Bipolar Disorder Self Injury - PowerPoint

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					Part I -- Bipolar Basics
               Kurt Weber, PhD
     Mental Health America – Brown County
          Bemis International Center
              St Norbert College
                 May 13, 2008
   “Manic-depression distorts moods and
    thoughts, incites dreadful behaviors,
    destroys the basis of rational thought, and
    too often erodes the desire and will to live It
    is an illness that is biological in its origins, yet
    one that feels psychological in the experience
    of it; an illness that is unique in conferring
    advantage and pleasure, yet one that brings
    in its wake almost unendurable suffering
    and, not infrequently, suicide.
   “I am fortunate that I have not died from my
    illness, fortunate in having received the best
    medical care available, and fortunate in
    having the friends, colleagues, and family
    that I do.”

   Kay Redfield Jamison, PhD, An Unquiet Mind,
    1995, p 6
           Purpose of today…
   Some foundation information that mental
    health professionals and “consumers”
    should know…
                  Bipolar disorder
   formerly known as manic-depressive disorder
   brain disorder
       causes unusual shifts in a person’s mood, energy, and
        ability to function
   Some people alternate mania and depression,
    others have episodes of mostly one kind
   Episodes vary in duration from days to years
   the symptoms of bipolar disorder are severe
       damaged relationships
       poor job or school performance
       suicide
                     good news
   treatable
       bipolar disorder can be treated, and people with
        this illness can lead full and productive lives
        Types of Bipolar Disorders
   The classic form of the illness, which involves recurrent
    episodes of mania and depression, is called bipolar I
   Some people, however, never develop severe mania but
    instead experience milder episodes of hypomania that
    alternate with depression; this form of the illness is called
    bipolar II disorder
   When 4 or more episodes of illness occur within a 12-month
    period, a person is said to have rapid-cycling bipolar
   Some people experience multiple episodes within a single
    week, or even within a single day
   Rapid cycling tends to develop later in the course of illness
    and is more common among women than among men
   Approximately 23 million Americans suffer from
    bipolar disorder
   National Comorbidity Study-Replicated (NCS-R)
       the lifetime prevalence of bipolar disorder is 51%
   National Epidemiologic Survey on Alcohol and
    Related Conditions (NESARC)
       lifetime prevalence of bipolar I disorder of 33%
       Native Americans have the highest incidence
       Asians and Hispanics have the lowest
   World Health Organization (1990)
       bipolar disorder is the sixth leading cause of disability
        worldwide among people 15-44 years old
   Studies suggest that bipolar disorder clients
    will be fully symptomatic 8% of the time, and
    symptomatic 59% of the time
   30% of bipolar clients have both manic and
    depressive episodes
   32% have mixed manic and depression
   22% have only manic episodes
   10% have only mixed episodes
        Depressive episodes in BD
   Depression
     most frequent episode
     episodes last longer (254 weeks) than manic
      episodes (55 weeks)
   485% of bipolar clients will have an anxiety
   708% will have a personality disorder
   Suicidal ideation is also highly associated
    with comorbid substance abuse
   There is a strong association of suicide
    attempts and comorbid anxiety disorders
   NIMH (2000)
       Suicide is a significant risk in bipolar disorder,
        the highest of any psychiatric disorder at 20%
   As many as 25-50% of clients will make a
    suicide attempt
   Most suicidal ideation occurs during
    depressed or mixed episodes
     features and subtypes (Mays)
                   Bipolar I             Bipolar II

   Psychomotor    retarded      agitated or retarded
   Sleep          hypersomnia   insomnia/hypersomnia
   Suicide            +++         ++++
   Switching to   mania         hypomania
   Gender         m=f           f>m
   Prevalence      1%           1-2%
                   mixed episodes
   50% of clients have mixed mania
   state of mind characterized by symptoms of both
    mania and depression
   more common in bipolar children and women
   may feel agitated, angry, irritable, and depressed
    all at once
   combines a high activity level with depression
       particular danger of suicide or self- injury
                        Rapid cycling
   frequently recurring (4+ episodes/yr) treatment resistant
    depression alternating with hypomanic/manic episodes
   most commonly seen in female clients and with bipolar II
   15-25% of clients
   early onset common
   not known whether antidepressants can initiate rapid
   Variations include
       ultra-rapid (1 day to 1 week)
       ultradian (<24 hours)
       continuous
                    gender issues
   no gender difference in the incidence of bipolar I
   both have onset in puberty
       men may have a slightly earlier onset
   Manic episodes
       equal frequencies among men and women
   Women are more likely to be treated than men and
    receive treatment earlier in the illness (NESARC)
   no evidence of difference in treatment
    responsiveness to mood stabilizers
   more frequent and more severe episodes of
   more comorbidities
       anxiety, obesity, migraine, thyroid
   greater relative increase in AODA and suicide
   more rapid cycling and mixed states
            Women with BD…
   have a high risk of anovulatory disorders and
    polycystic ovary syndrome (PCOS)
   metabolic condition that occurs in 7-15% of
    reproductive-aged women
     elevated androgens
     chronic anovulation
     insulin resistance
     elevated LDL with low HDL
     3x risk of endometrial cancer
   50% of women with bipolar disorder have the onset
    of symptoms within 1 year of menarche (Mays)
   however, most are not accurately diagnosed until
    they have had a child and developed postpartum
       67% of bipolar women will have postpartum depression
       33-50% of postpartum depressions begin during
        pregnancy and worsen postpartum
   Suicide risk for the new mother is 70x higher
    during baby's first year of life if mother has
    postpartum depression
            risk factors and
          warning signs for PPD
   Previous postpartum depression (50-75%)
   Having a mood disorder - bipolar disorder
    gives 25% risk
   Single motherhood
   Stressful events
   Substance abuse
   Mood disorder symptoms during pregnancy
   No psychotropic drugs are known to be safe for
    pregnancy or breastfeeding
   however, bipolar disorder itself is also dangerous
    for pregnancy due to
       substance abuse
       poor self-care
       suicide
   medication for bipolar reproductive-age females
       recall that 50% of pregnancies in the US are unplanned
   “…has anyone found the true cause of
    bipolar disorder? It would be wonderful to
    say that X or Y was the cause, but the
    answer is not that simple”
         biopsychosocial model
   Most scientists believe that mental illnesses
    are caused by a combination of several
    factors working together
   In bipolar disorder, these factors are usually
    divided into biological and psychological
   In plain English, the main reasons mental
    illness develops are physical (biological) and
                      genetic origins
   if one parent has bipolar illness, chances are 1:7 that their
    child will
   however, there are relatively few studies of the heritability
    of bipolar disorder
   why?
       numerous subtypes of the disorder
       categorical distinction between major depression and bipolar
        disorder (the presence of one manic episode) that confounds all
        genetic studies of depression since the disorders seem to be clearly
        related at some level
          so, what is inherited?
   neurotransmitter functioning!
   neurotransmitter system has received a
    great deal of attention as a possible cause of
    bipolar disorder
   some studies suggest that a low or high level
    of a specific neurotransmitter such as
    serotonin, norepinephrine or dopamine is
    the cause
   other studies indicate that an imbalance of
    these substances is the problem
       the specific level of a neurotransmitter is not as
        important as its amount in relation to the other
   still other studies have found evidence that a
    change in the sensitivity of the receptors on
    nerve cells may be the issue
                sounds like…
   researchers are quite certain that the
    neurotransmitter system is at least part of
    the cause of bipolar disorder
   further research is still needed to define its
    exact role
        Typical course of BD (Mays)
   median age of onset is 19
   first episode
       most likely to be mania in males, depression in females
   Severe psychosocial stressors appear more important in the
    first episode than latter episodes, i.e. there is “kindling” to
    stress – each episode requires less stress to occur
   90% of clients who have one manic episode will
    have another
   Four years after remission of the first episode, 60%
    had relapsed
   Without treatment, bipolar clients will have 9-10
    episodes in their lifetime, and each episode will last
    1-4 months
   The interval between episodes will diminish
    (kindling to episodes)
   Episodes will become more treatment resistant
       The course of BD (NIMH)
   Episodes of mania and depression typically
    recur across the life span
   Between episodes, most people with bipolar
    disorder are free of symptoms, but as many
    as one-third of people have some residual
   A small percentage of people experience
    chronic, unremitting symptoms despite
             without treatment…
   natural course of bipolar disorder tends to worsen
   over time, a person may suffer more frequent
    (more rapid-cycling) and more severe manic and
    depressive episodes than those experienced when
    the illness first appeared
   proper treatment can
       help reduce the frequency and severity of episodes
       help people with bipolar disorder maintain good quality
        of life
         Children and adolescents?
   Both children and adolescents can develop
    bipolar disorder
       more likely to affect the children of parents who have the
       children and young adolescents with the illness often
        experience very fast mood swings between depression and
        mania many times within a day
       Children with mania are more likely to be irritable and prone
        to destructive tantrums than to be overly happy and elated
       Mixed symptoms also are common in youths with bipolar
       Older adolescents who develop the illness may have more
        classic, adult-type episodes and symptoms
   Bipolar disorder in children and adolescents can be
    hard to tell apart from other problems that may
    occur in these age groups
       irritability and aggressiveness
            can indicate bipolar disorder
            can be symptoms of
                  attention deficit hyperactivity disorder
                  conduct disorder
                  oppositional defiant disorder
                  other types of mental disorders more common among adults such
                   as major depression or schizophrenia
       Drug abuse also may lead to such symptoms
              of course…
 For any illness, however, effective treatment
  depends on appropriate diagnosis
 Children or adolescents with emotional and
  behavioral symptoms should be carefully
  evaluated by a mental health professional
 Any child or adolescent who has suicidal
  feelings, talks about suicide, or attempts
  suicide should be taken seriously and should
  receive immediate help from a mental health
   New brain-imaging techniques allow researchers to take
    pictures of the living brain at work, to examine its structure
    and activity
   without the need or surgery or other invasive procedures
      magnetic resonance imaging (MRI)
      positron emission tomography (PET)
      functional magnetic resonance imaging (fMRI)
   the brains of people with bipolar disorder may differ from
    the brains of healthy individuals
   may develop a better understanding of the underlying
    causes of the illness
   may be able to predict which types of treatment will work
    most effectively
                NIMH clinical studies
   real-world studies
   Unlike traditional clinical trials
        multiple different treatments and treatment combinations
        include large numbers of people with mental disorders living in
         communities throughout the US and receiving treatment across a
         wide variety of settings
        Individuals with more than one mental disorder, as well as those
         with co-occurring physical illnesses, are encouraged to consider
         participating in these new studies
   Systematic Treatment Enhancement Program for Bipolar
    Disorder (STEP-BD)
                  the whole point
   improve treatment strategies and outcomes
       evaluate how treatments influence other
        important, real-world issues such as
          quality of life
          ability to work

          social functioning

       assess the cost-effectiveness of different
        treatments and factors that affect how well
        people stay on their treatment plans

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