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Bipolar Disorder

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Manic Episode

A distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least one week and including at least three of the following:

• inflated self-esteem or grandiosity• decreased need for sleep• pressure of speech• flight of ideas (thoughts racing one after another)• distractibility• increase in goal-directed activity or psychomotor agitation• excessive involvement in pleasurable activities with potential for negative consequences

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Hypomanic Episode

less severe symptoms shorter duration (4 days) no suicidal ideas

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Features Associated with Hypomania

• vividness of sensory perceptions• increased activation of associational networks• clarity of thought • facility for rhyming and alliteration• seemingly unbounded energy and enthusiasm• feelings of wellbeing and expectation • increased personal charisma• sexual attractiveness• dramatic gestures and vocalizations• feelings of oneness with the universe• feelings of invincibility• may rapidly change from magnanimous to angry

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Mixed Episode

Criteria for both mania and depression are met in the same episode (lasting at least one week)

May evolve out of either a manic or a depressive episode or may arise de novo

Usually includes agitation, insomnia, appetite dysregulation, psychotic features, and suicidal thinking

Often requires hospitalization

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Bipolar I Disorder• manic episodes or mixed episodes • usually includes depression

Bipolar II Disorder• hypomanic episodes alternating with depressive episodes

Rapid Cycling

• at least four episodes of mood disturbance within 12 months• more common in women (70-90% rapid cyclers are women)

(Bipolar sufferers typically have 8-12 mood disturbances over lifetime)

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Two Possible Subtypes

Paranoid/Destructive

Euphoric/Grandiose

Primarily mixed episodes cycling with depression

Primarily manic episodes cycling with depression

“Black” mania

“White” mania

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Bipolar Disorder

• episodes tend to come closer together over time

• typical age of onset is 18-22 but can occur at any time

• childhood onset may involve hyperactivity, temper tantrums, hypersexuality

• on average it takes people with bipolar disorder 8 years to get proper diagnosis

Etiology of Bipolar Disorder

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Genetics and Bipolar DisorderFamily Studies

• 1st degree relative of bipolar proband more likely to have either bipolar or unipolar depression

Twin Studies• MZ concordance = 69%, DZ concordance = 19%

• Offspring of twins discordant for bipolar (Bertelson & Gottesman, 1986)

MZ

affected unaffected21% BP 25%BP

DZ

affected unaffected14% BP 2%BP

• genetic contribution to mania and depression may be separate (McGuffin et al., 2003)

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Adoption Studies

• higher rate of affective disorder (both Bipolar (24%) and unipolar (12%) in bio parents of probands vs adoptive parents

Conclusion: There is a very strong genetic component in bipolar disorder

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Etiology of Bipolar Disorder

1) neurotransmitter dysregulation

2) Calcium channel abnormalities

3) G-protein abnormalities

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Possible Triggers for Manic Episodes

• seasonal (summer)

• sleep deprivation

• circadian rhythm changes (travel, etc)

• bright light therapy

• antidepressant medication

• stimulant drugs

• thyroid gland dysfunction

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Treatments for Bipolar Disorder

Mood Stabilizers

• lithium

• valproate (Depakote)

• carbemazepine (Tegretol)• aripiprazole (Abilify)

Neuroleptics (e.g., haldol) when psychotic symptoms are present Olanzepine (tolerated well for mania)

Antidepressants ((Wellbutrin) in conjunction with lithium)

Omega-3 fatty acids

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Treatments for Bipolar Disorder

Cognitive Behavioral Therapy

compliance with medication protocol

damage control

fear of future episodes

self esteem

family education

Psychosocial factors may contribute 25-30% of outcome variance in BD

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Bipolar Disorder is a lifetime disease.

There is no cure.

The risk for suicide is great.

In order to survive, those with Bipolar must

remain on unpleasant medications.

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Mania has… “brought into my life a different level of sensing and feeling and thinking. Even when I have been most psychotic - delusional, hallucinating, frenzied - I have been aware of finding new corners in my mind and heart. Some of those corners were incredible and beautiful and took my breath away and made mefeel as though I could die right then and the images would sustain me. Some of them were grotesque and ugly and I never wanted to know they were there or to see them again. But, always, there were those new corners...I cannot imagine becoming jaded to life, because I know of those limitless corners, with their limitless views.”

Kay Redfield Jamison An Unquiet Mind

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Are individuals like Kay Jamison “romanticizing”a deadly disorder that bring untold misery to bothpatients and their families?

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Suicide

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• More than 30,000 Americans complete suicide each year (1 every 20 minutes)

• 400,000 uncompleted attempts per year

• 80% of these are related to an affective disorder

• Suicide rate for 15-24 year olds has tripled since 1950

• Common methods: (in order of frequency) • handguns• drug overdose •cutting/stabbing

Suicide - Some Numbers...

• jumping • inhalation • hanging • drowning

• according to Jamison (1999), for men and women (15-44) worldwide:• suicide is 2nd most frequent cause of death for women• suiced is 4th most frequent cause of death for men

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Suicide with Different Motives(Schneidman, 1963, 1981, 1993)

• Death seekers• clearly and explicitly seek to end their lives• planful • impulsive

• Death initiators• clear intention to die but are hastening the inevitable• with fatal illness or AIDS

• Death ignorers• intend to end life to go to a “better place”• mass suicides of cults• suicide bombers

• Death darers• ambivalent about dying, may enjoy thrill of risk• Russian Roulette or take pills then call a friend

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Risk Factors

• Mood disorder• Schizophrenia• Alcoholism• Prior attempt(s) (increases risk 1,500 x)• Use of lethal method (gun or hanging)• Social isolation, rejection• Hopelessness• Older white male• Modeling• Work problems, unemployment• Marital, sexual problems• Negative life event• Anger, impulsivity• Physical illness

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Protective Factors

• Large social network• Marriage• Calm mood state• Happy mood state•High ego strength• High self-esteem• Religious beliefs

from National Strategy for Suicide Prevention: Goals and Objectives for Action (2001)

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Signs to Watch for

• sudden change in mood• life event that would be considered very stressful• change in eating or sleeping patterns• quits going to classes or out with friends• gives away things that are personally meaningful• talks about death or suicide• talks about celebs that you know have committed suicide• washes far more frequently than usual• expresses excessive guilt• increases use of substances• talks of loneliness, rejection, or alienation

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• Take your friend or family member seriously.

• Don’t promise confidentiality.

• Involve other people.

• Contact MH professionals working with the person.

• Listen attentively.

• Express your concern.

• Ask direct questions about suicidal intentions.

• Acknowledge the person’s feelings.

• Reassure them that things will become better.  Suicide is a permanent solution to a temporary problem.

• If possible, don’t leave the person alone until the person is safe.

guidelines from the National Depressive and Manic Depressive Association

When a friend is suicidal