1. History and Physicala. Age of onset: 28-33 y/o
b. Duration of episode: before 1960 = 7-13 months; after 1960= 2-4 months
c. Recovery: 5-10% don’t recover
d. Mortality and Suicide: 10-15% of patients with bipolar I disorder COMPLETES SUICIDE
e. Fluctuation between periods of deep, prolonged and profound depression and excessively elevated or irritable mood known as mania
f. 2 Types: Bipolar I and Bipolar II
2. Diagnostic Studies
a. Psychological Testing: Not involved in Bipolar Diagnosis
* “Dickstein and Leibenluft” Cambridge Neuropsychological Test Automated Battery (CANTAB) shows difficulties in attentional set shifting and visuospatial memory in pediatric bipolar disorder. Children with bipolar and anxiety d/o’s misinterpreted sad/happy/fearful child faces s angry vs. healthy children.
b. No lab findings are diagnostic
c. Neuroimaging- preliminary. MRI suggest white matter hyperintensities in cortical and subcortical brain regions and smaller amygdalar size.
3. Diagnosis
a. Manic Episode: Abnormal and persistently elevated/expansive/irritable mood for 1+ week (or any duration if hospitalized)
* During the disturbance, must have 3+ of following symptoms
-Inflated self-esteem or grandiosity
-Decreased need for sleep (ie- feels rested after 3 hours of sleep)
-More talkative than usual or pressure to keep talking
-Flight of ideas or subjective experience that thoughts are racing
-Distractibility
-Increase in goal-directed activity or psychomotor agitation
-Excessive involvement in pleasurable activities with high potential for painful consequences (unrestrained buying sprees)
-Symptoms doesn’t meet criteria for a Mixed Episode
b. Hypomanic Episode: Persistently elevated, expansive, or irritable mood lasting 4+ days clearly different from nondepressed mood
* Same as above (Manic Episode)
* Episode associated with an unequivocal change in fxning that is uncharacteristic of the person when not symptomatic
* Disturbance in mood/fxning is noticeable by others
* Not severe enough to cause marked impairment in social or occupational fxning or to necessitate hospitalization; NO PSYCHOTIC FEATURES
* SYMPTOMS NOT D/T SUBSTANCE ABUSE OR MEDICAL CONDITION
c. MIXED EPISODE = Criteria met both for Manic Episode and Major Depressive Episode nearly EVERY DAY during at least 1 week period
* MARKED IMPAIRMENT NOTED IN FXNING
* NOT D/T SUBSTANCE ABUSE NOR GENERAL MEDICAL CONDITION
d. BIPOLAR I-
* Currently/recently in a Manic Episode
* Previously at least 1 MDD, Manic Episode, or Mixed Episode
* Mood episodes in the first 2 criteria aren’t better accounted for by Schizoaffective Disorder and not superimposed on Schizophrenia, Schizophreniform D/O, Delusional D/O, or Psychotic D/O NOS
e. BIPOLAR II
* Presence (H/O) 1+ Major Depressive Episodes
* Presence (H/O) 1+ Hypo(mild) manic Episode
* NEVER has there been a MANIC episode NOR a MIXED episode
* Mood episodes in the first 2 criteria aren’t better accounted for by Schizoaffective D/O and are not superimposed on Schizophrenia, Schizophreniform D/O, Delusional D/O, or Psychotic D/O NOS
* Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
f. Differential Diagnosis: ADHD, schizophrenia, pervasive developmental disorder, child abuse, seizure disorders or other medical condition, substance abuse (steroids, amphetamines, cocaine)
4. Health Maintenance
a. Correlation b/w genetics and neuroimaging findings and Bipolar disorder; ie) stressful family environment and abuse associated w/ earlier onset, if 1 twin has Bipolar D/O most likely the other twin has it too
b. High rates in children of coexisting ADHD and anxiety D/O
c. In everyone else, comorbid disorders include: ADHD, ODD, Conduct D/O, Anxiety D/O, Substance-use D/O, and pervasive developmental D/O
5. Clinical Intervention
a. Psychotherapy: CBT may be effective in 8-18 y/o’s with BP
· Reward-based CBT with interpersonal psychotherapy; “empathetic validation”
b. Psychoeducation: teaching parents and teachers about symptoms, course, and tx of BP
c. Family focused therapy (FFT): addresses concerns of adolescents with BP and builds resources to manage stress and lower expressed emotion w/in family
d. ECT (electroconvulsive therapy)
e. Omega-3 fatty acids: FDA approved 3g/day in adults
6. Clinical Therapeutics
a. For BP1, Manic or mixed Episode without psychosis: Mood stabilizer +Atypical Antipsychotic
* First line = Mood Stabilizers (if non psychotic mania): Lithium, Divalproex (Depakote/Valproic Acid), and Carbamazepine OR Atypical Antipsychotics (yields a quicker response in patient): Olanzapine, Quetiapine, and Risperidone
* If only mild to moderate improvementàadd another agent to augment results (most likely another: mood stabilizer or atypical antipsychotic)
* If still no optimal resultsàdo monotherapy with another agent
b. For bipolar depression: Lithium(prophylactic drug)/Depakote/Atypical Antipsychotics/Lamotrigine OR Traditional Mood stabilizers + Atypical Antipsychotics + SSRIs/Bupropion
c. Note: since most children and adolescents with BP also have comorbid d/o’s like ADHD, tx should be directed to comorbid d/o’s
d. ADVERSE EFFECTS OF MEDS: All meds for BP-Weight gain (leading to DM, Hyperlipidemia, and elevation of LFTs), Valproate (Black box warning- PANCREATITIS), Lithium (Hypothyroidism, weight gain, changes in renal fxn)
e. No studies for BP II tx in children and adolescents
7. Scientific Concepts
a. N-acetyl-aspartate, choline, myoinositol, and creatinine/phosphocreatinine affected in fronto-striatal region, cingulated cortex, DLPFC, and other areas of brain
b. Pediatric BP- small amygdala size, decrease in hippocampal volume, white matter hyperintensities in cortical and subcortical brain regions, smaller parietal and temporal lobe cortical gray matter, reduced gray matter volume in dorsolateral prefrontal cortex, larger basal ganglia, increase in putamen size, increased left thalamus |
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