Recognition and Diagnosis of Bipolar Disorder and Its Spectrum - PowerPoint PPT Presentation

About This Presentation
Title:

Recognition and Diagnosis of Bipolar Disorder and Its Spectrum

Description:

Section 1: Recognition and Diagnosis of Bipolar Disorder and Its Spectrum Spectrum of Bipolar Disorders Bipolar I and II Hypomania Bipolar NOS Cyclothymia Rapidly ... – PowerPoint PPT presentation

Number of Views:106
Avg rating:3.0/5.0
Slides: 23
Provided by: Sash51
Category:

less

Transcript and Presenter's Notes

Title: Recognition and Diagnosis of Bipolar Disorder and Its Spectrum


1
  • Section 1
  • Recognition and Diagnosis of Bipolar Disorder and
    Its Spectrum

2
Spectrum of Bipolar Disorders
  • Bipolar I and II
  • Hypomania
  • Bipolar NOS
  • Cyclothymia
  • Rapidly changing mood swings
  • Major depression with a strong family history of
    bipolar disorder
  • Antidepressant-induced mania and hypomania
  • Secondary mania, due to other illness or drugs

Adapted from American Psychiatric Association.
Practice Guideline for the Treatment of Patients
with Bipolar Disorder. 2nd ed. Washington, DC
2002.
3
Bipolar Terminology
  • A distinct period of abnormally and persistently
    elevated, expansive, or irritable mood
  • Mania
  • Lasting at least 1 week with a significant
    decline in function
  • Hypomania
  • Lasting at least 4 days, (clearly different from
    the usual non-depressed mood), but without a
    significant decline in function and no psychosis

American Psychiatric Association Diagnostic and
Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision. Washington, DC American
Psychiatric Association 2000.
4
Bipolar Terminology (cont)
  • Mixed Episode
  • The criteria are met both for a manic episode and
    for a major depressive episode (bipolar I
    disorder)
  • Cyclothymia
  • Alternating mood states that do not meet full
    criteria for depressive, manic, or mixed episode
    for at least 2 years
  • Bipolar NOS
  • A mood episode that does not meet specific
    criteria for any specific bipolar disorder

American Psychiatric Association Diagnostic and
Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision. Washington, DC American
Psychiatric Association 2000.
5
296.80 Bipolar Disorder NOS
The Bipolar Disorder Not Otherwise Specified
category includes disorders with bipolar features
that do not meet criteria for any specific
bipolar disorder. Examples include
  • Very rapid alternation (over days) between manic
    symptoms and depressive symptoms that meet
    symptom threshold criteria but not minimal
    duration criteria for manic, hypomania, or major
    depressive episodes
  • Recurrent hypomanic episodes without intercurrent
    depressive symptoms
  • A manic or mixed episode superimposed on
    delusional disorder, residual schizophrenia, or
    psychotic disorder not otherwise specified
  • Hypomanic episodes, along with chronic depressive
    symptoms that are too infrequent to qualify for a
    diagnosis of cyclothymic disorder
  • Situations in which the clinician has concluded
    that bipolar disorder is present but is unable to
    determine whether it is primary, due to a general
    medical condition, or substance induced

American Psychiatric Association Diagnostic and
Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision. Washington, DC American
Psychiatric Association 2000.
6
(No Transcript)
7
Diagnostic Criteria for Major Affective Disorders
(DSM-IV)
Disorder Depressive Episode Manic or Mixed Episode Hypomanic Episodes
Bipolar I Disorder Common but not required 1 required Common but not required
Bipolar II Disorder 1 required None allowed 1 required
Bipolar Disorder NOS Common but not required None allowed Required, but do not meet criteria for a specific bipolar disorder
Cyclothymic Disorder Dysthymia, but not major depression None allowed Numerous periods over 2 years required
Major Depressive Disorder 1 required None allowed None allowed
Dysthymic Disorder 2 years required but not major depression None allowed None allowed
NOS Not otherwise specified
Adapted from the American Psychiatric
Association Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision.
Washington, DC American Psychiatric Association
2000345-428.
8
Diagnosing Bipolar Disorder Challenges
  • Variability of age of onset and presentation
  • Commonly presenting in the depressed phase and
    being misdiagnosed as unipolar depression
  • Prepubertal onset depression or dysthymia carries
    a 2040 risk of bipolar illness
  • Symptom overlap with other psychiatric conditions
  • Previous misdiagnosis common
  • Many clinically prominent psychiatric and medical
    comorbidities

Thomas P. J Affect Disord. 200479(suppl
1)S3-S8. Berk M, et al. Med J Aust.
2006184459-462.
9
The Bipolar Spectrum Stronger
Bipolar I
? 1 week
Bipolar II
? 4 Days
Bipolar NOS
lt 4 Days
Bipolar III
Antidepressant-related hypomania
Adapted from Akiskal HS, Pinto O. Psychiatr Clin
North Am. 199922517-534.
10
The Bipolar Spectrum Weaker
Hyperthymic
Bipolar IV
Depressive Mixed State IV ½
Recurrent Unipolar Depression Bipolar V
Adapted from Akiskal HS, Pinto O. Psychiatr Clin
North Am. 199922517-534. Akiskal HS, et al. J
Affect Disord. 200696197-205.
11
Bipolar Missed States! (Mixed States)
  • Bipolar mixed states depression and mania
    co-occurring
  • Dysphoric mania common especially in women
  • Depressive mixed states
  • Core of depression, but with racing thoughts
  • Mixed hypomania

Berk M, et al. Aust N Z Psych. 200539215-221. Su
ppes T, et al. Arch Gen Psychiatry.
2005621089-1096.
12
Self-Rated Screening ToolThe Mood Disorder
Questionnaire (MDQ)
  • Hyper or more energetic than usual
  • Predominately or thematically irritable
  • Distinctly self-confident, positive or
    self-assured
  • Less sleep than usual
  • More talkative or speaking faster than usual
  • Racing thoughts
  • Easily distracted
  • Problems at work and socially
  • More interest in sex
  • Taking unusual risks
  • Excessive spending










Hirschfeld RM, et al. J Clin Psychiatry.
20036453-59.
13
Bipolar Disorder Diagnosis Is Often Missed
  • gt 85,000 US adults surveyed
  • Positive screen rate for bipolar illness 3.7
    (gt 6 million people in US)
  • For those with positive screen

Diagnosed withbipolar disorder
20
Neither bipolar disorder nor depression diagnosis
49
Diagnosed with depressionbut not bipolar disorder
31
Only 20 of those with a positive screen had been
told by their doctors that they had bipolar
disorder
Hirschfeld RM, et al. J Clin Psychiatry.
20036453-59.
14
Unipolar Misdiagnosis May Lead to Inappropriate
Treatment
Bipolar disorder misdiagnosed as unipolar
depression in 37 of patients (N 85)
100
80
55
60
Patients ()
40
23
20
n 38
n 35
0
RapidCycling
Mania/Hypomania
Development of mania/hypomania or rapid cycling
while taking antidepressants.
Ghaemi SN, et al. J Clin Psychiatry.
200061804-808.
15
The Hazards of Misdiagnosis and Delayed
Diagnosis in Bipolar Disorder
  • Increased risk of
  • Rapid cycling or mixed features
  • Suicide attempts or completion
  • Violent behavior impulsive behavior
  • Sexual and other indiscretions
  • Worsening substance abuse
  • Loss of job or significant other
  • Treatment resistant

16
Self-Report Diagnostic Tools For Screening
Bipolar Disorder
Scale Description Limitations
Mood Disorder Questionnaire (MDQ) 13 item questionnaire (? 7 is a positive screen) More sensitive for bipolar I than II, should not replace a full diagnostic interview
Bipolar Spectrum Diagnostic Scale (BSDS) Screens for subtle versions of bipolar and can rate the probability of bipolar as high, moderate, low, or unlikely Should not replace a full diagnostic interview
Quick Inventory for Depression Symptomatology (QIDS) 16 item inventory, each item rated 0-3 Takes an average of 15 minutes to implement
17
Clinician-Administered Diagnostic Tools For
Screening Bipolar Disorder
Scale Description Limitations
Young Mania Rating Scale (YMRS) 11 item scale, each with a varied rating scale based on severity (mania 12, depression 3, euthymia 2) Usefulness of scale is limited in populations with diagnoses other than mania
Bipolarity Index Evaluation of bipolar presentation based on 5 dimensionseach worth up to 20 points for a total of 100 Time consuming, not peer reviewed
Hamilton Rating Scale for Depression (HAM-D) 17-21 item scale initially intended for identifying depressed patients Relies heavily on clinical interviewing skills and experience of the rater
Montgomery-Asberg Depression Rating Scale (MADRS) 10 selected items are rated on a scale of 0-6 with anchors at 2-point intervals Cost prohibitive and time consuming
18
Subthreshold Bipolar Disorder(The Soft Bipolar
Spectrum)
  • Boundaries of bipolarity have expanded over the
    past decade
  • Suggest that the diagnostic criteria for
    hypomania need revision
  • Further study is needed to evaluate the hard
    and soft definitions of bipolar II, minor
    bipolar disorder, and hypomania
  • A more expansive definition of bipolar II yields
    a cumulative prevalence rate of 10.9, compared
    to 11.4 for broadly defined major depression

Akiskal HS. Curr Psychiatry Rep.
200241-3. Angst J, et al. J Affect Disord.
200373133-146.
19
The Rule of 3 Hinting at Soft Bipolarity (NOS) in
a Clinically Depressed Person
  • Three or more
  • Major depressive episodes
  • Failed marriages
  • Failed antidepressants trials
  • Distinct professions
  • First degree relatives (or generations) with
    affective illness
  • Fields of eminence in the family
  • Substances of abuse
  • Impulsive behaviors (gambling, car racing,
    sexual, etc.)
  • Individuals dated simultaneously
  • Simultaneous jobs
  • Languages (for US-born citizens)
  • Triad of past histrionic, psychopathic, or
    borderline diagnoses
  • Triad of red car, necktie, or belt

Akiskal HS. J Affect Disord. 200584279-290.
20
Importance of Interviewing the Patient and Their
Family
  • Patients admitted with major depression
  • NIMH study
  • Step 1 Patient screened for bipolar disorder
  • Step 2 Family member interviewed (by another
    investigator interested in genetics)
  • Result Twice as many bipolar I diagnoses from
    interviewing both the patient and a family member

Blehar MC, et al. Psychopharmacol Bull.
199834239-243.
21
Physicians Must Use Patient Perspectives to
Improve Diagnosis and Care
  • Factors Necessary for Recovery
  • Communication between patient and physician best
    chance for recovery when patient feels hes being
    heard physician must try to understand how the
    world looks through patients eyes
  • Treatment plans that include patient input and
    preferences physician must discuss all options
    so patient has complete understanding of illness
  • Recovery-oriented treatment based on mutually
    agreed goals so patient feels like a partner in
    care

Lewis L, et al. Adm Policy Ment Health.
200532497-503.
22
Take Home Messages
  • Bipolar disorder can masquerade in different or
    mixed mood states
  • Bipolar disorder is often misdiagnosed as
    depression due to the prevalence of depressive
    episodes often as the presenting phase
  • Misdiagnosis can have serious detrimental effects
    on treatment effectiveness and outcomes
Write a Comment
User Comments (0)
About PowerShow.com