Transcript Joanne Fenton Presentation Bi-polar and

Bipolar and Personality
Disorders
Joanne Fenton
Consultant Psychiatrist
ACCES
Epidemilogy.
• 1 in 100 people.
• Can occur at any age,but more commonly
firsts develops between ages 18 and 24.
• 90% of cases evident before the age of
30.
• Same number of men and women.
• No difference in social class.
• 40,000 Irish people suffer from this illness.
Causes.
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Genetic: First degree relatives with BPI
are 7 times more likely to develop the
illness than general population.
• Environmental: stressful situations may
trigger an episode of mania or depression
in people prone to the condition.
• Stress is not the underlying cause.
“Manic depression distorts moods and
thoughts,incites dreadful behaviours,destroys
the basis of rational thought, and too often
erodes the desire and will to live.It is an illness
that is biological in its origins,yet one that feels
psychological in the experience of it: an illness
that is unique in conferring advantage and
pleasure,yet one that brings in its wake almost
unendurable suffering and,not
infrequently,suicide.”
Kay Redfield Jamison, Ph.D.,An Unquiet
Mind,1995,p.6.
Symptoms of Bipolar illness.
• Dramatic mood swings.
• From overly”high” and/or irritable to sad
and hopelesss, and then back again.
• Often with periods of normal mood in
between.
• Severe changes in energy and behaviour.
• Periods of highs and lows are called
episodes of mania or depression.
Mania(manic episode).
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Increased energy,activity and restlessness.Poor sleep.
Overly good ,euphoric mood.
Extreme irritability.
“flight of ideas”, racing thoughts.
Overtalkative,speech pressured.
Distractibility,poor concentration.
Unrealistic and grandiose beliefs in ones’s abilities and powers.
Poor judgement.
Spending sprees.
Increased sexual drive.
Abuse of drugs, cocaine,alcohol and sleeping tablets.
Provocative, intrusive , or aggressive behaviour.
Denial that anything is wrong.
Severe mania: psychotic symptoms also may be present .i.e: hallucinations
and grandiose delusions.
Description of Mania offered by a
patient .
• “ The fast ideas become too fast and there
are far too many… overwhelming
confusion replaces clarity…you stop
keeping up with it-memory goes. Infectious
humour ceases to amuse. Your friends
become frightened…everything is now
against the grain…you are
irritable,angry,frightened,uncomfortable,
and trapped.
Hypomania.
• Mild to moderate level of mania.
• Symptoms less severe or extreme as mania.
• Person may feel good, associated with good
functioning and enhanced productivity.
• Full of energy “life and soul” of the party, work
too much.
• Find it difficult to switch off and relax.
• At risk of making rash or dangerous decisions.
• Like being hypomanic.
Description of hypomania offered
by a patient.
• “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,
euphoria…you can do anything…but,
somewhere this changes.”
Depressive episode.
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Sad,anxious and empty mood.
Hopelessness and pessimism
Feelings of guilt, worthlessness, or hopelessness.
Los of interest or pleasure in activities, including sex.
Decreased energy, feeling of fatigue.
Restlessness or irritability.
Sleeping too much or can’t sleep.
Change in appetite or weight gain or loss.
Chronic pain/ other persistent bodily symptoms not caused by
physical illness: somatic.
• Thoughts of death or suicide, or suicide attempt.
• Psychotic symptoms .i.e: delusions of guilt or worthlessness.
Description od depression offered
by a patient.
• “ I doubt completely my ability to do anything
well. It seems as though my mood has slowed
down and burned out to the point of being
virtually useless….I am haunted with the total,
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?”.
Spectrum .
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Severe mania
Hypomania(mild to moderate mania)
Normal /balanced mood
Mild to moderate depression
Severe depression.
Types of bipolar illness
• Bipolar I disorder: recurrent episodes of
mania and depression
• Bipolar II disorder: Milder episodes of
hypomania that alternate with depression.
• Rapid cycling bipolar disorder: Four or
more episodes of illness occur within a 12month period.
Important to diagnose and treat BPI
as early as possible.
Compared to general population.
• 3 times as many BP patients get divorced.
• Twice as many BP patients suffer deterioration in their
level of employment.
• Risk of suicide attempts and death through suicide is 30
time more likely in patients with BPI. Between 25-30% of
BP patients will attempt suicide .10-15 % of patients
eventually succeeding in taking their own life.
• Co morbid alcohol and substance abuse very frequent .
How is Bipolar disorder treated?
Stages of treatment;
• Acute phase: treatment is aimed at ending
current manic, hypomanic or depressive
episode.
• Preventive or maintenance phase:
treatmemt is continued on a long-term
basis to prevent future episodes.
Components of Treatment.
• Medication: necessary for nearly all patients
during acute and preventive phase.
• Education: crucial in helping patients ,families
and carers to learn how to manage BP patients
and prevent complications.
• Psychotherapy: helps patients, families and
carers to deal with disturbing thoughts, feelings
and behaviours in a constructive manner.
Types of mediaction
• Mood stabilizers.
• Antidepressants
• Antipsychotics.
Mood stabilizers
• Lithium.
• Valporate.
• Carbamazepine.
Side effects:
• Weight gain, tremor,nausea , sedation and
increased urination.
Antidepressants.
• Used together with mood stabilizers.
• Can sometimes cause elation, needs to be
monitored.
• Prozac, paroxetine,sertraline(SSRI’s)
• Venlafaxine.
Antipsychotics.
• To control psychotic symptoms.
• May be used as a sedative in acute phase
of illness for insomnia, anxiety and
agitation.
• Newer antipsychotics have mood
stabilizing properties.(atypicals):
olanzapine/ risperidone/clozapine.
• Side affects: drowsiness and weight gain.
Electrocvulsive therapy.
• ECT: often life saving in severe depression and
mania.
• If patient is acutely and severely ill and can wait
for medications to work.
• Hx of unsuccessful mediation trials.
• Administrated under anaesthesia in carefully
monitored medical setting.
• 6-10 treatments over several weeks.
• Side effect: temporary memory problems, which
returns quickly.
What to do to help treatment.
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Maintain a stable sleep pattern.
Regular pattern of activity.
Do not use alcohol or drugs.
Enlist support of family or friends.
Reduce stress.
Learn about illness.
Learn and recognize “ early warning signs” of
new mood episode.
• Monitor your mood. ie: mood chart or diary.
Where to get help.
• Mental health team: psychiatrist,
CMHN,Social worker or psychologist.
• Knowledgeable General Practitioner.
• Support and advocacy groups: Aware,
www.aware. Mental health ireland.:
ww.mentalhealthireland.ie
• www.sane.org.uk
• www.rethink.org
• www.pendulum.org
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Hans Christian Anderson.
Charles Dickens.
Virginia Woolf.
William Blake.
Emily Dickinson.
Robin Williams.
Ted Turner.
Personality disorders
• disorders can be grouped into 3 clusters
• the odd and eccentric
• the dramatic, emotional or erratic
• the anxious or fearfull
What causes personality disorders
• differences between people are partly genetic and environmental
• these also influence personality development
• differences in structure and chemistry of the brain, inadequate
parenting, childhood neglect and abuse, trauma and religious
beliefs may all effect personality
• all these factors are mainly beyond the control of the individual
• above factors are usually stable enough by adolescence
for the inherent personality to be regarded as established
Development
• most often the first signs of a personality
disorder appear in late childhood or adolescence
and continue during adulthood
• personality disorders in children or adolescence
are sometimes described as conduct disorders
• however most conduct disorders in children do
not necessarily lead to personality disorders in
adults
Differential diagnosis
• personality disorder may be associated with
other mental health problems, such as:
depression, anxiety, panic disorders, eating
disorders, deliberate self-harm, substance
abuse, and manic depression.
• possible to mis-diagnose someone as having a
personality disorder if they have a syndrome
with similar symptoms:
e.g. post-traumatic stress disorder or Asperger's
Epidemiology
• Community prevalence – 2-3%
• Excess among males, cities, young
• Male prisoners – 60% prevalence
• Borderline personality well studied
good prognosis – only 25% retain diagnosis at age 50
marriage rates 50% average
25% have children
employment is common
Paranoid Personality Disorder
• very sensitive to experiencing failure or rejection
• hold grudges against people and will refuse to forgive
insults, injuries or slights
• very suspicious and will often misinterpret the friendly or
neutral behaviour of other people as being unfriendly or
hostile. Suspicious about the fidelity of sexual partners
• preoccupation with personal rights
• prone to believing in conspiracy theories
Schizoid Personality Disorder
• find pleasure in few, if any, aspects of their life
• unemotional, seem to be cold and unfeeling and find it very difficult
to express anger or warmth to other people
• unaffected by the praise or criticism of others and noticeably
insensitive to the norms and conventions held by society
• prefer to be on their own and have little interest in relationships
(including close friendships or sexual ones)
• very introspective and preoccupied with fantasy
Anti-Social Personality Disorder
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appear to be callous and unconcerned about how their behaviour makes
other people feel, do not feel guilt or profit from experience (for instance
punishment)
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on the other hand will tend to blame other people for their problems or to
find a way of rationalising what they have done
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because of their disregard for social norms, rules and obligations they act in
ways that are regarded as unacceptably irresponsible
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cannot cope with a long term relationship, although forming one is easy
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cannot tolerate frustration and are prone to outbursts of aggression and
violence
Borderline Personality Disorder
• marked tendency to act impulsively without considering
the consequences of these actions, eg engaging in
unprotected sex or substance abuse.
• an inability to plan ahead is coupled with a lack of
self control and outbursts of intense anger
• can resort to violence and other extreme behaviour,
especially if impulsive acts are challenged or prevented
by people around them
Borderline Personality Disorder
• emotional instability
• severe doubts about their self image, aims and sexual
preferences which cause upset and distress.
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it is common to experience a strong and debilitating
sense of emptiness and this can lead to self harm and
suicide threats.
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liable to become involved in intense but unstable
relationships which can cause them continual emotional
crises, which they will endure to avoid being abandoned.
Narcissistic Personality Disorder
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arrogant and self important
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fantasises about unlimited successes and achievements
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believes that they are special and can only be
understood by other special people
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constant need for attention and admiration
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exploits others to achieve own ends
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lacks empathy: is unwilling to recognize or identify with the feelings and
needs of others
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is often envious of others or believes that others are envious of them
Histrionic Personality Disorder
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uncomfortable if not center of attention
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interactions with others is often inappropriately sexually provocative or
seductive
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rapidly shifting & shallow expression of emotions
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uses physical appearance to draw attention to self
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impressionistic speech - lacking in detail
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exaggerated expression of emotion & theatricality, very suggestible
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overestimates the intimacy of their relationships
Histrionic
Anxious (Avoidant) Personality
Disorder
• persistent and pervasive feelings of shyness, insecurity,
apprehension and tension leading to restrictions in lifestyle
• believing oneself to be unlikeable, undeserving, socially inept, and
less important than other people
• leading to a reluctance to get involved in relationships unless certain
of being liked
• over-concerned by the fear of being criticised or rejected in social or
work situations
• leading to an avoidance of any activity that involves having to interrelate with other people
Obsessive-Compulsive
(Anankastic) Personality Disorder
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feelings of excessive doubt and caution compensated by a need to adhere
strictly to rules, lists and orders
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paradoxically this perfectionism often interferes with the successful
completion of tasks
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close relationships and pleasurable activities are difficult to maintain in the
face of the need to meet excessive standards of conscientiousness and
productivity
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this attitude is off putting to other people especially as you expect the same
dedication from others or conversely will unreasonably seek to prevent
others from doing things
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rigid and stubborn in outlook, whilst also pedantic about doing the right
thing.
Obsessive compulsive
Dependant Personality Disorder
• encouraging or allowing others to make important life decisions
• a limited ability to make every day decisions unless given excessive
reassurance and advice
• unwilling to make demands on people, especially those people who
play an important part in their life and becoming compliant and
subordinate to other peoples wishes
• feelings of helplessness and discomfort when alone
• anxiety about being abandoned by loved ones due to fears of being
unable to care for themselves.
Bryan, 23
• active in student government, charismatic, articulate,
and sociable
• when he met other students for the first time, he could
often convince them to participate in campus activities
that interested him
• women were quite attracted to him because of his charm
and self-disclosing nature
• described him as being exciting, intense, and different
from other men
• Bryan could form close relationships with others very
quickly
Bryan, 23
• could not, however, maintain his social relationships
• would have a brief but intense affair with a woman and
then abruptly and angrily ask himself what he ever saw
in her
• at other times, the woman would reject him after a few
dates, because she thought he was moody,
self-centered, and demanding
• he often called his friends after midnight as he felt
lonesome, empty, bored, and wanted to talk
• several times he threatened to commit suicide
Marilynn, 25
• had a series of confrontations with others over several
years
• several of which resulted in her arrest and brief jail terms
• despite this, she fails to see a problem in her behaviour
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sees herself as a "victim" who has been "taken
advantage of."
• she has rarely held a job for even as long as a year and
has had a series of shallow relationships.
Marilynn, 25
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although frequently described as "charming," she says
others often lose patience with her
• they are upset by such things as her tendency to lie to
them, to behave impulsively, and to "drop into their lives"
at the drop of a hat, then disappear
James, 35
• is a rather immature with poor social skills
• others especially note his problems with social situations
in that he prefers to be the center of attention
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engages in a variety of behaviors to get it (especially
sexualizing relationships and overdramatic descriptions
of his life and experiences)
• initially others see him as charming, but they are often
put off by the shallowness of his experience and
expression of emotions
James, 35
• despite this, he believes that his relationships are truly
intimate
• last week he reported that "he had just found his one
true love," while today he believes that relationship was
"nothing."
• he has had no close, long-term sexual relationships.
• his lack of real affection for others had been
demonstrated by a history of selfish and self-centered
behavior.
Personality disorders
• questions which need to be answered then include:
• how far such people should be blamed for what they do
• whether there is any way of changing them
• whether they can be made to do whatever is needed to
change them.