1 adult bipolar disorder anthony norelli, m.d. northwestern mutual wahlu presentation 4/16/15

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Adult Bipolar Disorder

Anthony Norelli, M.D.

Northwestern Mutual

WAHLU Presentation

4/16/15

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Goals

• Visit history of BPD

• Address epidemiology of BPD

• Briefly address diagnostic criteria

• Address why BPD is so difficult to diagnose

• Address why BPD is so difficult to treat

• Address what is in the underwriter’s armamentarium

• Time for Q&A

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BPD History

• Earliest mentions of BPD symptoms are found in Egyptian Papyri dating to approximately 2000 B.C.

• Aretaeus of Cappadocia – (practiced somewhere between 70-150 A.D.?) Gave early descriptions of diabetes, asthma, tetanus, diphtheria, and epilepsy among others. Also identified mania and depression as two separate forms found within the same illness.

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Cappadocia? (=Anatolia)

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Aretaeus of Cappadocia

• Aretaeus described a group of patients who ‘laugh, play, dance night and day, and sometimes go openly to the market crowned, as if victors in some contest of skill’ only to be ‘torpid, dull, and sorrowful’ at other times. Though he suggested that both patterns of behavior resulted from one and the same disorder, this idea did not gain currency until the modern era (e.g. mid-19th century)

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Ancient Greece/Rome Forward

• Mania and Melancholy

• Lithium baths were thought to be helpful

• 300-500 A.D. – manic individuals thought to be possessed, were executed

• 500-1600 – equally crummy care

• Burton, 1621 – Anatomy of Melancholy

• Baillarger, Falret 1854: folie a double forme, folie circulaire

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20th Century

• Emil Kraeplin

a. Broke with Freud (e.g. societal cause of mental illness)

b. Studied course of illness: delineated between démence précoce (dementia praecox; aka schizophrenia) and manic-depressive psychosis

c. DSM-V suggests Kraeplin had the right idea, and took BPD out of the mood disorders chapter and gave it its own chapter between mood disorders and psychosis.

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20th Century

• Treatment: lobotomy, ECT, etc.

• Dr. John Cade – Guinea pig experiments led to 1949 paper on Lithium Salts – fear of excess toxicity led to Lithium being banned in the US until 1970.

• 1950’s-60’s – BPD felt to be less stigmatizing than manic-depressive psychosis

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BPD Fiction

• Some have maintained that BPD is strictly a construct of “Western Medicine,” or even a “celebrity fashion statement.”

• Just how “Western” is Cappadocia?, or Ancient Egypt? Remember, these areas were trade centers back in that time, where people exchanged not only good but also ideas.

• 1583: Gao Lian published his “Eight Treatises on the Nurturing of Life” which discusses BPD-type symptoms (in detail) over centuries in his native China.

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BPD Nonfiction

• A number of well-known individuals have admitted to having BPD (and others were outed by confidants). A short list includes:

Ernest Hemingway, Marilyn Monroe, Britney Spears, Robert Schumann, Mel Gibson, Vivian Leigh, Jim Carey, Rosemary Clooney, Russell Brand, Ted Turner, Demi Lovato, Dick Cavett, Patricia Cornwell, Edward Elgar, Brian Wilson, Kurt Cobain, Robin Williams, and many more.

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Sylvia Plath

“It’s as if my life was run by two electric currents: joyous positive and despairing negative – whichever is running at the moment dominates my life, floods it.”

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BPD and Creativity

• It has been suggested that many of the renowned artists in history (think composers, painters, sculptors, etc.) were bipolar

• Some have asked if the availability of medication to control BPD has actually decreased overall creativity…

• Is there an evolutionary advantage of BPD?

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BPD Epidemiology

• Prevalence estimates range from 1% to 4.5% (can rise to 10% depending upon inclusion criteria). Closer to 4% is likely most accurate.

• Overall prevalence is equal in males and females. However:

a. Women tend to have more depressive presentations

b. Women tend to have more rapid cycling (3:1 ratio)

c. Men tend to have more psychosis (e.g. schizophrenia)

d. So when misdiagnosed, guess what the “misdiagnoses” are…

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BPD Epidemiology

• Average age of onset is 25

a. “Usual” is later teens to early 20’s

b. From teens through 5th decade is considered more typical

c. Pre-pubertal onset portends more aggressive course, and likely at least 1 parent with BPD

d. Onset ≥50’s – think underlying systemic disease first, and psych disorder second

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BPD Heritability

• Falret recognized that BPD seemed to run in families, and felt it was thus heritable

• A number of genes have been isolated that contribute to BPD development but none make development of BPD a given (e.g. ANK3, which codes for ankyrin, has strongest correlation of any gene with BPD – determines synaptic behavior)

• 1 parent with BPD confers 15-30% chance for their offspring to have BPD

• 2 parents with BPD confers 50-75% chance for their offspring to have BPD

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BPD Heritability

• Twin studies: Historically flawed and small

• One often-quoted study out of Denmark showed the following:

Probandwise Concordance Rate

Bipolar-Bipolar Monozygotic Twins

Dizygotic Twins

62%

8%

Bipolar-Bipolar/Unipolar

79%

19%

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BPD Triggers

• So if genetics helps “load the gun”, what helps “pull the trigger?”

a. Stressful life events (good or bad): loss of job, birth of baby, promotion, etc.

b. Disruption of sleep patterns – chronic sleep deprivation could theoretically lead to mania or hypomania; chronic excess sleep could lead to depression

c. Disruption to routine – studies have shown those who have regular sleep/wake schedules are less likely to develop (or have recurrence of) BPD

d. Excess external stimulation – clutter, traffic, noise, light, crowds, work deadlines, social activities

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BPD Triggers – Continued

• So if genetics helps “load the gun”, what helps “pull the trigger?”

e. Too much internal stimulation – overstimulation from excessive activity/excitement while trying to achieve challenging goals, or ingesting stimulants (caffeine, nicotine)

f. AODA – can trigger BPD; BPD patients are also more likely to abuse AODA

g. Excessive conflict/stress – think PTSD

h. Untreated/undiagnosed medical illness

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BPD Numbers

• According to WHO, BPD is the #6 cause of disability in the world

• BPD estimated cost to US economy $75 Billion in 2008

• BPD diagnosis translates to an average decrease of estimated lifespan by 9.2 years:

a. Treated appropriately, BPD mortality approaches general population mortality

b. 2007 study (Goodwin and Jamison) found untreated BPD mortality was 230% greater than general population

• Up to 20% of those with BPD complete suicide

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BPD Definition

• There are 4 main types of BPD:

a. Bipolar Type I (BPI)

b. Bipolar Type II (BPII) – greatest association with suicide risk

c. Cyclothymia – about 15% have rapid cycling

d. Bipolar disorder with atypia

Please also see handouts for DSM-V definitions

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Why BPD is so Challenging

• The definitions!

• BPI does not require a depressive episode

• BPII does not require a manic episode (and good luck nailing that hypomanic thingy)

• Cyclothymia – symptoms present >2 years and hypomania/depression has persisted for at least 1 year, and not more than 2 months have gone by without symptoms (and spouse has not tried to air mail patient to Siberia in their sleep)

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BPD – Points Worth Noting

• Typical BPD patient averages 8-10 manic or depressive episodes over a lifetime, though some may have many more or fewer episodes

• Even when optimally treated, the BPD symptoms may wax and wane significantly

• BPD diagnoses can change (i.e. patients with one type of bipolar diagnosis and go on to develop another, different bipolar diagnosis due to change in symptoms – which is another reason some experts believe different types of BPD are actually distinct from each other…)

• BPD is a lifelong disorder, but in any given year up to half of BPD patients may be off treatment (their choice, not the MD’s).

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BPD – Screening

Screening tests for BPD include:

a. Depression – any of the validated depression screening tests: Hamilton, Beck, PHQ-9, Major Depression Inventory, Zung scale, etc.)

b. Mania – either of

i. Mood Disorder Questionnaire (MDQ) – 13 questions

ii. (WHO) Composite International Diagnostic Interview (aka CIDI 3.0) – 12 questions

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BPD – Screening; A Few Parting Thoughts

• Screening for and treating depression and/or anxiety can be adequately performed in a primary care setting

• Screening for BPD can be adequately performed in a primary care setting

• However, confirmation of BPD diagnosis and formal BPD treatment should be the province of a specialist (psychiatrist and allied health professionals). Once an individual has been appropriately diagnosed and is stable on treatment it is not unreasonable for much of the maintenance care to happen in a primary care setting (med refills, blood testing, etc.) but the psych experts should stay involved at some level.

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BPD – Screening and Underwriting

• So, if the medical records indicate that screening tests were done – especially the MDQ or CIDI 3.0 – and the screen was determined to be positive, it is hard to argue with the diagnosis of BPD.

• If the records do not record how the diagnosis was made, look for these to increase likelihood of BPD Dx:

a. Positive family history (parent, sib, child)

b. Lithium use

c. Nonmedical evidence: multiple driving citations, OUI’s, arrests, bankruptcies, etc. (though this might carry a little less weight than a and b above in my mind)

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Why BPD is so Challenging

• The presentation

A. Mood – in descending order: irritability, euphoria, expansiveness, lability, depression

B. Cognitive – in descending order: racing thoughts/flight of ideas, distractibility/poor concentration, grandiosity/overconfidence, confusion/disorientation/impaired memory

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Why BPD is so Challenging

C. Activity and Behavior – in descending order of frequency: hyperactivity, increased speech output, rapid/pressured speech, decreased need for sleep, increased libido, violent/assaultive behavior, religiosity, extravagant spending sprees, nudity/sexual exposure, pronounced regression, catatonia

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Why BPD is so Challenging

Long differential:

Must first rule out

a. Thyroid disease b. Seizure disorder

c. Multiple sclerosis d. CVA

e. AODA f. Hyperparathyroidism

g. Personality disorder h. Schizophrenia

i. Infection (syphilis)

j. Traumatic Brain Injury (TBI)

k. Schizoaffective disorder

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Why BPD is so Challenging

Difficult to diagnose:

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Why BPD is so Challenging

• Inconsistent course:

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Why BPD is so Challenging

• The company it keeps:

a. Lifetime prevalence of at least one comorbid psychiatric disorder was 2x that of gen pop (92% vs. 46%)

b. Prevalence of anxiety was 2.5x gen pop

c. Prevalence of AODA in US

i. BPI – 4x gen pop

ii. BPII – 2.5x gen pop

d. Prevalence of ADHD is 4x gen pop

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Why BPD is so Challenging

e. Prevalence of eating disorders 3-5x gen pop

f. Prevalence of intermittent explosive disorder is 6x gen pop

g. Prevalence of comorbid personality disorder

i. Cluster A (paranoid, schizoid, schizotypal) was 2x gen pop

ii. Cluster B (antisocial, borderline, histrionic and narcissistic) was 7.5x gen pop

iii. Cluster C (avoidant, dependent, OCD, passive-aggressive) was 3.5x gen pop

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Why BPD is so Challenging

• Comorbids in general are associated with:

a. Earlier age of onset

b. More severe clinical course

c. More suicide attempts

d. Poorer psychosocial functioning

e. Greater potential for cognitive impairment

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Why BPD is so Challenging

• PATIENTS OFTEN LACK INSIGHT!

• Also, if I can get all my stuff done, have all the energy in the world and feel great, am I really interested in doing something that’s going to take that away?

• Similar to overtreated hypothyroidism

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Disclaimer

• I am not in any way saying that the individual in the next slide has BPD, diagnosed or otherwise. I am simply showing their response to a very appropriate question given their behavior at that time. You may remember parts of this…

• But for illustrative purposes this response would represent a classic lack of insight

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Why BPD is so Challenging

• Social Stigma

This individual has exhibited courage by blogging publicly about their BPD:

• https://www.youtube.com/watch?v=6zTw-TCBAL4

Note the flight of ideas, grandiosity, desire for AODA, rapidity of speech, questionable plausibility of some of their plans, etc.

I’m exhausted just listening to him.

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Same Individual, Depressed

• https://www.youtube.com/watch?v=PQWp4gsu9mQ

• Depressed entry preceded manic entry

• Posting dates were only 3 days apart = rapid cycling

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An Example of Good Insight…

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Current BPD Treatment Arsenal*

Generic Name Trade Name Manic Mixed Maintenance Depression

Valproate Depakote X      

Carbamazepine (ER) Equetro X X    

Lamotrigine Lamictal     X  

Lithium Eskalith X   X  

Aripiprazole Abilify X X X  

Risperidone Risperdal X X    

Asenapine Saphris X X    

Quetiapine Seroquel X     X

Chlorpromazine Thorazine X      

Olanzapine Zyprexa X X X  

Olanzapine/fluoxetine Symbyax       X

*FDA-Approved

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Benefits of Being an Underwriter

• Access to medical information psych and otherwise – or at least a single, rather terse paragraph – hopefully including appropriate screening tests

• Access to medication list (+/- Rx report)

• Access to driving records

• Access to criminal records

• Can re-contact proposed to clarify or develop more information

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Disadvantages of Being an Underwriter

• Summary Statements that state next to nothing

• Physicians contradicting one another

a. IS the patient bipolar?

b. Is the patient in remission?

c. Was initial diagnosis incorrect?

• Patient disagrees with diagnosis – Googled this; eye-opener

• Blank pharmacy report

• Documented noncompliance but the proposed looks like a rose

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Cause for Optimism?

• Regular followup

• Engaged with medication and CBT

• Family or other support system in place

• Symptom stability

• Stability both in home and at work

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Things to Remember

• Even though the symptoms may wax and wane, the disorder is lifelong

• Plugged into regular care = best prognosis both in life and in Life Underwriting

• Compliance with MD-directed management is key

• Underwriter is in a unique position – in clinic MD does not always have access to info about driving, financial indiscretions, etc.

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Questions?