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Bipolar Disorder: Journey Through Mania and Depression

Bipolar Disorder: Journey Through Mania and Depression. H.E. Logue, M.D. Bias Disclaimer. There is no pharmaceutical support for this program. I am active in the research field and involved in clinical trials for most of the major pharmaceutical companies. Goals and Objectives.

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Bipolar Disorder: Journey Through Mania and Depression

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  1. Bipolar Disorder:Journey Through Mania and Depression H.E. Logue, M.D.

  2. Bias Disclaimer • There is no pharmaceutical support for this program. • I am active in the research field and involved in clinical trials for most of the major pharmaceutical companies.

  3. Goals and Objectives • Promote better understanding of the following aspects of Bipolar Disorder: • Prevalence • Recognition and Diagnosis • Understanding Risk Factors • Genetic Predisposition • Treatment Considerations • Co-morbid Conditions • Referral Consideration

  4. Drew Carey • Dick Cavett • Ray Charles • Frederick Chopin • Winston Churchill • Dick Clark • Rosemary Clooney • Kurt Cobain • Natalie Cole • Samuel Coleridge • Sheryl Crow • Irving Berlin • Steven Foster • Lord Byron (George Gordon) • Noel Coward • Alexander the Great • Edwin “Buzz” Aldrin • Hans Christian Anderson • Roseanne Barr • Ludwig Von Beethoven • William Blake • Napoleon Bonaparte • Victor Hugo • Edgar Allen Poe • Leo Tolstoy • Michelangelo • Ezra Pound • Charlie Pride • Sergey Rachmaninoff • Patty Duke • Thomas Eagleton • Thomas Edison • T.S. Eliot • Ralph Waldo Emerson • William Faulkner • Eddie Fisher • F. Scott Fitzgerald • Betty Ford • Harrison Ford • Stephen Foster • Sigmund Freud • King George III • Tipper Gore • Robert E. Lee • Vivian Leigh • John Lennon • Alexander Hamilton • Joan Rivers • Norman Rockwell • Charles Schultz • King Saul • William Tecumseh Sherman • Neil Simon • Rod Steiger • William Styron • Alfred, Lord Tennyson • King Herod • Nathaniel Hawthorne • Ernest Hemingway • Audrey Hepburn • Howard Hughes • Thomas Jefferson • Joan of Arc • Lyndon Baines Johnson • Danny Kaye • Ted Turner • Mozart • Larry King • Jessica Lange • Mark Twain • Mike Tyson • Jean Claude Van Damme • Queen Victoria • Mike Wallace • George Washington • Robin Williams • Tennessee Williams • Thomas Wolfe • Virginia Woolf • Lord Tennyson • Vincent van Gogh • Peter Tchaikovsky • F. Scott Fitzgerald • Charles Dickens • Robert Louis Stevenson • Walt Whitman • Sylvia Plath • Marlon Brando • Art Buckwald • John Bunyan • Rodney Dangerfield • Charles Darwin • King David • John Denver • Princess Diana of Wales • Charles Dickens • Emily Dickenson • Theodore Dostoevski • Jack Dreyfus • Richard Dreyfuss • Kitty Dukakis • Liza Minnelli • Carman Miranda • Marilyn Monroe • J.P. Morgan • Ralph Nader • Sir Isaac Newton • Florence Nightingale • Ozzy Osbourne • Dolly Parton • Boris Pasternak • George Patton • Jane Pauley • Pablo Picasso • Cole Porter • Abraham Lincoln • Joshua Logan • Jack London • Greg Louganis • Martin Luther • Imelda Marcos • Ann Margaret • Herman Melville • Burgess Meredith • Kurt Vonnegut • Vivian Vance

  5. Prevalence • Bipolar Disorder affects approximately 5.7 million adult Americans • The median age of onset for Bipolar Disorder is 25 years. • An equal number of men and women develop Bipolar Disorder and it is found in all ages, races, ethnic groups and social classes. • Bipolar Disorder is the sixth leading cause of disability in the world. • Bipolar Disorder results in 9.2 years reduction in expected life span, and as many as one in five patients with bipolar disorder completes suicide.

  6. Bipolar Disorder Subtypes • Classic Bipolar Disorder • Bipolar I • Bipolar II • Subtypes • Cyclothymia • Major Depression Unipolar/Recurrent • Dysthymic Disorder • Bipolar NOS (Not Otherwise Specified) • Other Considerations • Rapid Cycling (part of Bipolar I) • Post-partum Onset • Seasonal Pattern Mood Disorders

  7. DSM-IV Criteria - Depression Five or more of the following: • Depressed mood • Diminished interest or pleasure in activities • Significant weight loss/gain or decrease/increase in appetite • Insomnia or hypersomnia • Psychomotor agitation or retardation • Fatigue or loss of energy • Feelings of worthlessness or excessive or inappropriate guilt • Diminished ability to think or concentrate, or indecisiveness • Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

  8. Diagnostic Dilemmas • Secondary Depression

  9. Depression with… • Other psychiatric illnesses • Schizophrenia • Anxiety • Panic disorder • Obsessive-compulsive disorder • Personality Disorders • Borderline • Compulsive • Post-traumatic stress disorder • Post-partum depression • Grief/depression • Practically any psychiatric disorder

  10. Depression with… • Organic/Medical Illnesses • Hypothyroidism • B-12 deficiency • Folate deficiency • Tuberculosis • Myasthenia gravis • Diabetes mellitus • Hepatitis C • Cushing’s disease • Mononucleosis • Parkinson’s disease • CHRONIC FATIGUE SYNDROME

  11. DSM-IV Criteria - Mania Three or more of the following: • 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 • Distractibility • Increase in goal-directed activity or psychomotor agitation • Excessive involvement in pleasurable activities that have a high potential for painful consequences

  12. Mood Symptoms • Euphoria/Mania • Depression (in mixed state) • Anxiety • Anger • Hostility • Irritability

  13. Behavioral Symptoms • Energized Activity • Diminished Need to/for Sleep • Impulsivity • Anger with Violence • Elevated Libido • Diminished Inhibitions • Reckless Behavior

  14. Cognitive Symptoms • Racing Rapid Thoughts • Diminished Insight/Invincibility • Sensory Hyperacuity • Hallucinations • Delusions • Perceptual Distortions • Distractible Disorganized Thoughts

  15. S-H-O-T • S: Symptomatology • Do the symptoms appear to be manic or depressed or repeated episodes of depression or mania or continuing mood swings? • H: History • What is the history of the person? The history of the family? Is there a family history of mood swings, mood disorders, substance abuse in persons with mood disorders or Bipolar diagnosis? • O: Ongoing illness • What is the progression of the illness? What is the course of the disease? Does it continue to go on in a progression appearing as a Bipolar disease course? • T: Treatment response • If one looks at the response of the treatment one should get a good deduction as to the nature of the illness.

  16. Understanding Risk Factors • Stress (major or prolonged) • Sleep Deprivation/Disruption • Alcohol (major problem) • “Recreational” Drug Use • Discontinuation of Medications • Loss or Perceived Loss (job, family, friends, finances, health, etc.) • Interpersonal Conflict • Travel Across Time Zones • Mood-Altering Medications (benzodiazepines, antidepressants, antipsychotics) • Death of Loved One or Friend • Inadequate Coping Skills • Early Dementia or Minimal Brain Damage

  17. Treatment • Depression vs. Bipolar Depression • Depression: Pre-Modern Era • Tincture of Time • Prescribed trip to Europe • Activity • Physical • Social • Mental • Somatic • Insulin shock • Electric shock • Spiritual • Depression: Modern Era • Education and Psychotherapy • Pharmacotherapy • 1950’s – Tricyclics • 1960’s – Tetracyclics, etc. • 1990’s – SSRIs (Prozac, Paxil, Zoloft) • SNRI (Wellbutrin) • SSNRIs (Effexor, Remeron, Cymbalta) • Spiritual

  18. Treatment Statistics • Patients with Bipolar Disorder face up to ten years of coping with symptoms before receiving an accurate diagnosis. • Nearly 9 out of 10 patients with bipolar disorder are satisfied with their current medication(s), although side effects remain a problem. • Participation in a Depression and Bipolar Support Alliance patient-to-patient support group improved treatment compliance by almost 86% and reduced in-patient hospitalization. • Consumers who report high levels of satisfaction with their treatment and treatment provider have a much more positive outlook about their illness and their ability to cope with it.

  19. Bipolar Disorder Type II (Depressed Type) • Incorporate all of the previous slide • Recent studies suggest antidepressants cause a sooner relapse or conversion to mania • Treating the Bipolar component is equivalent to casting both broken legs. • Mood stabilizers • Lithium – only drug proven to reduce suicide rate • Antidepressants • 1950’s – Richard Dreyfuss • 1990’s – Depakote, Tegratol, Trileptal, Lamictal • Atypicals?

  20. Bipolar Disorder Type I (Manic and Depressive) • Mania • Antipsychotics • 1953 – Thorazine/chlorpromazine • World’s first psychotropic medication • Could treat psychosis and mania • Other conventional antipsychotics followed • Risk and Benefits • Atypical Antipsychotics • Zyprexa, Seroquel, Abilify, Risperdal, Geodon • Risk and Benefits • Anticonvulsants • Depakote, Tegratol, Trileptal, Lamictal • Risk and Benefits • Electroconvulsive Therapy

  21. Genetics • Like the illness, a complicated topic… • Confounding issues: • Hypersexuality • Family disintegration • Separation of siblings • Twins

  22. Genetic Models • Mendelian vs. Polygenic Models • 1 affected parents = 1 in 4 affected offspring • 2 affected parents = 2 in 3 affected offspring • 1 dizygotic/fraternal twin = 1 in 6 affected twin • 1 monozygotoc/identical twin = 2 in 3 affected twin • Epistatic Model • Number 22 is prominently mentioned (same gene as schizophrenia • Gene 21q is also involved • Genes 18p and 18q also are involved

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