1. Bipolar Disorder- Assessment B. Anthony Lindsey, MD Professor and Vice Chair UNC Department of Psychiatry

2. Bipolar Disorder Characteristics of a Manic Episode A distinct period of abnormally and persistently elevated, expansive or irritable mood A distinct period of abnormally and persistently elevated, expansive or irritable mood During the period of mood disturbance, at least three of the following symptoms have persisted (four if the mood is only irritable) and have been persistent to a significant degree During the period of mood disturbance, at least three of the following symptoms have persisted (four if the mood is only irritable) and have been persistent to a significant degree –Inflated self esteem or grandiosity –Decreased need for sleep –More talkative than usual or pressure to keep talking –Flight of ideas or subjective experience that thoughts are racing

3. Characteristics (Cont.) –Distractability, i.e. attention too easily drawn to unimportant or irrelevant external stimuli –Increase in goal-directed activity or psychomotor agitation –Excessive involvement in pleasurable activities which have a high potential for painful consequences, e.g. unrestrained buying sprees, sexual indiscretions, or foolish business investments

4. Characteristics (Cont.) Mood disturbance sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relations with others, or to necessitate hospitalization to prevent harm to self or others Mood disturbance sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relations with others, or to necessitate hospitalization to prevent harm to self or others At no time during the disturbance have there been delusions or hallucinations for as long as two weeks in the absence of prominent mood symptoms At no time during the disturbance have there been delusions or hallucinations for as long as two weeks in the absence of prominent mood symptoms Not superimposed on schizophrenia, schizophreniform disorder, or delusional disorder or psychotic disorder NOS Not superimposed on schizophrenia, schizophreniform disorder, or delusional disorder or psychotic disorder NOS The disturbance is not due to the physiologic effects of a substance or general medical disorder The disturbance is not due to the physiologic effects of a substance or general medical disorder

5. Presentations of Bipolar Disorder Manic Manic Depressed Depressed Mixed Mixed

6. Types Type I - manic/mixed episode +/- major depressive episode Type I - manic/mixed episode +/- major depressive episode Type II - hypomanic episode + major depressive episode Type II - hypomanic episode + major depressive episode

7. Epidemiology Lifetime prevalence Type I - 0.7 - 0.8% Type I - 0.7 - 0.8% Type II - 0.4 - 0.5% Type II - 0.4 - 0.5% –Equal in males and females –Increased prevalence in upper socioeconomic classes Age of Onset Age of Onset –Usually late adolescence or early adulthood. However some after age 50. Late onset is more commonly Type II.

8. Genetics Greater risk in first degree relatives Greater risk in first degree relatives (4-14 times risk) (4-14 times risk) Concordance in monozygotic twins >85% Concordance in monozygotic twins >85% Concordance in dizygotic twins – 20% Concordance in dizygotic twins – 20%

9. Secondary Causes of Mania Toxins Drugs of Abuse Drugs of Abuse –Stimulants (amphetamines, cocaine) –Hallucinogens (LCD, PCP) Prescription Medications Prescription Medications –Common: antidepressants, L-dopa, corticosteroids Neurologic Nondominant frontal CVA Nondominant frontal CVA Nondominant frontal tumors Nondominant frontal tumors Huntington’s Disease Huntington’s Disease Multiple Sclerosis Multiple Sclerosis

10. Secondary Causes of Mania (Cont.) Infectious Neurosyphilis Neurosyphilis HIV HIVEndocrine Hyperthyroidism Hyperthyroidism Cushing’s Disease Cushing’s Disease

11. Treatment Education and Support Education and Support Medication Medication Acute mania Acute mania Lithium, Carbamazepine, Valproate, Lamotrigine, antipsychotics, benzodiazepines Lithium, Carbamazepine, Valproate, Lamotrigine, antipsychotics, benzodiazepines Long Term Mood Stabilization Long Term Mood Stabilization Lithium, Carbamazepine, Valproate, Lamotrigine, possibly atypical antipsychotics Lithium, Carbamazepine, Valproate, Lamotrigine, possibly atypical antipsychotics

12. Course Acute Episode Acute Episode –Manic - 5 weeks –Depressed - 9 weeks –Mixed - 14 weeks Long Term Long Term –Variable - most cover fully –Mean number of lifetime episodes 8-9

13. Cyclothymic Disorder Characteristics For at least two years (one for children and adolescents) presence of numerous Hypomanic Episodes and numerous periods with depressed mood or loss of interest or pleasure that did not meet criterion A of a Major Depressive Episode For at least two years (one for children and adolescents) presence of numerous Hypomanic Episodes and numerous periods with depressed mood or loss of interest or pleasure that did not meet criterion A of a Major Depressive Episode During a two year period (one year in children and adolescents) of the disturbance, never without hypomanic or depressive symptoms for more than a two month time During a two year period (one year in children and adolescents) of the disturbance, never without hypomanic or depressive symptoms for more than a two month time

14. Characteristics (Cont.) No clear evidence of a Major Depressive Disorder, or Manic Episode during the first two years of the disturbance (or one year for children and adolescents) No clear evidence of a Major Depressive Disorder, or Manic Episode during the first two years of the disturbance (or one year for children and adolescents) Not superimposed on a chronic psychotic disorder, such as schizophrenia or Delusional Disorder Not superimposed on a chronic psychotic disorder, such as schizophrenia or Delusional Disorder Not due to the direct physiologic affects of a substance or a general medical condition Not due to the direct physiologic affects of a substance or a general medical condition

15. Epidemiology Lifetime prevalence 0.4 – 1.0 % Lifetime prevalence 0.4 – 1.0 % same for males and females same for males and females Age of onset Age of onset –Usually in adolescence or early adulthood Genetics Genetics –Major Depression and Bipolar Disorder more common in first degree relatives

16. Cyclothymic Disorder Secondary causes of cyclothymic disorder Bipolar Disorder Bipolar Disorder Mood disorders due to a general medical condition Mood disorders due to a general medical conditionTreatment Initiation of biologic treatment is dependent on the degree of impairment Initiation of biologic treatment is dependent on the degree of impairment If treatment is indicated, it is similar to that of Bipolar Disorder If treatment is indicated, it is similar to that of Bipolar Disorder