Bipolar Disorder: Journey Through Mania and Depression H.E. Logue, M.D.
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Transcript of Bipolar Disorder: Journey Through Mania and Depression H.E. Logue, M.D.
Bipolar Disorder:Bipolar Disorder:Journey Through Mania Journey Through Mania
and Depressionand Depression
H.E. Logue, M.D.H.E. Logue, M.D.
Bias DisclaimerBias Disclaimer
There is no pharmaceutical support There is no pharmaceutical support for this program.for this program.
I am active in the research field and I am active in the research field and involved in clinical trials for most of involved in clinical trials for most of the major pharmaceutical the major pharmaceutical companies.companies.
Goals and ObjectivesGoals and Objectives
Promote better understanding of the Promote better understanding of the following aspects of Bipolar Disorder:following aspects of Bipolar Disorder: PrevalencePrevalence Recognition and Diagnosis Recognition and Diagnosis Understanding Risk FactorsUnderstanding Risk Factors Genetic PredispositionGenetic Predisposition Treatment ConsiderationsTreatment Considerations Co-morbid ConditionsCo-morbid Conditions Referral ConsiderationReferral Consideration
Richard Dreyfuss
Kitty Dukakis Liza Minnelli Carman
Miranda Marilyn
Monroe J.P. Morgan Ralph Nader Sir Isaac
Newton Florence
Nightingale Ozzy Osbourne Dolly Parton Boris
Pasternak George Patton Jane Pauley Pablo Picasso Cole Porter Abraham
Lincoln Joshua Logan Jack London Greg Louganis Martin Luther Imelda Marcos Ann Margaret Herman
Melville Burgess
Meredith Kurt Vonnegut Vivian Vance
Victor Hugo Edgar Allen
Poe Leo Tolstoy Michelangelo Ezra Pound Charlie Pride Sergey
Rachmaninoff Patty Duke Thomas
Eagleton Thomas Edison T.S. Eliot Ralph Waldo
Emerson William
Faulkner Eddie Fisher F. Scott
Fitzgerald Betty Ford Harrison Ford Stephen Foster Sigmund Freud King George III Tipper Gore Robert E. Lee Vivian Leigh John Lennon Alexander
Hamilton Joan Rivers Norman
Rockwell
Charles Schultz
King Saul William
Tecumseh Sherman
Neil Simon Rod Steiger William Styron Alfred, Lord
Tennyson King Herod Nathaniel
Hawthorne Ernest
Hemingway Audrey
Hepburn Howard
Hughes Thomas
Jefferson Joan of Arc Lyndon
Baines Johnson
Danny Kaye Ted Turner Mozart Larry King Jessica Lange Mark Twain Mike Tyson Jean Claude
Van Damme Queen
Victoria
Mike Wallace George
Washington Robin Williams Tennessee
Williams Thomas Wolfe Virginia Woolf Lord Tennyson Vincent van
Gogh Peter
Tchaikovsky F. Scott
Fitzgerald Charles Dickens Robert Louis
Stevenson Walt Whitman Sylvia Plath Marlon Brando Art Buckwald John Bunyan Rodney
Dangerfield Charles Darwin King David John Denver Princess Diana
of Wales Charles Dickens Emily Dickenson Theodore
Dostoevski Jack Dreyfus
Drew Carey Dick Cavett Ray Charles Frederick
Chopin Winston
Churchill Dick Clark Rosemary
Clooney Kurt Cobain Natalie Cole Samuel
Coleridge Sheryl Crow Irving Berlin Steven Foster Lord Byron
(George Gordon)
Noel Coward Alexander the
Great Edwin “Buzz”
Aldrin Hans Christian
Anderson Roseanne Barr Ludwig Von
Beethoven William Blake Napoleon
Bonaparte
PrevalencePrevalence
Bipolar Disorder affects approximately 5.7 million Bipolar Disorder affects approximately 5.7 million adult Americans adult Americans
The median age of onset for Bipolar Disorder is The median age of onset for Bipolar Disorder is 25 years.25 years.
An equal number of men and women develop An equal number of men and women develop Bipolar Disorder and it is found in all ages, races, Bipolar Disorder and it is found in all ages, races, ethnic groups and social classes.ethnic groups and social classes.
Bipolar Disorder is the sixth leading cause of Bipolar Disorder is the sixth leading cause of
disability in the world. disability in the world.
Bipolar Disorder results in 9.2 years reduction in Bipolar Disorder results in 9.2 years reduction in expected life span, and as many as one in five expected life span, and as many as one in five patients with bipolar disorder completes suicide. patients with bipolar disorder completes suicide.
Bipolar Disorder SubtypesBipolar Disorder Subtypes
Classic Bipolar DisorderClassic Bipolar Disorder Bipolar IBipolar I Bipolar II Bipolar II
SubtypesSubtypes CyclothymiaCyclothymia Major Depression Unipolar/RecurrentMajor Depression Unipolar/Recurrent Dysthymic DisorderDysthymic Disorder
Bipolar NOS (Not Otherwise Specified)Bipolar NOS (Not Otherwise Specified) Other Considerations Other Considerations
Rapid Cycling (part of Bipolar I)Rapid Cycling (part of Bipolar I) Post-partum OnsetPost-partum Onset Seasonal Pattern Mood DisordersSeasonal Pattern Mood Disorders
Five or more of the following:
Depressed mood Diminished interest or pleasure in activities Significant weight loss/gain or decrease/increase in
appetite Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or excessive or inappropriate
guilt Diminished ability to think or concentrate, or
indecisiveness Recurrent thoughts of death, recurrent suicidal ideation
without a specific plan, or a suicide attempt or a specific plan for committing suicide.
DSM-IV Criteria - DepressionDSM-IV Criteria - Depression
Diagnostic DilemmasDiagnostic Dilemmas
Secondary DepressionSecondary Depression
Depression with…Depression with… Other psychiatric illnessesOther psychiatric illnesses
SchizophreniaSchizophrenia Anxiety Anxiety
Panic disorderPanic disorder Obsessive-compulsive disorderObsessive-compulsive disorder
Personality Disorders Personality Disorders BorderlineBorderline CompulsiveCompulsive
Post-traumatic stress disorderPost-traumatic stress disorder Post-partum depressionPost-partum depression Grief/depressionGrief/depression Practically any psychiatric disorderPractically any psychiatric disorder
Depression with…Depression with… Organic/Medical IllnessesOrganic/Medical Illnesses
HypothyroidismHypothyroidism B-12 deficiencyB-12 deficiency Folate deficiency Folate deficiency TuberculosisTuberculosis Myasthenia gravisMyasthenia gravis Diabetes mellitusDiabetes mellitus Hepatitis CHepatitis C Cushing’s diseaseCushing’s disease MononucleosisMononucleosis Parkinson’s diseaseParkinson’s disease CHRONIC FATIGUE SYNDROMECHRONIC FATIGUE SYNDROME
DSM-IV Criteria - ManiaDSM-IV Criteria - Mania
Three or more of the following:
Inflated self-esteem or grandiosity Decreased need for sleep More talkative than usual or pressure to keep
talking Flight of ideas or subjective experience that
thoughts are racing Distractibility Increase in goal-directed activity or psychomotor
agitation Excessive involvement in pleasurable activities that
have a high potential for painful consequences
Mood SymptomsMood Symptoms
Euphoria/ManiaEuphoria/Mania Depression (in mixed state)Depression (in mixed state) Anxiety Anxiety AngerAnger HostilityHostility IrritabilityIrritability
Behavioral SymptomsBehavioral Symptoms
Energized ActivityEnergized Activity Diminished Need to/for SleepDiminished Need to/for Sleep ImpulsivityImpulsivity
Anger with Violence Anger with Violence Elevated LibidoElevated Libido Diminished InhibitionsDiminished Inhibitions Reckless BehaviorReckless Behavior
Cognitive SymptomsCognitive Symptoms
Racing Rapid ThoughtsRacing Rapid Thoughts Diminished Insight/InvincibilityDiminished Insight/Invincibility Sensory Hyperacuity Sensory Hyperacuity HallucinationsHallucinations DelusionsDelusions Perceptual DistortionsPerceptual Distortions Distractible Disorganized ThoughtsDistractible Disorganized Thoughts
S-H-O-TS-H-O-T S: Symptomatology
Do the symptoms appear to be manic or depressed or repeated episodes of depression or mania or continuing mood swings?
H: History What is the history of the person? The history of the
family? Is there a family history of mood swings, mood disorders, substance abuse in persons with mood disorders or Bipolar diagnosis?
O: Ongoing illness What is the progression of the illness? What is the
course of the disease? Does it continue to go on in a progression appearing as a Bipolar disease course?
T: Treatment response If one looks at the response of the treatment one should
get a good deduction as to the nature of the illness.
Understanding Risk FactorsUnderstanding Risk Factors
Stress (major or prolonged)Stress (major or prolonged) Sleep Deprivation/DisruptionSleep Deprivation/Disruption Alcohol (major problem)Alcohol (major problem) ““Recreational” Drug UseRecreational” Drug Use Discontinuation of MedicationsDiscontinuation of Medications Loss or Perceived Loss (job, family, friends, finances, Loss or Perceived Loss (job, family, friends, finances,
health, etc.)health, etc.) Interpersonal ConflictInterpersonal Conflict Travel Across Time ZonesTravel Across Time Zones Mood-Altering Medications (benzodiazepines, Mood-Altering Medications (benzodiazepines,
antidepressants, antipsychotics)antidepressants, antipsychotics) Death of Loved One or FriendDeath of Loved One or Friend Inadequate Coping SkillsInadequate Coping Skills Early Dementia or Minimal Brain DamageEarly Dementia or Minimal Brain Damage
TreatmentTreatment
Depression: Depression: Pre-Modern EraPre-Modern Era Tincture of Time Tincture of Time
Prescribed trip to EuropePrescribed trip to Europe ActivityActivity
Physical Physical SocialSocial MentalMental
SomaticSomatic Insulin shockInsulin shock Electric shockElectric shock
SpiritualSpiritual
Depression: Depression: Modern Modern EraEra Education and Education and
PsychotherapyPsychotherapy PharmacotherapyPharmacotherapy
1950’s – Tricyclics1950’s – Tricyclics 1960’s – Tetracyclics, 1960’s – Tetracyclics,
etc.etc. 1990’s – SSRIs 1990’s – SSRIs
(Prozac, Paxil, Zoloft)(Prozac, Paxil, Zoloft) SNRI (Wellbutrin)SNRI (Wellbutrin) SSNRIs (Effexor, SSNRIs (Effexor,
Remeron, Cymbalta)Remeron, Cymbalta) SpiritualSpiritual
Depression vs. Bipolar DepressionDepression vs. Bipolar Depression
Treatment StatisticsTreatment Statistics Patients with Bipolar Disorder face up to ten years of Patients with Bipolar Disorder face up to ten years of
coping with symptoms before receiving an accurate coping with symptoms before receiving an accurate diagnosis.diagnosis.
Nearly 9 out of 10 patients with bipolar disorder are Nearly 9 out of 10 patients with bipolar disorder are satisfied with their current medication(s), although side satisfied with their current medication(s), although side effects remain a problem. effects remain a problem.
Participation in a Depression and Bipolar Support Participation in a Depression and Bipolar Support Alliance patient-to-patient support group improved Alliance patient-to-patient support group improved treatment compliance by almost 86% and reduced in-treatment compliance by almost 86% and reduced in-patient hospitalization. patient hospitalization.
Consumers who report high levels of satisfaction with Consumers who report high levels of satisfaction with their treatment and treatment provider have a much their treatment and treatment provider have a much more positive outlook about their illness and their more positive outlook about their illness and their ability to cope with it. ability to cope with it.
Bipolar Disorder Type II Bipolar Disorder Type II (Depressed Type)(Depressed Type)
Incorporate all of the previous slideIncorporate all of the previous slide Recent studies suggest antidepressants Recent studies suggest antidepressants
cause a sooner relapse or conversion to cause a sooner relapse or conversion to maniamania
Treating the Bipolar component is equivalent Treating the Bipolar component is equivalent to casting both broken legs.to casting both broken legs. Mood stabilizersMood stabilizers
Lithium – only drug proven to reduce suicide rateLithium – only drug proven to reduce suicide rate AntidepressantsAntidepressants
1950’s – Richard Dreyfuss1950’s – Richard Dreyfuss 1990’s – Depakote, Tegratol, Trileptal, Lamictal1990’s – Depakote, Tegratol, Trileptal, Lamictal
Atypicals? Atypicals?
Bipolar Disorder Type I Bipolar Disorder Type I (Manic and Depressive)(Manic and Depressive)
ManiaMania AntipsychoticsAntipsychotics
1953 – Thorazine/chlorpromazine1953 – Thorazine/chlorpromazine World’s first psychotropic medicationWorld’s first psychotropic medication Could treat psychosis and maniaCould treat psychosis and mania Other conventional antipsychotics followedOther conventional antipsychotics followed
Risk and BenefitsRisk and Benefits Atypical AntipsychoticsAtypical Antipsychotics
Zyprexa, Seroquel, Abilify, Risperdal, Geodon Zyprexa, Seroquel, Abilify, Risperdal, Geodon Risk and BenefitsRisk and Benefits
AnticonvulsantsAnticonvulsants Depakote, Tegratol, Trileptal, LamictalDepakote, Tegratol, Trileptal, Lamictal Risk and BenefitsRisk and Benefits
Electroconvulsive TherapyElectroconvulsive Therapy
GeneticsGenetics
Like the illness, a complicated topic…Like the illness, a complicated topic… Confounding issues:Confounding issues:
HypersexualityHypersexuality Family disintegrationFamily disintegration Separation of siblingsSeparation of siblings TwinsTwins
Genetic ModelsGenetic Models
Mendelian vs. Polygenic ModelsMendelian vs. Polygenic Models 1 affected parents = 1 in 4 affected offspring1 affected parents = 1 in 4 affected offspring 2 affected parents = 2 in 3 affected offspring2 affected parents = 2 in 3 affected offspring 1 dizygotic/fraternal twin = 1 in 6 affected twin1 dizygotic/fraternal twin = 1 in 6 affected twin 1 monozygotoc/identical twin = 2 in 3 affected twin1 monozygotoc/identical twin = 2 in 3 affected twin
Epistatic ModelEpistatic Model Number 22 is prominently mentioned (same gene Number 22 is prominently mentioned (same gene
as schizophreniaas schizophrenia Gene 21q is also involvedGene 21q is also involved Genes 18p and 18q also are involvedGenes 18p and 18q also are involved