Bipolar basics for MRCPsych year 1
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Lecture on the basics of bipolar disorder for MRCPsych course year 1, delivered in Leicester 2010
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Bipolar basics for MRCPsych year 1
- 1. MRCPsych Masterclass Dr Nick Stafford Consultant Psychiatrist LPT
- 2. Epidemiology Aetiology Clinical findings Rating scales Laboratory findings & imaging Course of illness Differential diagnoses
- 5. ICD-11 & DSM V
- 6. ïĄ ïĄ ïĄ Mania Hypomania Depression ïĄ ïĄ ïĄ ïĄ Degree of symptoms Nature of symptoms Time of symptoms Number of symptoms ïĄ ïĄ ICD10 / DSMIV Other
- 7. SYMPTOM DOMAINS SEVERITY Mood âą Elevated Hypomania âą More persistent and marked than cyclothymia âą Several days on end Physical activity âą Quantity âą Speed Mania without psychosis âą Greater degree of mood elevation âą At least one week Mental activity âą Quantity âą Speed Mania with âą Congruous or incongruous âą Severe and sustained psychosis increase in activity
- 8. Elevated mood >=4days Symptoms (three or more) Unequivocal change in functioning Mood and function change observed by others No marked impairment in social / occupational functioning & no psychosis Not due to substance misuse or a medical condition
- 9. Mood elevate at least 1 week Symptoms (3 or more) Not Mixed Episode Severe impairment of functioning or relationships or need hospitalisation or psychosis Not due to substances misuse or a medical condition
- 10. ïĄ Beating Bipolar ï§ 1 â Symptoms I: Depression ï§ 1 â Symptoms II: Hypomania ï§ 1 â 4: Mixed and psychosis
- 13. ïĄ BB ï§ 1 â Life chart 5
- 14. Bipolar Depression Lifetime risk About 1-5% 10-20% Sex ratio (M:F) 1:1 1:2 Lifetime risk for bipolar About 10% About 2% Lifetime risk for unipolar depression 20-30% 20-30% Average age of onset 21 yrs (?earlier) 27 yrs Suicide 15% 10% First-degree relatives:
- 15. Factor Expressed Emotion Greater predictor of relapse than schizophrenia Family history Complex hereditability Social class High social class cf. other mood disorders Life events Significant with nature & degree Personality More maladaptive traits during relapse Need for reassurance and sensitivity to criticism Childhood experience Approx 50% bipolars and leads to more complex cases Postpartum Marked increases Menopause Deterioration in perimenopause Social support Bipolars get less social support Sleep deprivation Tends to mania, circadian disturbances Behavioural activation Excessive activity leads to mania
- 18. Depression Depression & mania at opposite ends of the spectrum Reduced NA Mania Increased NA
- 19. Depression Depression & mania at opposite ends of the spectrum Reduced NA Mania Increased NA
- 20. ïĄ BB ï§ 2 â Mood thermostat 3: I, II, III, IV
- 23. ïĄ Elevated basal plasma concentrations of TSH ïĄ Exaggerated TSH response to TRH ïĄ Rapid cyclers higher rate of hypothyroidism ïĄ Blunted / absent evening surge of plasma TSH ïĄ Blunted TSH response to TRH ïĄ Presence of antithyroid microsomal and/or anti-thyroglobulin antibodies
- 26. Beating Bipolar â 2:IV Hypomania Increasing age Depression
- 27. Improve functioning Mood charting Recognise early warning signs Medication understanding Prevent relapse Psychoeducation
- 28. ïĄ Beating Bipolar ï§ 4 â Nick Craddock onwards
- 29. ïĄ Children of affected parent(s) ï§ One parent: 15-30% ï§ Both parents: 50-75% ïĄ Siblings of affected sibling ï§ One sibling: 15-25% ï§ MZ concordance 60-70% ïĄ Additional genetic loading for depressive disorder, ADHD, OCD or Oppositional Defiant Disorder
- 30. ïĄ BDNF gene (Vall66) GAD1 gene (4s2241165) Dopamine transporter gene (rs41084) Serotonin transporter gene ïĄ Circadian / Clock genes ïĄ ïĄ ïĄ ï§ ARNTL (BmaL1) ï§ TIMELESS ï§ PERIOD3 ï§ RORA & RORB
- 31. ïĄ Bipolar I ï§ DAO, GRM3, GRM4, GRIN2B, IL2 RB, and TUBA8 ïĄ Overlapping with schizophrenia ï§ DPYSL2, DTNBP1, G30/G72, GRI D1, GRM4, and NOS1 ïĄ ïĄ ïĄ BDNF Alpha subunit of the voltagedependent calcium channel Glutamate signalling pathways
- 32. ïĄ Strongest linkage on chromosomes 10q25, 10p12, 16q24, 16p13, a nd 16p12 ïĄ ïĄ ïĄ 6q25 (suicidal behaviour) 7q21 (panic disorder) 16p12 (psychosis) using phenotypic subtypes
- 33. Bipolar Unipolar Substance abuse +++ + Family history ++++ + Seasonality ++++ + Onset before age 25 +++ + Postpartum onset +++ + Psychotic depression <age 35 +++ -- Atypical features ++++ + Rapid on/off pattern ++ -- Recurrent Major Depressive Episodes ++ + Antidepressants associated with hypomania / mania ++ -- ++++ -- Antidepressant wear-off ++ -- Mixed depression ++ -- Brief episodes of depression
- 34. Any mental health history Recurrent depressive disorder Any alcohol or substance misuse Repeated relationship problems Repeated occupational problems Family history
- 35. âą Functional mental illnesses Recurrent Depression, Anxiety âą Emotionally unstable / borderline Personality disorder types Substance and alcohol misuse âą Chronic or intermittent use Normal human emotion âą Chronic stress & psychosocial problems
- 36. Anxiety disorders Panic disorder Simple phobia Alcohol misuse Personality disorders Childhood bipolar Cluster B Conduct disorder Substance misuse Childhood mental health Borderline ADHD Emotionally unstable Social phobia GAD OCD Sleep disorders PTSD Any substance misuse
- 39. ïĄ Beating Bipolar ï§ 3: Section 3 ï§ Get CT1s to discuss each question in 2 groups âȘ What they think âȘ What they think the patient might thinks âȘ Consider pros & Cons ï§ Watch next film of patients (Mark & Jane) ïĄ Dr Alison Roberts â on lithium
- 41. ïĄ ïĄ ïĄ ïĄ ïĄ ïĄ ïĄ ïĄ Antidepressants Quetiapine Lamotrigine Benzodiazepines Typical antipsychotics Folic acid Metabolic syndrome Maudsley Guidelines
- 42. Exercise Stress reduction Diet Relaxation Pleasurable activities Social activities Sleep Cycles & rhythms
- 43. ïĄ Beating Bipolar ï§ Sections âȘ 2 â Sleep âȘ 3 â Rood & Exercise âȘ 5 â Routines
- 44. ïĄ Beating Bipolar ï§ Module 7 ï§ General group discussion about what it might be like to live with someone who has bipolar
- 46. Age of onset Duration of mania Duration of depression Recovery Long term outcome Mortality and suicide âą Average 21 years âą Mania âą Hypomania
- 47. ïĄ Beating Bipolar ï§ 2 â Triggers ï§ 3 â Monitoring mood ï§ 4 â Nipping episodes in the bud ï§ 5 â Dealing with suicidal thoughts
- 48. ïĄ Beating Bipolar Module 6 sessions
- 50. Axis I Axis II Delirium Emotionally unstable PD Dementia Histrionic PD Substance-related disorder Schizophrenia Schizoaffective disorder Delusional disorders Psychotic disorder NOS Cyclothymic disorder Factitious disorder Malingering ADHD Conduct disorder
- 51. Medications Substance abuse Neurological disease Infectious disease Neoplasms Metabolic & endocrine disorders Collagen-vascular conditions Miscellaneous
- 52. Isoniazid Procarbazine L-Dopa Corticosteroids and ACTH Hallucinogens Cimetidine Bromide Decongestants Bronchodilators Procyclidine Calcium replacement Phencyclidine Metoclopramide Sympathomimetic amines Disulfiram Barbiturates Anticonvulsants Benzodiazepines Cocaine TCAs
- 53. Postoperative states Haemodialysis Vitamin B12 Addisonâs disease Iatrogenic Cushingâs disease Post-infection states Dialysis Hyperthyroidism
- 54. Right temporal lobe seizures Multiple sclerosis Right hemisphere damage Seizure disorders Huntingtonâs disease Post-stroke
- 55. Neurosyphilis Herpes simplex encephalitis Q fever HIV infection
- 56. ïĄ Group discussion of principles ïĄ BeatingBipolar.org