Bipolar basics for MRCPsych year 1
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Lecture on the basics of bipolar disorder for MRCPsych course year 1, delivered in Leicester 2010
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Bipolar basics for MRCPsych year 1
- 1. MRCPsych Masterclass Dr Nick Stafford Consultant Psychiatrist LPT
- 2. Epidemiology Aetiology Clinical findings Rating scales Laboratory findings & imaging Course of illness Differential diagnoses
- 5. ICD-11 & DSM V
- 6. Mania Hypomania Depression Degree of symptoms Nature of symptoms Time of symptoms Number of symptoms ICD10 / DSMIV Other
- 7. SYMPTOM DOMAINS SEVERITY Mood • Elevated Hypomania • More persistent and marked than cyclothymia • Several days on end Physical activity • Quantity • Speed Mania without psychosis • Greater degree of mood elevation • At least one week Mental activity • Quantity • Speed Mania with • Congruous or incongruous • Severe and sustained psychosis increase in activity
- 8. Elevated mood >=4days Symptoms (three or more) Unequivocal change in functioning Mood and function change observed by others No marked impairment in social / occupational functioning & no psychosis Not due to substance misuse or a medical condition
- 9. Mood elevate at least 1 week Symptoms (3 or more) Not Mixed Episode Severe impairment of functioning or relationships or need hospitalisation or psychosis Not due to substances misuse or a medical condition
- 10. Beating Bipolar 1 – Symptoms I: Depression 1 – Symptoms II: Hypomania 1 – 4: Mixed and psychosis
- 13. BB 1 – Life chart 5
- 14. Bipolar Depression Lifetime risk About 1-5% 10-20% Sex ratio (M:F) 1:1 1:2 Lifetime risk for bipolar About 10% About 2% Lifetime risk for unipolar depression 20-30% 20-30% Average age of onset 21 yrs (?earlier) 27 yrs Suicide 15% 10% First-degree relatives:
- 15. Factor Expressed Emotion Greater predictor of relapse than schizophrenia Family history Complex hereditability Social class High social class cf. other mood disorders Life events Significant with nature & degree Personality More maladaptive traits during relapse Need for reassurance and sensitivity to criticism Childhood experience Approx 50% bipolars and leads to more complex cases Postpartum Marked increases Menopause Deterioration in perimenopause Social support Bipolars get less social support Sleep deprivation Tends to mania, circadian disturbances Behavioural activation Excessive activity leads to mania
- 18. Depression Depression & mania at opposite ends of the spectrum Reduced NA Mania Increased NA
- 19. Depression Depression & mania at opposite ends of the spectrum Reduced NA Mania Increased NA
- 20. BB 2 – Mood thermostat 3: I, II, III, IV
- 23. Elevated basal plasma concentrations of TSH Exaggerated TSH response to TRH Rapid cyclers higher rate of hypothyroidism Blunted / absent evening surge of plasma TSH Blunted TSH response to TRH Presence of antithyroid microsomal and/or anti-thyroglobulin antibodies
- 26. Beating Bipolar – 2:IV Hypomania Increasing age Depression
- 27. Improve functioning Mood charting Recognise early warning signs Medication understanding Prevent relapse Psychoeducation
- 28. Beating Bipolar 4 – Nick Craddock onwards
- 29. Children of affected parent(s) One parent: 15-30% Both parents: 50-75% Siblings of affected sibling One sibling: 15-25% MZ concordance 60-70% Additional genetic loading for depressive disorder, ADHD, OCD or Oppositional Defiant Disorder
- 30. BDNF gene (Vall66) GAD1 gene (4s2241165) Dopamine transporter gene (rs41084) Serotonin transporter gene Circadian / Clock genes ARNTL (BmaL1) TIMELESS PERIOD3 RORA & RORB
- 31. Bipolar I DAO, GRM3, GRM4, GRIN2B, IL2 RB, and TUBA8 Overlapping with schizophrenia DPYSL2, DTNBP1, G30/G72, GRI D1, GRM4, and NOS1 BDNF Alpha subunit of the voltagedependent calcium channel Glutamate signalling pathways
- 32. Strongest linkage on chromosomes 10q25, 10p12, 16q24, 16p13, a nd 16p12 6q25 (suicidal behaviour) 7q21 (panic disorder) 16p12 (psychosis) using phenotypic subtypes
- 33. Bipolar Unipolar Substance abuse +++ + Family history ++++ + Seasonality ++++ + Onset before age 25 +++ + Postpartum onset +++ + Psychotic depression <age 35 +++ -- Atypical features ++++ + Rapid on/off pattern ++ -- Recurrent Major Depressive Episodes ++ + Antidepressants associated with hypomania / mania ++ -- ++++ -- Antidepressant wear-off ++ -- Mixed depression ++ -- Brief episodes of depression
- 34. Any mental health history Recurrent depressive disorder Any alcohol or substance misuse Repeated relationship problems Repeated occupational problems Family history
- 35. • Functional mental illnesses Recurrent Depression, Anxiety • Emotionally unstable / borderline Personality disorder types Substance and alcohol misuse • Chronic or intermittent use Normal human emotion • Chronic stress & psychosocial problems
- 36. Anxiety disorders Panic disorder Simple phobia Alcohol misuse Personality disorders Childhood bipolar Cluster B Conduct disorder Substance misuse Childhood mental health Borderline ADHD Emotionally unstable Social phobia GAD OCD Sleep disorders PTSD Any substance misuse
- 39. Beating Bipolar 3: Section 3 Get CT1s to discuss each question in 2 groups ▪ What they think ▪ What they think the patient might thinks ▪ Consider pros & Cons Watch next film of patients (Mark & Jane) Dr Alison Roberts – on lithium
- 41. Antidepressants Quetiapine Lamotrigine Benzodiazepines Typical antipsychotics Folic acid Metabolic syndrome Maudsley Guidelines
- 42. Exercise Stress reduction Diet Relaxation Pleasurable activities Social activities Sleep Cycles & rhythms
- 43. Beating Bipolar Sections ▪ 2 – Sleep ▪ 3 – Rood & Exercise ▪ 5 – Routines
- 44. Beating Bipolar Module 7 General group discussion about what it might be like to live with someone who has bipolar
- 46. Age of onset Duration of mania Duration of depression Recovery Long term outcome Mortality and suicide • Average 21 years • Mania • Hypomania
- 47. Beating Bipolar 2 – Triggers 3 – Monitoring mood 4 – Nipping episodes in the bud 5 – Dealing with suicidal thoughts
- 48. Beating Bipolar Module 6 sessions
- 50. Axis I Axis II Delirium Emotionally unstable PD Dementia Histrionic PD Substance-related disorder Schizophrenia Schizoaffective disorder Delusional disorders Psychotic disorder NOS Cyclothymic disorder Factitious disorder Malingering ADHD Conduct disorder
- 51. Medications Substance abuse Neurological disease Infectious disease Neoplasms Metabolic & endocrine disorders Collagen-vascular conditions Miscellaneous
- 52. Isoniazid Procarbazine L-Dopa Corticosteroids and ACTH Hallucinogens Cimetidine Bromide Decongestants Bronchodilators Procyclidine Calcium replacement Phencyclidine Metoclopramide Sympathomimetic amines Disulfiram Barbiturates Anticonvulsants Benzodiazepines Cocaine TCAs
- 53. Postoperative states Haemodialysis Vitamin B12 Addison’s disease Iatrogenic Cushing’s disease Post-infection states Dialysis Hyperthyroidism
- 54. Right temporal lobe seizures Multiple sclerosis Right hemisphere damage Seizure disorders Huntington’s disease Post-stroke
- 55. Neurosyphilis Herpes simplex encephalitis Q fever HIV infection
- 56. Group discussion of principles BeatingBipolar.org