| What was Mozart's condition? | Incredible mental capacity but naive sometimes, he had cyclothymic disorder (mood swings), deeply religious, needs a lot of affection, loved Constanze faithful, unable to manage fincancially. Hideous laugh |
| How is misdiagnosis of bipolar? | 69% of cases are misdiagnosed, 60% depression, 26% anxiety, 18% schizophrenia, 17% cluster B personality disorders and 14% alcohol abuse
This is due to the flares and the presentation of the disorder |
| How is the manic episode of bipolar? | Abnormally perisitently elevated expansive or irritable mood abnormally and persistently increased goal directed energy lasting at least 1 week or any duration if it lead to hospitalization,
3 or more of [grandiosity, decreased need for sleep, more talkative, racing thoughts, distractability, increased activity, increased risky behavior], impairs social/occupational status may need hospitalization, no substance or medical condition leading to it.
Note that a full manic episode during AD treatment persisting beyond physiologic effect of the AD is evidence for manic episode and bipolar I diagnosis |
| How is hypomanic episode of bipolar? | Abnormally elevated activity, irritability, energy for at least 4 days with 3 or more of same as manic episode effects.
Episode is associated with an equivocal change in function, mood disturbance is evident, not severe enough to cause hospitalization, so if psychotic ->manic, not attributable to physiological effects of substance |
| What are mixed specifiers of bipolar? | 1- Manic or hypomanic episode, w/ mixed features:
Full criteria are met for a manic episode or hypomanic episode, and at least 3 of depressive symptoms present.
2- Depressive episode, w/ mixed features:
Full criteria are met for a major depressive episode, & at least 3 of manic/hypomanic symptoms present. |
| What is the clinical spectrum of bipolar? | Bipolar I Disorder: characterized by the presence of at least one manic episode
Bipolar II Disorder: one or more major depressive episode & at least one hypomanic episode
Cyclothymic Disorder
Substance/Medication-Induced Bipolar and Related Disorder
Bipolar and Related Disorder Due to Another Medical Condition
Other Specified Bipolar and Related Disorder
Unspecified Bipolar and Related Disorder |
| What is bipolar disorder spectrum> | Bipolar ½ Schizobipolar disorder
Bipolar I Manic-depressive illness
Bipolar 1 ½ Depression w/ protracted hypomania
Bipolar II Depression w/ spontaneous discrete hypomanic episodes
Bipolar III Repeated depression plus hypomania occurring solely w/ antidepressant or other somatic tx
Bipolar III ½ Depression, mood swings & hypomania occurring w/ substance & / or alcohol abuse
Bipolar IV Depression superimposed on a hyperthymic temperament
Bipolar V Recurrent depressions (≥ 5) |
| What is so peciuliar about bipolar? | Is it a continuum (mood episodes grading, severity, frequency, mixture of symptoms in same episode, many MDD shift bipolar in long term [first episode is depressive], residual manic episodes predict depressive recurrence, bipolar signs may be common in MDD makes difficult dx)
So we have phenotype and its opposite and middle, diverse cluster of symptoms, self-lethality, multiple comorbidities, AD may be saviours or killers. |
| What are the 4 cluster of symptoms of bipolar? | Manic/hypomanic (euphoria, pressured speech, impulsive, irritable, violence, excess libido, reckless, social intrusiveness, diminished need for sleep)
Depressive (sad, anhedonia, withdrawal, anxiety, suicide)
Cognitive (racing thoughts, distractable, disorgnaized, inattetiveness)
Psychotic (hallucination/delusion) |
| What are red flags in bipolar? | Age of onset (teens, 20s, 30s)
Psychotic episodes (more common)
Family hx high, temperament cyclothymic, numerous episodes, abrupt onset of episodes, postpartum increase, resistant to AD / poop out of AD treatment is common
Clues for bipolar in depressive episodes that are found more in bipolar than depression are total sleep time, hypersomnia, psychomotor retardation, post-partum episodes, while weight loss is more in depressive than bipolar
Other clues of bipolar in depressive disorders are seasonal depression, depression with sexual arousal, suicidal crisis |
| How is the transition from MDD to Bipolar? | nearly quarter of adults w/MDD after 12-14 years followup developed BD w/greatest risk of transition in first 5 years, seen in pt w/family hx of BD, earlier age of onset of MDD and presence of psychotic symptoms |
| How is epidemiology of BD? | Estimates for lifetime prevalence worldwide: 0.5% to over 5%. Diagnostic assessment methods and criteria varied broadly from study to study, males=females, age onset 18-20 yrrs, no variation in ethnicity if other factors controlled, marital status is debatable whether its the cause or consequence |
| How is clinical assessment of BD? | Third-party information, Adequate exam time
Diagnostic scales: Mood disorder questionnaire, Bipolar spectrum diagnostic scale…Longitudinal assessment, Family history.
Van Gogh was thought to have it due to his difference in paintings. |
| What are comorbidities associated with BD? | Medical (migraine, pain disorders, DM, CVD, Obesity)
Psychiatric (Personality disorders, ADHD, Impulse control, anxiety disorders, eating disorders, substance abuse)
30% obese, 43% hyperglycemia, 20% hypercholesterolemia, male, depressed/mixed and duration of illness more obesity. Older age, later disease onset and lower education more hyperglycemia
Other (more hospitalization, poorer tx response, pharmaco conflicts, worse outcomes, higher suicide risk, violence)
Suicide attempts most seen in Bipolar II, then Bipolar I and then unipolar |
| What are the objectives of BD treatments? | Control depression
Control mixed specifiers
Control Mania/Hypomania
Relapse prevention…
Control suicidality
Control side effects |
| What are treatments of manic episodes? | FDA approved (Lithium, valproate, olanzapine, chlorpromazine, risperidone, queiapine)
trials (carbamazepine, antipsychotics, ziprasidone, aripiprazole, ECT)
Mood stabilizers (Mania minded [treat from above, reduce mania or stabilize it to prevent recurrence of mania], depression minded [treat from below, reduce bipolar depression symptoms or stabilize it to prevent relapse and recurrence])
3 categories: Lithium, Anticonvulsants, and neuroleptics/antipsychotics. |
| How is Lithium tx? | 50 years and still The Reference/first choice drug.
1- inhibition of second messenger enzymes inositol monophosphatase
2- modulation of G proteins
3- inhibition of glycogen synthetase kinase 3 (GSK3) and protein kinase C. Promotes neuroprotection long-term plasticity. Evidence as best for suicide prevention.
Side effects: nausea, vomiting, and diarrhea, weight gain, hair loss, acne, tremor ...
Long-term adverse effects on the thyroid and kidney
-Prelithium workup: TSH, FT3, FT4, CBC, Electrolytes, BUN, Creatinine, Ca and EKG if more than 40 yrs.
-Therapeutic level :0.6 - 0.9 and clinical assessment. |
| What are anticonvulsants tx? | Valproic acid, Carbamazepine, Lamotrigine
Lamotrigine (May be effective in treatment of bipolar depression non FDA approved.
FDA approved prevent the recurrence of both mania & depression ie maintenance.
Well tolerated, except :rash, rarely Stevens—Johnson syndrome (toxic .epidermal necrolysis) minimized by very slow uptitration.
Best as add on
Mechanism of action: reduces the release of the excitatory glutamate, block calcium channel, block potassium channel |
| What are neuroleptics used in BD tx? | Old gen (Haloperidol, Chlorpromazine, Perphenazine, Pimozide, Zuclopenthixol)
Atypical/second Gen (Risperidone, Olanzapine, Quetiapine, Lurasidone, Aripiprazole, Clozapine (for resistant schizophrenia) |
| What is the biggest tx challenge? | Maintenance
Lifetime +++ for relapse prevention.
Monotherapy (ex. Lithium…) rare.
Combination is the rule +++
Regular follow-up for compliance and side-effect monitoring |
| Talk about stories regarding BD? | Churchill (his depression is his black dog, recorded to have manic episodes)
Wolff felon committed suicide to overcome guilt
Prephecy on marche sur la lune
Antigone (Sopholces 441 BC Oedipus/antigone, Ismene/antigone and haemon/antigon problems, suicide (religion, family cardinal signs), Haemon suicide more emotional |
