Transcript Bipolar Disorder -- diagnosis, symptoms, etc…

Bipolar Disorder -- diagnosis,
symptoms, etc…
Kurt Weber, PhD
Mental Health America – Brown County
Bemis International Center
St Norbert College
May 13, 2008
no definitive test…
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and…
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there are a number of physical conditions and
quite a few psychiatric disorders which present
symptoms that can be confused with those of
bipolar disorder
even more…
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many psychiatric disorders can occur in tandem
therefore…
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a psychiatrist will usually conduct the following
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complete medical history and physical exam
to rule out other physical or organic concerns
complete psychiatric history
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family history of medical and psychiatric concerns
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possibility of other mental disorders should be considered
previous mood swings (perhaps of less severity or duration)
may come to light
Current research indicates that mood disorders have genetic
underpinnings
evaluation of current symptoms
symptoms
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dramatic mood swings
overly high and/or irritable to sad and hopeless,
and then back again, often with periods of
normal mood in between
 severe changes in energy and behavior go along
with these changes in mood
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manic phase
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three stages of mania
1) hypomania - energetic, extroverted, assertive,
hypersexual, self-confident, rapid speech
 2) mania - loss of judgment, euphoria, grandiose,
paranoid, irritable, hyperactive, ideas of
reference, pressured, manipulative, demanding,
hyper-religious
 3) psychotic - paranoid, hyperactive, assaultive,
delusional, labile, depressed, circumstantial,
distractible, confused.
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delusions
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most frequent psychotic symptoms in mania
(50%)
hallucinations are present in 15%
70% of manic clients show severe thought
pathology equal to or greater than the
severity of formal thought disorders in acute
schizophrenia
differential diagnosis
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no symptom or cluster of symptoms reliably
distinguishes bipolar mania from schizophrenia
signs and symptoms
of a manic episode
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Increased energy, activity, and restlessness
Excessively high, overly good, euphoric mood
Extreme irritability
Racing thoughts and talking very fast, jumping from one idea to
another
Distractibility, can t concentrate well
Little sleep needed
Unrealistic beliefs in one s abilities and powers
Poor judgment
Spending sprees
A lasting period of behavior that is different from usual
Increased sexual drive
Abuse of drugs, particularly cocaine, alcohol, and sleeping medications
Provocative, intrusive, or aggressive behavior
Denial that anything is wrong
red flags (about.com)
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1. Make note of changes in sleeping patterns, especially if
your friend or loved one has lots of energy on just a few
hours of sleep.
2. Is he restlessly searching for ways to work off extra
energy? Washing the car every day? Make note of this.
3. Be alert to increased talkativeness. If her mouth runneth
over, this could be another symptom, especially if the talk
seems pressured.
4. Be aware if someone starts making "clang" associations,
i.e., gets distracted by the sounds of words - such as going
on about microphones, xylophones and ice cream cones.
5. If your spouse/partner is suddenly more sexually
demanding, it could be a symptom.
more
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6. Check your phone bill for calls to 900 sex numbers. This,
unfortunately, is another symptom of bipolar
hypersexuality.
7. Study your credit card bills diligently! Mania can cause
disastrous spending sprees. Consider taking the cards and
checkbook away.
8. Notice if he complains that his thoughts are racing
uncontrollably.
9. Be on the alert if she starts having delusions of grandeur for example, making exaggerated plans like "I'm going to
quit my job and write a novel" or "Let's move to Yemen this
weekend!“
10. Watch out for unreasonable irritability and/or hostility.
This is not just a symptom - it can be dangerous. Be
cautious!
even more…
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11. Increased religious zeal or involvement can be
another sign of mania. Make note of this if you see
it.
12. If she describes auditory or visual hallucinations
or shows paranoid behavior, contact her
psychiatrist immediately. These are serious
symptoms.
13. During a manic episode, a person is likely to
wear brightly colored or flamboyant clothing. Note
this if it occurs with other symptoms.
14. If manic symptoms occur following a change in
medications, contact the prescribing doctor
promptly.
one may consider…
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1. Make a pact with your friend that if you
bring these behaviors to his attention, he
will contact his doctor.
2. If your spouse/partner has a pattern of
manic spending sprees, keep money in your
name only.
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A manic episode is diagnosed if elevated
mood occurs with other symptoms most of
the day, nearly every day, for 1 week or
longer.
If the mood is irritable, 4 additional
symptoms must be present.
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Subjective experience -- mania
“The fast ideas become too fast and there are far
too many…
“overwhelming confusion replaces clarity...
“you stop keeping up with it and memory goes.
“Infectious humor ceases to amuse.
“Your friends become frightened...everything is
now
against the grain…
“you are irritable, angry, frightened,
uncontrollable, and trapped…”
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anatomy of a manic upswing
Mania can also be secondary to…
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Drugs
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CNS disorders
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amphetamines, alprazolam, antidepressants, baclofen, bromide,
bronchodilators, calcium, cocaine, corticosteroids, cyclobenzaprine,
cyclosporine, decongestants, digitalis, flutamide, isoniazid,
levodopa, methylphenidate, metoclopromide, niridazole,
phenocyclidine, procarbazine, procyclidine, reserpine withdrawal,
thyroid, tolmetin, antidepressants.
brain tumors, cerebrovascular disorder, trauma, epilepsy,
Huntington's, multiple sclerosis, Pick's, postencephalitic,
Parkinson's, spinocerebellar atrophy, Wilson's Disease.
Toxic/ Metabolic
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AIDS, calcium, Cushing's, hemodialysis, hyperthyroidism, influenza,
neurosyphilis, postoperative, post St. Louis type A encephalitis, Q
fever, lupus, vitamin B12 deficiency.
bipolar depressive episodes
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quite difficult to treat and prevent
nearly all classes of antidepressants have
been linked to mania, mixed states, and
rapid cycling, they should be avoided
without also using a mood stabilizer
signs and symptoms
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A depressive episode is diagnosed if 5 or more of these symptoms last
most of the day, nearly every day, for a period of 2 weeks or longer.
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Lasting sad, anxious, or empty mood
Feelings of hopelessness or pessimism
Feelings of guilt, worthlessness, or helplessness
Loss of interest or pleasure in activities once enjoyed, including sex
Decreased energy, a feeling of fatigue or of being slowed down
Difficulty concentrating, remembering, making decisions
Restlessness or irritability
Sleeping too much, or can’t sleep
Change in appetite and/or unintended weight loss or gain
Chronic pain or other persistent bodily symptoms that are not caused by
physical illness or injury
Thoughts of death or suicide, or suicide attempts
Subjective experience – depression
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I doubt completely my ability to do anything well
It seems as though my mind has slowed down and
burned out to the point of being virtually useless.
All I can experience is the total, the desperate
hopelessness of it all
Others say, "It's only temporary, it will pass, you
will get over it," but of course they haven't any
idea of how I feel, although they are certain they
do
If I can't feel, move, think or care, then what on
earth is the point?
red flags for depression
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1. If you start having trouble getting to sleep or staying
asleep, keep a record and watch for other symptoms.
2. Be on the alert if someone starts sleeping excessively.
Seriously depressed persons can sleep as much as 20 hours
a day in some cases.
3. Be concerned if someone begins cancelling social
engagements and staring at television programs he
otherwise wouldn't watch.
4. Notice if mail - even bills - is piling up unopened, or other
common tasks such as laundry, taking out garbage, etc., are
not being done.
5. Marked change in appetite (increase or decrease), or
significant weight gain or loss, can signify many conditions,
including depression; consider it in light of other depressive
symptoms.
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6. Keep track of episodes of unexplained and uncontrolled
crying.
7. Document feelings of sadness, guilt, worthlessness or
despair that last most or all day for several days.
8. Be alert if you or your loved one exhibits signs of unusual
worry, anger, negativity, helplessness or hopelessness.
9. Pay attention if you or a loved one begins to have
difficulty making even simple decisions. This is a very
common warning sign of depression.
10. Be sensitive to behavioral changes such as
disorganization, inability to concentrate, or indifference to
everyday necessary tasks.
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11. Notice if actions and thoughts seem to be slowing down
(psychomotor retardation) or speeding up jerkily
(psychomotor agitation).
12. Watch your loved one for physical signs of depression
such as slumped posture, frowning, decreased eye contact,
frequent sighing, inattentive speech, or decreased sexual
desires.
13. Contact the doctor quickly if you experience or someone
reports recurrent thoughts of death and suicide.
14. If depressive symptoms appear after a change in
medication, contact the prescribing doctor promptly.
it might be a good idea to…
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1. Depression can creep up slowly or descend
quickly. If slowly, it can be harder to notice,
especially in yourself. Get in the habit of observing
yourself if you have depressive episodes.
2. Make a pact with your friend or loved one (or
yourself) that if one of you sees anger signals in the
other (or in yourself), the affected person will take
appropriate action such as contacting a doctor
hypomania
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mild to moderate level of manic symptoms
may feel good to the person who
experiences it and may even be associated
with good functioning and enhanced
productivity
the person may deny that anything is wrong
without proper treatment, however,
hypomania can become severe mania in
some people or can switch into depression.
subjective experience -- hypomania
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at first when I'm high, it's tremendous... ideas are
fast... like shooting stars you follow until brighter
ones appear
All shyness disappears, the right words and
gestures are suddenly there... uninteresting
people, things become intensely interesting
Sensuality is pervasive, the desire to seduce and be
seduced is irresistible
Your marrow is infused with unbelievable feelings
of ease, power, well-being, omnipotence,
euphoria... you can do anything... but, somewhere
this changes.
psychosis
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severe episodes of mania or depression can
include psychotic symptoms
hallucinations (hearing, seeing, or otherwise
sensing the presence of things not actually
there)
 delusions (false, strongly held beliefs not
influenced by logical reasoning or explained by a
person s usual cultural concepts).
 Paranoia - believing that a person or group is
actively working to harm you, without any basis
in fact
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Psychotic symptoms in bipolar disorder tend to
reflect the extreme mood state at the time
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delusions of grandiosity, such as believing one is the
President or has special powers or wealth, may occur
during mania
delusions of guilt or worthlessness, such as believing
that one is ruined and penniless or has committed some
terrible crime, may appear during depression
People with bipolar disorder who have these symptoms
are sometimes incorrectly diagnosed as having
schizophrenia
continuum…?
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may be helpful to think of the various mood states
in bipolar disorder as a spectrum or continuous
range
at one end
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severe depression
moderate depression
mild low mood (if chronic, known as dysthymia)
then normal or balanced mood
then hypomania
then severe mania
at other end
mixed
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mania and depression may occur together
symptoms of a mixed state often include
agitation, trouble sleeping, significant change in
appetite, psychosis, and suicidal thinking
 someone may have a very sad, hopeless mood
while at the same time feeling extremely
energized – not a good mix...
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diagnostic concerns
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BD may appear to be a problem other than
mental illness
e.g., alcohol or drug abuse, poor school or work
performance, strained interpersonal
relationships.
 these concerns may be signs of an underlying
mood disorder
 more on this later in the dual diagnosis section
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WHIPLASHED
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Pies (Tufts) – mnemonic device
no data to support the use of this tool
could serve as a starting point or a reminder
for doctors to consider the possibility of
bipolar disorder when evaluating a patient
WHIPLASHED
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Worse or "wired" when taking antidepressants
Hypomania in the patient's history
Irritable
Psychomotor retardation or agitation
Loaded family history
Abrupt onset or termination of depressive bouts
Seasonal or postpartum pattern
Hyperphagia and hypersomnia
Early age at depression onset
Delusions, hallucinations or other psychotic
features
Bipolar III
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Just to confuse things even more…
Bipolar III Disorder – Cyclothymia
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long-term condition where the person's moods
cycle between
hypomania - a "high" that can be mild to fairly severe
but does not include delusions, hallucinations or
other psychotic features - and
 depression, also mild to fairly severe but not
incapacitating or suicidal
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suicide…
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of course, some people with bipolar disorder become
suicidal
Anyone who is thinking about committing suicide needs
immediate attention, preferably from a mental health
professional or a physician
Anyone who talks about suicide should be taken seriously
Risk for suicide appears to be higher earlier in the course of
the illness
recognizing bipolar disorder early and learning how best to
manage it may decrease the risk of death by suicide
suicide signs and symptoms
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talking about feeling suicidal or wanting to die
feeling hopeless, that nothing will ever change or get
better
feeling helpless, that nothing one does makes any
difference
feeling like a burden to family and friends
abusing alcohol or drugs
putting affairs in order (e.g., organizing finances or giving
away possessions to prepare for one s death)
writing a suicide note
putting oneself in harm’s way, or in situations where there
is a danger of being killed
If you are feeling suicidal or know
someone who is…
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call a doctor, emergency room, or 911 right away to get
immediate help
make sure you, or the suicidal person, are not left alone
make sure that access is prevented to large amounts of
medication, weapons, or other items that could be used for
self-harm
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some suicide attempts are carefully planned over time
others are impulsive acts that have not been well thought out;
important to understand that suicidal feelings and actions are
symptoms of an illness that can be treated
withproper treatment, suicidal feelings can be overcome
please consider…
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learning QPR…
and promoting its use and dissemination…
potential new understanding – may
become new assessment tool
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five key items as predictors for BD
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Co-morbid anxiety
Feelings of people being unfriendly
Family history of bipolar disorder
Recent diagnosis of depression
Legal problems
predictors identified in this study may help
physicians and patients identify depression
associated with bipolar disorder rather than
unipolar mood disorder