BIPOLAR DISORDER

4/4/14 BIPOLAR DISORDER
Jason Tentinger PA-C
1. Bipolar I Disorder
2. Bipolar II Disorder
3. Bipolar vs Unipolar Depression
4. Cyclothymic Disorder
5. Treatment
Epidemiology
•  Affects around 1% of the population
•  Equal in men and women
•  Manic episodes are more frequent in men
•  Major depressive episodes more frequent in women
BIPOLAR I DISORDER
•  Mean age of onset is 18
•  Can happen anytime from adolescence to 50 or older
•  Higher than average incidence in higher socioeconomic
groups
•  Biggest risk factor is family history
•  Having a parent with Bipolar I Disorder may increase risk by 10X
Diagnostic Criteria
•  Must have at least one manic episode
•  Which is defined by Criteria A-D in the DSM-V
•  Major depressive episodes typically occur, but not
necessary for diagnosis
•  Criterion A:
•  A distinct period of abnormally and persistently elevated,
expansive, or irritable mood
•  and abnormally and persistently increased goal-directed activity or
energy
•  lasting at least 1 week and present most of the day, nearly every
day (or any duration if hospitalization is necessary)
Diagnostic Criteria
•  Criterion B: During the period of mood disturbance and
increased energy or activity, three (or more) of the
following symptoms (four if the mood is only irritable) are
present
•  Must be present to a significant degree and represent a noticeable
change from usual behavior
Jesse Jackson, Jr.
Politician
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1 4/4/14 Diagnostic Criteria
Diagnostic Criteria
1.  Inflated self esteem or grandiosity
•  Inflated self esteem or gradiosity
•  Feelings of being important
•  Physically attractive
•  Successful
•  Unstoppable
2.  Decreased need for sleep
3.  More talkative than usual or pressure to keep talking
4.  Flight of ideas or subjective experience that thoughts
are racing
5.  Distractibility, as reported or observed
6.  Increase in goal-directed activity (either socially, at work
or school, or sexually) or psychomotor agitation
(purposeless non-goal-directed activity)
7.  Excessive involvement in activities that have a high
potential for painful consequences
•  Decreased need for sleep
•  May sleep only a few hours a night or
go days without sleeping
Catherine Zeta Jones, Actress
Image: http://www.health.com/health/gallery/0,,20307117_2,00.html
Diagnostic Criteria
Diagnostic Criteria
•  More talkative than usual or pressure to keep talking
•  Difficult to interrupt
•  Intrusive
•  Rapid
•  Distractibility, as reported or observed
•  Difficulty staying on task
•  Lack attention to small details
•  Increase in goal-directed activity (either socially, at
•  Flight of ideas or subjective experience that thoughts
are racing
work or school, or sexually) or psychomotor agitation
(purposeless non-goal-directed activity)
•  Jump from thing to thing
•  Constantly busy
•  “This pen is out of ink. I’m from Des Moines. My dad is a
•  If organized, may be very successful
firefighter. What time is supper? You’re boring. Can I use the
phone? I have a pig farm, you know.”
Diagnostic Criteria
Diagnostic Criteria
•  Excessive involvement in activities that have a high
•  Criterion C: Disturbance is sufficiently severe enough to
potential for painful consequences
•  Gambling
•  Sex
•  Spending sprees
•  Hitchhiking
cause marked impairment in social or occupational
functioning
•  Or the patient needs to be hospitalized to prevent harm to
self or others
•  Or there are psychotic features
•  Criterion D: The episode is not attributable to the effects of
a substance or to another medical condition
•  Criteria A-D constitute a manic episode, at least one of
which is necessary for a diagnosis of Bipolar I Disorder
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2 4/4/14 Specifiers
Considerations
•  With Mixed Features
•  Features of both manic and depressive symptoms present during
the majority of the mood episode
•  With Psychosis (up to 75%)
•  Specify mood congruent vs mood incongruent psychosis
•  Suicide risk is estimated to be more than 15 times that of
•  With rapid cycling (5-15%)
•  Presence of at least 4 mood episode in the previous 12 months
the general population
•  Over half of patients have a co-occurring substance use
disorder
•  With melancholic features
•  With anxious distress
Russel Brand, Actor
•  With catatonia
Virginia Woolf, Author
•  With seasonal pattern
•  With peripartum onset
•  During pregnancy or in the 4 weeks after delivery
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Considerations
•  Up to 60% of people may experience chronic
interpersonal or occupational problems between acute
episodes
•  20-30% have residual mood lability or other mood issues
BIPOLAR II DISORDER
Bipolar II Disorder
Bipolar II Disorder
•  Average onset is in the mid 20’s
•  At least one hypomanic episode and one major
•  Prevalence in the US: 0.8%
•  Hypomanic episode: A distinct period of abnormally and
depressive episode
•  Like bipolar I disorder, there are strong genetic factors
•  Patients with bipolar II disorder have a higher total
number of lifetime episodes than patients with bipolar I
disorder or cyclothymic disorder
persistently elevated, expansive, or irritable mood and
abnormally and persistently increased goal-directed
activity or energy, lasting at least 1 week 4 days and
present most of the day, nearly every day
•  Same symptoms as listed for manic episode, but
•  Do not cause marked impairment in social or occupational
functioning
•  Hypomania does not generally impair function, but major
depressive episodes do.
•  Do not require hospitalization
•  No psychosis
3 4/4/14 Major Depressive Episode
5 or more of the following symptoms during a 2 week period
1.  Depressed mood most of the day, nearly every day
1.  In children may be irritable mood
2.  Markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day
3.  Significant weight loss when not dieting (change in 5% of
4. 
5. 
6. 
7. 
8. 
9. 
body weight) or weight gain, or decrease or increase in
appetite
Insomnia or hypersomnia nearly every day
Psychomotor agitation or retardation (observable by others)
Fatigue or loss of energy
Feelings of worthlessness or excessive or inappropriate guilt
Diminished ability to think or concentrate, indecisiveness
Recurrent thoughts of death, recurrent suicidal ideation,
suicide attempt, or specific plan
BIPOLAR VS UNIPOLAR
DEPRESSION
Bipolar vs Unipolar Depression
More Common in Bipolar Depression
•  Up to 40% of patients with a bipolar disorder are initially
•  Psychotic features
diagnosed with unipolar depression
•  Younger age of onset (under 25)
•  Family history
•  Depression may come first
•  Antidepressant induced mania or hypomania
•  Seasonality
•  Patient may not admit to manic symptoms
•  Atypical features
•  Excessive sleepiness, weight gain, psychomotor retardation
•  Poor insight
Jane Pauley
Journalist
•  ALWAYS SCREEN FOR A HISTORY OF MANIA OR
HYPOMANIA
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Cyclothymic Disorder
•  2 years
•  Numerous periods of periods with hypomanic symptoms
that do not meet criteria for a manic or mixed episode
•  Don’t have to meet criteria for a hypomanic episode
•  Numerous periods of depression that don’t meet criteria
for a major depressive episode
CYCLOTHYMIC DISORDER
•  After the two years, there may be manic, mixed or MD
episodes
•  In which case a diagnosis of bipolar I or II disorder is added
•  15-50% chance the person will develop bipolar I or II
4 4/4/14 Mood Stabilizers
•  Lithium
•  Exact MOA unknown, several theories exist
•  Stabilizes glutamate uptake, enhances serotonin and norepinephrine in CNS
•  Watch for toxicity
•  Dehydration, NSAIDs (Level 0.8 – 1.2)
•  Symptoms: Severe tremor, stupor, confusion, ataxia, GI upset,
•  Eliminated by kidneys
TREATMENT
•  BUN/Creatinine at baseline and every 2-3 months X 6 months, then every
6-12 months
•  Hypothyroidism
•  TSH/Free T4 at baseline and again in the first 6 months, then every 6-12
months
•  Tremor
•  Neurotoxicity – delirium, encephalopathy
•  Protective against suicide
Mood Stabilizers
Mood Stabilizers
•  Valproate (Depakote)
•  Loading dose strategy in acute mania
•  Anticonvulsant – taper dose when discontinuing
•  Metabolized by liver (Check liver function at baseline and monitor)
•  Reduces irritability and aggression
•  Side effects
•  Lamotrigine (Lamictal)
•  Anticonvulsant
•  Maintenance therapy of Bipolar I Disorder
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GI effects (most often at start of treatment and transient)
Hair loss (early and treatment and usually transient)
Sedation
Tremor
Weight gain
PCOS
Leukopenia and thrombocytopenia
Teratogenic
Rare pancreatitis
•  Increases time to next mood episode
•  No acute antimanic activity
•  May help bipolar depression
•  Dose titrated very slowly over 8 weeks due to rare Stevens-
Johnson Syndrome
•  Cut dose in half if given with valproate
•  Increase dose if given with carbamazepine or oxcarbazepine
•  Side effects:
•  Rash – SJS (0.02%), benign rashes, systemic hypersensitivity
•  If rash develops, stop drug immediately and seek medical attention
•  Headache, nausea, dizziness
•  Weight neutral
Second Generation Antipsychotics
Antidepressants
•  All are approved for acute mania (except clozapine and
•  Can be helpful for bipolar depression
lurasidone) and psychosis
•  Lurasidone, quetiapine, and olanzapine indicated for
bipolar depression
•  Many can also be used for acute agitation
•  Several available in long acting injectable formulations
•  Side effects
•  EPS
•  But may induce manic/mixed episodes
•  olanzapine/fluoxetine (Symbyax)
•  paroxetine and bupropion may be least harmful
•  Tardive dyskinesia
•  Metabolic side effects
•  Weight gain, diabetes, dyslipidemia
•  Hyperprolactinemia
5 4/4/14 References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA:
American Psychiatric Publishing.
Black, M.D, Donald, and Nancy Andreasen, M.D., Ph.D. Introductory Textbook of Psychiatry. 5th Ed. Washington, DC:
American Psychiatric Publishing, Inc., 2011. Print.
Cuellar, Amy, Sheri Johnson, and Ray Winters. "Distinctions Between Bipolar and Unipolar Depression." Clinical
Psychology Review. (2005): 307-399. Print.
Julien, Robert, Claire Advokat, and Joseph Comaty. A Primer of Drug Action. 11th Ed. New York, NY.: Worth Publishers,
2008. Print.
Kaye, Neil. "Is Your Depressed Patient Bipolar?." Journal of the American Board of Family Medicine. 18.4 (2005):
271-281. Print.
Sadock, MD, Benjamin, and Virginia Sadock, MD. Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 9th
ed. Philadelphia: Lippincott Williams & Wilkins, 2003. Print.
Schatzberg, MD, Alan, and Charles Nemeroff, MD, Ph.D. Essentials of Clinical Psychopharmacology. 3rd Ed.
Washington, DC: American Psychiatric Publishing, Inc., 2013. Print.
Stovall, Jeffrey, Paul Keck, and David Solomon. "Bipolar Disorder in Adults: Pharmacotherapy for Acute Depression."
UpToDate. (2014): n. page. Web. 11 Mar. 2014.
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