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  1. 1. Psychiatric Medicine 1 March 23, 2004 Transcriber: Rebecca Nardi ( Lecturer: Dr. Janis Cutler ( Bipolar Disorder/Manic-Depressive Disorder This lecture focuses mainly on the manic episodes, but they will be put in the context of bipolar disorder. It will refer back to depression at points, and fill in things from last week’s lecture. Patients with mania tend to experience a euphoric mood state, a sort of “high”, where they feel on top of the world. - Lots of energy and need less sleep - Get more pleasure out of pleasurable activities, including sex - Often the “life of the party”. They appear funny, sharp, and insightful. That sounds terrific – who would want to treat that? But that’s not the only side to the disease (or else we wouldn’t be talking about it). However, it is important to realize that someone in this state would not want to seek psychiatric care. Because of this, it can be difficult to get a videotape of someone in a manic episode, so Dr. Cutler used an unusual source, a clip from the film Aladdin when the Genie is first released. Genie has a reason to be happy, because he has been let out after 10,000 years. But his thoughts, which are quick, sharp, and confusing, but connected, resemble those of a manic patient.  This is known as Flight of Ideas, where the thoughts go fast and stream together, but the ideas are connected. It can be very hard for an observer to keep up. Dr. Cutler then read an excerpt from a collection of short stories entitled You Are Not a Stranger Here by Adam Haslett. The story is entitled “Notes to My Biographer”, and its narrator is in the middle of a manic episode; he is writing these notes assuming that he will be famous. - In the introduction, the narrator contends that the psychiatric establishment has attempted to “redefine eccentricity as illness”, and that his family wants “to render me docile and, if possible, immobile”. - The narrator describes an idea he has for a new invention, the pages of specs he has developed, and the several people he has called in the course of an afternoon that could help develop his idea. He orders $1200 worth of champagne, which his son must pay for. This is a smart person who gets carried away. It seems like he is productive and creative, but it quickly degenerates into motion without getting anywhere. It is exhausting for people around the person who is manic. Mania can get out of control; a person’s judgment can become so poor that they cannot function. - This can involve mood-congruent delusions, i.e. grandiose delusions. - Even when they are not psychotic, judgment can be impaired.
  2. 2. In over 90% of cases, patients with mania will have some form of depression – either major depression (discussed last week), or a milder, more chronic form of depression known as dysthymia. - It is also possible to have mood-congruent delusions with depression – delusions of guilt that fit with that mood. - If someone has one episode of mania or hypomania (see below), the diagnosis is bipolar disorder, even if there is no history of a prior depressive episode. - Major depressive disorder and depressive episodes in bipolar disorder typically have the same symptoms. Bipolar disorder is episodic; between episodes, many patients are asymptomatic. - This is an important distinction from schizophrenia, a psychotic disorder where symptoms persist all of the time. - When the patient is psychotic, it is difficult to tell a mood disorder from schizophrenia. - The two kinds of episodes (manic and depressive) are not related in any way with regards to timing. They do not necessarily alternate. - Asymptomatic periods can be very variable – years or months. Dr. Cutler showed a video inherited from Dr. Sharp. The clips jump from patient to patient, which mimics the experience of being with a manic patient. The video demonstrated many points that Dr. Cutler made through the rest of the lecture. - During depressive episodes, patients are slower, and may feel stupid. During manic episodes, there is a quickness; patients feel smart and sharp, but out of control. - One patient had delusions and grandiose thoughts, but didn’t appear to be manic. This patient may have schizoaffective disorder, a combination of schizophrenia and bipolar disorder. Sometimes a patient may have just psychotic symptoms, while other times the patient may demonstrate symptoms of both psychotic and mood disorders. - One of the doctors in the video could not get any questions out; the patient kept interrupting. This pressured speech is typical of mania. Often, the patients in the ER who barge into the doctors’/nurses’ area without knocking are those being treated for mania. - Patients may find it unpleasant that their thoughts go so fast and are out of control. One patient described it as “wheels moving too quickly,” “I could not keep up with myself”. - It may be confusing and difficult to determine if someone is manic, or depressed and agitated. Depressed patients who have insomnia are tired, and wish they could get some sleep. Manic patients may also get only a couple hours of sleep, but they are not tired, and report having lots of energy. Some patients have symptoms that describe a Mixed State, a mixture of mania and depression. - These patients have bipolar disorder. - There is a high risk of suicide. People who are depressed and have no energy are less likely to plan and carry out a suicide attempt. Mixed patients have more energy to plan.
  3. 3. Patients can be irritable, threatening, impulsive, and provocative, which causes problems in their lives. - They can get into trouble by doing things like picking fights - Empty bank accounts and run up bills - Sexual indiscretions, including unsafe sex, adultery  They feel sorry afterwards, but it can take years to rebuild their lives ONSET AND ETIOLOGY Dr. Sharp’s first exposure to mania was in a study group in med school. One of the group members said that med students were too dependent on sleep and could be weaned off it (an appealing idea!). They all decided to cut down on their sleep over a week. Everyone else became exhausted and abandoned the project, while the person with the idea continued with it and seemed to be functioning well, with lots of energy. It soon became clear, though, that he was not all right, and was having his first manic episode.  The “contagious enthusiasm” demonstrated by people with mania is apparent – this person convinced these smart, rational medical students to go along with such an irrational idea. - The typical age of onset is the early twenties. - There is a stronger genetic component in bipolar disorder than in major depression o Stresses and childhood experiences probably play some role, but less of a role than in depression - Men and women are affected equally (from last week – depression affects women twice as much) - Two percent of population - Episodic, with asymptomatic periods in between - Episodes become more frequent and severe with age o Mixed states o Rapid Cycling, defined as four episodes within a year  Patients with rapid cycling may not have been as compliant with treatment previously – “kindling effect” Hypomania – milder form of mania - The distinction is one of degree. The number of symptoms is the same, but the degree of severity is different. (This is incorrect in the text) - Patients are less likely to get treatment during hypomanic episodes, since their functioning is much less problematic. - They will need treatment for depression, and are more likely to seek treatment for that. Bipolar Type 1: Mania + Depression Bipolar Type 2: Hypomania + Depression (other distinctions in text) Treatment Mood stabilizers are effective. However, patients tend to not want to take the medications because of the positive aspects of mania. As shown in the video, what the doctor calls the “worst episode” is considered the best by the patient, because of the feelings of euphoria. It is only
  4. 4. during the depressive episodes that they realize they have a problem. Patients must stay on mood stabilizer indefinitely, since an episode could come at any time. Dr. Cutler read from An Unquiet Mind by the psychologist Kay Redfield Jamison, a memoir about the author’s own experiences with bipolar disorder. Be aware: A potential problem for clinicians is that people are presenting in their twenties with depression and with bipolar disorder. A first depressive event could be part of bipolar disorder or major depressive disorder. As we will learn in pharmacology, when bipolar disorder is treated with an antidepressant, it will push the person into a manic state. Some final points: - Substance abuse factors into all the disorders we will be hearing about o Patients self-medicate o Can exacerbate mania or depression o Unclear if drugs set off the disease. Typical drug users are in their teens and twenties, near the age of onset. It is hard to tell if the drug was the cause, or the disease would have come out at a later time. - Childhood bipolar disorder o Only has been diagnosed the past few years o Previously diagnosed as hyperactive disorder (with symptoms of irritability), but these children developed bipolar disorder later in life.