Unipolar, Bipolar or Borderline:

How do you tell what’s what…A Guide for Clinicians

John P. Hendrick, M.D., DFAPAAssociate Professor of Psychiatry, ETSU

Chief, Inpatient Psychiatry, Mountain Home VAMCSite Coordinator for Psychiatric Residency - VA/ETSU

Residency Training Coordinator for Neurosciences and Psychopharmacology

Facts about depression• Affects about 10% of the U.S. population with nearly three out of four in the

workplace (Gemignani, 2001) – Incidence• 15 to 25% of the overall population - Prevalence• Prevalence among school age children and adolescents is 4.6% (Wagner,

2003)

• Millions do not seek treatment due to inadequate benefits and the stigma associated with depression (U.S. Surgeon General, 2000)

• < 25% under the care of a mental health specialist• Twice as common in women

• Peak incidence during primary reproductive years (25 to 45 yrs)

• Effective pharmacotherapy combined with psychotherapy has been shown to reduce healthcare costs and the rate of suicide attempts (Ballenger, 1999)

• Average disability length as well as disability relapse are greater for depression than most comparison medical groups (Conti and Burton, 1994)

How can a primary care doc make a reasonable psychiatric differential diagnosis?• Language:

– Symptoms– Diagnostic categories

• DSM-IV:– 6484 signs, symptoms, inclusion criteria– 405 diagnoses– 18 diagnostic categories

• DSM-IV PC starts the process but is inefficient and “psychiatric”

Mood Disorders

• Major Depression– Single episode– Recurrent

• Dysthymia• “Double” Depression• Bipolar Disorder

– Mania– Hypomania (Type II ?)

• Psychotic Depression (especially post - partum psychosis)

• Depressive Disorder NOS (Seasonal Affective Disorder)

• Cyclothymia• Mood Disorder

secondary to GMC• Substance-Induced

Mood Disorder• Adjustment Disorder

(separate classification)

Common Causes of Depression

CHAIN OF EVENTS• Stress & loss• Biological depression• Physical illness and

its treatment interact with depression in older adults

Recent Loss

___ recent relocation?___ change in relationships?___ change in health?___ change in functional abilities?___ change in sensory status?___ change in financial status?___ death of loved one? (even a pet)___ loss of control over daily routines?___ loss of significant role, change in social status? ___declining social contacts due to health limitations

DEPRESSION

NORMAL MOOD

RECOVERY OR REMISSION

EPISODE OF DEPRESSION

TIME6 - 24 months

5-1 Stahl S M, Essential Psychopharmacology (2000)

Major Depression – Questions:

• How is your mood?• Have you been feeling

sad, blue or depressed?• Have you lost interest in or

do you get less pleasure from the things you used to enjoy?

• Has there been any change in your appetite? (5% weight change in 1 month)

• How have you been sleeping?

• How has your energy level been?

• Have you been more fidgety?

• Have you felt slowed down, like you were moving in slow motion or stuck in mud?

• How have you been feeling about yourself?

• Have you been blaming yourself for things?

• Have you had problems thinking or concentrating?

Major Depressive Disorder (MDD)• >2 week period of

change in behavior with 5 of the following:– *depressed mood– *anhedonia– appetite disturbance– sleep disturbance– psychomotor

disturbance (sluggish behavior, tearfulness)

– fatigue or loss of energy

– worthlessness or guilt

– impaired concentration

– suicidal thoughts• * 1/5 symptoms

must be these• Rule out physical

causes

MINOR Depression (Dysthymia)

People with this illness are mildly depressed for years. They function fairly well on a daily basis but their relationships suffer over time.

• Also known as – subsyndromal

depression– subclinical

depression– mild depression

• 2 - 4 times more common than major depression

• Associated with:– subsequent major

depression– greater use of health

services– reduced physical,

social functioning– loss of quality of life

• Responds to same treatments!

2+ years

DEPRESSION

NORMAL MOOD

DYSTHYMIA

5-7 Stahl S M, Essential Psychopharmacology (2000)

6 - 24 months2+ years

DEPRESSION

NORMAL MOOD

DYSTHYMIA PARTIAL RECOVERY

DOUBLE DEPRESSION

5-8 Stahl S M, Essential Psychopharmacology (2000)

Depression. It’s not only a state of mind.

Reference: Adapted fromAmerican Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition ,Text Revision. Washington, DC; American Psychiatric Association. 2000:345-356,489.

The symptoms of depression

Emotional Symptoms Include:

Sadness

Loss of interest or pleasure

Overwhelmed

Anxiety

Diminished ability to think or concentrate, indecisiveness

Excessive or inappropriate guilt

Physical Symptoms Include:

Vague aches and pains

Headache

Sleep disturbances

Fatigue

Back pain

Significant change in appetite resulting in weight loss or gain

Pain perception

• “Is it all in my head?”• Emotional aspects of pain• Biology of pain perception• Cultural factors

Reference:1. Simon GE, et al. N Engl J Med. 1999;341(18):1329-1335.

Depression – the physical presentationIn primary care, physical symptoms are often

the chief complaint in depressed patients

N = 1146 Primary care patients with major depression

In a New England Journal of Medicine study, 69% of diagnosed depressed patients reported unexplained physical symptoms as their chief compliant1

• 76% of compliant depressed patients with lingering symptoms of depression relapsed within 10 months1*

The importance of emotional and physical symptoms

*Psychiatric inpatients and outpatients.

Reference:1. Adapted from: Paykel ES, et al. Psychol Med. 1995;25:1171-1180.

94% of depressed patients who experienced lingering symptoms had mild to moderate physical symptoms1

Treatments

• Pharmacotherapy• Psychotherapy• Social interventions• ECT• TMS• VNS

Study in chronic depressed patients

*p.05 vs nonresponse. **p.05 vs response.

Miller IW, et al. J Clin Psychiatry. 1998;59(11):608-619.

Normal(n=482)

Remission (n=202)

Response(n=122)

Nonresponse(n=299)

Soci

al A

djus

tmen

t Sca

le-S

R

(Mea

n ±

SD)

***

*

1

2

3

5

Treatment outcome: Effect on work & social functioning

Higher Score indicates greater

impairment

Remitted patients virtually equaled healthy controls on functioning levels at endpoint of 12-week treatment trial

(Responders & non-responders did not)

Statistics

• 60-70% tolerant patients respond to 1st line monotherapy• Up to 50% treated with single

antidepressant don’t reach full remission • 1/3+ become treatment resistant

Available Types of Pharmacotherapy

• Tricyclic antidepressants (TCA)

• MAOI’s• SSRI’s• SNRI’s• Atypical antidepressants• Mood stabilizers• Antipsychotics

But Which Medication?

• Safety • Tolerability• Efficacy• Payment• Simplicity

SSRIs

• Used first because of high tolerability/ low toxicity

• No response from SSRI 1 or 2 (or intolerable)

-What’s the next step? Med switches? Augmentation?

Novel or AtypicalAntidepressants

• Bupropion (NE and DA reuptake inhibition)

• Trazodone (5 HT2 alpha-ANT)

• Venlafaxine and Duloxetine (NE and 5 HT reuptake blockers – SNRI’s)

• Mirtazapine (presynaptic alpha 2 ANT and 5 HT2 and 5 HT3 ANT)

Med Switches

• 1 in 4 patients on SSRI’s have a response on 2nd drug:

• Within class 1st SSRI may be ineffective/

intolerable 2nd SSRI may be effective/

tolerable• Out-of-class• Dual-action agent

Augmentation

• Sustained release bupropion group

• Buspirone group

Similar response and remission rates

BUTBupropion had greater

symptom reduction and tolerability

• Quetiapine in 150 -200 mg dose as adjuvant therapy

Many depressed patients are still depressed.

References:

1. Nierenberg AA, et al. J Clin Psychiatry. 1999:60(suppl 22):7-11.

2. O’Reardon JR, et al. Psychiatr Ann. 1998;28:633-640.

Lynch ME.

3. J Psychiatry Neurosci. 2001;26(1):30-36.

Depressed patients continue to have needs that are not being fully addressed1

• Depressed patients present with emotional and physical symptoms.

• Approximately 30% of depressed patients achieve remission in clinical trials2*

• Up to 70% of patients who respond fail to remit2*

• Incomplete relief from symptoms may increase the risk of relapse2,3

• Lingering emotional and physical symptoms may jeopardize achieving remission.

*In antidepressant clinical drug trials.

Pseudoresistant• Inadequate dosing/ early treatment

discontinuation• Patient noncompliance• Misdiagnosis

General Treatment Rules

• Often takes 4-6 weeks for response• Monitor for response versus remission• Vegetative symptoms tend to improve first,

cognitive symptoms take longer• SSRI’s are the first line of treatment for most

MDD’s• Address biopsychosocial needs and maintain

meds for 6-12 months

Psychotherapy in Depression

• Supportive• Insight-oriented• Interpersonal• Cognitive-behavioral• Psychodynamic• Individual, group or family

Resources & Abilities

___ family support?___ community support?___ social network?___ physical abilities?___ functional abilities?___ cognitive abilities?___ financial resources? ___ personality traits? personal history?___ experiences, beliefs, convictions?

Promote Autonomy

• Create mastery experiences– break tasks into steps– assure success– promote self worth, build

confidence

• Encourage personal control, power– independent activity– decision-making– involvement in care

Focus on Positive

• Current abilities– knowledge, wisdom– experiences– attitudes, beliefs– attributes

• Reminiscence – promotes self worth– strengthens tie to

identify, “former self”– stimulates interests,

conversation

Encourage Group Activities

• Psychosocial therapies– Reminiscence– Remotivation – Health, stress management– Sensory stimulation

• Many benefits– Social interaction– Mastery experiences– Realization “I am not alone in this!

Promote Creativity

• Lots of alternatives:– Singing, playing music– Story-telling– Drawing, painting– Poetry, writing– Making crafts, jewelry

• Associated with positive health outcomes– Decreased depression, loneliness– Increased health, morale, satisfaction, activity

Enhance Social Support

• Identify a “point person” to help identify, mobilize resources– family member– friend, neighbor– church members– clergy– volunteer visitor– peer counselor

Things to Avoid

• Don’t make long-term commitments or important decisions unless necessary

• Don’t assume things are hopeless• Don’t engage in “emotional reasoning” (i.e.: because

I feel awful, my life is terrible)• Don’t assume responsibility for events which are

outside of your control• Don’t avoid treatment as a way of coping

Bipolar Disorder

• People with this type of illness change back and forth between periods of depression and periods of mania (an extreme high).

• Symptoms of mania may include: -Mood changes are usually gradual, but can be sudden -Less need for sleep -Overconfidence -Racing thoughts -Reckless behavior -Increased energy

New Concepts of Bipolar Disorder

• Life-threatening medical illness

• Lifelong medical illness

• Lifelong treatment warranted

• Akiskal asserts at least 50% of depressions are bipolar at some level

Potentially 8 Identifiable Patterns• Bipolar I (Classic Pattern) - 40 – 50 % of episodes are dysphoric

Percentage of dysphoria is much higher in the psychotic condition

• Bipolar II (Sunny) - Recurrent anergic depression with hypomania often on tail end of a depression

• Bipolar II ½ (Dark) - Female preponderance, Panic and social phobia often comorbid, Suicide seems increased, Easily misidentified as Borderline PDO

• Bipolar III (Switch Sensitive Doubles) - Hypomania in response to antidepressant therapy, Often tempermentally dysthymic and may be a “double depressive”

• Bipolar III ½ (Agitated Alcoholism) - Excitement and minor depressions closely linked to alcohol abuse, sometimes in abstinence, Combination treatments useful

• Bipolar IV (Executive) - Depressive episodes overlaying a hyperthymic temperament, males with Type A personality characteristics-“narcissistic” PDO misdiagnosis

• Bipolar V (Borderline Mimic) - High recurrence rate (>5 episodes), Positive family history, Hypomania overlays depression in a “mixed” fashion, Positive family history

• Bipolar VI (Late Onset) - Patients have early dementia, Mood instability, sexual disinhibition, agitation and impulsive behavior, Antidepressants may aggravate symptoms

• Remote history of hypomanic episodes or positive family history may be present (collateral information), May be responsive to divalproate or ACD mood stabilizers,Worsen on antidperesants, Increased importance with dementia/atypical black box

Mania and Hypomania - Questions:

• Have there been times lasting at least a few days when you felt the opposite of depressed, that is when you were very cheerful or high and felt different than your normal self?

• Did you feel hyper, or like you were high on drugs, even though you hadn’t taken anything?

• Did anyone notice there was something different?

• How long did it last?

• What was your self-esteem like?

• During this time did you sleep?

• Were you more talkative than usual?

• Did it feel like your thoughts were going very fast and racing through your mind?

• Were you easily distracted?

• Were you more active than usual?

Bipolar Disorder

• Lifetime prevalence1

– BP I = 1.0%-1.6%– BP II = 0.5%

• 90% recurrence2

• Number of episodes correlates with residual symptoms between episodes and response to treatment2

• 25%-50% of patients attempt suicide2

– 15% suicide rate1

• High comorbidity—eg, substance abuse1

Probably underestimated

1. Evans. J Clin Psychiatry. 2000;61(suppl 13):26.2. Brady. J Clin Psychiatry. 2000;61(suppl 13):32.

5-5 Stahl S M, Essential Psychopharmacology (2000)

DEPRESSION

NORMAL MOOD

MANIA

HYPOMANIA

MIXED EPISODE

Bipolar Depression

• 80% of patients exhibit significant suicidality

• 60% of patients with dysphoric mania exhibit suicidality

• Depressive episodes dominate course of bipolar disorder (twice the amount of time as in mania)

• 25-30% of patients initially diagnosed with unipolar depression subsequently have a manic or hypomanic episode

• 50% of first bipolar episodes are depressive episodes

• Depressive episodes in bipolar disorder are associated with considerable morbidity and mortality

• Bipolar depressive episodes have a chronic course

Goodwin FK and Jamison KR. Manic Depressive Illness

Impact of Bipolar Disorder Vs. Unipolar Disorder — Heavy Impact on Daily Life

48

2629

23

5

54

05

1015

2025

3035

4045

50

Ever Fired or Laid Off Supervisor UnhappyWith Work, Behavior, or

Attitude

Jailed, Arrested, orConvicted of a Crime

Other Than DrunkDriving

MDQ positive

MDQ negative

Calabrese. J Clin Psychiatry. 2003;64:425-432.

Per

cen

t

* P<0.0001

*

*

*

Epidemiology

• 15% to 20% of untreated patients succeed in committing suicide1

• High recurrence rate of bipolar disorder2

• High economic burden2

• Bipolar is a multidimensional disease1,3

1Evans DL. J Clin Psychiatry 2000;61(suppl 13):26-312Woods SW. J Clin Psychiatry 2000;61(suppl 13):38-413Goodwin FK et al. In: Goodwin FK, Jamison KR, eds. Manic-Depressive Illness. New York, NY: Oxford University Press;1990:74-84

Akiskal. J Clin Psychopharmacol. 1996;16(suppl 1):4S-14S.

Predictors of Suicide in Bipolar Disorder

• High Impulsivity• Alcohol and Substance

Abuse • DEPRESSION and MIXED

Episodes• History of Abuse in

Childhood• Exacerbated by incorrect

treatment

Treatment Challenges in Bipolar Disorder

• Often unrecognized• Often untreated • Often misdiagnosed• Often inadequately treated• Exacerbated by incorrect

treatment

BIPOLAR DISORDERThe Major Challenge: Misdiagnosis

NDMDA survey of its bipolar membersRate of misdiagnosis

73%69%

Most frequent misdiagnosis: Unipolar depressionTreatment as unipolar depression can lead to

worsening of symptoms by switching into mania or cycle acceleration

Goodwin & Jamison (1990); Hirschfeld et al (2003); Lish et al (1994)

19942000

Physician Diagnoses Among MDQ Positives in the Community

Dx withbipolar disorder

Dx with depressionbut not bipolar disorder

Neither bipolar disorder nor depression Dx

20%

31%

49%

Hirschfeld RMA, et al. J Clin Psychiatry. 2003;64:53-59.

80% of patients who screened positive for BP were not diagnosed w/ BP

Steps to Increase Recognition of Bipolar Disorder and to Improve Diagnosis

• Education of physicians about the illness, particularly how it presents itself in clinics

• Ask patients directly about history of symptoms of Bipolar Disorder

• Involve family members in clinical evaluations• Increase patients’ and families’ awareness of the illness• Screen for Bipolar Disorder, especially in depressed patients

The Evolution of Therapies for Acute Mania/Hypomania

1950 1960 1970 1980 1990 2000

Chlorpromazine*Trifluoperazine*FluphenazineThioridazineHaloperidolMesoridazine

Anticonvulsants

1940

ECT Lithium*First-generationantipsychotics

RisperidoneClozapine

Anticonvulsants

GabapentinLamotrigineTopiramateOxcarbazepine

Second-generationantipsychotics

Olanzapine*QuetiapineZiprasidone

CarbamazepineValproate*

2002

Next-generationantipsychotics

Aripiprazole

*Approved for use for acute mania.McElroy and Keck. Biol Psychiatry. 2000;48:539.Nemeroff. J Clin Psychiatry. 2000;61(suppl 13):19.

Why are SOME Anticonvulsants Mood Stabilizers?

Valproate, Carbamazepine, Oxazapine, Lamotrigine, Clonazepam

• Reducing glutamate and increasing GABA transmission potentially– Raises the seizure

threshold– Reduces overstimulation– Prevents or inhibits

behavioral sensitization– Prevents or inhibits

kindling• Yet not all anticonvulsants

are mood stabilizers

Other ANTICONVULSANTS

• Gabapentin• Pregabalin• Levetiracetam• Tiagabine• Topiramate

NO PROVEN EFFICACY

Treatments with Evidence for Effective Continuation

Try to use treatments with evidence for relapse prevention in patients who have responded to the drug:

– Lithium

– Divalproex

– Atypicals: olanzapine has best evidence

– Combination of lithium or divalproex with olanzapine or risperidone

Valproate / Divalproex

• Uses– acute mania and maintenance treatment of bipolar

disorder– ? bipolar depression

• Advantages– better tolerability than lithium– can be loaded rapidly– once-a-day formulation available

• Disadvantages– drug-drug interactions– fetal abnormalities

Appropriate Use of Monotherapy

• 30 - 40% of patients succeed on monotherapy

• Complex regimens –Are expensive

–May decrease adherence

–Pose difficulty in elucidating which medications are beneficial and which cause side effects

Bowden CL, et al. JAMA. 1994;271:918-924.

When Monotherapy Is Not Enough• Many patients remain symptomatic on

monotherapy

• After patients are treated with the right dose for an adequate time period, assess symptom response

• Combination therapy may be required– Acute psychosis, bipolar mania, and bipolar depression– Maintenance treatment for full symptom remission

Choosing Treatment• Episode characteristics

– Pure, uncomplicated mania: favorable response to all treatments

– Predictors of poor lithium response:• Severity; psychosis• Mixed/depressive features• Complications

• Past history– Unstable course of illness– History of complications (e.g., head trauma, substance

abuse) predisposes to mixed states

Selection of Treatments

• Start with proven treatments

• Use response predictors

• Identify and monitor target symptoms

• Assure adequate dose and time

• Additional/new treatments based on evidence and feasibility

• Collaborate

Finding the Best Dose

• Establish diagnostic context and target symptoms

• Priorities: is time of the essence?

• Increase dose to maximum that is tolerated

• Evaluate response and toleration– Not improving: tolerating or not?– Improving: if levels feasible, steady-state level as

benchmark

• Primary consideration is how the patient responds, not dose or level

If Patient Response is Inadequate

• Tolerating: increase dose

• Not tolerating or extenuating circumstances– Augment– Reduce dose and augment– Switch to another treatment

• Augmentation– Drug with complementary mechanism– Pharmacokinetically compatible– A drug that you are comfortable giving the patient for at least six

months, or preferably indefinitely

Ch

ang

e F

rom

Ba

selin

e o

f MA

DR

SLamotrigine in Acute Treatment of Bipolar Depression

LTG 50 mg/day (n = 64) LTG 200 mg/day (n = 63) Placebo (n = 65)

Week

0

-5

-10

-15

-20

0 1 2 3 4 5 6 7

* P<0.1; † P<0.05. LOCF = last-observation-carried-forward.Calabrese et al. J Clin Psychiatry. 1999;60:79-88.

Week

0

-5

-10

-15

-20

0 1 2 3 4 5 6 7

LOCF Observed

*

*†

†††

†

†† †

†

†† †

†

Strategy and Time Course

Acute Continuation Maintenance

Sachs et al. J Clin Psychopharm 1996. 16(2suppl1):32s-47s; Tohen et al. Am J Psychiatry 2000. 157:220-228.

0 - 8 weeks 1 - 6 months Indefinite

Syndromal recovery Functional recoveryMaximized function; stability

Maximize mood-stabilizers; adjunctive treatments

Optimize tolerability; taper adjunctive when possible

Optimize; anticipate prodromes

Support/structure; education; involve family

Behavioral; systems; institute monitoring

Strategies to optimize adaptation

Anticipating an Episode

• Prodromes weeks-months before episodes consistent within individuals– Smith & Tarrier. 1992. Soc Psychiat Psychiat Epid 27:245-248.

• Look for early changes in the underlying illness– Motivated activity– Sleep-activity cycle– Impulsivity– Interpersonal behavior– Affect – often is a later indicator

Consequences Of Premature Treatment Discontinuation

Tohen ME, et al. Br J Psychiatry, 2004.

Time to Recurrence of Mania or Depression (days)

Pro

bab

ility

of

Re

ma

inin

g in

R

em

issi

on

(%)

0

20

40

60

80

100

0 100 200 300 400 500

*

Lithium or valproate + olanzapine (n = 30); Li = 0.78, VPA = 69.2Lithium or valproate monotherapy (n = 38); Li = 0.75, VPA = 67.6

*P = 0.023

Subjects had reached remission on combination treatment andwere randomized to have olanzapine withdrawn or continued

Early relapse when part oftreatment was withdrawn

Long-term Antidepressants in Bipolar Disorder

• No evidence for relapse prevention in controlled studies – Ghaemi

• Patients who required antidepressants for an acute episode (15-20% of patients) appeared to benefit from 6-12 months continuation

– Altshuler L et al. Am J Psychiatry 2003(July):160(7):1252-1262.

• Pattern of poor response/loss of response – Sharma et al. J Affect Disord 2005:84:251-257.

• Development of irritable dysphoria during long-term treatment

– El-Mallakh & Karippot. J Affect Disord 2005:84:267-272.

Combinations

• Lithium plus valproate

• Atypical plus lithium/valproate– Risperidone– Olanzapine– Quetiapine– Combination therapy appeared more efficacious, but doses

of mood stabilizer were often inadequate

• Antipsychotic plus valproate– Valproate addition reduced antipsychotic dose and improved

outcome

Valproate Reduces Neuroleptic Requirement in Mania

0

20

40

60

80

100

120

0 5 10 15 20 25Day

Neu

role

ptic

% D

ose

PlaceboValproate

Muller-Oerlinghausen et al. J Clin Psychopharmacology 2000;20:195-203.

Summary of Combination Therapy for Acute Mania in Bipolar Disorder

• Combination therapy is efficacious in treatment of acute mania in bipolar disorder

– Divalproex and lithium– Divalproex or lithium and atypical antipsychotics (risperidone, olanzapine,

quetiapine) – Divalproex or lithium and typical antipsychotics (haloperidol)

• Combination therapy randomized, controlled studies that included lithium and/or divalproex used suboptimal doses, yet demonstrated increased efficaciousness with these agents

• Combination therapy with divalproex could result in lower doses of antipsychotic agent

• Divalproex and lithium are the foundation of bipolar therapy

Switch Rates on Antidepressants

• All antidepressants while on mood stabilizers• High rates of switch (over 10% short term)

– TCA’s, venlafaxine, MAOI’s• Low rates of switch (under 10% short term)

– Bupropion, SSRIs• Much higher if not on a mood stabilized

• Paroxetine is the most well studied: three double blind studies

• All add-on• All double blind against placebo, imipramine,

venlafaxine, and combined lithium and divalproexYoung et al., Am J Psychiatry 2002; Nemeroff et al., Am J Psychiatry 2001; Vieta et al., J Clin Psychiatry 2002

ON THE OTHER HANDDepression Following Antidepressant Discontinuation in Bipolar Patients

(Chart Review)

Weeks After Improvement

% W

ell (

Not

Dep

ress

ed)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 13 26 39 52

Discontinued Antidepressant n=25

Continued Antidepressant n=19

Altshuler et al., J Clin Psychiatry, 2001; 62:612-616.

Goodwin FK, Jamison KR. Manic-Depressive Illness. New York, Oxford University Press, 1990; Tohen M, et al. Am J Psychiatry 1992.

Psychosis Is Common in Bipolar Disorder

• Two-thirds of patients have at least 1 psychotic symptom.

• All forms of psychosis, including mood-incongruent, bizarre, Schneiderian first-rank symptoms, formal thought disorder, and catatonia may occur in Bipolar I disorder.

Swann AC. 2000; Corruble E, et al. J Affect Disord 1999; Greil W, et al. J Clin Psychopharmacol 1998; Bowden CL. Neuropsychopharmacology 1998; Vestergaard P, Aagaard J. J Affect Disord 1991.

Strategies for Reducing Suicidal Risk

• Prevent episodes, especially depressive, mixed (Swann 2000)• Reduce impulsivity and substance abuse (Corruble 1999)• Lithium more effective than carbamazepine in treating classical

bipolar cases (Greil 1998)• Lithium, divalproex equally effective in pure manic patients;

divalproex more effective than lithium in patients with mixed mania or psychotic symptoms in only controlled study (Bowden 1998)

• Provide structured, supportive therapeutic relationship (Vestergaard 1991)

APA Practice Guidelines for the Treatment of Patients With Bipolar Disorder

• Medication with the best evidence for maintenance– Lithium and valproate– Alternatives include lamotrigine or

carbamazepine or oxcarbazepine– Maintenance ECT may also be

considered

• Antipsychotics should be discontinued unless required for persistent psychosis or prophylaxis against recurrence

• While maintenance with atypical antipsychotics may be considered, no definitive evidence comparable to lithium or valproate

• Likely benefit from concomitant psychosocial intervention – Psychotherapy to address illness

management (adherence, lifestyle changes, early detection of prodromal symptoms) and interpersonal difficulties

• Group therapy may also address adherence, adaptation, self-esteem, and personal and psychosocial issues

• Support groups provide useful information about bipolar disorder and its treatment

American Psychiatric Association. Am J Psychiatry. 2002;159(Suppl 4):1-50.

Maintenance Treatment

Summary

• Maximize standard mood stabilizers, including combination.

• Utilize anxiolytic/hypnotics, atypical neuroleptics, and novel anticonvulsants as mood stabilizers to adjunctive therapy.

• Brief, acute intermittent antidepressant treatment.

• Address psychoeducational needs.

The “Big 5” Personality Traits Openness to experience (v. premature closures) Conscientiousness (v. irresponsibility) Extraversion (v. introversion) Agreeableness (v. uncooperativeness) Neuroticism (v. a healthy world view and positive adjustments)

personality disorders represent extreme variations of OCEAN

Main Features of PDs• Extreme patterns of thinking, feeling, and behaving that

deviate from a person’s culture• Listed on Axis II of the DSM-IV-TR• Begin early in life and remain stable• Not contextual or transient, Little behavior change over

time • Inflexible and maladaptive, Effects behavior in many

situations• Cause significant functional impairment and subjective

distress • Ego-syntonic vs. ego-dystonic • Causes distress in others due to dysfunctional theory of

mind• Onset usually late childhood, early adolescence• Pathological uncooperativeness, Poor insight

What are they?

Personality Disorders require 3 overarching characteristics:

Personality Disorder

- Inflexible patterns of behavior (maladaptive)

- Begins early in adulthood (lifelong)

- Results in social, occupational problems or distress (pervasive)

Cluster AOdd, Eccentric

Cluster BAngry

Cluster CAnxious

Cluster A Personality DisordersParanoid, schizoid, and schizotypal personality

disorders

Marked by eccentricity, odd behavior, not psychosis

Share a superficial similarity with schizophrenia (as if a milder version)

Cluster C Personality Disorders

Avoidant, obsessive-compulsive, dependent disorders

Individuals are often anxious, fearful, and depressed

Cluster B Personality DisordersAntisocial, borderline, histrionic, and

narcissistic personality disorders

Being self-absorbed, prone to exaggerate importance of events

Having difficulty maintaining close relationships

Poor capacity to engage in ongoing cooperative relationships

Primary Cluster B Personality Disorders

• Borderline 56%• NOS 22%• Narcissistic 14%• Antisocial 7%• Histrionic 1%

“Borderline Personality Organization” - Kernberg

John Gunderson, MD

• Psychotic Borderline• The Borderline Syndrome• The As – If Borderline• The Neurotic Borderline

Grinker, Werble and Drye, 1968

BORDERLINE PDUnstable Relationships, Affect Disturbance, Dysfunctional Self-Image Plus Impulsiveness

AND 5 + of :

• Fears Abandonment• Mood Shifts (Affective

Instability, hours, even minutes)

• Unstable RelationshipsFeels Empty

• Changing Self-Image

• Impulsive Sex, Spending

• Identity disturbances

• Recurrent suicidal or self-mutilating behavior

• Feelings of emptiness

• Inappropriate intense anger

• Transient paranoia or dissociation

• Paranoia

Borderline and comorbidity

• High degree of overlap with both Axis I and Axis II disorders

• 24%-74% also diagnosed with major depression; 4% to 20% bipolar

• 25% of bulimics also diagnosed with BPD• 67% also diagnosed with substance use

disorder

Splitting

A primitive defense. Negative and positive impulses are split off and unintegrated. Fundamental example: An individual views other people as either innately good or innately evil, rather than as a whole continuous person.

* Tellin’ a man to go to hell and makin’ him do it are two entirely different propositions

Acting OutActing Out is performing an extreme behavior in order to

express thoughts or feelings the person feels incapable of otherwise expressing. Instead of saying, “I’m angry with you,” a person who acts out may instead throw a book at the person, or punch a hole through a wall. When a person acts out, it can act as a pressure release, and often helps the individual feel calmer and peaceful once again. For instance, a child’s temper tantrum is a form of acting out when he or she doesn’t get his or her way with a parent. Self-injury may also be a form of acting-out, expressing in physical pain what one cannot stand to feel emotionally.

Projective IdentificationProjective Identification refers to a psychological process in which a

person engages in the ego defense mechanism projection in such a way that their behavior towards the object of projection invokes in that person precisely the thoughts, feelings or behaviors projected.

Projective identification differs from simple projection in that projective identification is a self-fulfilling prophecy, whereby a person, believing something false about another, relates to that other person in such a way that the other person alters their behavior to make the belief true. The second person is influenced by the projection and begins to behave as though he or she is in fact actually characterized by the projected thoughts or beliefs. This is a process that generally happens outside the awareness of both parties involved, though this has been debated.

So…When you give a lesson in meanness to a critter or a person, don’t be surprised if they learn their lesson.

Reducing Suicide Risk

• Use medicines that reduce recurrence and impulsivity

• Work for early recognition of risky internal states and of early signs of recurrence

• Dialectical Behavior Therapy

• Foster a forward-looking approach– Social structure and contact– Sequential, attainable goals– Constructive anticipation of changes and problems– Responsibility for health and decisions– Encourage mindfulness of behavior– Construct and observe careful and appropriate boundaries

TRUE FALSE

Suicide in Older Adults

• Represent 13% of the population

• Account for 1/5 (20%) of all reported suicides

• Lowest rate of ATTEMPTS• Highest rate of COMPLETED SUICIDE

Indirect Suicide• Starvation, refusing

to eat• Refusing needed

medications• Mixing medications• Alcohol abuse• Loss of “will to live”

Poor OutcomesComorbid Conditions• Anxiety• Medical problems• Cognitive impairmentConcurrent Problems & Issues• Psychotic depression• Impaired social support• Stressful life events • Multiple previous episodes

Incidence of Post Stroke Depression

• Approximately 1/3 of persons will experience clinically significant depression at some point following a stroke. Hacket, et al., 2005

• Robinson found that 19.3% and 18.5% of stroke survivors had major depression or minor depression, respectively, in acute care rehabilitation settings. Robinson, RB, 2003

• No significant difference in incidence between hemorrhagic and infarct strokes

Distinguishing types of crying:

• Pathological crying linked to infarct in basis of pontis and corticobulbar pathways and occurs in response to mood incongruent cues.

• Emotionalism is crying that is congruent with mood (sadness) but patient is unable to control crying as they would have before stroke.

• Catastrophic reaction is crying or withdrawal reaction triggered by a task made difficult or impossible by a neurologic deficit (e.g. moving a hemiplegic arm)

LONG TERM CONSEQUENCES OF POSTPARTUM MAJOR DEPRESSION

• Babies of mothers with PMD were perceived by their mothers as more difficult to care for and more bothersome.

Postpartum Blues

• Often viewed as “normal”

• Affects 40 to 85% of new mothers

• Peaks between postpartum days 3 and 5

• Resolves within 24 to 72 hours

• Subsides without treatment by postpartum day 14

• Symptoms:– Sadness, anxiety, irritability

– Uncontrollable tearfulness

– Wide mood swings

– Occasional negative thoughts

• Primary Treatment:– Supportive care and

reassurance about the condition

Postpartum Depression

• Difficulty concentrating or making decisions

• Psychomotor agitation or retardation

• Fatigue

• Changes in appetite and/or sleep patterns

• Recurrent thoughts of death or suicide

• Feelings of worthlessness or guilt (especially focusing on failure at motherhood)

• Excessive anxiety

• Frequently focusing on the child’s health

Postpartum Psychosis

Rare condition, affecting 1 to 2 out of 1000 women after childbirth

Presentation can be dramatic

• Early Symptoms– Restlessness– Irritability– Sleep disturbance

Onset as early as 48 to 72 hours postpartum

Symptoms develop within the first 2 weeks after delivery

• Progressive Symptoms– Depressed or elated

mood – Disorganized behavior– Mood swings/

instability– Delusions– Hallucinations

Suicide Assessment

Always ASK!!!“Have you thought that life isn’t worth living?”

If YES, then . . .“Have you thought about harming yourself?

If YES, then . . . “Do you have a plan?”

If YES, examine lethality. . .Is the plan viable? Can they execute it?

Are means deadly, available?

References• Blais MA, Smallwood P, Groves JE, Rivas-Vazquez RA.

Personality and personality disorders. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier;2008:chap 39.

• Borderline Personality Disorder Demystified by Robert O. Friedel, M.D., Marlowe & Co., 2004

• National Education Alliance for Borderline Personality Disorder’s Teachers Manual for Family Connections, 2006

• A BPD Brief, An Introduction to Borderline Personality Disorder by John G. Gunderson, M.D., 2006

• A REMINDER for assessing psychosis- John Hendrick, MD- CURRENT PSYCHIATRY April 2010 Volume 9, No. 4