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. 1. MRCPsych Masterclass Dr Nick Stafford Consultant Psychiatrist LPT
  2. 2. Epidemiology Aetiology Clinical findings Rating scales Laboratory findings & imaging Course of illness Differential diagnoses
  3. 3. ICD-11 & DSM V
  4. 4.    Mania Hypomania Depression     Degree of symptoms Nature of symptoms Time of symptoms Number of symptoms   ICD10 / DSMIV Other
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8.  Beating Bipolar  1 – Symptoms I: Depression  1 – Symptoms II: Hypomania  1 – 4: Mixed and psychosis
  9. 9.  BB  1 – Life chart 5
  10. 10. 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:
  11. 11. 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
  12. 12. Mood thermostat Neuroendocrine effects Neurotransmitters
  13. 13. Depression Depression & mania at opposite ends of the spectrum Reduced NA Mania Increased NA
  14. 14. Depression Depression & mania at opposite ends of the spectrum Reduced NA Mania Increased NA
  15. 15.  BB  2 – Mood thermostat 3: I, II, III, IV
  16. 16.  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
  17. 17. Beating Bipolar – 2:IV Hypomania Increasing age Depression
  18. 18. Improve functioning Mood charting Recognise early warning signs Medication understanding Prevent relapse Psychoeducation
  19. 19.  Beating Bipolar  4 – Nick Craddock onwards
  20. 20.  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
  21. 21.  BDNF gene (Vall66) GAD1 gene (4s2241165) Dopamine transporter gene (rs41084) Serotonin transporter gene  Circadian / Clock genes     ARNTL (BmaL1)  TIMELESS  PERIOD3  RORA & RORB
  22. 22.  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
  23. 23.  Strongest linkage on chromosomes 10q25, 10p12, 16q24, 16p13, a nd 16p12    6q25 (suicidal behaviour) 7q21 (panic disorder) 16p12 (psychosis) using phenotypic subtypes
  24. 24. 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
  25. 25. Any mental health history Recurrent depressive disorder Any alcohol or substance misuse Repeated relationship problems Repeated occupational problems Family history
  26. 26. • 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
  27. 27. 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
  28. 28. CVS disease Obesity & Diabetes Metabolic syndrome
  29. 29.  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
  30. 30. Lithium Antiepileptics Antipsychotics Carbonate Carbamazepine Olanzapine Citrate Valproate Quetiapine Risperidone
  31. 31.         Antidepressants Quetiapine Lamotrigine Benzodiazepines Typical antipsychotics Folic acid Metabolic syndrome Maudsley Guidelines
  32. 32. Exercise Stress reduction Diet Relaxation Pleasurable activities Social activities Sleep Cycles & rhythms
  33. 33.  Beating Bipolar  Sections ▪ 2 – Sleep ▪ 3 – Rood & Exercise ▪ 5 – Routines
  34. 34.  Beating Bipolar  Module 7  General group discussion about what it might be like to live with someone who has bipolar
  35. 35.      Pregnancy Childbirth Stress Medication Genetics & children
  36. 36. Age of onset Duration of mania Duration of depression Recovery Long term outcome Mortality and suicide • Average 21 years • Mania • Hypomania
  37. 37.  Beating Bipolar  2 – Triggers  3 – Monitoring mood  4 – Nipping episodes in the bud  5 – Dealing with suicidal thoughts
  38. 38.  Beating Bipolar Module 6 sessions
  39. 39. 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
  40. 40. Medications Substance abuse Neurological disease Infectious disease Neoplasms Metabolic & endocrine disorders Collagen-vascular conditions Miscellaneous
  41. 41. 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
  42. 42. Postoperative states Haemodialysis Vitamin B12 Addison’s disease Iatrogenic Cushing’s disease Post-infection states Dialysis Hyperthyroidism
  43. 43. Right temporal lobe seizures Multiple sclerosis Right hemisphere damage Seizure disorders Huntington’s disease Post-stroke
  44. 44. Neurosyphilis Herpes simplex encephalitis Q fever HIV infection
  45. 45.  Group discussion of principles  BeatingBipolar.org

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