Bipolar Disorder -- Bipolar Disorder -- diagnosis, symptoms, diagnosis, symptoms,

etc…etc…Kurt Weber, PhDKurt Weber, PhD

Mental Health America – Brown CountyMental Health America – Brown CountyBemis International CenterBemis International Center

St Norbert CollegeSt Norbert CollegeMay 13, 2008May 13, 2008

no definitive test…no definitive test…

and… 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… many psychiatric disorders can occur in

tandem

therefore…therefore…

a psychiatrist will usually conduct the following complete medical history and physical exam to rule out other physical or organic concerns complete psychiatric history

possibility of other mental disorders should be considered previous mood swings (perhaps of less severity or duration)

may come to light family history of medical and psychiatric concerns

Current research indicates that mood disorders have genetic underpinnings

evaluation of current symptoms

symptomssymptoms

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

manic phasemanic phase

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.

delusionsdelusions

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 no symptom or cluster of symptoms reliably

distinguishes bipolar mania from schizophrenia

signs and symptoms signs and symptoms of a manic episodeof a manic episode

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)red flags (about.com) 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.

moremore 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…even more… 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…one may consider…

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.

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.

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…”

anatomy of a manic upswing

Mania can also be Mania can also be secondary to…secondary to…

Drugs 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.

CNS disorders brain tumors, cerebrovascular disorder, trauma, epilepsy,

Huntington's, multiple sclerosis, Pick's, postencephalitic, Parkinson's, spinocerebellar atrophy, Wilson's Disease.

Toxic/ Metabolic AIDS, calcium, Cushing's, hemodialysis, hyperthyroidism,

influenza, neurosyphilis, postoperative, post St. Louis type A encephalitis, Q fever, lupus, vitamin B12 deficiency.

bipolar depressive bipolar depressive episodesepisodes

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 symptomssigns and symptoms 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.

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

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 depressionred flags for depression 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.

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.

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 it might be a good idea to…to…

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

hypomaniahypomania

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 -- subjective experience -- hypomaniahypomania

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.

psychosispsychosis

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

Psychotic symptoms in bipolar disorder tend to reflect the extreme mood state at the time 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…?continuum…? may be helpful to think of the various mood

states in bipolar disorder as a spectrum or continuous range

at one end severe depression moderate depression mild low mood (if chronic, known as dysthymia) then normal or balanced mood then hypomania then severe mania

at other endat other end

mixedmixed

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...

diagnostic concernsdiagnostic concerns

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

WHIPLASHEDWHIPLASHED

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 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 IIIBipolar III

Just to confuse things even more… Bipolar III Disorder – Cyclothymia

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

suicide…suicide… 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 suicide signs and symptomssymptoms

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…

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 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…please consider…

learning QPR… learning QPR… and promoting its use and and promoting its use and

dissemination…dissemination…

potential new potential new understanding – may understanding – may

become new assessment become new assessment tooltool five key items as predictors for BD

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