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Nirvana’s Lithium
I'm so happy 'cause today I've found my friends
They're in my head I'm so ugly, but that's okay, 'cause ...
Bipolar Disorder
 Also known as manic depression, a mental
illness that causes a person’s moods to
swing from extremely h...
Mood Disorders
AKA: Affective Disorders
Affect – “emotion” or “mood”
Unipolar & Bipolar Depression
Unipolar Bipolar
Depressive Disorder, NOS
Dysthymia
Major Depression
-Single Episode
-Recurrent
- - -
Seasonal Affective
D...
Mania/Hypomania
-Extreme euphoria
-Lack of need for sleep
-Inflated Ego and Self-Esteem
-Loose Associations/Flight of Idea...
Continuum of Causes of Affective
Disorders
Biological Bipolar
Major Depression
Environmental Dysthymia
Genetics
 30-70% Identical twins
 75% Both parents bipolar
Mood Disorders
 Growing consensus that Bipolar is
organically based with a notable genetic
factor
 Like Major Depression...
Mood Disorders
“Defective Membrane” Theory of
Bipolar Disorder
1. Nerve impulse moves along
neuron electro-chemically
2. I...
GRK3 regulates sensitivity to
neurotransmitters
 Decreases the sensitivity of neurons
to neurotransmitters
 Acts as a br...
GRK3 is a Gene For
Bipolar Disorder
 GRK3 is inherited with bipolar disorder
 GRK3 is turned on by amphetamine
 A mutat...
Mood Disorders
 Genetic studies, especially of twins,
indicate a genetic predisposition for
bipolar disorder
 40% of ide...
Epidemiology of Bipolar Disorder
 Prevalence: 1% of population Adults =
Adolescents
 Males = Females
 2-3 million Ameri...
Controversy
 Severity and duration
 Onset before puberty is estimated to be
rare
 Developmental variability
 Retrospec...
Vincent Van Gogh
“It isn’t possible to get
values and color. You
can’t be at the pole
and the equator at the
same time. Yo...
Assessment/Diagnosis of Bipolar
Disorder
 Often very complicated; it mimics
many other disorders and has
comorbidity (pre...
Mood history
 Mania
 Giddy, goofy, laughing fits, class
clown
 Explosive (how often, how long,
how destructive and aggr...
DIGFAST – Mental Status Exam
 Distractible
 Increased activity/psychomotor agitation
 Grandiosity/Super-hero mentality
...
Bipolar Disorder
 Significant functional impairment
 Bipolar I people go through cycles of major
depression and mania
 ...
Suicide Risk Factors
 22% of adolescents with completed
suicides had bipolar disorder
 Family history of suicide
 Subst...
 Major depression often presents first
(estimated that 20 - 40% of children
presenting with major depression within 5
yea...
Pediatric-Onset Bipolar Disorder
 Geller (American Journal of Psychiatry,
2001) followed up 72 depressed
prepubertal chil...
 Atypical presentation in juveniles-
exacerbation of disruptive behavior,
moodiness, low frustration tolerance,
explosive...
Pediatric-Onset Bipolar Disorder:
Differential Diagnosis with ADHD
 ADHD confusion although identifying presence
of mood ...
Time Magazine, August 19, 2002
Time Magazine, August 19, 2002
Prioritizing Target Symptoms
1. Treat mania and/or psychosis
2. Treat depression
3. Anxiety and ADHD
Medications
 Mood Stabilizers
 Lithium
 Divalproex Sodium
(Depakote)
 Carbamezapine
 Improvement is seen when mood
stabilizers are used
 Kowatch et al (JAACAP 2000)
 Response rates:
 53% depakote
 38% ...
Geller et al.
 High relapse rate
 Geller longitudinal study
 1 year f/u recovery rate 37%
 Relapse rate 38%
Newer Agents
 Neurontin
 Lamictal
 Topamax
 Gabatril
 Atypical antipsychotics
Atypical Antipsychotics
 Risperidol
 Olanzapine (Zyprexa)
 Quetiapine (Seroquel)
 Abilify
 Geodon
 Increasingly used...
Key Point
 Just because a child improves on a mood
stabilizer does not prove the diagnosis.
Mood stabilizers have been us...
Multiple Modalities
 Psychotherapy
 Psychoeducation/Support
 School Support/Consultation
 Residential Placement, Acute...
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Transcript of "Bipolar lecture"

  1. 1. Nirvana’s Lithium I'm so happy 'cause today I've found my friends They're in my head I'm so ugly, but that's okay, 'cause so are you... We've broken our mirrors Sunday morning is everyday for all I care... And I'm not scared Light my candles in a daze... 'Cause I've found god - yeah, yeah, yeah I'm so lonely but that's okay I shaved my head... And I'm not sad And just maybe I'm to blame for all I've heard... But I'm not sure I'm so excited, I can't wait to meet you there... But I don't care I'm so horny but that's okay... My will is good - yeah, yeah, yeah I like it - I'm not gonna crack I miss you I'm not gonna crack I love you I'm not gonna crack I kill you I'm not gonna crack
  2. 2. Bipolar Disorder  Also known as manic depression, a mental illness that causes a person’s moods to swing from extremely happy and energized (mania) to extremely sad (depression)  Chronic illness; can be life-threatening  Most often diagnosed in adolescence
  3. 3. Mood Disorders AKA: Affective Disorders Affect – “emotion” or “mood” Unipolar & Bipolar Depression
  4. 4. Unipolar Bipolar Depressive Disorder, NOS Dysthymia Major Depression -Single Episode -Recurrent - - - Seasonal Affective Disorder (SAD) Postpartum Depression Mood Disorder, NOS Cyclothymia Bipolar II Disorder Bipolar I Disorder Bipolar Disorder, NOS
  5. 5. Mania/Hypomania -Extreme euphoria -Lack of need for sleep -Inflated Ego and Self-Esteem -Loose Associations/Flight of Ideas (from topic to topic) -May become psychotic when in episode (in mania only)
  6. 6. Continuum of Causes of Affective Disorders Biological Bipolar Major Depression Environmental Dysthymia
  7. 7. Genetics  30-70% Identical twins  75% Both parents bipolar
  8. 8. Mood Disorders  Growing consensus that Bipolar is organically based with a notable genetic factor  Like Major Depression, Bipolar Disorder linked to low serotonin activity  Theory: low serotonin  dysregulation of other important neurotransmitters, e.g., norepinephrine Etiology of Bipolar Disorder
  9. 9. Mood Disorders “Defective Membrane” Theory of Bipolar Disorder 1. Nerve impulse moves along neuron electro-chemically 2. Impulse carried via exchange of Na & K ions across neural membrane Na K 3. Defect in process  impulse carried too quickly or too slowly
  10. 10. GRK3 regulates sensitivity to neurotransmitters  Decreases the sensitivity of neurons to neurotransmitters  Acts as a brake to stress  Maintains balance in the brain
  11. 11. GRK3 is a Gene For Bipolar Disorder  GRK3 is inherited with bipolar disorder  GRK3 is turned on by amphetamine  A mutation in GRK3 increases risk to bipolar disorder 3 fold
  12. 12. Mood Disorders  Genetic studies, especially of twins, indicate a genetic predisposition for bipolar disorder  40% of identical twins concordant, vs. 5 to 10% of fraternal twins Etiology of Bipolar Disorder
  13. 13. Epidemiology of Bipolar Disorder  Prevalence: 1% of population Adults = Adolescents  Males = Females  2-3 million American adults are diagnosed with bipolar disorder  NIMH estimates that one in very one hundred people will develop the disorder
  14. 14. Controversy  Severity and duration  Onset before puberty is estimated to be rare  Developmental variability  Retrospective study of adults
  15. 15. Vincent Van Gogh “It isn’t possible to get values and color. You can’t be at the pole and the equator at the same time. You must choose your own line, as I hope to do, and it will probably be color.”
  16. 16. Assessment/Diagnosis of Bipolar Disorder  Often very complicated; it mimics many other disorders and has comorbidity (presents with other disorders)  Alphabet soup diagnosis  Half of bipolar children have relatives with bipolar disorder  It is important to first rule out the possibility of any other organic diagnosis:  Thyroid disorder  Seizure disorder  Multiple sclerosis  Infectious, toxic, and drug- induced disorders
  17. 17. Mood history  Mania  Giddy, goofy, laughing fits, class clown  Explosive (how often, how long, how destructive and aggressive)  Irritable, cranky, angry, disrespectful, threatening  Grandiosity may present as EXTREME defiance and oppositionality  Depression  Low frustration tolerance, self- destructive, no pleasure, lower level of irritability  DSM Criteria :A distinct period of abnormally and persistently elevated, expansive, or irritable mood  DIGFAST acronym (at least 3 of 7 symptoms)
  18. 18. DIGFAST – Mental Status Exam  Distractible  Increased activity/psychomotor agitation  Grandiosity/Super-hero mentality  Flight of ideas or racing thoughts  Activities that are dangerous or hypersexual  Sleep decreased  Talkative or pressured speech
  19. 19. Bipolar Disorder  Significant functional impairment  Bipolar I people go through cycles of major depression and mania  Bipolar II similar to Bipolar I except that people have hypomanic episodes, a milder form of mania  Rapid cyclers
  20. 20. Suicide Risk Factors  22% of adolescents with completed suicides had bipolar disorder  Family history of suicide  Substance abuse i.e. adolescent with impulse control disorder, depression, suicidality, substance use and access to a weapon is potential for lethality
  21. 21.  Major depression often presents first (estimated that 20 - 40% of children presenting with major depression within 5 years will be bipolar)  Comorbidity  70 - 90 % of adolescents have other disorders  ADHD, Conduct Disorder, Substance abuse
  22. 22. Pediatric-Onset Bipolar Disorder  Geller (American Journal of Psychiatry, 2001) followed up 72 depressed prepubertal children into adulthood  48.6% (N=35) developed bipolar disorder by mean age 20.7 years
  23. 23.  Atypical presentation in juveniles- exacerbation of disruptive behavior, moodiness, low frustration tolerance, explosive anger and difficulty sleeping at night  Comorbidity of ADHD/BPD more severe presentation, often severe affect dysregulation, marked impairment, violent temper outbursts
  24. 24. Pediatric-Onset Bipolar Disorder: Differential Diagnosis with ADHD  ADHD confusion although identifying presence of mood disorder helpful in guiding treatment Talkativeness Physical hyperactivity Distractibility
  25. 25. Time Magazine, August 19, 2002
  26. 26. Time Magazine, August 19, 2002
  27. 27. Prioritizing Target Symptoms 1. Treat mania and/or psychosis 2. Treat depression 3. Anxiety and ADHD
  28. 28. Medications  Mood Stabilizers  Lithium  Divalproex Sodium (Depakote)  Carbamezapine
  29. 29.  Improvement is seen when mood stabilizers are used  Kowatch et al (JAACAP 2000)  Response rates:  53% depakote  38% lithium  38% carbamazepine
  30. 30. Geller et al.  High relapse rate  Geller longitudinal study  1 year f/u recovery rate 37%  Relapse rate 38%
  31. 31. Newer Agents  Neurontin  Lamictal  Topamax  Gabatril  Atypical antipsychotics
  32. 32. Atypical Antipsychotics  Risperidol  Olanzapine (Zyprexa)  Quetiapine (Seroquel)  Abilify  Geodon  Increasingly used because they can cause rapid patient stabilization  Zyprexa can help with depression, mania and psychosis  Weight gain
  33. 33. Key Point  Just because a child improves on a mood stabilizer does not prove the diagnosis. Mood stabilizers have been used for a long time to help with aggression in children.
  34. 34. Multiple Modalities  Psychotherapy  Psychoeducation/Support  School Support/Consultation  Residential Placement, Acute Hospitalization  Mood Charting  Teach Good Sleep Hygiene  Legal intervention  Hope
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