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HOHBipolar
Bipolar disorder is currently classified categorically but there is evidence it may be better defined dimensionally. The risk of suicide is 20-30 times higher for those with bipolar disorder compared to the general population. While medications and psychotherapy can help treat bipolar disorder, the current diagnostic system is limited and new treatments are still needed. Improved classification systems incorporating dimensional assessments may lead to better outcomes and more targeted treatment approaches.
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HOHBipolar
- 1. Bipolarity:Bipolarity: A Tendency Searchingfor a DiagnosisA Tendency Searching for a Diagnosis Laurence P. Karper, M.D.Laurence P. Karper, M.D. Vice-Chair, PsychiatryVice-Chair, Psychiatry Lehigh Valley Health NetworkLehigh Valley Health Network
- 2. The 10 LeadingCauses of DeathThe 10 Leading Causes of Death 2010 – 2013 All Races, Both Sexes2010 – 2013 All Races, Both Sexes Office of Statistics and Programming, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention Data Source: National Center for Health Statistics (NCHS), National Vital Statistics System
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- 4. IntroductionIntroduction ▪ What isthe nature of bipolar disorder? ▪ Classifications •Definitions •Context •Is there such a thing as Bipolar Disorder? ▪ Treatments •Medications •Psychotherapy
- 5. Risk for SuicideRiskfor Suicide ▪ Review of Literature published in 2013Review of Literature published in 2013 ▪ All relevant papers published between 1980 and 2011. A total of 34 articles meeting inclusion criteria were included in the review ▪ The risk for suicide in Bipolar disorder isThe risk for suicide in Bipolar disorder is 20-30 times the risk in the general20-30 times the risk in the general population.population. Epidemiology of suicide in bipolar disorders: a systematic review of the literature, Bipolar Disorders 15:2013, 457–490.
- 6. Ernest Hemingway (1889-1961)ErnestHemingway (1889-1961) Hemingway spent the first half of 1961 fighting his depression and paranoia, seeing enemies at every turn and threatening suicide on several more occasions. On the morning of July 2, 1961 Hemingway rose early, as he had his entire adult life, selected a shotgun from a closet in the basement, went upstairs to a spot near the entrance-way of the house and shot himself in the head. It was little more than two weeks until his 62nd birthday.
- 7. Treatment WorksTreatment Works 0 5 10 15 20 25 30 StandardMortalityRatio UntreatedTreated Cancer CVD Suicide
- 8. Social Integration andSuicide Association Between Social Integration and Suicide Among Women in the United States, JAMA Psychiatry. 2015;72(10):987-993. Copyright © 2015 American Medical Association. All rights reserved. The follow-up period was from 1992 to 2010, with estimates of the incidence of suicide stratified by social integration category measured in 1992.
- 9. Placebo Change andSeverityPlacebo Change and Severity JAMA. 2010;303(1):47-53.
- 10. Subjective Well-BeingSubjective Well-Being R.M. Nesse Natural selection and the elusiveness of happiness, Phil. Trans. R. Soc. Lond. B (2004) 359, 1333–1347
- 11. Epidemiology of MoodDisorders Statistic Any Mood Disorder Major Depression Bipolar Disorder 12 Month Prevalence 7.5% 4.1% 0.72% Lifetime Prevalence 14.1% 6.7% 0.82% Prevalence and Incidence Studies of Mood Disorders: A Systematic Review of the Literature. Can J Psychiatry 2004;49:124–138.
- 12. Arch Gen Psychiatry.2011 Mar; 68(3): 241–251. Copyright © 2015 American Medical Association. All rights reserved. Cumulative age-at-onset distributions of bipolar disorder type I (BP-I), bipolar disorder type II (BP-II), and sub- threshold bipolar disorder (BP) among respondents projected to develop these disorders in their lifetime. Cumulative Risk Developing a Bipolar Spectrum Disorder
- 13. Depression: A SystemicIllness—Depression: A Systemic Illness— The Emotional and Physical SignsThe Emotional and Physical Signs ▪ Depressed moodDepressed mood ▪ AnhedoniaAnhedonia ▪ HopelessnessHopelessness ▪ Low self-esteemLow self-esteem ▪ Impaired memoryImpaired memory ▪ DifficultyDifficulty concentratingconcentrating ▪ AnxietyAnxiety ▪ PreoccupationPreoccupation with negativewith negative thoughtsthoughts ▪ HeadacheHeadache ▪ FatigueFatigue ▪ Disturbed sleepDisturbed sleep ▪ DizzinessDizziness ▪ Chest painChest pain ▪ Vague joint/limb painVague joint/limb pain ▪ Vague back/Vague back/ abdominal painabdominal pain ▪ GI complaints (nausea,GI complaints (nausea, vomiting, constipation,vomiting, constipation, diarrhea, gas)diarrhea, gas) ▪ SexualSexual dysfunction/apathydysfunction/apathy ▪ Menstrual problemsMenstrual problems DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000. Kroenke K, et al. Arch Fam Med. 1994;3:774-779.
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- 15. Explanatory Hypothesis:Explanatory Hypothesis: TheHeartThe Heart
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- 17. Disturbance of BehaviorDisturbanceof Behavior
- 18. Limitations of theLimitationsof the “Bipolar” Diagnosis“Bipolar” Diagnosis
- 20. The Diagnostic ChallengeTheDiagnostic Challenge ▪ Why Bother?Why Bother? •Diagnosis leads to PrognosisDiagnosis leads to Prognosis •Improves outcomesImproves outcomes •Allows a point of entry for individualAllows a point of entry for individual growth and developmentgrowth and development •Targeted therapeutic actionTargeted therapeutic action
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- 22. Dimensional vs. CategoricalDimensionalvs. Categorical
- 23. Natural KindsNatural Kinds "Ineveryday terms, a natural kind is a collection or category of things that are all the same as one another, but different from some other set of things. These things may (or may not) look the same on the surface, but they are equivalent in some deep, natural way. In the most straightforward philosophical sense, a natural kind is a non-arbitrary grouping of instances that occur in the world. This grouping, or category, is given by nature and is discovered, not created, by the human mind.“ -- Lisa Feldman Barrett
- 24. Flower or Weed?Floweror Weed? Any plant that grows where it'sAny plant that grows where it's not wanted is a weed. A case innot wanted is a weed. A case in point, the common blue violetpoint, the common blue violet (Viola sororia, U.S. Department(Viola sororia, U.S. Department of Agriculture plant hardinessof Agriculture plant hardiness zones 3 through 7) is oftenzones 3 through 7) is often considered attractive in a flowerconsidered attractive in a flower bed but may be perceived as abed but may be perceived as a weed if it begins spreading in aweed if it begins spreading in a lawn. Weeds also compete forlawn. Weeds also compete for nutrients, sun and water, and,nutrients, sun and water, and, like the common chickweedlike the common chickweed (Stellaria media), may host pests(Stellaria media), may host pests or spread diseases to otheror spread diseases to other garden plants.garden plants. Viola Sororia
- 25. A Proposal fora DimensionalA Proposal for a Dimensional ClassificationClassification Deconstructing Bipolar Disorder: A Critical Review of its Diagnostic Validity and a Proposal for DSM-V and ICD-11, Schizophrenia Bulletin vol. 33 no. 4 pp. 886–892, 2007
- 26. Mood Disorder QuestionnaireMoodDisorder Questionnaire
- 27. Relationships among RegionsMediatingRelationships among Regions Mediating CBT and Drug ResponseCBT and Drug Response
- 28. Stress and theSerotonin Transporter GeneStress and the Serotonin Transporter Gene
- 29. Diagnosis or Condition?Diagnosisor Condition?
- 30. Diagnosis or Condition?Diagnosisor Condition?
- 31. Distribution of StroopDistributionof Stroop Interference ScoresInterference Scores
- 32. PsychopharmacologyPsychopharmacology ▪ Mood StabilizersMoodStabilizers • Lithium (1970)Lithium (1970) • Lamotrigine (2003)Lamotrigine (2003) ▪ AntipsychoticsAntipsychotics ▪ Clozapine (1989)Clozapine (1989)
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- 34. PsychotherapyPsychotherapy Interpersonal Social Rhythm Therapy Cognitive-BehavioralTherapy Support Groups
- 35. SummarySummary ▪ Current classificatorysystem is inadequate.Current classificatory system is inadequate. ▪ New treatments are sorely needed.New treatments are sorely needed. ▪ PsychotherapyPsychotherapy ▪ Somatic TherapySomatic Therapy ▪ Hopefully new understandings will lead toHopefully new understandings will lead to improved treatmentimproved treatment ▪ If you have questions or would like a copy ofIf you have questions or would like a copy of the slides email me atthe slides email me at ▪ Laurence.karper@lvhn.orgLaurence.karper@lvhn.org
Editor's Notes
- #10 http://jama.ama-assn.org/cgi/content/full/303/1/47 JAMA. 2010;303(1):47-53 (doi:10.1001/jama.2009.1943) Jay C. Fournier; Robert J. DeRubeis; Steven D. Hollon; et al. Patient-Level Meta-analysis http://jama.ama-assn.org/cgi/content/full/303/1/47
- #11 R. M. Nesse Natural selection and the elusiveness of happiness Phil. Trans. R. Soc. Lond. B (2004) 359, 1333–1347 The quest for happiness has expanded from a focus on relieving suffering to also considering how to promote happiness. However, both approaches have yet to be conducted in an evolutionary framework based on the situations that shaped the capacities for happiness and sadness. Because of this, the emphasis has almost all been on the disadvantages of negative states and the benefits of positive states, to the nearly total neglect of ‘diagonal psychology’, which also considers the dangers of unwarranted positive states and the benefits of negative emotions in certain situations. The situations that arise in goal pursuit contain adaptive challenges that have shaped domain-general positive and negative emotions that were partially differentiated by natural selection to cope with the more specific situations that arise in the pursuit of different kinds of goals. In cultures where large social groups give rise to specialized and competitive social roles, depression may be common because regulation systems are pushed far beyond the bounds for which they were designed. Research on the evolutionary origins of the capacities for positive and negative emotions is urgently needed to provide a foundation for sensible decisions about the use of new mood-manipulating technologies.
- #12 The aggregate lifetime prevalence of BP-I disorder was 0.6%, BP-II was 0.4%, subthreshold BP was 1.4%, and Bipolar Spectrum (BPS) was 2.4%. Twelve-month prevalence of BP-I disorder was 0.4%, BP-II was 0.3%, subthreshold BP was 0.8%, and BPS was 1.5%. Severity of both manic and depressive symptoms, and suicidal behavior increased monotonically from subthreshold BP to BP-I. By contrast, role impairment was similar across bipolar subtypes. Symptom severity was greater for depressive than manic episodes, with approximately 75% of respondents with depression and 50% of respondents with mania reporting severe role impairment. Three-quarters of those with BPS met criteria for at least one other disorder, with anxiety disorders, particularly panic attacks, being the most common comorbid condition. Less than half of those with lifetime BPS received mental health treatment, particularly in low-income countries where only 25% reported contact with the mental health system.
- #13 Prevalence and Correlates of Bipolar Spectrum Disorder in the World Mental Health Survey Initiative Arch Gen Psychiatry. 2011 Mar; 68(3): 241–251.
- #14 Key Point Physical symptoms may be the major mediating morbid event leading a patient to seek treatment Background Patients with MDD can present with a variety of emotional and physical signs and symptoms In addition to depressed mood and anhedonia, emotional symptoms associated with MDD include feelings of hopelessness, low self-esteem, impaired memory, difficulty concentrating, anxiety, and preoccupation with negative thoughts Patients with MDD also may present with a wide variety of physical complaints; indeed, physical symptoms are the predominant complaint among patients seeking treatment in general medical settings As these symptoms are general in nature, it is important to obtain a complete medical history and to rule out other physical illnesses to ensure an accurate diagnosis of depression References 1. DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000. 2. Kroenke K, et al. Arch Fam Med. 1994;3:774-779.
- #26 The development of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and International Classification of Diseases, Eleventh Edition, deserves a significant conceptual step forward. There is a clear need to improve and refine the current diagnostic criteria, but also to introduce dimensions, perhaps not as an alternative but rather as a useful complement to categorical diagnosis. Laboratory, family, and treatment response data should also be systematically included in the diagnostic assessment when available. We have critically reviewed the content, concurrent, discriminant, and predictive validity of bipolar disorder, and to overcome the validity problems of the current classifications of mental disorders, we propose a modular system which may integrate categorical and dimensional issues, laboratory data, associated nonpsychiatric medical conditions, psychological assessment, and social issues in a comprehensive and nevertheless practical approach.
- #28 Goldapple, K. et al. Arch Gen Psychiatry 2004;61:34-41. Schematic model illustrating relationships among regions mediating cognitive behavior therapy (CBT) and drug response. Regions with known anatomical and functional connections that also show significant metabolic changes following successful treatment are grouped into 3 compartments—cognitive, autonomic, and self-reference. Red regions designate areas of change seen with both treatments. Green regions designate changes unique to CBT. Blue regions designate changes unique to paroxetine. Solid black lines and arrows identify known corticolimbic, limbic-paralimbic, and cingulate-cingulate connections. Gray arrows indicate reciprocal changes with treatment. The model proposes that illness remission occurs when there is modulation of critical common targets (red regions), an effect facilitated by top-down (medial frontal, anterior cingulate) effects of CBT (green) or bottom-up (brainstem, striatal, subgenual cingulate) actions of paroxetine (blue). PF9 indicates dorsolateral prefrontal; p40, inferior parietal; pCg, posterior cingulate; mF9/10, medial frontal; aCg24, anterior cingulate; oF11, orbital frontal; bg, basal ganglia; thal, thalamus; Cg25, ventral subgenual cingulate; a-ins, anterior insula; am, amygdala; hth, hypothalamus; and bs, brainstem. Numbers are Brodmann area designations.