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Understanding People Who Have Bipolar Disorders

Understanding People Who Have Bipolar Disorders. Mary Bittle, PhD, RN, LMFTA. Objectives. Recognize characteristics of bipolar disorders. Differentiate DSM-IV-TR and DSM-V characteristics, effective 1/1/14. Differentiate between mania and hypomania

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Understanding People Who Have Bipolar Disorders

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  1. Understanding People Who Have Bipolar Disorders Mary Bittle, PhD, RN, LMFTA

  2. Objectives • Recognize characteristics of bipolar disorders. • Differentiate DSM-IV-TR and DSM-V characteristics, effective 1/1/14. • Differentiate between mania and hypomania • Recognize contributing factors of genetics and brain chemistry. • Recognize common treatments • Recognize challenges of managing • Recognize famous people who have/had • Acknowledge people with successful management can lead successful lives

  3. What are Bipolar Disorders? • Disturbances of mood that significantly interfere with the daily functioning of an individual. DSM IV-TR mood DO. DSM V places in separate category • Two types: Bipolar I and Bipolar II • 19th century called manic-depressive, no longer a correct term. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.

  4. Bipolar Disorders U.S. • Prevalence: 2.6% • Classified Severe: 82.9% (2.6%) = 2.2% National Institute for Mental Health. National Institutes for Health. (2005). Bipolar disorder among adults. Retrieved 11/13/13 from http://www.nimh.nih.gov/statistics/1bipolar_adult.shtml • Some 10 million people National Alliance on Mental Illnesses. Bipolar Disorder FACT SHEET. Retrieved 11/13/13 from http://www.nami.org/factsheets/bipolardisorder_factsheet.pdf

  5. Bipolar I A. Must have at least one manic episode lasting at least 1 week B. During manic episode must have 3 or more out of 7 behavioral manifestations of mania(next slide) C. Major impairment in life functioning D. Cannot be explained by medications or drugs for another medical condition May also be followed or preceded by hypomania and/or major depression. Hypomania/MD not necessary for BPI DO. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.

  6. Behaviors of Mania • Grandiosity, increased self esteem • Insomnia • Pressured or continuous talking • Expresses that thoughts are racing or expressed thoughts jump rapidly from one topic to another, called flight of ideas • Distractibility • Increase in goal-directed or non-goal-directed activity, called psychomotor activity • Activities are of increased risk: pain, excessive spending, hypersexuality… May include psychotic behavior American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.

  7. Behaviors of Hypomania Same as for mania except: • Lasts at least 4 days • Uncharacteristic for usual behaviors of the person • Others notice the increased/expansive behaviors • Not severe enough for major impairment in life functioning American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.

  8. Bipolar I • Typical age of onset ~18 years old • Prevalence: • US 0.6% • 11 other countries 0.0% - 0.6% • Male to female occurrence 1.1:1 • More common in countries with higher incomes • Higher rates in separated, widowed • Suicide risk 15 X that of general population • 36.3% Lifetime risk American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.

  9. Bipolar II Same as Bipolar I EXCEPT: • Elevated mood of at least 4 days. • Not characteristic of person • Observable by others • Does not significantly interfere with functioning nor require hospitalization Must include at least one major depressive episode, present or past American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.

  10. Other Characteristics of Bipolar II • Common impulsive behaviors troublesome. • Suicide ideation and risk increased • 1/3 have suicide attempt in lifetime, 32.4 % • Use more lethal means , so success greater • Substance abuse • Value of increased creativity leads to denial and aversion to treatment American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.

  11. Bipolar II • Prevalence • 0.8% US • 0.3% Internationally • Typical age for development mid 20s • Usually begins with a depressive episode • Once there is ever a hypomanic episode, DX = BP II and not MDD • More lifetime episodes than BP I • May be rapid cycling, females more likely, poorer prognosis • Once there is a manic episode, DX changes to BP I American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.

  12. Bipolar Moods Time -----------------------------------------------

  13. Comparison Bipolar I 1 week elevated mood 3/7 characteristics (4 if mood irritable) Marked impairment ADLs Psychosis when present defines BP I May have major depression American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing. Bipolar II 4 days elevated mood 3/7 Characteristics (4 if mood irritable) ADLs NOT markedly affected. Hospitalization not necessary. Behaviors noted by others Must include Major Depression

  14. DSM V Coding • 296. for Bipolar I • Codes following decimal: • Mild, Moderate, Severe • Most current episode Mania, Hypomania, Depressed • Psychotic feature present • Partial or Full Remission • 296.89 for Bipolar II • Further modifiers are written in words American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.

  15. Major Depression • For at least a period of 2 weeks, 5 of 9 symptoms (next slide) have occurred. Depressed mood or anhedonia (loss of pleasure) Represents change from usual. The symptoms are not due to another medical condition. B. Major impairment in life functioning/distress C. Not due to another medical condition or effects of a substance American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.

  16. Behaviors of Depression • Depressed mood (sadness, emptiness, hopelessness, crying) most all day, most every day. • No or nearly no interest in pleasure or activities, most all day, most every day. (Anhedonia) • Significant loss of appetite with unplanned weight loss (=/>5%) • Too much or too little sleep, insomnia or hypersomnia • Significant activity slowing or irritability American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.

  17. Behaviors of Depression 6. Continuous low energy and/or fatigue 7. Feeling of excessive guilt (may be delusional) or worthlessness. 8. Less ability to concentrate or make decisions most all day, most every day. 9. Thoughts of death: suicidal ideation with or without a plan The above may be subjective or observed by others. The above may not be normal reactions to significant loss American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.

  18. Depression Major depressive SX are the most common first presentation for which people with BP II disorder seek medical attention, particularly hospitalization. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.

  19. Suicide Ideation • Thoughts of • Death • Wanting relief • The world will be better off w/o me • Significant others will be better off w/o me • Contemplation • Plan • Means and lethality • Energy with which to carry out

  20. Clues to Suicide and Interventions • Verbalizing the future w/o oneself • Giving things away • Threats ALWAYS take any clue to suicide seriously. • ADDRESS person openly • Do want to harm yourself? • Do you have a plan? • What is you plan? • Notify significant others and /or authorities • Offer HOPE. • Things NOT to say: guilt, shame, false reassurance, can “snap out of it.”

  21. Suicide Prevention? • Research does not support effectiveness of “Suicide Contracts.” American Psychiatric Association. (2003). Practice guidelines for the assessment and treatment of patients with suicidal behaviors. American Journal of Psychiatry, 160(11Suppl.), 1-60. • Use written “Plan for Life” (positive approach) • When I feel______________ (describe) • I will ___________________ (activities) • I will call ________________ (support persons) • I will call ________________ (Suicide Contact ph. #s, 911)

  22. PsychosisBPI may have psychotic features Psychoses of BPD are usually of the type of Delusions – strongly held/fixed beliefs that defy evidence or reality Examples: grandiosity, persecutory, referential, erotomanic, somatic, nihilistic…. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.

  23. Bipolar Typical Characteristics • People who have mania or hypomania frequently do not recognize/deny that their behaviors are abnormal. • They may enjoy their elevated moods. • They may value ability to accomplish goals. • If behaviors are serious enough, persons may have to be hospitalized. Usually they are resistant to hospitalization resulting in involuntary admission. • Behaviors, particularly delusional, may result in illegal transgressions. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.

  24. Co Morbidity • Drug and Substance use, abuse, and addictions are common • Alcohol • Marijuana • Persons desperately want to relieve symptoms

  25. Etiology – Multiple - Complex • Familial • Relatives of those with Bipolar Disorders are more likely to have. 10X the risk. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing. -Both parents: 50-75% chance for children; one parent 27% -Identical Twins 78-80% concordance -Familial Twins 17-19% Concordance Snow, D. (2009). Bipolar lecture. University of Texas at Arlington College of Nursing. - White matter reduction Sprooten, E. et al. (2013). Reduced white matter integrity in sibling pairs discordant for bipolar disorder. Am J Psychiatry 2013;170:1317-1325 • Multiple genes involved • Polymorphisms at the G72/G30 gene locus, on L13q33 Hattori, E. et al. (2003). Polymorphisms at the G72/G30 gene locus, on L13q33, are associated with bipolar disorder in two independent pedigree series. American Journal of Human Genetics, 72(5), 1131-1140. • Corticotropin receptor and subunit of G protein genes on C-18 • Snow, D. (2009). Bipolar lecture. University of Texas at Arlington College of Nursing. • Environmental

  26. Neurobiological Correlates • Brain areas: prefrontal cortex (executive function),medial temporal lobe (memory functions), via PET & MRI evidence • Neurotransmitters: norepinephrine, dopamine, serotonin - decreased availability associated with mood lowering • Endocrine – thyroid: • Low thyroid– risk for depression , and rapid cycling Varcarolis, E. (2006). Mood disorders: Bipolar. In Foundation of Psychiatric Mental Health Nursing : A Clinical Approach. St. Louis, MO. Saunders. 359-393.

  27. Treatment Options • Medications • Talk or Psychotherapy • Electroconvulsive Therapy (ECT) Every person is different with presentation of BPD. Since multiple causal and environmental factors are involved, the management is challenging and often takes much trial and error and readjustment.

  28. Treatment Estimates • ~48.8% receive • ~38.8% minimally adequate National Institute for Mental Health. National Institutes for Health. (2005). Bipolar disorder among adults. Retrieved 11/13/13 from http://www.nimh.nih.gov/statistics/1bipolar_adult.shtml Parody of psychiatric and medical treatment access could increase these

  29. MedicationsMood Stabilizers • Lithium is classic (Eskalith or Lithobid) • Long term necessary • Therapeutic and toxic levels are close • Lab tests closely monitor levels • Acts like salt, so balance /w table salt important • Decreased levels of salt can raise levels of lithium • Can cause dry mouth, sensitivity to cold, muscle/joint pain, brittle nails/hair, acne, indigestion, restlessness • Need monitoring of kidney and thyroid function National Institute for Mental Health. National Institutes for Health. Retrieved 11/8/13 from http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml Varcarolis, E. (2006). Mood disorders: Bipolar. In Foundation of Psychiatric Mental Health Nursing : A Clinical Approach. St. Louis, MO. Saunders. 359-393.

  30. MedicationsMood Stabilizers Anticonvulsants - FDA approved • Valproic acid or divalproex sodium (Depakote) • Lamotrigine (Lamictal) • Gabapentin (Neurontin) • Topiramate (Topamax) • Oxcarbazepine (Trileptal) National Institute for Mental Health. National Institutes for Health. Retrieved 11/8/13 from http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml Varcarolis, E. (2006). Mood disorders: Bipolar. In Foundation of Psychiatric Mental Health Nursing : A Clinical Approach. St. Louis, MO. Saunders. 359-393.

  31. MedicationsMood Stabilizers Side and/or Untoward Effects • Warnings of increased risk for suicide • GI: Diarrhea/constipation/heartburn • Nasal: Stuffy/runny nose • Neuro: Headache, drowsiness/dizziness • Potentially fatal skin rash from Lamotrigine  (Stevens-Johnson syndrome) • Young women & Valproic acid, risk for polycystic ovaries/birth defects National Institute for Mental Health. National Institutes for Health. Retrieved 11/8/13 from http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml Varcarolis, E. (2006). Mood disorders: Bipolar. In Foundation of Psychiatric Mental Health Nursing : A Clinical Approach. St. Louis, MO. Saunders. 359-393.

  32. Having Bipolar Disorders are serious life altering challenges to individuals who have them and to their families. Can be managed successfully to have productive life. Requires tremendous insight in individual and supportive understanding by those closest to them .

  33. Famous People Who may have had or have BPDs • Vivien Leigh • Carrie Fisher • Jean-Claude Van Damme • Linda Hamilton • Sinéad O'Connor • Vincent van Gogh • Virginia Woolf • Jane Pauley • Mariette Hartley • Catherine Zeta-Jones Bhatia, J. (2011). 10 Famous people with bipolar disorder: The price of fame? Retrieved 11/14/13 from http://www.everydayhealth.com/bipolar-disorder-pictures/famous-people-with-bipolar-disorder.aspx#/slide-1

  34. Famous People Who may have had or have BPDs Author. (2012). Retrieved 11/13/13 from http://famouspeoplewithbipolardisorder.blogspot.com/2012/12/bipolar-famous-people.html • Jack Nicholson • Jim Carey • Rowan Atkinson • Robert Pattinson • Ben Stiller • Hugh Laurie • Craig Manning • Rapper "DMX'“ • Kurt Cobain • Alfred Hitchcock • Salvador Dali‘ • Kim Novak • Richard Dreyfuss • Margot Kidder • Demi Lovato • Sir Winston Churchil • Macy Gray • Jimi Hendrix • Madonna • Buzz Aldrin • Abraham Lincoln • Charley Pride • Kristy McNichol • Connie Francis • Ozzie Osbourne • Sir Isaac Newton • Ludwig Van Beethoven • John Forbes Nash Jr. • Rita Lee • Pete Wentz • Patti Duke • Pablo Picasso

  35. Resources • Skywriting: A Life Out of the Blue, a book by Jane Pauley • National Alliance on Mental Illness http://www.nami.org • National Institute for Mental Health. National Institutes for Health www.nimh.nih.gov • www.mayoclinic.com/health/bipolar-disorder

  36. References • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing. • American Psychiatric Association. (2003). Practice guidelines for the assessment and treatment of patients with suicidal behaviors. American Journal of Psychiatry, 160(11Suppl.), 1-60. • Author. (2012). Famous people with bipolar disorder. Retrieved 11/13/13 from http://famouspeoplewithbipolardisorder.blogspot.com/2012/12/bipolar-famous-people.html • Bhatia, J. (2011). 10 Famous people with bipolar disorder: The price of fame? Retrieved 11/14/13 from http://www.everydayhealth.com/bipolar-disorder-pictures/famous-people-with-bipolar-disorder.aspx#/slide-1 • Hattori, E. et al. (2003). Polymorphisms at the G72/G30 gene locus, on L13q33, are associated with bipolar disorder in two independent pedigree series. American Journal of Human Genetics, 72(5), 1131-1140. • National Alliance on Mental Illnesses. Bipolar Disorder FACT SHEET. Retrieved 11/13/13 from http://www.nami.org/factsheets/bipolardisorder_factsheet.pdf • National Institute for Mental Health. National Institutes for Health. (2005). Bipolar disorder among adults. Retrieved 11/13/13 from http://www.nimh.nih.gov/statistics/1bipolar_adult.shtml • National Institute for Mental Health. National Institutes for Health. (2006). Retrieved 11/8/13 from http://www.nimh.nih.gov/news/science-news/2006/early-findings-from-largest-nimh-funded-research-program-on-bipolar-disorder-begin-to-build-evidence-base-on-best-treatment-options.shtml • National Institute for Mental Health. National Institutes for Health. Retrieved 11/8/13 from http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml • Snow, D. (2009). Bipolar lecture. University of Texas at Arlington College of Nursing. • Sprooten, E. et al. (2013). Reduced white matter integrity in sibling pairs discordant for bipolar disorder. Am J Psychiatry 2013;170:1317-1325. • Varcarolis, E. (2006). Mood disorders: Bipolar. In Foundation of Psychiatric Mental Health Nursing : A Clinical Approach. St. Louis, MO. Saunders. 359-393.

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