Call Girl Coimbatore Prisha☎️ 8250192130 Independent Escort Service Coimbatore
Hanipsych, bipolar
1.
2. Bipolar disorder: A new horizon
By
Prof. Dr. Hni Hamid Dessoki
Acting Dean, Faculty of Applied Health Sciences
Prof. of Psychiatry Department
Beni Suef University
Supervisor of Psychiatry Department, El-Fayoum University
APA member
Dr. Ahmed Abd elaziz Ezzat
Lecturer of psychiatry- faculty of medicine- Bani Suif
University
Dr. Mohammed Sultan
Lecturer of psychiatry- faculty of medicine- Elfayoum
University
3. Objectives
• To know about subtle bipolar disorder
• To know about bipolar disorder in special
population
• To learn the different lines of treatment in
guidelines
for different episodes of bipolar disorder.
4. Prof. Hani Hamed Dessoki, M.D.Psychiatry
Prof. Psychiatry
• Acting Dean, Faculty of Applied Mental Health sciences
Beni Suef University
Supervisor of Psychiatry Department
El-Fayoum University
APA member
Hidden Bipolar Disorder
11. Post test Question 2
The most commonly diagnosed personality disorder in
bipolar disorder is
1. Avoidant Personality Disorder
2. Obsessive-Compulsive Personality Disorder
3. Borderline Personality Disorder
4. Histrionic Personality Disorder
5. Schizotypal Personality Disorder
12. Epidemiology
• Bipolar I: range from 0.5% to 7.5%.
Bipolar II > bipolar I
• Frequently misdiagnosed as recurrent major depression
• The estimated life time prevalence of bipolar spectrum is as high
as 4%.
• Men = female
• Bipolar II : female > male
• The majority of cases have an onset before the age of 30.
13. Cost of Bipolar Disorder
BAD is not only a chronic, severe psychiatric disorder,
but also expensive to treat and expensive to society.
WHO report , BAD ranked :
• 6th in the top 10 causes of disability worldwide in the 15-to 44-year age
group.
• 3rd among mental illnesses after unipolar major depression and
schizophrenia as the source of disease burden in established market
economies. (Murray & Lopez, 1996)
14. Costs of Bipolar Disorder
Direct Cost
Cost of
Misdiagnosis
Cost of Comorbidity
Indirect Cost
15. Psychosocial Consequences of
Bipolar Disorder
• Greater unemployment rate (6 times greater than US average)
• Negative impact on relationships of patients with
bipolar disorder
• 38-68% disruption in family relationships
• 49% marital difficulties
• 73% job and school-related problems
• Higher divorce rate (vs general population)
• 23.5% of patients with bipolar disorder (compared
with 11.95%)
*Average in female with onset at age 25.
1. Kogan JN, et al. Bipolar Disord. 2004;6(6):460-469.
2. Albanese MJ, Pies R. CNS Drugs. 2004;18(9):585-596.
3. Matza LS, et al. Drug Benefit Trends. 2004;16(9):476-481.
4. Morselli PL, et al. Bipolar Disord. 2004;6(6):487-497.
5. Hirschfeld RMA, et al. J Clin Psychiatry. 2003;64(2):161-174.
16. Bipolar disorder is multidimensional
Subsyndromal Mania
(Hyperthymia)
Mania
Depression
Maintenance
Subsyndromal Depression
(Dysthymia)
Hypomania
Young AH et al. Practical Management of Bipolar Disorder, Cambridge University Press, 2010.
Comorbidity:
alcohol
Mixed
17. 5.9%9.3%
31.9% 52.7%
Frequency of symptoms
n=146, bipolar I; n=86, bipolar II
Follow up: a12.8 years; b13.4 years
Judd et al 2002; 2003
Time asymptomatic
Time depressed
Time manic / hypomanic
Time cycling / mixed
2.3%1.3%
50.3% 46.1%
Bipolar I disordera Bipolar II disorderb
Irrespective of the bipolar subtype, patients spend the majority
of their time in depressed state
18.
19.
20. *Akiskal HS, et al. J Affect Disord
2000 Sep;59 Suppl 1:S5-S30
Bipolar Disorder:
Subtypes
• Mixed Mania
• Simultaneous mania and depression
• May be > 40% prevalence of episodes*
• Rapid Cycling
• > 4 episodes/year
• Bipolar II
• Hypomania (< 4 days duration) alternating with depression
• Secondary Mania
• e.g., drugs, tumor, CVA, lupus, endocrine, infectious,
Huntington’s, Wilson’s
21. Problems of bipolar disorder
• Recurrent long-term illness
• Misdiagnosis
• Suicide risk:
• At least 25% attempt suicide
• Suicide rate: 11-19%
• 25-50% suicidal ideation in mixed mania
• Co morbidity complications
• Psychosocial consequences
22. Cost of Misdiagnosis; the High Rate of Misdiagnosis
Most frequent misdiagnosis
Unipolar depression—60%
Average of 3.5 misdiagnoses and 4
consultations before an accurate diagnosis
was made
2000 NDMDA
Bipolar Survey1*
35% of patients were symptomatic for 10
years before correct diagnosis made
10+ years
*(N=600) patients with bipolar disorder; not all patients responded to all survey questions.
NDMDA=National Depressive and Manic Depressive Association.
1. Hirschfeld RMA, et al. J Clin Psychiatry. 2003;64(2):161-174.
69%
Misdiagnosed
23. Misdiagnosis is common in bipolar disorder
• ~70% of patients are initially misdiagnosed
• Most frequent misdiagnoses:
• Major depressive disorder – 60%
• Anxiety disorder – 26%
• Schizophrenia – 18%, schizoaffective disorder – 11%
• Borderline/antisocial personality disorder – 17%
• Substance abuse or dependence – 14%
• Bipolar-II identified late after initial unipolar depression diagnosis
1Hirschfeld et al. J Clin Psychiatry 2003; 2Manning et al. Compr Psychiatry 1997
24. 14%
46%
6%
41%
0
20
40
60
80
Patients With Bipolar Disorder General Population
Alcohol abuse
Substance abuse
Prevalence of Bipolar Disorder and
Substance Abuse
1. Levin FR, Hennessy G. Biol Psychiatry. 2004;56(10):738-748.
2. Regier DA, Farmer ME, Rae DS, et al. JAMA/1990;264:2511-2418.
%PrevalenceRate
100
N=20,291
25. Clinical Features that predict Bipolarity
Early age of onset
Psychotic depression before age 25
Postpartum, seasonal onset
Rapid onset
More than 5 episodes of depression
Cyclothymic, hyperthymic personality traits
Switching or lack of efficacy with antidepressants
Mixed depressive states
Family history of bipolar disorder or several generations with
depression
Reverse vegetative symptoms (overeating, oversleeping)
26. “Pseudo-Unipolar” Forms
• Bipolar II (major depressive and hypomanic
episodes).
• Bipolar III (major depressive episodes and
antidepressant-associated hypomania).
• Bipolar IV (major depressive episodes
superimposed on hyperthymic temperament).
• Other Candidates: Recurrent depressions with
abrupt onset and offset; seasonal depressions,
even without discernible hypomanic episodes.
Okasha 2008
27. Other Conditions Considered for
Inclusion in the Bipolar Spectrum
• Episodic obsessive-compulsive forms.
• Periodic states of irritability.
• Acute suicidal crises in the absence of clear-cut
affective symptoms.
• Cyclical neurasthenic or sleep complaints.
• Severe brief recurrent depressions.
• Impulse-ridden behaviours in the realms of
control of aggression, gambling and paraphilias.
Okasha 2008
28. Conditions whose Boundaries with
Bipolar Disorder are Regarded as
Uncertain
• Schizoaffective disorder
• Borderline personality disorder
• Substance use disorders
• Adult-attention-deficit/hyperactivity
disorder
Okasha 2008
30. Suicide risk in bipolar disorder
• Suicide is a particular risk in patients with bipolar disorder
• Completed suicide occurs in 10–15% of patients with bipolar I
disorder1
• 30–60 fold higher than in the general population2
• Risk of suicide is particularly high during the first years after
diagnosis1
• Suicidal ideation or attempts in individuals with bipolar disorder
are more likely to occur during depressive or mixed episodes1
1American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. APA,
2000;
2Baldessarini et al. CNS Spectr 2006
31. Steps to improve diagnosis
Leverich & Post 1998; Hirschfeld et al 2000; Benazzi 2002
Accurate history tracking
Close monitoring of mood changes
Systematic probing for manic and depressive symptoms
Look for indicators of bipolarity
36. • The first change in the DSM-V that will affect people
with bipolar disorder is the categorization.
• Instead of being classified as a mood disorder,
bipolar disorder is now in the category of “bipolar
and related disorders.”
• Depressive disorders are now in their own category,
instead of being in the mood disorder category with
bipolar disorder.
Changes to Bipolar Disorder Treatment in the New
DSM-5
37. • Mixed episodes have also been eliminated. Instead of
labeling an episode as mixed, the provider will now
have the option to specify a manic or depressive
episode with a certain specification, “with mixed
features” attached to it.
Changes to Bipolar Disorder Treatment in the New
DSM-5
38. • A bipolar 2 diagnosis can now include episodes with
mixed features.
• According to past editions of the manual, a person
who had mixed episodes would not be diagnosed
with bipolar 2. This change has made it easier to put
people in less severe categories than bipolar 1.
Changes to Bipolar Disorder Treatment in the New
DSM-5
39. Face the Facts
• Bipolar disorder is serious and relatively common.
• Bipolar disorder is a life long disease with
unpredictable episodes.
• Bipolar disorder is a progressive disease causing
impairment in neuroplasticity /cellular resilience with
systemic consequences.
41. Bipolar Disorder: Treatment Challenges
• Can be difficult to diagnose
• Complicated to treat
• Polypharmacy is a standard of care
• High morbidity and mortality
• Recurrent illness in >90% of patients care
• Functional recovery often lags behind symptomatic
recovery
• Recurrent episodes may lead to progressive deterioration in
functioning
• Number of episodes may affect subsequent treatment
response and prognosis
1. McElroy SL and Keck PE, Biol Psych 2000; 539-557.
2. Thase MD and Sachs GS, Biol Psych 2000; 558-572.
3. APA Bipolar Guidelines Am J Psych 2002;159 (Suppl4):1-50.
4. Tohen et al. Arch Gen Psych 1990:47:1106-1111.
5. Dion G et al. Hosp and Community Psych 1988;39(6);652-657.
6. Goodwin FK. Jamison KR: Manic Depressive Illness 1990.
7. Keck PE Jr, et al. Am J Psych 1998; 155(5):646-652.
8. Tohen et al. Biol Psych 2000; 48:467-476.
42. Relapse is very Common
Euthymia
Symptoms
Syndrome
Remission
Response
Recovery – 6 months
Continuation
treatment
Maintenance
treatment
Relapse Recurrence
43. Potential Predictors of Relapse
• Number of past episodes and interval
between episodes
• Stressful life events
• Medication treatment
• Psychodemographic/psychosocial factors
• Clinical factors
• Substance abuse
Altman S, et al. J Psychiatr Pract. 2006;12(5):269-282.
44. Evaluation of Mania
• Young Mania Rating Scale items*:
• Elevated mood
• Increased motor activity
• Sexual interest
• Sleep
• Irritability
• Speech
• Language
• Content
• Disruptive/aggressive behavior
• Appearance
• Insight
*Possible Score = 0-60
