Bipolar and Related Disorders, Depressive Disorders, Schizophrenia Spectrum Trisha Economidis Marilee Elias Lake-Sumter State College Fall, 2014

Mood Also called pervasive and sustained emotion that may have a major influence on a person’s perception of the world. Also called pervasive and sustained emotion that may have a major influence on a person’s perception of the world. DepressionJoy DepressionJoy ElationAnger ElationAnger Anxiety Anxiety

Bipolar Disorder A psychobiological disorder characterized by alternating mood disturbances of mania, hypomania, depression and mixed episodes A psychobiological disorder characterized by alternating mood disturbances of mania, hypomania, depression and mixed episodes

Etiology of Bipolar Disorder Strong genetic link Strong genetic link May be related to hormone imbalances May be related to hormone imbalances Neurotransmitter levels definitely implicated Neurotransmitter levels definitely implicated

Mania Symptoms Racing thoughts, increased energy, less need for sleep Racing thoughts, increased energy, less need for sleep Talkative Talkative More self-confident than usual More self-confident than usual Focused on getting things done, while accomplishing little Focused on getting things done, while accomplishing little Risky or unusual activities to the extreme Risky or unusual activities to the extreme

Depression - Symptoms Sadness, anhedonia Sadness, anhedonia Feeling worthless, hopeless, guilty Feeling worthless, hopeless, guilty Sleep disturbances Sleep disturbances Appetite/weight changes Appetite/weight changes Anergia Anergia Restlessness Restlessness Problems concentrating or making decisions Problems concentrating or making decisions Thoughts of death or suicide Thoughts of death or suicide

Bipolar Disorder Treatment Lithium Lithium Must be at therapeutic level – mEq/L for acute mania; mEq/L for maintenance Must be at therapeutic level – mEq/L for acute mania; mEq/L for maintenance Can easily become toxic Can easily become toxic Many side-effects Many side-effects

Other pharmacological treatments Anticonvulsant (antiepileptic) meds often first-line treatment as well – Valproic Acid (Depakote), Lamotrigine (Lamictal), Carbamazepine (Tegretol) Anticonvulsant (antiepileptic) meds often first-line treatment as well – Valproic Acid (Depakote), Lamotrigine (Lamictal), Carbamazepine (Tegretol) Antipsychotics may be used alone or in combination with lithium; Risperidone (Risperdal), Olanzepine (Zyprexa), Aripiprazole (Abilify) Antipsychotics may be used alone or in combination with lithium; Risperidone (Risperdal), Olanzepine (Zyprexa), Aripiprazole (Abilify) Antidepressants used VERY cautiously Antidepressants used VERY cautiously Anxiolytics Anxiolytics

Tips for Preventing Manic Episodes Get plenty of sleep Get plenty of sleep Set reasonable work hours Set reasonable work hours Join a support group Join a support group Take meds as prescribed Take meds as prescribed Track history of episodes, looking for triggers Track history of episodes, looking for triggers Avoid destabilizers (alcohol, drugs, caffeine) Avoid destabilizers (alcohol, drugs, caffeine)

Consider psychotherapy Consider psychotherapy Get regular check-ups with primary care physician Get regular check-ups with primary care physician Have someone you trust monitor your behavior and moods. Bipolar disorder often attacks insight first Have someone you trust monitor your behavior and moods. Bipolar disorder often attacks insight first

Depressive Disorders Major Depressive Disorder Major Depressive Disorder Persistent Depressive Disorder (Dysthymia) Persistent Depressive Disorder (Dysthymia) Premenstrual Dysphoric Disorder Premenstrual Dysphoric Disorder Depressive Disorder due to another medical condition Depressive Disorder due to another medical condition Substance/Medication-induced Depressive Disorder Substance/Medication-induced Depressive Disorder

Depression Depression and anxiety are most common psychiatric disorders seen in primary care Depression and anxiety are most common psychiatric disorders seen in primary care Less than 50% of those with depression actually ask for help Less than 50% of those with depression actually ask for help It is a potentially lethal illness It is a potentially lethal illness

Risk Factors for Depression Family history Family history Personal history Personal history Female gender Female gender Life stressor Life stressor Loss of parents at young age Loss of parents at young age Childhood abuse Childhood abuse

Risk factors, cont. Alcohol or substance abuse Alcohol or substance abuse Anxiety disorders Anxiety disorders Neurologic or medical disorders Neurologic or medical disorders Primary sleep disorders Primary sleep disorders Elderly Elderly Post-partum Post-partum

Treatment for Depression Individual Psychotherapy Individual Psychotherapy Group and/or family therapy Group and/or family therapy Psychopharmacology Psychopharmacology SSRI’s SSRI’s SNRI’s SNRI’s Atypical antidepressants (Mirtazapine (Remeron), Bupropion HCL (Welbutrin)) Atypical antidepressants (Mirtazapine (Remeron), Bupropion HCL (Welbutrin)) Others as discussed with anxiety treatment Others as discussed with anxiety treatment

Suicide 11 th leading cause of death in the U.S. 11 th leading cause of death in the U.S. Males successful 4 times more often than females Males successful 4 times more often than females Females attempt suicide 3 times more often than males Females attempt suicide 3 times more often than males Firearms are most commonly used by males Firearms are most commonly used by males Poisoning is most common method by females Poisoning is most common method by females

Suicide Myths or Facts People who commit suicide always leave a note People who commit suicide always leave a note

Myth or Fact People who die from suicide don’t warn others People who die from suicide don’t warn others Myth Myth Or Or Fact Fact

Myth or Fact People who talk about suicide are only trying to get attention. They won’t really do it. People who talk about suicide are only trying to get attention. They won’t really do it. Myth Myth Or Or Fact Fact

Myth or Fact Don’t mention suicide to someone who’s showing signs of severe depression. It will plant the idea in their minds, and they will act on it. Don’t mention suicide to someone who’s showing signs of severe depression. It will plant the idea in their minds, and they will act on it. Myth Myth Or Or Fact Fact

Myth or Fact If a person attempts suicide and survives, they will never make a further attempt. If a person attempts suicide and survives, they will never make a further attempt. Myth Myth Or Or Fact Fact

Myth or Fact Suicide is painless. Suicide is painless.MythOrFact

Myth or Fact MYTH: Many suicide methods are very painful. MYTH: Many suicide methods are very painful.

Warning Signs of Suicidal Thoughts or Intent Recent suicide or death of a friend/relative Recent suicide or death of a friend/relative Previous suicide attempt Previous suicide attempt Preoccupation with death Preoccupation with death Depression Depression Giving away prized possessions Giving away prized possessions Major change in sleep patterns Major change in sleep patterns Changes in eating patterns Changes in eating patterns

Warning Signs, cont. Withdrawal from friends/family Withdrawal from friends/family Dropping out of group activities Dropping out of group activities Personality changes Personality changes Irritability or unexplained crying Irritability or unexplained crying Expressions of failure Expressions of failure Lack of interest in the future Lack of interest in the future

Warning Signs, cont. Frequent school absence, poor performance Frequent school absence, poor performance Expressions of self-destructive behavior, verbal hints Expressions of self-destructive behavior, verbal hints SUDDEN cheerfulness after a period of depression as though there is relief from the suffering SUDDEN cheerfulness after a period of depression as though there is relief from the suffering

SAD PERSONS SCALE A Suicide Risk Assessment S – Sex – 1 pt if male S – Sex – 1 pt if male A – Age – 1 pt if 25-44, or 65+ A – Age – 1 pt if 25-44, or 65+ D – Depression – 1 pt if present D – Depression – 1 pt if present P – Previous attempt – 1 pt P – Previous attempt – 1 pt E – Ethanol use – 1 pt E – Ethanol use – 1 pt R – Rational thinking loss – 1 pt if psychotic R – Rational thinking loss – 1 pt if psychotic

SAD Person Scale, cont. S – Social supports lacking – 1 pt S – Social supports lacking – 1 pt O – Organized plan – 1 pt O – Organized plan – 1 pt N – No spouse – 1 pt N – No spouse – 1 pt S – Sickness – 1 pt S – Sickness – 1 pt 0-2 Send home with follow-up 0-2 Send home with follow-up 3-4 Closely follow or hospitalize 3-4 Closely follow or hospitalize 5-6 Strongly consider hospitalization 5-6 Strongly consider hospitalization 7-10 Hospitalize or commit 7-10 Hospitalize or commit

Interventions for Outpatient Client Don’t leave client alone Don’t leave client alone Establish a no-suicide contract Establish a no-suicide contract Make sure environment is safe Make sure environment is safe Establish frequent appt schedule Establish frequent appt schedule Establish therapeutic relationship Establish therapeutic relationship Be direct Be direct

Interventions, cont. Be aware that antidepressant use may increase risk of suicide in 1-3 weeks after they’ve been started. Level of energy increases and they are more able to carry out a plan. Be aware that antidepressant use may increase risk of suicide in 1-3 weeks after they’ve been started. Level of energy increases and they are more able to carry out a plan.

Schizophrenia Spectrum and other Psychotic Disorders Now viewed as a spectrum of disorders from least severe to most severe Now viewed as a spectrum of disorders from least severe to most severe Brief Psychotic Disorder Brief Psychotic Disorder Delusional Disorder Delusional Disorder Psychotic Disorder due to another medical condition Psychotic Disorder due to another medical condition Schizophrenia Schizophrenia

Schizophrenia Affects more than 2 million people in the US Affects more than 2 million people in the US 1 in every 100 people, across cultures 1 in every 100 people, across cultures Chronic, severe, disabling brain disease that has no known single cause Chronic, severe, disabling brain disease that has no known single cause

Schizophrenia Etiology Current theory is Variable Combination of: Current theory is Variable Combination of: Genetic Predisposition Genetic Predisposition Biochemical Dysfunction Biochemical Dysfunction Physiological Factors Physiological Factors Psychosocial Stress Psychosocial Stress

Are you Positive about those Symptoms?

Common Symptoms – Content of Thought Delusions: Delusions: Delusion of Persecution Delusion of Persecution Delusion of Grandeur Delusion of Grandeur Delusion of Reference Delusion of Reference Delusion of Control Delusion of ControlReligiosityParanoia

Symptoms – Form of Thought Associative Looseness Associative Looseness Neologisms Neologisms Concrete Thinking Concrete Thinking Clang associations Clang associations Word Salad Word Salad Tangentiality Tangentiality Perseveration Perseveration

Symptoms - Perception Hallucinations Hallucinations Auditory Auditory Visual Visual Tactile Tactile Gustatory Gustatory Olfactory OlfactoryIllusions

Symptoms – Sense of Self Echolalia Echolalia Echopraxia Echopraxia Depersonalization Depersonalization

How can you be so Negative?

Symptoms - Affect Inappropriate Affect Inappropriate Affect Flat or blunted affect Flat or blunted affect Apathy Apathy

Symptom - Volition Ambivalence – Conflicting ideas, emotions, ideas at the same time about a particular person, situation Ambivalence – Conflicting ideas, emotions, ideas at the same time about a particular person, situation

Symptoms – Impaired Interpersonal Functioning Autism – living in a fantasy world Autism – living in a fantasy world Deteriorated appearance – lack of self- care Deteriorated appearance – lack of self- care

Symptoms – Psychomotor Behavior Pacing and rocking Pacing and rocking Anergia – lack of energy Anergia – lack of energy

Symptoms – Associated features Anhedonia Anhedonia Regression Regression

Positive Symptoms (Something present that shouldn’t be there) Delusions Delusions Hallucinations Hallucinations Disorganized thinking and speech Disorganized thinking and speech Disorganized behaviors Disorganized behaviors

Negative Symptoms (Something missing that should be there) Flat or blunted affect Flat or blunted affect Alogia Alogia Avolition/apathy Avolition/apathy Anhedonia Anhedonia Social Isolation Social Isolation

Treatment Psychoanalytic psychotherapy? Psychoanalytic psychotherapy? Why NOT? Why NOT? Treatment Programs Treatment Programs Psychopharmacology Psychopharmacology Teaching Client to manage symptoms Teaching Client to manage symptoms Supportive Family Therapy Supportive Family Therapy Reality Oriented Psychotherapy Reality Oriented Psychotherapy

Psychopharmacology Antipsychotics Antipsychotics Side effects make compliance difficulty Side effects make compliance difficulty Up to 75% of schizophrenics smoke – the nicotine decreases the effectiveness of the medication Up to 75% of schizophrenics smoke – the nicotine decreases the effectiveness of the medication Dopamine believed to be the neurotransmitter most closely linked to schizophrenia Dopamine believed to be the neurotransmitter most closely linked to schizophrenia

Atypical Antipsychotics Block both serotonin and dopamine receptors Block both serotonin and dopamine receptors Treat positive and negative symptoms Treat positive and negative symptoms Have fewer side effects by still have unpleasant ones Have fewer side effects by still have unpleasant ones Clozapine (Clozaril), Respiridone (Risperdal), Olanzepine (Zyprexa), Quietapine (Seroquel), Ziprasidone (Geodon), Aripiprazole(Abilify) Clozapine (Clozaril), Respiridone (Risperdal), Olanzepine (Zyprexa), Quietapine (Seroquel), Ziprasidone (Geodon), Aripiprazole(Abilify)

Typical or Conventional Antipsychotics Many side effects including Extrapyramidal symptoms: Many side effects including Extrapyramidal symptoms: Dystonias Dystonias Akathesia Akathesia Parkinsonism Parkinsonism Tardive dyskinesia Tardive dyskinesia Life-Threatening Side Effect: Neuroleptic Malignant Syndrome Life-Threatening Side Effect: Neuroleptic Malignant Syndrome Haloperidol (Haldol), Fluphenazine (Prolixin), Chlorpromazine (Thorazine), Thioridazine (Mellaril) Haloperidol (Haldol), Fluphenazine (Prolixin), Chlorpromazine (Thorazine), Thioridazine (Mellaril)

Coming Attractions It’s All Psych The End Class 5 Personality D/Os Personality D/Os Eating D/Os Eating D/Os D/Os common in Children & Adolescents D/Os common in Children & Adolescents Pharmacological & Non-pharmacological management of these D/Os Pharmacological & Non-pharmacological management of these D/Os