. The mood episodes in Criteria A and are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified.

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DSM IV-TR Criteria for Manic Episode

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).

B. During the period of mood disturbance, three or more of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: 1. inflated self-esteem or grandiosity 2. decreased need for sleep (feels rested after only 3 hours of sleep) 3. more talkative than usual or pressure to keep talking 4. flight of ideas or subjective experience that thoughts are racing 5. distractibility (attention too easily drawn to unimportant or irrelevant external stimuli, impulsive) 6. increase in goal directed activity (either socially, at work or school, or sexually) or psychomotor agitation 7. excessive involvement in pleasurable activities that have a high potential for painful consequences (unrestrained buying sprees, sexual indescretions, etc)

C. The symptoms do not meet criteria for a mixed episode.

D. The mood disturbance is sufficiently severe to cause marked impairment…

E. The symptoms are not due to direct physiological effects of a substance…

Previous Manic Episode7

Bipolar I DisorderDSM IV-TR Diagnostic Criteria for Secerity/ Psychotic/ Remission Specifiers for Current or Most Recent Manic Episode

Severe With Psychotic Features Presence of Delusions or Hallucinations

Specify:

Mood Congruent Psychotic Features

Mood-Incongruent Psychotic Features

Delusions or hallucinations whose content is consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment.

Delusions or hallucinations whose content does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Included are such symptoms as persecutory delusions (not directly related to depressive themes), thought insertion, thought broadcasting, and delusions of control.

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Psychotic Features

PERSECUTORY DELUSIONS MOOD – INCONGRUENT

PSYCHOSIS

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Clinical Impression: DSM IV

Axis III

•No Physical Disorders•No Medical Conditions

Axis II

•No Personality Traits/ Disorders•No Mental Retardation

Axis I

• Bipolar I Disorder with Recent Manic Episode and Mood Incongruent Psychotic Symptoms

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Clinical Impression: DSM IV

Axis IV

•Pyschosocial and Environmental Factors contributing to her disorder

•Previous history of ADHD•Pressures from growing up years

to excel academically•Moving to the Philippines

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91-100 Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by others because of his or her many qualities. No symptoms.

81-90 Absent or minimal symptoms, good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns.

71-80 If symptoms are present they are transient and expectable reactions to psychosocial stresses; no more than slight impairment in social, occupational, or school functioning.

61-70 Some mild symptoms OR some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships.

51-60 Moderate symptoms OR any moderate difficulty in social, occupational, or school functioning.

41-50 Serious symptoms OR any serious impairment in social, occupational, or school functioning.

31-40 Some impairment in reality testing or communication OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood.

21-30 Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communications or judgment OR inability to function in all areas.

11-20 Some danger of hurting self or others OR occasionally fails to maintain minimal personal hygiene OR gross impairment in communication.

1-10 Persistent danger of severely hurting self or others OR persistent inability to maintain minimum personal hygiene OR serious suicidal act with clear expectation of death.

0 Not enough information available to provide GAF.

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Clinical Impression: DSM IV

Axis V

•Global Assessment of Functioning Score of 31-40

•Some impairment in reality testing or communication OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood.

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Review DSM IV

DSM IV Diagnosis of EB

Axis I Bipolar I Disorder with Recent Manic Episode and Mood Incongruent Psychotic Symptoms

Axis II • No Personality Traits/ Disorders• No Mental Retardation

Axis III •No Physical Disorders•No Medical Conditions

Axis IV • Pyschosocial and Environmental Factors contributing to her disorder

• Previous history of ADHD• Pressures from growing up years to excel academically• Moving to the Philippines

Axis V • Global Assessment of Functioning Score of 31-40• Some impairment in reality testing or communication

OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood.

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Clinical Impression: ICD 10

http://priory.com/psych/ICD.htm

F31.2.21 Bipolar Affective Disorder, Current Episode Manic with Mood Incongruent Psychotic Symptoms

1. BIPOLAR II DISORDER2. SCHIZOAFFECTIVE DISORDER3. BORDERLINE PERSONALITY DISORDER

Differential Diagnosis16

Bipolar II Disorder

Involves Major Depressive Episodes and Hypomanic Episodes

Bipolar II vs Bipolar I (Hypomanic + MDD) (Manic + MDD)

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Bipolar II Disorder

• Bipolar II is often a first step to Bipolar I.

• Over 5 years, between 5% and 15% of those will Bipolar II will change diagnosis to Bipolar I.

• Approximately 0.5% of people will develop Bipolar II in their lifetimes.

http://www.a-silver-lining.org/BPNDepth/dsmiv.html

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DSM-IV-TR Diagnostic Criteria forBipolar II Disorder

A) Presence (or history) of one or more Major Depressive Episodes B) Presence (or history) or at least one Hypomanic Episode C) There has never been a Manic Episode or a Mixed Episode D) The mood symptoms in Criteria A and B not better accounted for

by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

E) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specifiers:Hypomanic. used if the current (or most recent) episode is

a Hypomanic Episode.  Depressed. used if the current (or most recent) episode is a

Major Depressive Episode.

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Hypomanic Episode

• A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.

• During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: – inflated self-esteem or grandiosity – decreased need for sleep (e.g., feels rested after only 3 hours of sleep) – more talkative than usual or pressure to keep talking – flight of ideas or subjective experience that thoughts are racing – distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) – increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation – excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person

engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

• The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.

• The disturbance in mood and the change in functioning are observable by others. • The episode is not severe enough to cause marked impairment in social or

occupational functioning, or to necessitate hospitalization, and there are no psychotic features.

• The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).NOTE: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II Disorder.

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Schizoaffective Disorder

A. An uninterrupted period of illness during which, at some time, there is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia.

Note: The Major Depressive Episode must

include Criterion A1: depressed mood.

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Schizoaffective Disorder

B. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms.

C. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness.

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Schizoaffective Disorder

D. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

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Borderline Personality Disorder

DSM IV Diagnostic Criteria A pervasive pattern of instability of interpersonal

relationships, self- image and affects and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following: Frantic efforts to avoid real or imagined abandonment A pattern of unstable and intense interpersonal

relationships characterized by alternating between extremes of idealization and devaluation

Identity disturbance: markedly and persistently unstable self-image or sense of self

Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).

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Borderline Personality Disorder

Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

Chronic feelings of emptiness. Inappropriate, intense anger or difficulty

controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).

Transient, stress-related paranoid ideation or severe dissociative symptoms.

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Why Consider Borderline Personality Disorder?

Impulsivity in at least two areas that are potentially self-damaging Shops for clothes and jewelries, maxing out her 2

credit cards Went to SM mall of asia and spent at least 14,000

for shopping Tendency to shoplift things

Chronic feelings of emptiness She was approached by a man who told her she

looks miserable and sick (2002)

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Why Consider Borderline Personality Disorder?

Transient, stress-related paranoid ideation When they got stuck on traffic, she got out of the car

and ran away because she thought there was a coup d’etat going on

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Why It Is Not Borderline Personality Disorder?

Only 3 out of the required 5 or more criteria

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Treatment29

Therapeutic Goals

Relief of immediate symptomsImprovement of patient’s well-beingElimination of stressorsCombined pharmacotherapy and

psychotherapyImproved medication complianceBetter monitoring of clinical statusDecreased number and length of hospitalizationsDecreased risk of relapseImproved social and occupational functioning

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Pharmacotherapy

DIVISION Acute Phase Maintenance Phase

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Treatment of Acute Mania

• Lithium Carbonate – the prototypical “mood stabilizer– Therapeutic lithium levels are between 0.6 and 1.2 mEq/L Controls acute mania and prevents relapse in about 80% of

persons with bipolar I disorder Has a relatively slow onset of action when used and exerts its

antimanic effects over 1-3 weeks Thus a benzodiazepine, dopamine receptor antagonist,

serotonin-dopamine antagonist, or valproic acid is usually administered for the first few weeks.

Caution: Nephrotoxic (request Creatinine/BUN, monitor Blood levels) Teratogen (Pregnancy Test) Hypothyroidism

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Treatment of Acute Mania

Valproate only indicated for acute mania; has prophylactic

effects Typical dose levels of valproic acid are 750 to 2,500

mg per day, achieving blood levels between 50 and 120 µg/mL

Carbamazepine and Oxcarbazepine Typical doses of carbamazepine to treat acute mania

range between 600 and 1,800 mg per day associated with blood levels of between 4 and 12 µg/mL

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Treatment of Acute Mania

• Clonazepam and Lorazepam– effective and are widely used for adjunctive treatment of

acute manic agitation, insomnia, aggression, and dysphoria, as well as panic

– Adjuvant to Lithium, may result in an increased time between cycles and fewer depressive episodes

• Lamotrigine– Prevent recurrences of manic episodes

• ECT– Effective in acute mania– Reserved for rare refractory mania or with medical

complications

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Treatment of Acute Bipolar Depression

Combination of Antidepressants and Mood Stabilizer Olanzepine and Fluoxetine

Electroconvulsive TherapyCalcium Channel Blocker

Verapamil Has acute antimanic efficacy

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Table 15.1-37 US Food and Drug Administration (FDA)-Approved Medications for the Treatment of Bipolar Disorders

ManiaMaintenance

Aripiprazole (Abilify) Yes (2004) NoCarbamazepine XR (Equetro)

Yes (2004) No

Divalproex (Depakote) Yes (1996) NoLamotrigine (Lamictal) No Yes (2003)Lithium (Lithobid) Yes (1970) Yes (1974)Olanzapine (Zyprexa) Yes (2000) Yes (2004)Risperidone (Risperdal) Yes (2003) NoQuetiapine (Seroquel) Yes (2004) NoZiprasidone (Geodon) Yes (2004) No

Maintenace Treatment of Bipolar Disorder

MOOD STABILIZERS– Lamotrigine– Lithium– Olanzapine

• Ameliorate affective and psychotic symptoms during acute manic episodes

• Improve depression episodes during acute bipolar depressive episodes

• Prevent future mood episodes with sustained treatment at therapeutic levels (prophylactic benefit)

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Psychotherapy

• Patients taking lithium or other treatments for bipolar I disorder are usually medicated for an indefinite period of time to prevent episodes of mania or depression

• Most psychotherapists insist that patients with bipolar I disorder be medicated before starting any insight-oriented therapy. Without such premedication, most patients with bipolar I disorder are unable to make the necessary therapeutic alliance.

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Psychotherapy

• When those patients are depressed, their abulia seriously disrupts their flow of thoughts, and the sessions are nonproductive.

• When they are manic, their flow of associations can be rapid, and their speech can be so pressured that the therapist may be flooded with material and may be unable to make appropriate interpretations or to assimilate the material into the patient's disrupted cognitive framework.

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Psychotherapy

American Psychiatric Association (APA) practice guideline for bipolar disorder Recommends combined therapy as the best approach It increases compliance, decreases relapse, and

reduces the need for hospitalization

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Thank you.41

Major Depressive Episode

• Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

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Major Depressive Episode

1. depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.

2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

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Major Depressive Episode

3. significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.

4. insomnia or hypersomnia nearly every day 5. psychomotor agitation or retardation nearly

every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

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Major Depressive Episode

6. fatigue or loss of energy nearly every day 7. feelings of worthlessness or excessive or

inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

8. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

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Major Depressive Episode

9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

• The symptoms do not meet criteria for a Mixed Episode

• The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

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Major Depressive Episode

• The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

• The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

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Manic Episode

A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).

During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

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Manic Episode

1. inflated self-esteem or grandiosity 2. decreased need for sleep (e.g., feels rested

after only 3 hours of sleep) 3. more talkative than usual or pressure to

keep talking 4. flight of ideas or subjective experience that

thoughts are racing 5. distractibility (i.e., attention too easily

drawn to unimportant or irrelevant external stimuli)

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Manic Episode

6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

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Manic Episode

• The symptoms do not meet criteria for a Mixed Episode

• The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

• The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

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Mixed Episode

• The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.

• The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

• The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

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Schizophrenia – Criterion A

• Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):

- delusions - hallucinations

- disorganized speech- frequent derailment or incoherence

- grossly disorganized or catatonic behavior - negative symptoms

- affective flattening, alogia, or avolition

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Schizophrenia – Criterion A

Only one symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.

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