1. Bipolarity:Bipolarity:
A Tendency Searching for 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 Leading Causes 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
4. IntroductionIntroduction
▪ What is the nature of bipolar disorder?
▪ Classifications
•Definitions
•Context
•Is there such a thing as Bipolar Disorder?
▪ Treatments
•Medications
•Psychotherapy
5. Risk for SuicideRisk for 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)Ernest Hemingway (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.
11. Epidemiology of Mood Disorders
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.
20. The Diagnostic ChallengeThe Diagnostic 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
23. Natural KindsNatural Kinds
"In everyday 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?Flower or 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 for a 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
35. SummarySummary
▪ Current classificatory system 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
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
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.
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.
Prevalence and Correlates of Bipolar Spectrum Disorder in the World Mental Health Survey Initiative Arch Gen Psychiatry. 2011 Mar; 68(3): 241–251.
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.
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.
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.
