Bipolar Disorder Uncovered

Stop With Bipolar Disorder

This ebook guide teaches you how to keep your symptoms of bipolar disorder under control and have a manageable, excellent life even with bipolar symptoms. You will be able to stop engaging in destructive behavior, get your emotions under control, and handle stress in the way that you usually envy everyone else doing. It is not fair that you are afflicted with this; bipolar disorder is under-diagnosed and tends to affect your live and lives of those you love in a powerful, often negative way. You can put that behind you now. You no longer have to live that way. This ebook guide teaches you how to tell your negative symptoms to take a hike, and MAKE them do so. You do not have to feel guilt over your disorder. You cannot help it. But now, we can help you control it, and manage your symptoms so you can have the normal life you deserve. More here...

Bipolar Disorder Stop Summary

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Onset of bipolar disorder and depression

In patients admitted to hospital between 1913 and 1940 and not treated by electroconvulsive therapy or modern psychotropic drugs, bipolar disorder clearly manifested earlier than unipolar depression (8) this finding is confirmed by modern community studies. Bipolar disorder generally begins during adolescence but may manifest even earlier. Epidemiological studies identify the age of onset of bipolar disorder as between 15 and 19 years (means), whereas studies of hospitalized patients date its onset in the early twenties or in the thirties. The age-of-onset curve is skewed, and therefore mean values are not representative. In a large Canadian general population study,(9) 95 per cent of manic cases manifested before the age of 26 (males) and 25 (females), and 95 per cent of major depressive episodes before the age of 55 (males) and 43 (females). There was a considerable time lag between the age at onset of the first impairing symptoms (15 years), diagnosis (19 years), first treatment...

Maintenance treatment of bipolar disorder

Maintenance treatment of bipolar disorder has been reviewed extensively.(4 46. and 4Z> Controlled trials of lithium against placebo have been criticized because of the possibility of withdrawal effects,(4.8) but there is little doubt of therapeutic effects.(49) Lithium is also superior to tricyclic antidepressant alone, particularly because of high rates of mania with the latter.(44) Lithium has not been well evaluated as an active antidepressant, but effects appear to be weak. (50)

Neuroimaging And Neuropsychology Of Bipolar Disorder

Bipolar disorder was traditionally considered an episodic illness showing complete remission of symptoms between bouts of elevated or depressed moods. However, many patients experience significant social impairment between episodes, and different lines of investigation, including brain imaging and neurocognitive assessment, provide evidence of structural or functional brain alterations that are independent of the illness episode. Neuroimaging studies have reported increased size and reduced glucose utilisation in the amygdala and basal ganglia, and parts of the prefrontal cortex appear to be smaller in bipolar patients than in controls. Phosphorous magnetic resonance spectroscopy (MRS) has revealed abnormalities of membrane phospholipid metabolism in frontal and striatal regions (Strakowski et al., 2000). The subgenual prefrontal cortex, which is part of the cin-gulate cortex, is of particular interest (Drevets et al., 1997). Abnormalities in this region were first identified in...

Cytogenetic Studies May Help To Localise Genes Contributing To Bipolar Disorder

One of the earliest areas of interest was chromosome 21, stemming from the longheld idea that Down's syndrome (trisomy 21) as a condition is mutually exclusive with bipolar disorder. This is not the case, and there are good descriptions of both mania and depression in Down's syndrome, although the risk of bipolar disorder may be decreased, and unipolar disorder is held by some to be increased in frequency. Trisomies involving the sex chromosomes have also been implicated, but the initial studies were not well controlled, and more recent work has not provided good evidence that they are a substantial risk factor for bipolar disorder (Mors et al., 2001). Candidate genes for schizophrenia and bipolar disorder isolated by a direct molecular genetic analysis of the breakpoint, DISC1 and DISC2, were detected by cloning of a translocation breakpoint that disrupted their exonic structure (Millar et al., 2000). A small pedigree has been described with a t(9 11)(p24 q23.1) translocation where...

The Cognitive Behavioural Model Of Bipolar Disorder

Many authors have argued that there is a marked lack of a coherent psychological model of bipolar disorder (e.g., Jones, 2001 Scott, 2001a). Recent research, however, highlights the role of cognitive and psychosocial factors in the development and course of bipolar disorder, and the first treatment manuals were published in recent years, delineating the application of CBT principles to bipolar disorders (Basco & Rush, 1996 Lam et al., 1999 Newman et al., 2002 Scott, 2001b). A body of research focused on cognitive factors such as attributional styles (Alloy et al., 1999) perfectionism, deficits in problem-solving skills, and elevated scores of sociotropy and autonomy (Lam et al., 2000) and maladaptive schemata (Young, 1999). These factors appear to play a significant role in the interaction of severe changes in behaviour, reactions to and the creation of significant psychosocial stressors, disruptions in chronobiological functioning and varied responsiveness to psychotropic...

The Application Of Cbt In The Treatment Of Bipolar Disorder

Overall, the cognitive behavioural approach to the treatment of bipolar disorder aims to enhance non-pharmacological coping skills, to enhance elements of self-efficacy and responsibility in the treatment of the condition, to support individuals in recognising and managing psychosocial stressors and the impact of past episodes, to introduce specific strategies to deal with cognitive and behavioural difficulties, and to modify underlying schemata and core assumptions. CBT for bipolar disorder relies on the basic characteristics of a CBT model. In that the cognitive behavioural model is most effective when the individuals are full collaborative partners in the treatment process. The therapist educates individuals about the diathesis-stress model of bipolar disorder, socialises them into the cognitive model of mood changes, CBT for bipolar disorder is naturally phase specific. The specific focus of the intervention varies depending on the individual formulation of treatment goals and the...

The pharmacological treatment of bipolar disorder

The primary aim of long-term treatment is the prevention of recurrent episodes (either mania or depression) (see also Chapter 11). According to current guidelines, any patient who has had at least two episodes in 5 years is likely to benefit from prophylactic treatment (American Psychiatric Association, 1994). Despite problems with tolerability, lithium still remains the 'gold standard' against which other treatments are measured. The effectiveness of long-term treatment with lithium to prevent recurrences in bipolar disorder is supported Some subtypes of what has become known as the 'bipolar spectrum' may not respond as well to lithium. These include patients with 'mixed mania', that is, depression during mania. (Swann et al., 1997), and 'rapid cycling' (Dunner & Fieve, 1974). Emerging evidence would seem to suggest a role for anticonvulsants in these patients. For example, carbamazepine, compared with lithium or placebo, is effective in the long-term treatment of bipolar...

Bipolar disorders Diagnostic issues

While classical bipolar disorder with episodes of euphoric mania interspersed with episodes of depression is one of the clearest clinical syndromes in psychiatry, the boundaries of bipolar disorder remain contested. As case definition is central to epidemiology, all the contested boundaries of bipolar disorder could influence prevalence rates and our understanding of risk factors. Some of the major boundary issues for bipolar disorder include the overlap of bipolar disorder with psychotic features, with schizoaffective disorder and schizophrenia, and the overlap of bipolar disorder with unipolar major depression when patients who present primarily with depression have brief or mild episodes of hypomania. There is also the overlap of bipolar disorder with apparent personality disorder, especially Cluster B personality disorders such as borderline and narcissistic, and the issue of when hyperthymic personality merges into bipolar disorder. (23) Another important issue in determining...

Competing Classifications

Unfortunately, much of the pressure for change has continued to originate from clinical and political demands. Revisions have sometimes had the appearance of tinkering in order to capture some imagined essence of the disorders included (Birley, 1990). What looks like fine-tuning can nevertheless make considerable differences to whether individual cases meet criteria or not, and thus disproportionately affects the putative frequency of disorders. We should jettison classifications only on grounds of inadequate scientific utility and as seldom as possible, since too rapid revision defeats the objective of comparison. Like all such classifications, DSM and ICD are created by committees. The natural tendency to horse-trading between experts selected precisely because they are powerful and opinionated leads to an over-elaborate structure, an excess of allowable classes and subclasses, and complicated defining criteria. Thus, in DSM-IV-R (APA, 1994), there are potentially 14 categories to...

Familygenetic vulnerability

There is evidence that affective disorders in adults have a genetic component. Genetic influences seem strongest for bipolar disorders (McGuffin & Katz, 1986), but unipolar major depressions also show significant heritability (Kendler et al., 1993), as do seasonal affective disorders (Madden et al., 1996). There have thus far been no large systematic twin or adoption studies of depressive disorder in young people. There is, however, evidence from twin studies of modest genetic influences on depressive symptoms in late childhood and adolescence (Eaves et al., 1997 Thapar & McGuffin, 1994), though this has not been replicated in adoption studies (Eley et al., 1998). Twin studies also suggest that some of the stability in depressive symptoms arises from genetic factors (O'Connor et al., 1998).

Classification Categories or continuua

Bipolar affective disorder and schizophrenia constitute the twin pillars of classically defined psychosis. As Goodwin and Jamison (1990) point out, Kraepelin's (somewhat unintentional) legacy has divided psychotic illness into two entities, schizophrenia and manic depression. This can leave many patients in a diagnostic no man's land. Kendler (1986) has stated that no area in psychiatric nosology has been as controversial. This controversy has formed the scaffolding for contemporary classification. However, excessive reliance on presenting symptoms and narrative and too little on the history of patients and their families can lead to undue reliance on one set of diagnostic rules at the expense of the true picture. Argument about the validity of the dichotomous classification of the major psychoses has been in progress for the last century, beginning soon after Kraepelin (1896) described his classification of dementia praecox and manic-depressive insanity in the fifth edition of his...

Geneexpression Analysis

New tools for measuring the expression of genes on a large scale are now available with oligonucleotide or cDNA microarrays and by proteomic technologies (Avissar & Schreiber, 2002). Advances in genomics and proteomics make it possible to screen very large numbers of candidate genes and proteins. One example of this approach was a study in which methamphetamine-treated rats were used as a model for mania (Niculescu et al., 2000). Gene expression in specific brain regions was compared in treated and untreated animals by oligonucleotide microarrays. Amphetamine administration led to changes in the expression of several genes in rat cortex, and the human homologues of these genes were considered candidates for a role in the pathogenesis of bipolar disorder, including a G-protein coupled receptor kinase (GRK3). This was selected for further examination, as it was mapped to a region of chromosome 22 where linkage to bipolar disorder had previously been reported and weak evidence for...

Kim Wright and Dominic

While extensive research into unipolar depressive disorder has resulted in the formulation of various cognitive and behavioural models (e.g., Abramson et al., 1978 Beck, 1967 Lewinsohn, 1974), comprehensive psychological theories of bipolar disorder remain limited in terms of both quantity and empirical support. Some studies comparing the somatic and cognitive symptoms of unipolar and bipolar depression have concluded that the two states are very similar, while others have found differences in the prevalence of symptoms such as psychomotor agitation, anxiety and irritability (Depue & Monroe, 1978 Mitchell et al., 1992). Thus, at present, difficulties exist in applying the findings of unipolar research to the study of bipolar disorder. Moreover, despite depressive symptoms often being present during a manic episode, any comprehensive model of bipolar disorder must account for the development of manic symptoms as well as for those of depression The salient fact to bear in mind when...

Cognitive Behavioural Model

The following model is largely pragmatic and takes into account the complex picture of biological, psychological and social elements surrounding manic depression. Figure 12.1 summarises the cognitive model of bipolar affective disorder, which is discussed below in terms of the interaction between dysfunctional cognitions, behaviour, biological vulnerability and mood.

Treatment Implications Psychoeducation and monitoring

Periods of BAS over- or underactivity would appear to constitute risky periods, despite the fact that clear symptoms of hypomania or depression may be absent at this stage. Therefore, a first step would be to monitor mood level in order to identify such periods. While mood and activity diary-keeping already form a part of existing therapy packages, the BAS theory suggests that monitoring should also take into account the status of BAS outputs such as level of motivation, optimism, physical restlessness and speed of thought. In fact, these are common prodromes of bipolar disorder, as measured by spontaneous self-report (Lam & Wong, 1997).

Sagar V Parikh and Sidney H Kennedy

Bipolar disorder is often characterized by grandiosity as a cardinal symptom of mania, but grandiosity may also characterize the illness from another perspective virtually no other psychiatric disorder is as grand in its plethora of clinical presentations (Goldberg & Harrow, 1999 Goodwin & Jamison, 1990). Depression, mania, and mixed states each require substantially different biological, psychological, and social interventions, and even the same episode can be approached very differently by two biological psychiatrists or two psychotherapists (Prien & Potter, 1990 Prien & Rush, 1996). How is a practitioner to choose among the many pathways to treatment The science of medicine identifies the efficacy of each particular path, but only the art of medicine the weighing of individual circumstances with clinical judgement and the capacity to integrate approaches allows for truly effective treatment. This chapter explores several dominant approaches to treatment, each of which...

Patient Interventions

Medication remains the cornerstone of treatment for bipolar disorder, so prescription of at least a mood stabilizer would be routine. Furthermore, while there may be cost factors in seeing a physician and filling a prescription, for all practical purposes such interventions are feasible in virtually all health-care environments in the developed world. Specific medication recommendations are outlined elsewhere in this volume, and would be combined with basic clinical management (supportive therapy including specifying treatment and monitoring outcome, offering practical advice for immediate problems such as work or school stressors, and instilling hope for relief of symptoms). However, abundant data demonstrate poor medication adherence in bipolar disorder (Cohen et al., 2000) thus, the next level of intervention would be compliance-enhancing strategies. Such strategies would generally fall into the category of psychoeducation, which multiple studies have demonstrated to improve...

Provider Interventions

Specific provider interventions in bipolar disorder have not been reported. In a pilot study we have just completed (Parikh et al., unpublished), we created a bipolar treatment optimization program that incorporated a patient intervention and a simultaneous provider education and support intervention for the patient's primary care physician. Patients benefited, but it is too early to determine to what extent the provider intervention was effective. However, the larger context of medical care, and depression in particular, has been studied exhaustively with respect to provider interventions, such as providing education in the form of treatment guidelines, continuing medical education events, and providing feedback of screening tools such as depression self-report scales routinely administered to all patients in a practice setting. From medicine as a whole, traditional education in the form of conventional continuing medical education events, distribution and teaching of guidelines,...

Integration Of Patient Provider And Systems Approaches

This chapter began by citing the example of a young man with bipolar disorder, and posed a question about the best treatment approach. Surely, the start of the answer is rooted in evidence, and some of the evidence has been reviewed briefly earlier. But clinical reality is influenced by a number of variables that extend beyond research evidence or best practices. Patient attitudes, stigma on the part of both the patient and the provider, costs, availability of suitable providers, convenience, transportation access, the enthusiasm of providers, the nature of the treatment alliance, and the specific treatment preferences of a local environment are among the determinants of treatment initiation and continuation (Parikh, 1998). Large epidemiological surveys, such as the US National Comorbidity Survey (Kessler et al., 1994) and the Mental Health Supplement to the Ontario Health Survey (Parikh et al., 1996 1997a 1999), document that most individuals who fulfill diagnostic criteria for...

Interpersonal Functioning

Of the facilitation of successful transitions following major episodes, significant psychosocial changes, and the adjustment to necessary lifestyle changes. As in the above mentioned model of the importance of corrective experiences and behaviour change in individuals with bipolar disorder, these changes in the cognitive emotional schemata of the bipolar patient are achieved through consistent behavioural adaptations to the vulnerabilities intrinsic to the disorder. In their reformulation of the interpersonal psychotherapy (IPT) framework for bipolar disorder (IP SRT), Frank and colleagues (1997) combine the key interpersonal difficulties associated with bipolar disorder with an introduction to the strict monitoring of social routines and circadian rhythms (see Chapter 15). By addressing interpersonal problems and the regularity of daily routines, this method deals with both concurrent symptoms and the impact of interpersonally based stressors on patients' life, and increases their...

Integrating the components

The initial phase of IPSRT consists of gathering a psychiatric history, providing psycho-education about bipolar disorder, carrying out the interpersonal inventory, and introducing the patient to the SRM. During this phase, all patients are evaluated by a psychiatrist (if the therapist is not a physician) to optimize pharmacotherapy. Patients may enter IPSRT when they are euthymic, subsyndromal, or fully symptomatic. Thus, the duration of the initial phase varies considerably, ranging from 2 weeks to 2 months. During this time, the patient is seen weekly by the therapist and as often as needed by the psychiatrist in order to stabilize medications. An important issue that typically arises during the middle phase of treatment is the balance between stability and spontaneity. Many patients suffering from bipolar disorder are accustomed to hectic variations in mood and energy states. The prodigious efforts of the therapist to curb the variability in their mood and activities are not...

Preliminary Findings Study design

A single large trial of IPSRT as a treatment for bipolar disorder (in combination with medication) is currently nearing completion at the University of Pittsburgh. This study, Maintenance Therapies in Bipolar Disorder (MTBD), is funded by a grant from the National Institute of Mental Health (R37 MH29618). In MTBD, acutely ill patients meeting criteria for bipolar I disorder are treated with medication and randomly assigned to either IPSRT or intensive clinical management (ICM). In order to enter the protocol, subjects must meet the Schedule for Affective Disorders and Schizophrenia criteria (Spitzer & Endicott, 1978) or the Research Diagnostic Criteria (Endicott et al., 1977) for bipolar I disorder with a score of 15 or greater on the 24-item HRSD (Hamilton, 1960 Thase et al., 1991) or the Bech-Rafaelson Mania Scale (Bech et al., 1979). Exclusion criteria include pregnancy, chronic alcohol and drug abuse, rapid cycling (defined as four or more affective episodes in 1 year), or an...

Attempted suicide and ideation

How many of those who are depressed have suicidal ideation Of course, it depends on what is meant by suicidal ideation, but it is probably accurate to say that more than half of depressed people have suicidal thoughts (Lonnqvist, 2000). For example, Schaffer et al. (2000) retrospectively reviewed 533 patients with major depression and found that 58 had suicidal ideation. There are also high rates of suicidal thoughts in bipolar patients, though it seems to be mainly accounted for by levels of depression rather than mania. Dilsaver et al. (1994) studied a sample of bipolar I patients, some of whom also met criteria for concurrent major depression, which they termed 'depressive mania'. Of the 49 pure mania patients, only one exhibited suicidal ideation. In contrast, 24 out of 44 depressive mania patients showed suicidal thoughts. Strakowski et al. (1996) also found higher rates of suicidal ideation in patients with mixed bipolar disorder than those with manic bipolar disorder. Further...

Depression In Suicidal Behaviour

I disorder was present in 86 of cases, but that this was major unipolar depression in only 32 and bipolar depression in 4 of cases. One very large-scale study looked at reported suicides over a 5-year period in the UK (Department of Health, 2001). The study found that about one-quarter of almost 21 000 suicides over the period were in contact with mental health services, and so consultants were able to provide diagnostic information about these individuals. Of those in contact with services, 42 met criteria for major affective disorder and 10 for bipolar disorder. It is reasonable to assume that the rates of depression might be lower in those not in contact with the services, so the overall rate may have been lower than 42 . It does appear that depression is more common in non-fatal self-harm than it is in suicide. This is true even when comparable methods of assessment are used. In a sample of 202 suicides in New Zealand, Beautrais (2001) found that 56 met diagnostic criteria for a...

Selfmonitoring And Prodromal Changes

Dealing with manic and hypomanic phases has been described as being the biggest clinical challenge in the treatment of bipolar individuals. Most individuals suffering from bipolar disorder would describe a manic phase as being inescapable. Once their mood starts to rise, the initial positive reinforcement of experiencing new sources of energy and creativity develops. Especially when this happens after long periods of depressed mood, it easily develops into a self-reinforcing pattern that seems impossible to stop. The early warning signs paradigm, originally developed for relapse prevention in early-onset psychotic disorders, especially schizophrenia, has been adapted for use with people suffering from bipolar disorders (Lam & Wong, 1997). Patients learn to identify prodromal and early symptoms of relapse and develop a range of behavioural techniques to improve their coping skills in order to counteract early symptoms effectively and to avoid their development into a full-blown...

Types categories dimensions and discontinuities

Based, and various mixed states (Gilbert, 1984, 1992), with a new category of atypical depression also being suggested (Posternak & Zimmerman, 2002). In fact, depression is more often than not comorbid with other (especially anxiety) disorders (Brown et al., 2001). To complicate the picture further, Akiskal and Pinto (1999) suggest that a substantial minority of depressions are related to a spectrum of bipolar disorders, some of which may be destabilised on traditional antidepressants. Coyne (1994) raised major concerns about dimensional approaches (for example, mild, moderate, and severe), and, assuming that results from studying mildly depressed or dysphoric people (for example, some students) can be extrapolated to more severe depression, as there may be quite different process involved.

Overview Of Interpersonal And Social Rhythm Therapy Ipsrt

IPSRT was developed as a response to the observation that pharmacotherapy, although essential to the treatment of bipolar disorder, is often not enough for patients suffering from (1) the instability model of bipolar disorder proposed by Goodwin and Jamison (1990) In their instability model, Goodwin and Jamison (1990) define three interconnected pathways to episode recurrence taxing life events, medication noncompliance, and social rhythm disruption. Each pathway potentially leads a stable patient towards an episode of depression or mania. Their model suggests that individuals with bipolar disorder are fundamentally (biologically) vulnerable to disruptions in circadian rhythms. Psychosocial stressors, in turn, interact with this biological vulnerability to cause symptoms. For instance, stressful life events (such as the birth of a child) disrupt social rhythms, causing disturbances in circa-dian integrity, which, in turn, may lead to recurrence. Alternately, problematic interpersonal...

Cyclothymia hypomania hyperthymia and personality disorder Axis II

Despite the vagaries of epidemiology and the interpretation of various rates, it is useful to spend a moment reflecting on what constitute the outer edges of bipolar disorder. Kraepelin (1921) and Kretschmer (1936) both described affective states which ranged from the severest to the mildest and which existed on a continuum that included personal predisposition or temperament. Both described cyclothymic people in whom low-grade subdepressive and hypomanic presentations occurred. One of the difficulties of this area of research is the separation on the continuum between personality disorder features and the point at which symptoms become disorder in terms of bipolar disorder rather than abnormalities of personality or temperament. An awareness of boundaries is important, as personality tests in common use have been known to misattribute subthreshold mood changes to borderline personality disorder (O'Connell et al., 1991). RAPID-CYCLING BIPOLAR DISORDER the essential constituents of...

Subsyndromally depressed hospitalized elderly patients

The success of IPT in treating unipolar mood disorders has led to its expansion to treat other psychiatric disorders. Frank and colleagues in Pittsburgh have been assessing a behaviorally modified version of IPT as a treatment adjunctive to pharmacotherapy for bipolar disorder. They report on this adaptation elsewhere in this volume (Chapter 15) (Frank, 1991b Frank et al., 1999 2000a b). Frank, E. (1991b). Biological order and bipolar disorder. Presented at the meeting of the American Psychosomatic Society, Santa Fe, NM, March. Frank, E., Swartz, H.A., Mallinger, A.G., Thase, M.E., Weaver, E.V. & Kupfer, D.J. (1999). Adjunctive psychotherapy for bipolar disorder Effects of changing treatment modality. J Abnorm Psychol, 108, 579-587. Frank, E., Swartz, H.A. & Kupfer, D.J. (2000b). Interpersonal and social rhythm therapy Managing the chaos of bipolar disorder. Biol Psychiatry, 48, 593-604.

Behavioural Activation System Dysregulation Model

Development Depression Biological

Another system that has been considered as a possible site of pathology in bipolar disorder is the behavioural activation system (BAS). The concept of the BAS was derived from investigations of the motivational effects of appetitive and aversive stimuli upon the behaviour of animals (Gray, 1982). The BAS governs approach behaviour, such that it is activated by, and seeks to bring the animal into contact with, conditioned and unconditioned In summary, the BAS model proposes that weak regulatory mechanisms within a biological system constitute the biological vulnerability in bipolar disorder, and that associated

Neurotransmitter Systems

A large proportion of candidate-gene studies have focused on key enzymes and proteins involved in dopamine-norepinephrine- and serotonin-based neurotransmitter systems. Among the first candidates to be studied by association analysis was the gene for tyrosine hydroxylase, a rate-limiting enzyme in the metabolism of catecholamines. The apparent success of linkage to chromosome 11p15 in the large Old Order Amish kindreds with multiple cases of bipolar disorder (Egeland et al., 1987) led to further studies of genes in the area. Initial promising results (Leboyer et al., 1990) were followed by a series of conflicting, but overall negative studies (Furlong et al., 1999 Turecki et al., 1997). This story has been repeated for many of the other candidates subsequently investigated, and, at present, even partly replicated findings have to be approached with some caution. The enzyme catechol-omethyl transferase (COMT) is also involved in the degradation of monoamines. The gene coding for this...

Discontinuity And Recovery Developmental discontinuities

The first point to make is that there may be developmental differences in the continuity of depressive disorders. Interest in the possibility of such differences has been increased by the finding of marked age differences in the prevalence of affective phenomena such as depression, suicide, and attempted suicide (Harrington et al., 1996). Thus, for example, it seems that depressive disorders show an increase in frequency during early adolescence (Angold et al., 1998). The reasons for these age trends are still unclear, but there is some evidence that they are accompanied by developmental differences in continuity. Thus, in our child-to-adult follow-up of depressed young people, continuity to major depression in adulthood was significantly stronger in pubescent postpubertal depressed probands than in prepubertal depressed subjects (Harrington et al., 1990). All five cases of bipolar disorder in adulthood occurred in the postpubertal group. Similarly, Kovacs et al. (1989) reported that...

Depression

Depression can be classified in various ways and can take many forms, including bipolar or manic depression (Akiskal & Pinto, 1999 Goodwin & Jamison, 1990), major depression (Beckham et al., 1995), and dysthymia (Griffiths et al., 2000). The symptoms of major depression include loss of pleasure (anhedonia) (Clark, 2000 Willner, 1993) loss of motivation interest (Klinger, 1975 1993 Watson & Clark, 1988) negative thinking about the self, world and future (Beck et al., 1979) increased negative emotions (such as anxiety and anger) (van Praag, 1998) problems in cognitive functions such as memory, attention, and concentration (Gotlib et al., 2000 Watts, 1993) dysfunctional changes in sleep and restorative processes (Moldofsky & Dickstein, 1999) and a host of biological changes in various neurotransmitter and hormonal systems (McGuade & Young, 2000 Thase & Howland, 1995), and various brain areas such as the frontal cortex (Davidson, 2000). Major depression, although highly...

Comorbidity

The issue of comorbid conditions has been more readily recognized in contemporary studies. For example, McElroy et al. (2001) evaluated 288 outpatients with bipolar I or bipolar II, using structured diagnostic interviews to determine the diagnosis of bipolar, comorbid Axis I diagnoses and demographics. They found that 187 (65 ) with bipolar disorder also met DSM-IV criteria for at least one comorbid lifetime Axis I disorder. More had anxiety (42 ) and substance misuse (42 ) than eating disorder (5 ). There were no differences in comorbidity between bipolar I and bipolar II. Both lifetime and current Axis I comorbidity were associated with an earlier age of onset. Current Axis I comorbidity was associated with history of both cycle acceleration and more severe episodes over time. One overarching problem in the epidemiology of bipolar disorder is the debate surrounding broad or narrow criteria. The above discussion illustrates the case for more specific criteria. However, there has been...

Disorder

The neurobiological basis of bipolar disorders and the complex interactions of environmental and inherited factors that create vulnerability to abnormal moods remain essentially unknown. However, several lines of research are providing important clues about the type of biological processes underlying moods and their disorders. The established approaches of neurochemistry and pharmacology that gave rise to the present generation of anti-depressant and mood-stabilising drugs have highlighted the importance of neurotransmitters and cell signalling pathways. Advances in neuroimaging techniques have identified several brain regions showing structural or functional changes in subjects with mood disorders, and cognitive deficits found in patients are in keeping with these imaging findings. It is also now firmly established that genetic factors have a major role in determining the risk of bipolar disorder, and recent developments in genomics and proteomics since the sequencing of the human...

Association Studies

In the absence of a clearly biological hypothesis, the choice of candidate genes is large because almost any gene expressed in the brain can be construed as a possible candidate for bipolar disorder. In practice, candidates have been selected for several reasons. Positive linkage studies or consistent chromosome abnormalities in patients with bipolar disorder can provide pointers to a particular chromosomal region (candidate loci). Candidates may also arise from assumptions made about proteins or systems of proteins connected with the assumed underlying pathology of the illness, or from our knowledge of the targets of drugs that are useful in treating the disorder (candidate genes). A major limitation of the candidate-gene approach is our incomplete knowledge of the neurochemistry and pathophysiology of bipolar disorders, so that a reasonable case can be argued to include almost any of the 10 000 genes known to be expressed in the human brain in a list of candidate genes worth...

System Interventions

System interventions incorporate multiple elements, and inevitably overlap with the domains of patient and provider maneuvers. Furthermore, studies of system reorganization strategies do not easily allow unbundling of the different components to identify the most potent elements. Nonetheless, such system interventions are clear to specify and clear to study. Historically, the establishment of lithium clinics for bipolar disorder was an early example of a relatively pure system intervention, as reviewed by Gitlin and Jamison (1984). The staff of these clinics fostered a clear understanding of the medical model for bipolar disorder, built care along multidisciplinary lines, and established routines for the evaluation and monitoring of patients, as well as the provision of basic psychoeducation. Virtually no advances in systems interventions in bipolar disorder had been reported until the launching of two randomized, controlled studies (comparison condition is treatment-as-usual), both...

Cognitive Strategies

The cognitive therapy techniques used for bipolar disorders include strategies aimed at the processing of symptoms and cognitive distortions relating to hypomanic and manic episodes. Furthermore, they aim to address beliefs and attributional biases linked to the psychological effects of long-term impairment through chronic mood-related difficulties and or residual symptoms. Most patients suffering from bipolar disorders describe mood-related difficulties and their social and interpersonal consequences as dating back to early adolescence. The longstanding nature of many of the associated difficulties and variation in intensity and severity over time make it difficult for many patients to identify areas of normal functioning or the clear demarcations of the healthy self. Some schema work can therefore prove to be extremely useful in re-examining the value and evidence of old belief systems and the generation of new sets of beliefs adaptive to the current actuality. Individuals with...

Outcomes

Early investigations of CBT techniques in bipolar disorder focused almost solely on the adherence to medical treatments. The main studies of this particular CBT application are by Benson (1975) and Cochran (1984). Benson (1975) reports a retrospective analysis of 31 bipolar disorder patients who were all in a manic phase at the start of treatment, receiving a combination treatment of lithium and psychotherapy. Comparisons were made between relapse in this group of people with a diagnosis of bipolar disorder and previous reports of relapse rates with lithium alone. He reports that 14 of his patients relapsed compared with the reported mean relapse rate of 34 with lithium alone. He suggests that psychotherapy is important to keep the patient motivated to continue lithium, to provide basic therapeutic support, and to monitor the patient's mood as a way of early detection of falling serum lithium levels. Cochran's (1984) study is probably the most cited paper in the context of cognitive...

Clinical vignette

Although built on the principles of IPT, IPSRT differs from IPT in several respects (Swartz et al., 2002). Firstly, IPT focuses on the links between life events and mood. In IPSRT, life events are viewed not only as sources of mood dysregulation but also as potential triggers of rhythm disruption. Thus, IPSRT addresses interpersonal problems using both IPT strategies and behavioral strategies designed to regulate the social rhythm disruptions associated with the interpersonal problem. In addition, IPT for unipolar depression is a therapy of interpersonal change. The therapist actively encourages depressed patients to take interpersonal risks and make relatively large changes in their interpersonal circumstances in a brief period of time. By contrast, patients who suffer from bipolar disorder may destabilize in the face of relatively minor change (Frank et al., 1999), and are likely to deteriorate in the setting of very stimulating shifts in their interpersonal lives. Therefore, in...

Epidemiology

The present and immediate future for epidemiology is showing increased use of genetic epidemiology methods to study both unipolar and bipolar depressions through the use of large-scale twin studies (e.g., Kendler & Prescott, 1999) and large-scale family studies that can look at, for example, obligate carriers (see Chapter 11). A recent such study by Sullivan et al. (2002) found that for unipolar depression there was 37 heritability and no significant shared environment effects, but only individual-specific environmental factors (such as specific individual life events or traumas) in their analysis of the presence and absence of depression in a large family study. These genetic epidemiology studies show great promise and can begin to disentangle genetic, gender, age, and cultural effects in their contributions to both unipolar and bipolar disorders in the next decade. However, large-scale, prospective, high-risk studies, in which adolescents and young adults who are at increased...

Treatment

The development and adaptation of treatment approaches for both unipolar and bipolar disorders continues to gather pace. In the area of unipolar disorders, there are now well-established pharmacotherapeutic treatments that continue to be added to with new generations of antidepressants (see Chapter 7). Psychological treatments such as CBT and IPT have been shown to be efficacious in randomised, controlled trials in adults (see Chapters 8 and 9). The main challenge now for psychosocial approaches, and one that Markowitz (Chapter 9) details most clearly, is how these effective psychosocial treatments can be adapted for use with different populations such as adolescents (see also Chapter 5), older adults (see also Chapter 19), and specific disorder groups such as suicidal patients (see also Chapter 18). In some ways, perhaps the most exciting area for the development of psychosocial treatments is now the neglected area of the bipolar disorders. Kay Redfield Jamison's writings, both her...

Theoretical Models

Before we finish this section, some comments must also be made specifically about theoretical developments in the bipolar disorders. The study of bipolar disorders has suddenly opened up to psychological and social approaches, having long been ignored and left to the medicobiological approach. Even here, there have been few significant advances in theory, and the approach has focused primarily on pharmacotherapy (see Chapters 11 and 7). The promise of the psychological and the social approaches has been raised both by Wright and Lam (Chapter 12) and by Swartz et al. (Chapter 15). Although the primary focus of the last two chapters was on treatment (see also next section), the fact that the cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT) models have an impact on the course of bipolar disorders is in itself of theoretical importance. Wright and Lam have highlighted both the role of specific types of dysfunctional beliefs that may be specific to bipolar...

Are the results relevant for your patient

To determine the relevance of the study to real-life patients, it is important to examine the inclusion and exclusion criteria of the trial. The main inclusion criteria are discussed above. Patients excluded from the trial were women who were pregnant or of child-bearing age but unwilling to use an effective contraceptive method. Exclusion criteria also included major medical conditions, bipolar disorder, psychosis, panic disorder, concurrent major depressive disorders, generalized anxiety disorder, history of alcohol or other drug dependency within the previous 12 months, serious suicidal risk, previous non-response to two or more adequate antidepressant trials, and use of psychotropic drugs within 2 weeks of enrolment. The use of the study results will have to take these inclusion and exclusion criteria into account, and the clinician needs to judge the relevance of the results for the individual patient.

Summary and pathophysiological conclusions

In summary, the number of postmortem studies on mood disorders is still very limited, but there is some evidence for changes in the basal ganglia and brainstem. Structural brain imaging studies support the notion that mood disorders are associated with regional structural brain abnormalities, in particular regions involved in mood regulation, such as the limbic portion of the basal ganglia and brainstem structures. Because small numbers of subjects were studied, only some postmortem studies distinguished between unipolar and bipolar depression. (46> Nevertheless, a recent review of the structural imaging studies(53) found this distinction worthwhile. The main abnormalities found in unipolar depression were smaller basal ganglia, cerebellum, and possibly frontal lobe, which may reflect local atrophy. Bipolar disorder appeared to be associated with larger third ventricle, smaller cerebellum, possibly smaller temporal lobe, and perhaps changes in the hippocampus. In both groups there...

The mindbrain interface

The psychodynamic psychiatrist eschews reductionism. Recognizing that mental life and psychiatric symptoms are both overdetermined and multiply caused, psychodynamic clinicians are always interested in the interface between the biological and the psychosocial. Psychodynamic psychiatry is not antibiological. The psychodynamic psychiatrist is the integrator par excellence. Avoiding Cartesian dualism, the mind is seen as the expression of the activity of the brain. (13> Subjective experience affects the brain just as mental phenomena arise from the brain. Every treatment intervention is seen as being biopsychosocial in nature. Medications have psychological effects. Psychotherapeutic interpretations affect the brain. Moreover, psychodynamic psychotherapy and medications may work synergistically to provide better outcomes for patients. For example, a patient with a bipolar disorder who is denying that he has an illness and refusing to take lithium may ultimately have better compliance...

Treatment and management

Currently, no treatment influences the course of illness of Huntington' disease, although advances in research on the function of the Huntington' disease gene may change that. Nevertheless, psychiatric treatments can relieve some of the troublesome symptoms. Clinical experience suggests that the depression, anxiety, and obsessive-compulsive disorder associated with Huntington' disease usually respond to the pharmacological treatments used for the similar idiopathic disorders. Because some patients seem unaware of their depressed mood (just as they can be unaware of their involuntary movements) an informant is needed to elicit the symptoms. It is also important to distinguish depression (from which the patient is miserable and sleepless) and apathy, which does not cause the patient distress. Occasionally, mood and anxiety disorders are chronic and unresponsive to treatment. Severe, unresponsive depression can be treated successfully with electroconvulsive therapy.( 8) Bipolar disorder...

Schizoaffective disorder Clinical features

In general, the disorder is more common in females than in males. (1,5) The age of onset varies, but tends to be younger than that of unipolar or bipolar disorder. Tsuang et al.(1) found the median age of onset for schizoaffective disorder was 29 years, which was significantly lower than groups with bipolar or unipolar affective disorder, but similar to a group with schizophrenia. Marneros et al.(6) also reported that a median age of onset of 29 years for schizoaffective disorder was lower than the median age for groups with affective disorders (35 years), but also reported that it was higher than a group with schizophrenia (24 years). To an extent, relative differences in the age of onset between schizoaffective and other disorders reflects differences in the diagnostic criteria employed and the heterogeneity of the disorder.

Moving from depression to diagnosis

A common misperception among some clinicians and patients is to think of 'depression' as being equivalent to unipolar depression, which is then treated with antidepressants. There are a number of reasons for this phenomenon the first is that patients often lack insight into their manic symptoms not knowing that they are ill, they deny their manic symptoms to clinicians. Second, depressive symptoms tend to last longer than manic symptoms, sometimes are more frequent, and often are more psychically painful thus, patients tend to seek assistance when depressed rather than when manic. Third, the many new antidepressants that have become available over the past 10 years have been extensively marketed to physicians at the same time that 'depression awareness' programmes have educated the public about the availability of safe and effective treatments. Simultaneously, few new treatments for bipolar disorder have become available, and there has been scant professional and public education...

Classification of affective mood disorders Formal classification

Both ICD-10 and DSM-IV have course specifiers for bipolar disorder containing 10 and four subgroups, respectively. In addition to the number of subgroups, differences include a greater emphasis on distinguishing bipolar I and II in DSM-IV, and cyclothymia being listed as a 'bipolar disorder' in DSM-IV as against being a 'persistent' mood disorder overlapping with a personality style in ICD-10.

Materials and methods

History of psychosis, or a history of schizophrenia, schizoaffective disorder or bipolar disorder, a serious concomitant medical condition, a history of seizures or misuse of alcohol or drugs (recent use of any psychotropic drugs within one month of baseline), clinically significant abnormalities in electrocardiogram or laboratory findings, or a serious risk of suicide. Combat-related symptoms included intrusive images of screaming soldiers, fire, bombing, rocketing, etc. Individuals taking cholesterol-lowering drugs were excluded. The procedures were fully explained and written informed consent was obtained from all patients. The local Ethics committee approved this protocol.

Use of health services

In the ECA study, 39 per cent of those with bipolar I or bipolar II disorders received outpatient psychiatric treatment within 1 year and about 10 per cent would receive inpatient treatment within a 6-month period. In the NCS study, 45 per cent of those with bipolar disorder had received psychiatric treatment in the previous 12 months although 93 per cent reported lifetime treatment for their bipolar disorder. However, both of these studies suggest that more than half the individuals with bipolar disorder are not currently in psychiatric treatment and, given the high morbidity and mortality associated with bipolar disorder, this is of major concern. (4)

The importance of course and the limits of our knowledge

Our understanding of the course of affective disorders is limited for several reasons. The course of bipolar disorder and unipolar depression are markedly different however, Kraepelin's(l) unification of bipolar disorder(2) with all affective disorders to form the single diagnosis 'manic depressive insanity' resulted in there being very little investigation of the natural history of the two subgroups (bipolar and depressive disorders) before the introduction of modern pharmacotherapy. Moreover, modern studies are carried out on treated patients, and the effect of drug-induced changes on the natural history of disorders is difficult to estimate. Another methodological limitation of modern studies of course is the selection of samples. Traditionally, samples have comprised hospitalized psychiatric patients, with a minority including psychiatric outpatients studies following patients in primary care or in the community have been rare. Yet another methodological problem is that of memory...

Rapid cycling mood disorder

Rapid cycling is found almost exclusively in bipolar disorder. It is defined by the presence of four or more affective episodes in 12 months, and is more frequent in females and in the bipolar II subtype. Rapid cycling does not appear to represent a chronic endstage form of bipolar disorder it is often a transient non-familial manifestation of bipolar disorder. (42) A prospective follow-up study conducted over approximately 3 years showed diagnostic stability in about half the cases and the other half had fewer than four further episodes per year in a control group 10 per cent of the non-rapid-cycling patients converted to rapid cycling. (43)

Consequences for treatment

After the initial split into bipolar disorder and unipolar depression, the last 30 years have seen the progressive subdivision of mood disorders into further subgroups bipolar I, bipolar II, rapid cycling bipolar disorder, minor depression, dysthymia, SAD, and so on. In the process the characteristics of the course of a disorder have been incorporated into the classification, which means that course and prognosis are no longer independent of the diagnostic definition. The distinction between bipolar disorder and unipolar depression is fundamental. These disorders differ markedly in their course and outcome, with bipolar disorder having an earlier onset, higher episode frequency, slightly shorter episode length, and poorer outcome (fewer full recoveries, slightly more chronicity), but, unexpectedly, probably fewer suicides. All bipolar disorders and most unipolar depressive disorders are recurrent, with a minority having a really good prognosis without residual symptoms and further...

Psychological treatments general issues

There is high public demand for psychotherapies for unipolar depression. Recently, the use of these interventions in bipolar disorder has also been advocated. (55) Guidelines for the use of psychotherapy in depression are less well developed than for pharmacotherapy and are based on less robust empirical data. Early research into the benefits of psychotherapy in depression comprised single case studies, small case series, and open or non-randomized treatment trials. The increase in randomized, controlled trials of psychotherapy for depression can be attributed both to the introduction of 'manualized' (or 'protocol-driven') therapies, enabling consistency of application and valid and reliable evaluations, and to the emphasis on evidence-based medicine and cost-effectiveness. (57)

Continuation and maintenance trials

Bipolar disorder Psychotherapy for bipolar disorders has not been systematically studied. No studies are available on psychological interventions in acute mania. Reviews by Scott (55> and by Roth and Fonagy(57> highlight that psychosocial interventions undertaken during other phases of bipolar disorder all resulted in greater symptomatic improvement and social adjustment than treatment with medication alone. However, the studies were poorly designed and the data are weak. The only controlled trial published(83) randomly assigned a small sample of 28 subjects to either six sessions of compliance-oriented cognitive therapy or standard clinic care. In the next 6 months lithium compliance appeared to be enhanced in the cognitive-behavioural therapy group, who also showed fewer hospitalizations. The most promising approaches to bipolar disorders appear to be cognitive therapy, interpersonal therapy-social rhythms therapy, and family therapy, and large-scale controlled trials of these...

Acute treatment of mania

A number of mood stabilizers are reported to have an acute antimanic effect, but the Expert Consensus Guideline on the Treatment of Bipolar Disorder (1 3) advocated either lithium or valproate as the drugs of first choice. Valproate is often preferred for patients with mixed states or rapid cycling disorder. Response to lithium or valproate is usually delayed by 7 to 14 days, so most clinicians also use other drugs such as neuroleptics or atypical antipsychotics. These are effective within a matter of days in controlling the acute symptoms of mania, particularly delusions, hallucinations, thought disorder, or severe agitation. The main problem with the classic combination of haloperidol and lithium is the need for close monitoring, as manic patients are at greater risk of neuroleptic malignant syndrome and a combined lithium-neuroleptic neurotoxicity syndrome has also been reported. Benzodiazepines such as lorazepam and clonazepam are frequently used to treat hyperactivity, insomnia,...

Continuation and maintenance treatment

Bipolar disorder is more recurrent than unipolar disorder, and the disinhibition of mania can have catastrophic long-term effects on personal life. The threshold for maintenance treatment is therefore lower than for unipolar disorder. There is a case for 1 to 2 years' maintenance following a first episode of mania. Poor or partial responses are not uncommon, and carbamazepine or valproate should be added. They are alternatives as single drugs where the patient prefers. Valproate is increasingly a drug of first choice in the United States. Blood levels for bipolar disorder are not well established but it is usual to target blood levels in the anticonvulsant range. In treatment-resistant cases, there is an increasing trend toward the use of combinations of mood stabilizers (particularly lithium and valproate). The indications and precautions necessary when using such combinations are reviewed by Freeman and Stoll. (104.) Antidepressants can often be slowly withdrawn in bipolars after...

Chapter References

McElroy, S., Keck, P., and Pope, H. (1992). Valproate in the treatment of bipolar disorder literature review and clinical guidelines. Journal of Clinical Psychopharmacology, 12, 42-52. 45. McElroy, S.L. and Weller, E. (1997). Psychopharmacological treatment of bipolar disorder across the lifespan. In Review of psychiatry, Vol. 16 (ed. L.J. Dickstein, M.B. Riba, and J.M. Oldham), pp. 124-78. American Psychiatric Press, Washington, DC. 50. Calabrese, J.R., Bowden, C. and Woyshville, M.J. (1995). Lithium and the anticonvulsants in the treatment of bipolar disorder. In Psychopharmacology the fourth generation of progress (ed. F.E. Bloom and D.J. Kupfer), pp. 1099-111. Raven Press, New York. 51. Suppes, T., Baldessarini, R.J., Faedda, G.L., and Tohen, M. (1991). Risk of recurrence following discontinuation of lithium treatment in bipolar disorder. Archives of General Psychiatry, 48, 1082-8. 53. Keller, M.B., Lavori, P.W., Kane, J.M., et al. (1992). Subsyndromal symptoms in bipolar...

Aetiological considerations

Several lines of observation have challenged the concept of 'character neurosis' as an explanation for low-grade depression, and thereby forced a return to the more classical European concept of temperament with its biological underpinnings. First, in a 1980 study of rapid eye movement ( REM) latency (normally 90 min, measured from sleep onset to the first REM period) conducted in 'depressive characters' who were not in a state of major depression, we reported that REM latency was less than 60 min, and sleep was redistributed to the early part of the night(27) (which was the reverse of what we observed in chronic anxious patients(51)). Moreover, a family history for major affective illness (including bipolar) was significantly high in short-REM latency patients. (38) (The reverse was true for those with familial alcoholism and sociopathy.) The sleep findings were so reminiscent of those seen in major affective illness that we were compelled to give our patients systematic open trials...

Clinical features and diagnostic considerations

By definition, individuals with cyclothymia report short cycles of depression and hypomania that fail to meet the sustained duration criterion for major affective syndromes. At various times, they exhibit the entire range of manifestations required for the diagnosis of depression and hypomania, but only from a few days at a time up to 1 week, rarely longer. (79) These cycles follow each other in an irregular fashion, often changing abruptly from one mood to another, with only rare interposition of 'even' periods. The unpredictability of mood swings is a major source of distress for cyclothymes, as they do not know from moment to moment, how they will feel.(80) As one patient put it, 'my moods swing like a pendulum, from one extreme to another'. The rapid mood shifts, which undermine the patients' sense of self, may lead to the misleading diagnostic label of borderline personality. But unlike a personality disorder, the mood changes in cyclothymes have a circadian component. One...

Course and prognosis Adults and adolescents

Andreasen and Hoenk(63) report that the long-term outcome of AD has a good prognosis for adults, but that a majority of adolescents eventually have major psychiatric disorders. Follow-up at 5 years after original diagnosis of AD revealed that 71 per cent of adults were completely well, 8 per cent had an intervening problem, and 21 per cent had developed a major depressive disorder or alcoholism. However, in adolescents at 5-year follow-up, only 44 per cent were without a psychiatric diagnosis, 13 per cent had an intervening psychiatric illness, and 43 per cent went on to develop major psychiatric morbidity (e.g. schizophrenia, schizoaffective disorders, major depression, bipolar disorder, substance abuse, and personality disorders). In contrast with the adults, the chronicity of the illness and the presence of behavioural symptoms in the adolescents were the strongest predictors for major psychopathology 5 years after the initial AD diagnosis. The number and type of symptoms were

Interpersonal relations

Antisocial personality disorder is frequently comorbid with depression, which usually has atypical features. Bipolar disorder (manic phase) and mental retardation (learning difficulties) should be excluded. Substance abuse may be comorbid from childhood, and antisocial behaviour may be secondary to premorbid alcoholism type 2. Atypical schizophrenic disorder (pseudopsychopathic schizophrenia), temporal-lobe epilepsy, or a limbic-lobe syndrome should also be excluded.

Associated psychopathology and comorbidity

Intermittent explosive disorder often co-occurs with other psychiatric disorders. For example, of 46 impulsive violent offenders ( n 24) and fire-setters (n 22) in one study,(8) 33 (72 per cent) of whom met the DSM-III criteria for intermittent explosive disorder, 44 (96 per cent) had a lifetime diagnosis of alcohol abuse, 41 (89 per cent) had borderline personality disorder, 24 (52 per cent) had a mood disorder, and nine (20 per cent) had antisocial personality disorder. Of 27 subjects with DSM-IV intermittent explosive disorder evaluated with the Structured Clinical Interview for DSM-IV, (6) 25 (93 per cent) met lifetime criteria for a mood disorder (with 15 (55 per cent) meeting criteria for a bipolar disorder), 13 (48 per cent) for a substance use disorder, 13 (48 per cent) for an anxiety disorder (with six (22 per cent) meeting criteria for obsessive-compulsive disorder), six (22 per cent) for an eating disorder, and 12 (44 per cent) for an impulse control disorder other than...

Other Mood Stabilizing Agents

In 1995, valproic acid was approved by the FDA for treatment of acute mania and is now considered a first-line agent. Other anticonvul-sants under investigation include lamotrigine and top-iramate, which are covered in Chapter 32. The atypical antipsychotic agent olanzapine received FDA approval in 2000 for use in acute mania and mixed episodes associated with bipolar disorder it is covered in Chapter 34.

Levels of homovanillic acid and 5hydroxyindoleacetic acid in cerebrospinal fluid

The association between lowered 5-HIAA cerebrospinal fluid levels and suicidality has not been convincingly shown for bipolar disorder, but it does hold for people with unipolar depression, schizophrenia, and those with personality disorders. It therefore appears to represent a biochemical marker for suicidality, and is largely independent of diagnosis.(2)

Genderrelated aspects

Two studies (n 188,(5) n 58(14> ) found that men and women have generally similar clinical features, although one of these studies (5) found that women were more likely to focus on their hips and weight, pick their skin, and camouflage with make-up and have comorbid bulimia nervosa men were more likely to be preoccupied with body build, genitals, and hair thinning, use a hat for camouflage, be unmarried, and have alcohol-abuse or dependence problems. In the other study, (1.4> women were more likely to focus on their breasts and legs, check themselves in a mirror, and use camouflage techniques and have panic disorder, generalized anxiety disorder, and bulimia, whereas men were more likely to focus on their genitals, height, and excessive body hair, and have bipolar disorder.

Selection criteria for psychotherapy outcome studies

The choice of selection criteria for a psychotherapy outcome study depends, of course, on the nature of the research question to be asked. From a public health perspective, samples are usually chosen based upon the presence of a discrete disorder or problem that has significance to society. The selection of the target disorder, however, is only the beginning of the selection process. For studies of DSM Axis I non-psychotic disorders, it is typical that other major psychotic disorders such as schizophrenia and bipolar disorder are excluded from the study. However, there is wide variability across research studies in the extent to which other Axis I and Axis II disorders are included in a study or not.

Introduction and history

Psychiatric patients, like patients with epilepsy, were also thought to be possessed by demons. Interestingly, many of the same medications used to treat epilepsy are now being used to treat some psychiatric disorders, particularly bipolar disorder. At present, we have a limited understanding of the mechanisms of action of the antiepileptic drugs in seizure disorders, but our understanding of their actions in psychiatric disorders is even less clear.

Moral Aspects Of Antisociality

Such conceptual development during childhood is coincident with tremendous growth in the frontal lobe, including myelinization, synaptic growth and pruning, etc. (Schore, 1994). The dependence of moral functioning on higher order cognitive development (abstraction and decentering) explains why lower frontal function is a significant risk factor for impulsive, destructive behavior (Barratt et al, 1997). On the other hand, and perhaps of more interest, are those true psychopaths with intact cognitive function whose interpersonal belief systems are not informed by empathy and attachment. In such cases, we might posit that a deficit in the limbic circuitry underlying attachment and related affect precluded integration of such circuits with the pre-frontal networks subserving higher level cognition. The linking of the frontally-mediated higher order cognitions with more limbic-driven affective states is influenced by early affective experience (Schore, 1994) such that subtle differences in...

General effectiveness of traditional folk healing in psychiatric conditions

Traditional healing is much less effective than modern psychotropic medication in schizophrenic and bipolar disorders. However, traditional milieu, occupational therapy, and physiotherapy at religious places or healer's compounds may lead to behavioural improvement and facilitate rehabilitation and resocialization.

Counselling in primary care

Patients with severe and enduring mental illness such as schizophrenia, bipolar disorder, dementia, and 'treatment-resistant' depression are best managed by community mental health services with assistance from primary care. Examples of such assistance are the provision of generalist services such as cervical cytology, helping with patient review, providing medication, watching for signs of deterioration and relapse, and notifying community mental health teams of any changes. (5 ,67>

Relation Between Obstructive Sleep Apnea and Depression

OSA leads to EDS, fatigue, and impairment in daytime functioning in various neu-ropsychological, cognitive, behavioral, and social domains. Thus the symptoms of OSA can mimic symptoms of an MDD, leading to an erroneous diagnosis of depression, complicating the diagnosis, and management of both conditions. For over two decades clinical studies have suggested a relationship between OSA and depression. In recent years, a number of studies have confirmed an increasing prevalence and severity of depression in patients with OSA. Sharafkhaneh et al. (49) studied the prevalence of comorbid psychiatric conditions in 4,060,504 Veterans Health Administration beneficiaries with and without sleep apnea. They found a statistically significantly greater prevalence of depression (21.8 ), anxiety (16.7 ), PTSD (11.9 ), psychosis (5.1 ), and bipolar disorders (3.3 ) in patients with sleep apnea as compared with patients without sleep apnea. While several investigators have reported an increasing...

Evidence For Altered Synaptogenesis In Depression

Post mortem studies suggested that complexin I is decreased in both schizophrenia and major depression in the prefrontal cortex77. Complexin II was shown to be decreased in the anterior cingulate cortex and the hippocampus in major depression and bipolar disorder, implicating a specific vulnerability of excitatory synapses78,79. The genomic localization of complexin I (4p13.3) and complexin II (5q35.2) has been associated with the risk to develop affective disorders in several independent investigations80-82.

Psychopharmacological interventions

In meta-analyses of adult studies, lithium maintenance treatment greatly reduces (8.6-fold) the recurrence of suicide attempts in adults with bipolar or other major affective disorders. Further, when lithium is discontinued there is a sevenfold increase in the rate of suicide attempts and a ninefold increase in the rates of suicide. (42> Other mood stabilizers, such as valproate and carbamazepine, are also widely used to treat bipolar disorders in children and adolescents although their efficacy has yet to be empirically demonstrated. Depressed suicidal children and adolescents with a history of bipolar disorder should first be treated with a mood stabilizer before receiving an antidepressant.

From Normality to Abnormality

The aforementioned characteristics of a borderline are presented in Jenny's case, though hers are more toward the pathological side of the applicable contrasts. Far from being merely more emotionally intense or spontaneous than average, she is emotionally labile, as seen most readily at the beginning of the clinical interview and again in the intense argument with her boyfriend. Moreover, her emotions are so intense that they contribute to a dissociative dysphoria that Jenny treats by cutting herself with a razor blade. Finally, she experiences periods of intense anger that she controls only with great difficulty, as evidenced by a rapid erosion of decorum that gives way to an erratic stream of hatred and accusation directed at Vera near the beginning of the interview. As Bockian (2002) succinctly explains, people with the disorder may struggle throughout their lives to gain a sense of identity while managing feelings of inadequacy, impulsiveness, self-destructive behavior, and even...

Neurodevelopment and psychological development

If the developmental processes of the kind described here are important then schizophrenia may appear after many years of mismatched and unsatisfactory interactions. There is ample evidence that the emotional atmosphere in the home, and especially the level of criticism, hostility, and over involvement, (which together are termed 'expressed emotion') influences the course of schizophrenia (Bebbington and Kuipers 1994 Butzlaff and Hooley 1998). Mueser et al. (1998) found high rates of traumatic events in patients with schizophrenia and bipolar disorder, and Garety et al. (2001) reported that severe trauma was associated with psychotic symptoms unresponsive to medication. The mechanism is unclear, but probably entail interactional processes with mutual influences between parental and (adult) child behaviours.

Diagnosis of patients with early symptoms

Patients with Huntington' disease who initially consult psychiatrists usually present with depression or irritability, and occasionally with bipolar disorder, obsessive-compulsive disorder, schizophrenia, or excessive anxiety. When associated with Huntington' disease, these psychiatric syndromes are clinically indistinguishable from idiopathic psychiatric disorders and may persist as the only manifestation of the illness for several years. It is often during this prodromal phase that patients commit suicide, which may occur even if the patient does not know of his risk for Huntington' disease. (1 ) Additional presenting symptoms must often be elicited from an informant because the patient minimizes them or is embarrassed about them. These include loss of efficiency at work, which may have precipitated demotion or warnings from superiors stemming from loss of work speed and accuracy a tendency to become irritated or physically aggressive in response to annoying stimuli that would not...

The Evolutionary Neurodevelopmental Perspective

In a review of more than 100 studies on the comorbidity of narcissism and narcissistic personality disorder with major mental illness, Ronningstam (1996) found that narcissism is not linked systematically to any specific Axis I disorder. Instead, it would appear that a narcissistic personality only colors the expression of any Axis I disorder that develops. Although the energy, dominant control, and love of hearing themselves talk suggest some fundamentally biological relationship between the narcissistic personality and bipolar disorder, Stormberg, Ronningstam, Gunderson, and Tohen (1998) found that bipolar patients exhibit most of the criteria of pathological narcissism only while in the manic phase. When not manic, their levels of pathological narcissism are no higher than other general psychiatric patients. Some reports suggest that narcissistic personality disorder may exacerbate the severity of posttraumatic stress disorder (B. Johnson, 1995), perhaps because the omnipotent...

Passive Aggressive Personality Disorder Dsmivtr Appendix B

The first DSM noted that Passive-Aggressive Personality Disorder was characterized by three types passive-dependent, aggressive, and passive-aggressive. The passive-dependent type has seemingly evolved into the current Dependent Personality Disorder because the first version of the DSM listed feelings of helplessness, indecisiveness, and a tendency to cling childlike to a parentlike figure. The aggressive type appears to share many symptoms of the modern Borderline Personality Disorder such as temper tantrums, recurrent anger, irritability, and destructive behavior. It is the third, passive-aggressive type, that appears to have evolved into the modern Passive-Aggressive Personality Disorder with historical and current features of stubbornness, procrastination, inefficiency, and passive obstructivism.

Effect of Treatment of Sleep Apnea on Depression

The belief that depression is an actual phenomenon seen increasingly in patients with sleep apnea is well documented by numerous studies showing significant improvement in depression, daytime sleepiness, and quality of life following treatment of sleep apnea with CPAP (58-63). Schwartz et al. (62) demonstrated this effect in patients with RDI > 15 and in patients with and without antidepressant pharmacotherapy. Hilleret et al. (64) reported an interesting case of a 50-year-old man with no previous history of bipolar disorder, diagnosed with severe depression and resistant to seven weeks of treatment with venlafaxine and trazodone. A diagnosis of OSA and use of CPAP was followed a few days later by a mood switch to first hypomania and then a mixed disorder. Thus OSA might not only be associated with a depressive syndrome but its presence may also be responsible for failure to respond to appropriate pharmacological treatment. Furthermore, undiagnosed OSA might be exacerbated by...

Drug Interactions

Lithium carbonate, administered for affective and bipolar disorders, may enhance the effects of antithy-roid drugs. Potassium iodide, used as an expectorant, is a major ingredient in many cough medications. Iodide derived from this source may enhance the effects of an-tithyroid drugs and lead to iodine-induced hypothy-roidism. Iodine in topical antiseptics and radiological contrast agents may act in a similar manner.

The DSM Multiaxial Model

Axis Psychological Disorderrs

Disorders include depression and bipolar disorder. Other branches recognize sexual disorders, eating disorders, substance abuse disorders, and so on. Finally, each disorder is broken down into diagnostic criteria, a list of symptoms that must typically be present for the diagnosis to be given. Axis II, personality disorders, is the subject of this text.

Cyclothymic disorder and labileirritable variants History

Kraepelin 9) included the cyclothymic disposition as one of the temperamental foundations from which manic-depressive illness arose. Kretschmer(30) went one step further and proposed that this constitution represented the core characteristic of the illness some patients were more likely to oscillate in a sad direction, while others would more readily resonate with cheerful situations these were merely viewed as variations in the cyclothymic oscillation between these two extremes. Kurt Schneider,(20) who did not endorse the concept of 'temperament', instead referred to 'labile psychopaths' whose moods constantly changed in a dysphoric direction, and who bore no relationship to patients with manic depression. To confuse matters further, Schneider used the term 'cyclothymia' as a synonym for all manic depressive illness, from the mildest to the most severe psychotic forms. Today, 'cyclothymia' is still sometimes used in this broader sense in Germanophone psychiatry. But in much of the...

The Case of Mickey Antisocial Personality Disorder

These individuals do not come into treatment voluntarily to work on their personalities, but are frequently encountered in hospital ERs and in prisons. Individuals with ASPD often experience dysphoria, anxiety, and rage attacks, and they typically respond to these affects by acting out or self-medicating with alcohol or drugs, or both. Trying to take a reliable clinical history is nearly impossible as these characters lie and withhold information to advance their cause, whether to appear more frightening and dangerous or more benign, bending the facts so that past behaviors can appear almost reasonable. Individuals with ASPD may claim or fake an Axis I disorder as a cover for their antisocial exploits. However, comorbid Axis I conditions are prevalent with ASPD, including Major Depression, Bipolar Disorder, Panic Disorder, and Posttraumatic Stress Disorder (PTSD). Mood disorders are especially likely to develop as the individual reaches middle age. In addition, approximately 70 of...

Recurrent brief depression

Seasonal depression is seen most frequently in winter, and less frequently in summer. In DSM-IV, seasonal depression has been adopted as a specifier (rather than a diagnostic category) which can be applied not only to recurrent depression but also to bipolar disorder. The seasonal episodes (e.g. winter depression) have to outnumber any non-seasonal depressive episodes in the same patient. In ICD-10 only seasonal depression is briefly mentioned, and that in an annex for disorders under consideration.

Indications and contraindications

It was originally supposed (l,30) that patients presenting with endogenous symptoms were not suitable for treatment. However, in practice they are as likely to respond well as non-endogenous patients. IB Bipolar disorder too has traditionally been considered unsuitable for cognitive therapy. This conclusion may have been premature, given promising results from recent integrations of ideas from the cognitive-behavioural treatment of severe, chronic depression and of psychosis. The disappointing performance of cognitive therapy with more severely depressed patients in the NIMH trial (6.) is difficult to interpret, and inconsistent with other outcome research.(7)

Differential main subsidiary and alternative diagnoses

A differential diagnosis should be placed in the case records in a prominent place, with a clear indication of who made it ('diagnosis' will be used in this section because of current conventions, but the difference between identifying a disorder and inferring an underlying diagnosis already noted must be kept in mind). When the patient suffers from more than one disorder it is usually possible to select one as the main diagnosis and specify the other(s) as additional or subsidiary diagnoses. The main diagnosis will usually be the one that is leading to immediate action, but the choice may depend upon the purposes for which the diagnoses are being recorded. Usually it reflects the reason for the current contact with services or admission but there are patients and occasions when, for instance, it makes more sense to record a lifetime diagnosis (such as schizophrenia or bipolar disorder) as the main diagnosis, even though something else such as anxiety or a phobic disorder is the...

Other drugs including lithium carbamazepine and buspirone

There have been several studies of the effects of lithium treatment in children and adolescents. In a (short-term) placebo-controlled study of lithium given to young individuals with early-onset bipolar disorder followed by later substance abuse, lithium was efficacious for both disorders. (39) Active responders had a mean lithium serum level of 0.9 mmol l. In another well-controlled study, lithium did not lead to an improvement of the symptoms of conduct disorder. (49 However, lithium was much superior to placebo (and equally effective as haloperidol, and with fewer side-effects) in controlling aggression in hospitalized children with conduct disorder. (24) Few, if any, other studies of lithium in children or adolescents have been controlled. Lithium is the recommended treatment for bipolar disorder in adolescents, .P but at present has no other clear indications in child and adolescent psychiatry.

Diagnostic subtypes of mood disorders in DSMIV

Bipolar disorder is characterized by manic or hypomanic states the patient is either depressed, euthymic (normal in mood), or hypomanic manic. Bipolar disorder differs from unipolar disorder by including manic states. No matter how many times a patient is depressed, only one manic hypomanic episode is required to diagnose bipolar rather than unipolar disorder. Bipolar disorder is further characterized as type I or type II. Type I is diagnosed when at least one manic episode is identified. Usually recurrent depression also occurs, but in 5 to 10 per cent of cases there are no diagnosable major depressive episodes, although almost always there will be minor depressive episodes. Bipolar disorder type II requires the absence of even one manic episode, and instead the occurrence of at least one hypomanic episode and at least one major depressive episode. The critical difference between mania and hypomania, in current DSM-IV nosology, is that mania requires significant social and...

Psychological factors Personality

Community and clinical epidemiology findings point to the presence of other psychiatric disorders as one of the most significant psychological risk factors in alcoholism. The risk is particularly high in persons with schizophrenia, bipolar disorder, major depression, social phobia, panic disorder, post-traumatic stress, attention-deficit hyperactivity disorder, and antisocial and borderline personality disorders. (40)

Alpf Medical Research Personality

Paranoid traits are expressed by all of the severe personality disorders but also in avoidants, narcissists, sadists, antisocials, and compulsives. They also often overlap with delusional disorder anxiety disorders mood disorders, particularly depression and perhaps bipolar disorder somatization disorders in an effort to escape the shame of not being able to engage the world effectively and substance abuse, especially when the paranoid is experiencing symptoms of anxiety.

Prevalence

There are no epidemiological studies of prevalence for schizoaffective disorder, but prevalence estimates are available, based on samples that were treated in clinics. Because a variety of factors influence the decision to enter and remain in treatment, the estimates show substantial variation. For example, Muller-Oerlinghausen et al 22 showed that the prevalence of schizoaffective disorder assessed in lithium clinics ranged from Z per cent in Aarhus, to 15 per cent in Berlin, 23 per cent in Vienna, and 32 per cent in Hamilton. Junginger et al.(23) found that 14 per cent of delusional patients met DSM-IIIR criteria for schizoaffective disorder, compared with 60 per cent who met the criteria for schizophrenia and 17 per cent who met the criteria for bipolar disorder. Data from the Cologne Longitudinal Study showed that 28.5 per cent of the sample with psychoses met DSM-IIIR criteria for schizoaffective disorder, which was similar to the rate for affective disorders (30 per cent), but...

Cyclothymia

Previously this was considered to be a personality disorder or the first stage of a bipolar illness. The essential feature of cyclothymic disorder is a persistent fluctuating mood disturbance including numerous periods of depressive symptoms. These are periods, not episodes, of hypomania or depression. Thus it is a disorder of subsyndromal mood swings analogous to dysthymia in unipolar depression. About one-third of patients with cyclothymic disorder will develop bipolar disorder. (18,)

Risk factors

In considering the risk factors for the development of bipolar disorder, it is useful to separate risk factors into those that are risk factors for lifetime vulnerability (for example genetic factors) and those that are risk factors for the onset of an episode of depression or mania (for example life events). Thus, in determining risk factors for lifetime vulnerability, genetic factors constitute the largest single risk factor. However, if one is considering who is vulnerable to an episode of mania over the next 6 months, genetic factors will play a relatively smaller part and predictions may best be based on other factors such as past history, childbirth, being treated for depression with antidepressant medication, and the approach of spring or summer. Genetic risk factors are discussed further in CMOiei.i.S.SJ ,. Although organic factors, such as some type of central nervous system damage, are unusual risk factors in young adults, in late-onset bipolar disorder (age of onset more...

Length of episodes

Most bipolar and depressive episodes are short, but a minority become chronic (lasting more than 2 years) the distribution of episode length is log normal, and therefore percentiles and not averages should be used as parameters. Using the data collected a century ago by Mendel (1.0) and Ziehen(H) on the natural length of episodes of mania and bipolar disorder, mainly among hospitalized patients, it is possible to compute a median length of 4 to 6 months for mania and 5 to 6 months for bipolar disorder. Wertham (12) also reports a median length of 4 to 6 months based on analysis of 2000 manic attacks. These figures do not differ from those obtained today despite a wide range of antimanic and antidepressant treatments. Among hospitalized patients episode length (median) was 4.2 months for bipolars and 5.4 months for major depressives (13) 25 per cent of bipolar episodes lasted more than 7.3 months and 25 per cent of depressive episodes lasted more than 11 months. By contrast, in the...

Mortality

A meta-analysis(32) of 58 studies covering 2257 cases of suicide gave the following SMRs for suicide mortality compared with suicides in the general population (SMR 1.0) bipolar disorder, 15.05, major depressive disorder major depressive episode, 20.35 dysthymia, 12.12 depression not otherwise specified, 16.10. Taking all diagnostic categories together, suicide among mood-disorder patients was 13.65 times more frequent than in the general population.

Lithium

In addition to its acute actions, Li+ can reduce the frequency of manic or depressive episodes in the bipolar patient and therefore is considered a mood-stabilizing agent. Accordingly, patients with bipolar disorder are often maintained on low stabilizing doses of Li+ indefinitely as a prophylaxis to future mood disturbances. Antidepressant medications are required in addition to Li+ for the treatment of breakthrough depression.

Highrisk strategies

Important strategies in preventing suicide in patients with affective disorders include very active treatment of individual episodes of illness, use of lithium and other mood stabilizers for patients with recurrent bipolar disorders, (56) and use of long-term antidepressants in patients with frequent relapses of depressive disorders. The risk factors in schizophrenia indicate that risk is greatest not so much during acute episodes but between episodes when patients may have insight and feel hopeless about their circumstances and prospects.(5Z) Continuity of care is likely to be a particularly important factor in preventing suicides in such patients at risk, with care being continued energetically during periods of remission. Community psychiatric nurses have a very important role with such patients. The use of the newer atypical neuroleptics might also be beneficial.(58)

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Understanding And Treating Bipolar Disorders

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