1 adult bipolar disorder anthony norelli, m.d. northwestern mutual wahlu presentation 4/16/15

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  • 1 Adult Bipolar Disorder Anthony Norelli, M.D. Northwestern Mutual WAHLU Presentation 4/16/15
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  • 2 Goals Visit history of BPD Address epidemiology of BPD Briefly address diagnostic criteria Address why BPD is so difficult to diagnose Address why BPD is so difficult to treat Address what is in the underwriters armamentarium Time for Q&A
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  • 3 BPD History Earliest mentions of BPD symptoms are found in Egyptian Papyri dating to approximately 2000 B.C. Aretaeus of Cappadocia (practiced somewhere between 70-150 A.D.?) Gave early descriptions of diabetes, asthma, tetanus, diphtheria, and epilepsy among others. Also identified mania and depression as two separate forms found within the same illness.
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  • 4 Cappadocia? (=Anatolia)
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  • 6 Aretaeus of Cappadocia Aretaeus described a group of patients who laugh, play, dance night and day, and sometimes go openly to the market crowned, as if victors in some contest of skill only to be torpid, dull, and sorrowful at other times. Though he suggested that both patterns of behavior resulted from one and the same disorder, this idea did not gain currency until the modern era (e.g. mid-19 th century)
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  • 7 Ancient Greece/Rome Forward Mania and Melancholy Lithium baths were thought to be helpful 300-500 A.D. manic individuals thought to be possessed, were executed 500-1600 equally crummy care Burton, 1621 Anatomy of Melancholy Baillarger, Falret 1854: folie a double forme, folie circulaire
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  • 8 20 th Century Emil Kraeplin a. Broke with Freud (e.g. societal cause of mental illness) b. Studied course of illness: delineated between dmence prcoce (dementia praecox; aka schizophrenia) and manic-depressive psychosis c. DSM-V suggests Kraeplin had the right idea, and took BPD out of the mood disorders chapter and gave it its own chapter between mood disorders and psychosis.
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  • 9 20 th Century Treatment: lobotomy, ECT, etc. Dr. John Cade Guinea pig experiments led to 1949 paper on Lithium Salts fear of excess toxicity led to Lithium being banned in the US until 1970. 1950s-60s BPD felt to be less stigmatizing than manic- depressive psychosis
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  • 10 BPD Fiction Some have maintained that BPD is strictly a construct of Western Medicine, or even a celebrity fashion statement. Just how Western is Cappadocia?, or Ancient Egypt? Remember, these areas were trade centers back in that time, where people exchanged not only good but also ideas. 1583: Gao Lian published his Eight Treatises on the Nurturing of Life which discusses BPD-type symptoms (in detail) over centuries in his native China.
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  • 11 BPD Nonfiction A number of well-known individuals have admitted to having BPD (and others were outed by confidants). A short list includes: Ernest Hemingway, Marilyn Monroe, Britney Spears, Robert Schumann, Mel Gibson, Vivian Leigh, Jim Carey, Rosemary Clooney, Russell Brand, Ted Turner, Demi Lovato, Dick Cavett, Patricia Cornwell, Edward Elgar, Brian Wilson, Kurt Cobain, Robin Williams, and many more.
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  • 12 Sylvia Plath Its as if my life was run by two electric currents: joyous positive and despairing negative whichever is running at the moment dominates my life, floods it.
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  • 13 BPD and Creativity It has been suggested that many of the renowned artists in history (think composers, painters, sculptors, etc.) were bipolar Some have asked if the availability of medication to control BPD has actually decreased overall creativity Is there an evolutionary advantage of BPD?
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  • 14 BPD Epidemiology Prevalence estimates range from 1% to 4.5% (can rise to 10% depending upon inclusion criteria). Closer to 4% is likely most accurate. Overall prevalence is equal in males and females. However: a. Women tend to have more depressive presentations b. Women tend to have more rapid cycling (3:1 ratio) c. Men tend to have more psychosis (e.g. schizophrenia) d. So when misdiagnosed, guess what the misdiagnoses are
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  • 15 BPD Epidemiology Average age of onset is 25 a. Usual is later teens to early 20s b. From teens through 5 th decade is considered more typical c. Pre-pubertal onset portends more aggressive course, and likely at least 1 parent with BPD d. Onset 50s think underlying systemic disease first, and psych disorder second
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  • 16 BPD Heritability Falret recognized that BPD seemed to run in families, and felt it was thus heritable A number of genes have been isolated that contribute to BPD development but none make development of BPD a given (e.g. ANK3, which codes for ankyrin, has strongest correlation of any gene with BPD determines synaptic behavior) 1 parent with BPD confers 15-30% chance for their offspring to have BPD 2 parents with BPD confers 50-75% chance for their offspring to have BPD
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  • 17 BPD Heritability Twin studies: Historically flawed and small One often-quoted study out of Denmark showed the following: Probandwise Concordance Rate Bipolar-BipolarMonozygotic Twins Dizygotic Twins 62% 8% Bipolar- Bipolar/Unipolar 79% 19%
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  • 18 BPD Triggers So if genetics helps load the gun, what helps pull the trigger? a. Stressful life events (good or bad): loss of job, birth of baby, promotion, etc. b. Disruption of sleep patterns chronic sleep deprivation could theoretically lead to mania or hypomania; chronic excess sleep could lead to depression c. Disruption to routine studies have shown those who have regular sleep/wake schedules are less likely to develop (or have recurrence of) BPD d. Excess external stimulation clutter, traffic, noise, light, crowds, work deadlines, social activities
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  • 19 BPD Triggers Continued So if genetics helps load the gun, what helps pull the trigger? e. Too much internal stimulation overstimulation from excessive activity/excitement while trying to achieve challenging goals, or ingesting stimulants (caffeine, nicotine) f. AODA can trigger BPD; BPD patients are also more likely to abuse AODA g. Excessive conflict/stress think PTSD h. Untreated/undiagnosed medical illness
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  • 20 BPD Numbers According to WHO, BPD is the #6 cause of disability in the world BPD estimated cost to US economy $75 Billion in 2008 BPD diagnosis translates to an average decrease of estimated lifespan by 9.2 years: a. Treated appropriately, BPD mortality approaches general population mortality b. 2007 study (Goodwin and Jamison) found untreated BPD mortality was 230% greater than general population Up to 20% of those with BPD complete suicide
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  • 21 BPD Definition There are 4 main types of BPD: a. Bipolar Type I (BPI) b. Bipolar Type II (BPII) greatest association with suicide risk c. Cyclothymia about 15% have rapid cycling d. Bipolar disorder with atypia Please also see handouts for DSM-V definitions
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  • 23 Why BPD is so Challenging The definitions! BPI does not require a depressive episode BPII does not require a manic episode (and good luck nailing that hypomanic thingy) Cyclothymia symptoms present >2 years and hypomania/depression has persisted for at least 1 year, and not more than 2 months have gone by without symptoms (and spouse has not tried to air mail patient to Siberia in their sleep)
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  • 24 BPD Points Worth Noting Typical BPD patient averages 8-10 manic or depressive episodes over a lifetime, though some may have many more or fewer episodes Even when optimally treated, the BPD symptoms may wax and wane significantly BPD diagnoses can change (i.e. patients with one type of bipolar diagnosis and go on to develop another, different bipolar diagnosis due to change in symptoms which is another reason some experts believe different types of BPD are actually distinct from each other) BPD is a lifelong disorder, but in any given year up to half of BPD patients may be off treatment (their choice, not the MDs).
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  • 25 BPD Screening Screening tests for BPD include: a. Depression any of the validated depression screening tests: Hamilton, Beck, PHQ-9, Major Depression Inventory, Zung scale, etc.) b. Mania either of i. Mood Disorder Questionnaire (MDQ) 13 questions ii. (WHO) Composite International Diagnostic Interview (aka CIDI 3.0) 12 questions
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  • 26 BPD Screening; A Few Parting Thoughts Screening for and treating depression and/or anxiety can be adequately performed in a primary care setting Screening for BPD can be adequately performed in a primary care setting However, confirmation of BPD diagnosis and formal BPD treatment should be the province of a specialist (psychiatrist and allied health professionals). Once an individual has been appropriately diagnosed and is stable on treatment it is not unreasonable for much of the maintenance care to happen in a primary care setting (med refills, blood testing, etc.) but the psych experts should stay involved at some level.
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  • 27 BPD Screening and Underwriting So, if the medical records indicate that screening tests were done especially the MDQ or CIDI 3.0 and the screen was determined to be positive, it is hard to argue with the diagnosis of BPD. If