Bipolar Disorder. Manic Episode

Bipolar Disorder

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

Hypomanic Episode

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

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

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

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)

Two Possible Subtypes

Paranoid/Destructive

Euphoric/Grandiose

Primarily mixed episodes cycling with depression

Primarily manic episodes cycling with depression “Black” mania

“White” mania

•Bipolar III cyclothymia

•Bipolar IV antidepressant-induced hypomania

•Bipolar V the individual meets the diagnostic criteria for major depression and there is a family history of Bipolar Disorder •Bipolar VI the individual meets diagnostic criteria for manic

episodes, but not any of the depressive conditions Leslie E. Packer, PhD, 2006

Additional Subtypes of Bipolar

(Not Recognized by DSM IV)

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

Genetics and Bipolar Disorder

Family 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 unaffected 21% BP 25%BP DZ affected unaffected 14% BP 2%BP 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

• hyperintensities in periventricular areas (in white matter)

• abnormalities in basal ganglia involving dopamine transmission

• higher glucose metabolism in basal ganglia

• abnormalities in left (DLPFC) involving glutamate

• increased number of G-proteins in untreated patients

Bipolar Disorder

Etiology of Bipolar Disorder

1) neurotransmitter dysregulation 2) Calcium channel abnormalities 3) G-protein abnormalities

Possible Triggers for Manic Episodes

• seasonal (summer) • sleep deprivation

• circadian rhythm changes (travel, etc) • bright light therapy

• antidepressant medication • stimulant drugs

• thyroid gland dysfunction

Treatments for Bipolar Disorder

• lithium

• valproate (Depakote) • carbemazepine (Tegretol)

Neuroleptics (e.g., haldol) when psychotic symptoms are present

Antidepressants (in conjunction with lithium)

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

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.

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 me feel 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.”

Suicide

• 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

Suicide with Different Motives

• 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

Suicide by cop Forced suicide Copycat suicide Internet suicide Suicide pact Mass suicide Cult suicide Ritual suicide Suicide bombing Murder-suicide Euthanasia / Assisted suicide

Types of suicide

Risk Factors

• 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

How about SSRIs?

Protective Factors

• Large social network • Marriage

• Calm mood state • Happy mood state • Social supports • Father’s sociability • Mother’s sociability • Mother’s acceptance • High ego strength • High self-esteem • Religiosity

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

• 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 (1996)