bipolar disorders (manic depressive illness) larry labbate, m.d
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Bipolar Disorders(Manic Depressive Illness)
Larry Labbate, M.D.
Mania sometimes brings Euphoria
All Things Possible
What is bipolar disorder?
• Cyclic mood disorder
• Extremes of euphoria and depression during episodes
• Mania and depression
• May include psychosis, paranoia, hallucinations
• Suicide common (>10%)
• Alcohol and drug addiction common (50%)
Mania Descriptions
• “When you’re high it’s tremendous”
• “The ideas and feelings are fast and frequent like shooting stars.”
• “Sensuality is pervasive. Shyness goes”
• “I bounce checks, think I can do anything, get wild ideas.”
• “When will it happen again?”
Mania Descriptions
• “Too much of everything is just enough”
• “Rock music played far too loud is what satisfies”
• “Emotions tear me apart. I can laugh and cry at the same time”
Mania Descriptions
• “A feeling of intimate personal relationship with God is perhaps its paramount feature”
• “I was God!”
• “I could find the cure for cancer.”
Language Changes in Mania
• Puns and Rhymes common:
• “God is a Herbivore/ Thyme passes/ Mixed with long grasses of herbs in the field/
Rosemary weeps into meadow sweeps”
Depression in Bipolar
• “My life is in ruins. Look what I did when I was manic”
• “I just want to be in bed all the time”
• “I can’t do anything”
• “I just want to be by myself and cry”
• “What is the use of this life”
Recurrent Illness
• Long lived illness that often starts in 20s
• May start any time in life span
• .5% - 1% population; milder forms more common?
• Most have depression and mania, 10% pure mania (one manic episode buys the diagnosis)
• Episodes come more frequently over time
Kindling
• Seizure model: low level electrical impulses start with no effect, then seizures in response to same impulse. Eventually spontaneous seizures follow without impulse.
• Bipolar first related to environmental changes, loss, stress, drugs, sleep deprivation
• Ultimately: autonomous cycling
Manic Symptoms - DSM IV• Inflated self esteem • Decreased need for sleep• Distractibility• Pressured/rapid speech• Flight of ideas or racing thoughts• Increased goal directed behavior• Excessive involvement in pleasurable activities (sex,
cars, money) that may have painful results.
Soft signs of mania
• Large hats on men
• Multiple rings on men
• Excessive visible cleavage on women or exposed chest on men
• Public nudity
• Public masturbation
Thought disorder: mania vs schizophrenia
• May appear to have schizophrenia because of prominent delusions or hallucinations and thought disorder
• Thoughts often disorganized, abundant, elaborate, and sometimes playful
• Schizophrenia thoughts more bland, fragmented, bizarre with affect less intense
Illness Affects Many
• Family and friends
• Work disrupted
• Legal system involved
Bipolar Disorder Types
• Bipolar I - Manic episode, with or without an episode of major depression.
• Bipolar II - Major depression & hypomania (hypo means below)
Bipolar diagnosis
• One episode of mania gets the diagnosis of Bipolar 1 because 90% go on to have depression
• Only called Bipolar II if you have hypomania and another episode of major depression
• Some have “mixed episodes” with depression and mania at the same time
Bipolar Spectrum
Bipolar Epidemiology
• Lifetime prevalence (adults)– Bipolar I 1 %
– Bipolar II 1 %
– (May be underestimates)
• Age of onset– Mean age 21 years
– Peak age 15-19 years
• Gender– Bipolar I male =
female
– Bipolar II female > male
Model of Evolution of Bipolar Course
Modified from: Post RM, Rubinow DR, Ballenger JC. Conditioning and sensitization in the longitudinal course of affective illness. Br J Psychiatry. 1986;149:191-201
Range of Illness
• Some patients may do very well between episodes: true cycles
• Mild mania (hypomania) may be helpful in work• Many have residual signs/symptoms of illness• Psychotic mania predicts poor outcome
Range of Illness
• Depression is commonly chronic
• Sometimes looks like schizophrenia (e.g. with prominent psychotic signs) in acute mania
• Substance abuse worsens course
• Suicide in 15%
Secondary Mania
• Mania due to… or substance induce mood disorder
• Early onset mania is usually idiopathic bipolar
• Onset of mania after 40 is often related to some medical cause – drugs (dopamine agonists – cocaine, antidepresants, amphetamine; steroids – anabolic or glucocorticoids; brain trauma, HIV, stroke, multiple sclerosis, epilepsy, brain tumor)
Mania precipitants
• Post-partum state• Sleep deprivation• Dopamine agonist drugs (amphet/L-Dopa)• Antidepressants• Stroke or brain injury• Jet lag; especially West to East• Severe life stress
Hypomania vs. Mania
• Hypo (below)
• Less intense form of mania – not hospitalized
• Paranoia, delusions, hallucinations, need for hospitalization = mania
• Hypomania may be effective (in business)
• Hypomanic patients diagnosed Bipolar II
Insight
• Patients are often unaware in mania
• Feels too good to be an illness
• Family, friends, legal system, bring them to attention
• False positives on retrospective questions (“yeah I had periods of feeling good, didn’t sleep”)
Course of Bipolar
• Most people who experience mania will have a recurrence and have depressive episodes
• Up to 40% may experience a mixed state or dysphoric mania (both mania and major depression simultaneously).
• 10-15% develop Rapid Cycling, defined as 4 or more mood episodes/year.
Course of Bipolar
• Mania or depression may last for 4-8 months and remit spontaneously
• May go from mania directly into depression or vice-versa
• May go for years without episodes
• Depressions usually more common than manias
• Depression may be chronic, last years
Bipolar Disorder Symptoms AreChronic and Predominantly Depressive
53%32%
9%6%
Asymptomatic
Depressed
Manic/hypomanic
Cycling/mixed
% of Weeks
146 bipolar I patientsfollowed 12.8 years
86 bipolar II patientsfollowed 13.4 years
46%*50%
1% 2%
Judd LL, et al. Arch Gen Psychiatry. 2002;59:530-537.Judd LL, et al. Arch Gen Psychiatry. 2003;60:261-269. *%s do not add to 100 due to rounding
Bipolar Depression
• Often have “atypical depression”
• Excessive sleeping
• Increased eating
• Suicide risk
• Teen atypical depression may be first sign of bipolar disorder
Bipolar Depression
• Early teen onset depression may mark start of bipolar disorder
• Often “atypical” features (increased sleeping, increased eating)
• May be seasonal (winter depressions)
• May have psychosis (hearing voices, delusions)
Bipolar Depression
• Suicide happens in this phase
• Hypothyroidism may result from Li+ use
• Hypothyroid symptoms similar to depression
• Alcohol use may start during depressed phase
Bipolar Depression
• Most patients have more depression than mania
• Depression often more debilitating
• Treatment more difficult for depression
• Antidepressant treatment tightrope
Cyclothymia
• For at least 2 years, the presence of hypomania and numerous periods of depressive symptoms that do not meet criteria for major depression.
• Results in distress or functional impairment.
• A chronic, smoldering form of bipolar illness.
Addiction and Bipolar
• Drug or alcohol addiction are common (>50%)
• Ethanol or benzodiazepines may slow the high. ?brain structures underlying addiction and mania linked?
• Cocaine or amphetamine intoxication may mimic mania; patients may seek the intoxicating manic rush
• Crash from stimulants looks like depression
Addiction and Bipolar
• Some patients not diagnosed until they “dry out”
• Need to treat addiction and mood disorder
• Patients often harder to treat because the drug “payoff” is greater in those with bipolar
Living with Bipolar
• When is the next episode coming?
• Is what I’m feeling normal or part of my illness?
Le Joie de Vivre
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