Transcript (PPS, 1.8MB) - Psychiatrist in Sydney

Bipolar disorder in the
workplace
Himalee Abeya
Consultant Psychiatrist
WPH, Surry Hills
It is as if my life were magically run by
two electric currents: joyous positive and
despairing negative - whichever is running
at the moment dominates my life, floods it.
Sylvia Plath (2000)
The Unabridged Journals of Sylvia Plath, 1950-1962
New York: Anchor Books
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Bipolar origin
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First known as ‘manic depressive psychosis’
1920
The term “bipolar”—which means “two poles”
signifying the polar opposites of mania and
depression—first appeared in the American
Psychiatric Association’s Diagonostic and
Statistical Manual of Mental Disorders (DSM)
in its third revision in 1980.
Prevalence in Australia
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Bipolar I disorder may be experienced by up to 1%
Australians over their lifetime (there being no gender
difference).
The lifetime risk of Bipolar II disorder is up to 5%
(with rates higher in women).
Across both sub-types, bipolar disorder affects
around one in 33 (3%) men and women in their
lifetime [1].
However, prevalence of bipolar disorder is probably
higher than the statistics suggest, as many cases
are often undetected or misdiagnosed.
Australian Bureau of Statistics (2009). National Survey of Mental Health and Wellbeing: Summary
of Results, 4326.0, 2007. ABS: Canberra.
Diagnosis
NIMH (2007)
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Cartoonist Ellen Forney Documents Her Struggle with Bipolar Disorder in ‘Marbles’, An
Illustrated Graphic Memoir
DSM-5 Diagnosis
Diagnostic Classifications
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Bipolar I Disorder
1.
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APA (2013)
One or more Manic Episode or Mixed Manic
Episode
Minor or Major Depressive Episodes often present
May have psychotic symptoms
Severity Ratings: Mild, Moderate, Severe
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DSM-5 Diagnosis
Diagnostic Classifications
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Bipolar II Disorder
2.
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APA (2013)
One or more Major Depressive Episode
One or more Hypomanic Episode
No full Manic or Mixed Manic Episodes
Severity Ratings: Mild, Moderate, Severe
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DSM-5 Diagnosis
Diagnostic Classifications
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3.
Cyclothymia
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For at least 2 years (1 in children and adolescents),
numerous periods with hypomanic symptoms that do not
meet the criteria for hypomanic episode
 Present at least ½ the time and not without for longer than
2 months
Criteria for major depressive, manic, or hypomanic episode
have never been met
APA (2013)
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“There is a particular kind of pain, elation, loneliness, and terror
involved in this kind of madness. When you're high it's
tremendous. The ideas and feelings are fast and frequent like
shooting stars, and you follow them until you find better and
brighter ones. Shyness goes, the right words and gestures are
suddenly there, the power to captivate others a felt certainty.
There are interests found in uninteresting people. Sensuality is
pervasive and the desire to seduce and be seduced irresistible.
Feelings of ease, intensity, power, well-being, financial
omnipotence, and euphoria pervade one's marrow. But,
somewhere, this changes. The fast ideas are far too fast, and
there are far too many; overwhelming confusion replaces clarity.
Memory goes. Humor and absorption on friends' faces are
replaced by fear and concern. Everything previously moving with
the grain is now against-- you are irritable, angry, frightened,
uncontrollable, and enmeshed totally in the blackest caves of the
mind. You never knew those caves were there. It will never end,
for madness carves its own reality.”
― Kay Redfield Jamison, An Unquiet Mind: A Memoir of Moods
and Madness
DSM-5 Diagnosis
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Manic Episode Criteria
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A distinct period of abnormally and persistently
elevated, expansive, or irritable mood.
Lasting at least 1 week.
Three or more (four if the mood is only irritable) of the
following symptoms:
1.
2.
3.
4.
5.
6.
7.
APA (2013
Inflated self-esteem or grandiosity
Decreased need for sleep
Pressured speech or more talkative than usual
Flight of ideas or racing thoughts
Distractibility
Psychomotor agitation or increase in goal-directed activity
Excessive involvement in activities with potential for
painful consequences
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DSM-5 Diagnosis
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Manic Episode Criteria (cont.)
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APA (2013)
Causes marked impairment in occupational
functioning in usual social activities or
relationships, or
Necessitates hospitalization to prevent harm to self
or others, or
Has psychotic features
Not due to substance use or abuse (e.g., drug
abuse, medication, other treatment), or a general
medial condition (e.g., hyperthyroidism).
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DSM-5 Diagnosis
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Hypomanic Criteria
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Similarities with Manic Episode
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Same symptoms
Differences from Manic Episode
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APA (2013)
Length of time
Impairment not as severe
May not be viewed by the individual as pathological
 However, others may be troubled by erratic behavior
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Changes From DSM-IV-TR
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No longer classified as a “mood disorder” – has own category
Placed between the chapters on schizophrenia and depressive
disorders
 Consistent with their place between the two diagnostic classes in
terms of symptomatology, family history, and genetics.
Bipolar I criteria have not changed
Bipolar II must have hypomanic as well as history of major depression
and have clinically significant
 can now include episodes with mixed features.
 past editions, a person who had mixed episodes would not be
diagnosed with bipolar II
 diagnosis of hypomania or mania will now require a finding of
increased energy, not just change in mood
Source: APA (2013)
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Bipolar I
Alternative Diagnosis
Differential Consideration
Major Depressive
Disorder
Person with depressive Sx never had
Manic/Hypomanic episodes
Bipolar II
Hypomanic episodes, w/o a full Manic episode
Cyclothymic Disorder
Lesser mood swings of alternating depression hypomania (never meeting depressive or manic
criteria) cause clinically significant
distress/impairment
Normal Mood Swings
Alternating periods of sadness and elevated mood,
without clinically significant distress/impairment
Schizoaffective
Disorder
Sx resemble Bipolar I, severe with psychotic features
but psychotic Sx occur absent mood Sx
Schizophrenia or
Delusional Disorder
Psychotic symptoms dominate. Occur without
prominent mood episodes
Substance Induced
Bipolar Disorder
Stimulant drugs can produce bipolar Sx
Source: Francis (2013)
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How would BPD present in the workplace
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Actual manic symptoms or depressive
symptoms
Distractibility
Reduced concentration
Poor work output
Absenteeism
Interpersonal issues : too loud, unusually
gregarious, irritable
Mishaps and mistakes
Odd behaviour - could be due to psychotic
symptoms
Case Vignette
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46 year old lady originally from Hong Kong – Grade
8 Operations Officer - EPA.
Refereed by employers:
Loud, excitable and distractible – they could hear her
laugh down the corridor.
Took unnecessary risks.
Overestimates her capabilities.
Work output diminished
Presented as very charming with uncritical self
confidence. Completely denied all allegations made
about behaviour
Considerations in employment
Person
 Stability of condition / treatment engagement
 Risks in relapse – degree of harm
 Impact on cognition (illness, medication)
 Insight and resilience/prognosis
Work
 Shift work (Social Rhythm Stability Hypothesis )
 Type of work – responsibility/risk
 Challenging work environment/ high pressure work
Considering potential risks
Manic phase:
 Risk to reputation
 Risk of misadventure (overconfidence/ lack of
judgement OR Psychotic Symp)
Depressive phase:
 Risk of harm to self
Bipolar disorder – 15% more risk of suicide
over lifetime
Adjustments at all?
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Type of work - ?less challenging
Shifts/ hours
May require periodic leave
Flexibility to attend medical appointments
Case Vignette…….contd
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2 Depressive episodes and 2 hypomanic
episodes over 2 years
Very poor insight and acceptance
Initially –temp unfit –needs Rx
Then – gradual RTW with adjustments
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Fewer days -gradual increase
lower rank (fewer duties/challenges) - temp
See Ψ/ doctor – provide certification
The Evidence –
Manic-Depressive Illness and Creativity
1.
2.
Jamison, K. R. Manic-Depressive Illness and Creativity. Scientific American. February, 1995
Andreasen et al. The relationship between creativity and mental disorders. Dialogues in Clinical Neurosciences. 10,2.121264,2008
Factors suggesting a poor prognosis
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Poor job history
Substance abuse
Psychotic features
Depressive features between periods of
mania and depression
Evidence of depression
Male sex
Pattern of depression-mania-euthymia
Factors suggesting a better prognosis
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Length of manic phases (short duration)
Late age of onset
Few thoughts of suicide
Few psychotic symptoms
Few medical problems
Outcome after an initial episode
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Within the first 2 years after the initial episode,
40-50% of patients experience another manic
attack.
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50-60% of patients with BPI who are on lithium
gain control of their symptoms.
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In 7% of these patients, symptoms do not recur,
45% of patients experience more episodes, and
40% go on to have a persistent disorder.
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Often, the cycling between depression and
mania accelerates with age. More depression
Natural History of Bipolar Disorder
Management of Mood disorders
Acute 
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Admission needed?
Medication
ECT
-Depression
V. Severe (life threateningstupor)
Suicidal
Psychotic
-Mania
Drug resistant / severe
4.
5.
6.
Educate- patient/family
Psychotherapy
Address social issues
Depression
Mania
Anti depressant
Anti psychotic
-Tricyclic
amitriptyline
imipramine
-SSRI
Fluoxetine
-MAOI
-Atypical
-Typical
Mood stabilizer
-Lithium carbonate
-Carbamezapine
-Na valproate
Benzodiazepine
-clonazepam
-lorazepam
Long Term 
Prevent relapses –
Medication -
Mania/ BAD:- Continue mood stabilizer
(1st episode – consider recurrence risk)
- Antidepressant/ antipsychotic to
cover the episode
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Educate to recognize relapse signs early
Educate about illness and drugs compliance
To improve quality of life - advice on lifestyle
address personal/marital problems
Schumann’s
Musical works
Jamison, K. R. Touched with Fire: Manic-Depressive Illness and the Artistic Temperament. Free Press/Macmillan,1993.
Jamison, K. R. Manic-Depressive Illness and Creativity. Scientific American. February, 1995
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So why would I want anything to do with this illness? Because I
honestly believe that as a result of it I have felt more things, more
deeply; had more experiences, more intensely; loved more, and
been more loved; laughed more often for having cried more often;
appreciated more the springs, for all the winters; worn death "as
close as dungarees," appreciated it-and life-more; seen the finest
and the most terrible in people, and slowly learned the values of
caring, loyalty and seeing things through. I have seen the breadth
and depth and width of my mind and heart and seen how frail they
both are, and how ultimately unknowable they both are. Depressed,
I have crawled on my hands and knees in order to get across a
room and have done it for month after month. But, normal or manic,
I have run faster, thought faster and loved faster than most I know.
And I think much of this is related to any illness-the intensity it gives
to things and the perspective it forces on me.
From The Unquiet Mind - Prof Kay Redfield Jamison –Professor of psychiatry at the
Johns Hopkins University School of Medicine