Sheila Ward APRN Norton Womens Counseling Louisville KY
[email protected]
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Bipolar
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Bipolar-- What it is Manic Episode Distinct period of
abnormally and persistently elevated or irritable mood and
abnormally and persistently increased goal-directed activity or
energy With 3 (or 4 for irritable type) Inflated self-esteem
Decreased need for sleep Flight of ideas Distractibility Increase
in activity Doing stupid things
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New in DSM-5 Bipolar 1 Bipolar 2 Psychosis and lifetime
experience of Major Depression are not requirements for Bipolar 1
Requires 1 week of mania or hospitalization Episode of Major
Depression is required Bipolar (soft bipolar) is no longer
considered to be a milder form of bipolar illness
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More DSM-5 News Now include both changes in mood and changes in
activity or energy Mixed Type deleted Specifiers with mixed
features and anxious distress added
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MDQ A screening tool for bipolar disorder (Hirschfeld 2000)
Positive screen just as likely to have Borderline Personality
Disorder (Zimmerman 2010) In primary care settings, the MDQ could
be useful in identifying patients who should be referred for
further psychiatric evaluation. Mark Zimmerman, Janine N. Galione,
Camilo J. Ruggero, Iwona Chelminski, Kristy Dalrymple, and Diane
Young Comprehensive Psychiatry, 2011-11-01, Volume 52, Issue 6,
Pages 600-606 Mark Zimmerman, Janine N. Galione, Camilo J. Ruggero,
Iwona Chelminski, Kristy Dalrymple, and Diane Young
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Generalized Anxiety Disorder Excessive worry about everything
Uncontrollable worry Three or more Restless, on edge Fatigue Poor
concentration (racing mind) Muscle tension (headache, GI sx, body
pain) Sleep disturbance Irritable Impairment in function
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PTSD A qualifying event Combat Rape Childhood Sexual Abuse
Domestic Violence MVA Surgical Trauma Childbirth Trauma Witness to
violence Vicarious Trauma Repressed Trauma-Unremembered
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PTSD Intrusive Symptoms (1) ___ Bad memories of a traumatic
event _____ Nightmares _____ Flashbacks (re-living the traumatic
event) _____ Feeling stressed from reminders of the traumatic event
_____ Panic symptoms (heart racing, shaking, difficulty breathing,
choking)
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PTSD Hyper-Arousal Symptoms (2) _____Difficulty falling or
staying asleep _____Irritability ____ Outbursts of anger !
_____Difficulty concentrating _____Feeling alert or watchful when
there is no need to be _____Jump or startle easily, for no
reason
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PTSD Avoidant Symptoms (3) _____Avoiding thoughts, feelings, or
conversations about it _____Avoiding activities, places or people
that remind you of it _____Difficulty remembering details of it
_____Loss of interest or pleasure in normal activities _____Feeling
distant or cut off from others _____Difficulty feeling normal
feelings such as love and happiness _____Feeling that the future
will be cut short
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PTSD Does what happened to you cause you a lot stress, or
damage your relationships, employment, or other important things in
your life? _______
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Panic Disorder
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ADHD Inattentive Hyperactive Impulsive Fidgets Cant sit still
Restlessness Cant be quiet Talks excessively On the go, driven by a
motor Blurts out Difficulty waiting turn Interrupts others
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Personality Disorders Cluster B as in Bad Antisocial Pervasive
pattern of disregard Failure to conform Deceitful Impulsivity
Irritable and aggressive Reckless Irresponsible Lack Remorse
Narcissistic Grandiosity Fantasies of success Special Requires
Admiration Sense of entitlement Exploitative Lacks empathy Envious
Arrogant
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Cluster B Girls Borderline Abandonment Unstable relationships
Identity Disturbance Impulsivity Recurrent suicidal acts Mood
swings ! Emptiness Intense Anger Paranoia or Dissociation
Histrionic Persistent pattern of excessive emotionality and
attention seeking Center of Attention Sexually seductive Rapidly
shifting emotions Physical appearance to draw attention
Impressionistic Speech Theatrical Suggestible Exaggerates
relationships
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Schizoaffective Disorder Continue to have psychotic symptoms
between episodes of mania and depression
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One of my people Candy 18 y.o. Presents with hx of BP Aged out
of state system Unknown father Raised by MGM, foster home Hx of
childhood sexual abuse Fighting, Drugging, D.V. Legal issues Boy
Friend incarcerated Wants to know can I write a letter for
SSID
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Candy Chief Complaint Pertinent History Bipolar and Bad nerves
Wants Xanax (Mom has bipolar and she gets Xanax) Works great, makes
her feel normal!!! No clear history of manic episode Tantrums
Family history ??? Has nightmares, flashbacks, outbursts, poor
concentration, Sad, low appetite, tired, and cant keep up with
anything anymore.
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Differentials for Candy CD PTSD Borderline Personality Disorder
ADD Bipolar Disorder
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Then what happened? Lost to care Wanted bipolar dx for SSI,
angry Wanted Xanax, didnt get it I could get this crap from
anybody
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Another one of mine Gina 26 y.0. Presents with female partner I
cannot take these moods! I dont know who will wake up with me, the
one I love or the hateful one. Artist PCOS
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Clinical Course Dx Bipolar Discontinued SSRI (weaned) Mood
Stabilizers Gave up after a year More historyrecurrent depression,
no manic but a lot of irritable moods No traumano qualifying event
Normal dysfunctional family PMS Back to SSRIs, some better
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Clinical Course Consideration of personality disorder
(Zimmerman 2010) Borderline screeningBingo! Patient
Resistance/Denial No Access to DBTPartner self studied Partner
identifies ADD Stimulant trialAnother Bingo Current therapies
Celexa 40/60 Trazodone Ritalin Continuous method OCP Obama
Care=Insurance and DBT!!!
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DBT Behavioral Treatment for Borderline and other Marcia
Lindehan 100% Validation Distress Tolerance Mindfullness Coping
Skills
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Keri 24 y, o. History of recent seizure onset Opioid abuse
Episodes of not myself Does not sleep or eat Sort of buzzing
feeling Ideas are out there Thought are warp speed Pacing a lot
Several day duration Sometimes not when using
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Keri Social Lives with parents Going to collegehx of flunking
out, starting over Feels guilty for depending on parents Gets very
uncomfortable in class when called upon, palpatations, assumes
everyone thinks is a f___up. No girlfriend, ever
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Kirk Work up BDI II 39 with no SI (depressed) Beck Anxiety
Scale 44 Severe anxiety Tox Negative Family confirms manic Rule out
personality Disorders Rule out PTSD Rule out ADD Diagnosis Opioid
Abuse Bipolar 1 Social Anxiety Disorder
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Treatment so far Seroquel IR 200 mg Seroquel XR 600 mg
Metoprolol for social anxiety Lithium starting after another manic
episode probably triggered by stress of a new job Referral to
Addiction medicine consult in LA.
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A Typical Case Starla 40 y.o. at 20 weeks gest Dx bipolar by
former psychiatrist On Lamictal 400 and abilify Intention to
breastfeed Marital Conflict (understatement) Stayed on meds
throughout pregnancy and lactation Manic episodes ????
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Next chapter 4 years later 2 months postpartum at 44 y.o. CPS
requiring psych care Verbal abuse of older child Still on bipolar
meds Borderline screening +/- Court ordered psychiatrist Dx
borderline Privately secured second opinion Dx Histrionic
Personality DO I fired her for mistreating staff
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Do Over Question the Bipolar Dx Screen for personality DO Set
limits on behaviors tolerated No special treatment No meds DBT Get
a different job!
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Case Example Dominique 24 y.o. Army Private Episode in Vehicle
Felt trapped Too hot Felt out of body No recall Inappropriate
behavior Transferred to psych Diagnosed with Bipolar Disorder
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History / Work-up/ Treatment No manic criteria Personality
screening neg Has some Cluster B traits (dissociation, mood
instability, Center of attention issues) High strung individual Hx
of childhood sexual abuse Dose not meet criteria for PTSD Diagnosis
= Panic Disorder DBT still advised along with Rx for anxiety
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Resources
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Upshot Never accept a prior history Dx of Bipolar Assume it is
wrong until criteria met Use Depression NOS, or Mood Swings, or
Insomnia Never Dx bipolar until all differentials ruled out Always
assume you can be wrong Antidepressants could be wrong drug
Lamotrigine is never wrong unless its wrong Use standardized scales
and assessment tools Get an easier job!