1. Psychiatry III 1

2. Clinical Impression 2

3. 3

4. Bipolar I Disorder Also known as Bipolar Affective Disorder A psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated mood clinically referred to as mania or hypomania A condition in which people experience abnormally elevated (manic or hypomanic) and abnormally depressed states for a period of time in a way that interferes with functioning. http://en.wikipedia.org/wiki/Bipolar_disorder 4

5. Bipolar I Disorder DSM IV-TR Diagnostic Criteria for Bipolar I Disorder, Most Recent Episode Manic A. Currently or mostly in a manic episode. B. There has previously been at least one major depressive episode, manic episode, or mixed episode. C. The mood episodes in Criteria A and are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified. Page 546 5

6. DSM IV-TR Criteria for Manic Episode A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). B. During the period of mood disturbance, three or more of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: 1. inflated self-esteem or grandiosity 2. decreased need for sleep (feels rested after only 3 hours of sleep) 3. more talkative than usual or pressure to keep talking 4. flight of ideas or subjective experience that thoughts are racing 5. distractibility (attention too easily drawn to unimportant or irrelevant external stimuli, impulsive) 6. increase in goal directed activity (either socially, at work or school, or sexually) or psychomotor agitation 7. excessive involvement in pleasurable activities that have a high potential for painful consequences (unrestrained buying sprees, sexual indescretions, etc) C. The symptoms do not meet criteria for a mixed episode. D. The mood disturbance is sufficiently severe to cause marked impairment… E. The symptoms are not due to direct physiological effects of a substance…

7. Previous Manic Episode 1993 Impulsive: grabbed the car’s steering wheel while mother was driving April 2002 Very talkative in class because or numerous running ideas in her mind Spend recklessly, buying a lot of things from the mall maxing out her 2 credit cards 2008 October: Observed to be very talkative while on the way to the cemetery, spent 14,000 for shopping December: episodes of hyperactivity, spent most of the time at the gym to lose weight 7

8. Bipolar I Disorder DSM IV-TR Diagnostic Criteria for Secerity/ Psychotic/ Remission Specifiers for Current or Most Recent Manic Episode Severe With Psychotic FeaturesPresence of Delusions or Hallucinations Specify: Mood Congruent Psychotic FeaturesMood-Incongruent Psychotic Features Delusions or hallucinations whose content is consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Delusions or hallucinations whose content does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Included are such symptoms as persecutory delusions (not directly related to depressive themes), thought insertion, thought broadcasting, and delusions of control. Page 544

9. Psychotic Features Thought that her co-workers at the library were talking about her of the thesis that she was doing. April 2002 Got out and ran away from the car because she thought there was a coup d’etat going on. October 31, 2008 PERSECUTORY DELUSIONS  MOOD – INCONGRUENT PSYCHOSIS 9

10. Clinical Impression: DSM IV Axis III No Physical Disorders No Medical Conditions Axis II No Personality Traits/ Disorders No Mental Retardation Axis I Bipolar I Disorder with Recent Manic Episode and Mood Incongruent Psychotic Symptoms 10

11. Clinical Impression: DSM IV Axis IV Pyschosocial and Environmental Factors contributing to her disorder Previous history of ADHD Pressures from growing up years to excel academically Moving to the Philippines 11

12. 91-100 Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by others because of his or her many qualities. No symptoms. 81-90 Absent or minimal symptoms, good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns. 71-80 If symptoms are present they are transient and expectable reactions to psychosocial stresses; no more than slight impairment in social, occupational, or school functioning. 61-70 Some mild symptoms OR some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships. 51-60 Moderate symptoms OR any moderate difficulty in social, occupational, or school functioning. 41-50 Serious symptoms OR any serious impairment in social, occupational, or school functioning. 31-40 Some impairment in reality testing or communication OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. 21-30 Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communications or judgment OR inability to function in all areas. 11-20 Some danger of hurting self or others OR occasionally fails to maintain minimal personal hygiene OR gross impairment in communication. 1-10 Persistent danger of severely hurting self or others OR persistent inability to maintain minimum personal hygiene OR serious suicidal act with clear expectation of death. 0 Not enough information available to provide GAF. 12

13. Clinical Impression: DSM IV Axis V Global Assessment of Functioning Score of 31-40 Some impairment in reality testing or communication OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. 13

14. Review DSM IV DSM IV Diagnosis of EB Axis IBipolar I Disorder with Recent Manic Episode and Mood Incongruent Psychotic Symptoms Axis II No Personality Traits/ Disorders No Mental Retardation Axis III No Physical Disorders No Medical Conditions Axis IV Pyschosocial and Environmental Factors contributing to her disorder Previous history of ADHD Pressures from growing up years to excel academically Moving to the Philippines Axis V Global Assessment of Functioning Score of 31-40 Some impairment in reality testing or communication OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. 14

15. 15 Clinical Impression: ICD 10 F30-39 Mood (Affective) Disorder F31.2 Bipolar Affective Disorder, Current Episode Manic with Psychotic Symptoms.21 With mood incongruent psychotic symptoms http://priory.com/psych/ICD.htm F31.2.21 Bipolar Affective Disorder, Current Episode Manic with Mood Incongruent Psychotic Symptoms

16. 1. BIPOLAR II DISORDER 2. SCHIZOAFFECTIVE DISORDER 3. BORDERLINE PERSONALITY DISORDER Differential Diagnosis 16

17. Bipolar II Disorder Involves  Major Depressive Episodes and  Hypomanic Episodes Bipolar IIvsBipolar I (Hypomanic + MDD) (Manic + MDD) 17

18. Bipolar II Disorder Bipolar II is often a first step to Bipolar I. Over 5 years, between 5% and 15% of those will Bipolar II will change diagnosis to Bipolar I. Approximately 0.5% of people will develop Bipolar II in their lifetimes. http://www.a-silver-lining.org/BPNDepth/dsmiv.html 18

19. DSM-IV-TR Diagnostic Criteria for Bipolar II Disorder A) Presence (or history) of one or more Major Depressive Episodes B) Presence (or history) or at least one Hypomanic Episode C) There has never been a Manic Episode or a Mixed Episode D) The mood symptoms in Criteria A and B not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. E) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specifiers: Hypomanic. used if the current (or most recent) episode is a Hypomanic Episode. Depressed. used if the current (or most recent) episode is a Major Depressive Episode. 19

20. Hypomanic Episode A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.elevatedexpansiveirritable mood During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:symptoms – inflated self-esteem or grandiositygrandiosity – decreased need for sleep (e.g., feels rested after only 3 hours of sleep) – more talkative than usual or pressure to keep talking – flight of ideas or subjective experience that thoughts are racing flight of ideas – distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) – increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitationpsychomotor agitation – excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments) The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic. The disturbance in mood and the change in functioning are observable by others. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.psychotic The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). NOTE: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II Disorder.somatic 20

21. Schizoaffective Disorder A. An uninterrupted period of illness during which, at some time, there is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia.Major Depressive EpisodeManic EpisodeMixed EpisodeCriterion A for Schizophrenia Note: The Major Depressive Episode must include Criterion A1: depressed mood. 21

22. Schizoaffective Disorder B. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms. C. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness. 22

23. Schizoaffective Disorder D. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. 23

24. Borderline Personality Disorder DSM IV Diagnostic Criteria  A pervasive pattern of instability of interpersonal relationships, self- image and affects and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following:  Frantic efforts to avoid real or imagined abandonment  A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation  Identity disturbance: markedly and persistently unstable self- image or sense of self  Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). 24

25. Borderline Personality Disorder Recurrent suicidal behavior, gestures, or threats, or self- mutilating behavior. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). Chronic feelings of emptiness. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). Transient, stress-related paranoid ideation or severe dissociative symptoms. 25

26. Why Consider Borderline Personality Disorder? Impulsivity in at least two areas that are potentially self-damaging  Shops for clothes and jewelries, maxing out her 2 credit cards  Went to SM mall of asia and spent at least 14,000 for shopping  Tendency to shoplift things Chronic feelings of emptiness  She was approached by a man who told her she looks miserable and sick (2002) 26

27. Why Consider Borderline Personality Disorder? Transient, stress-related paranoid ideation  When they got stuck on traffic, she got out of the car and ran away because she thought there was a coup d’etat going on 27

28. Why It Is Not Borderline Personality Disorder? Only 3 out of the required 5 or more criteria 28

29. Treatment 29

30. Therapeutic Goals Relief of immediate symptoms Improvement of patient’s well-being Elimination of stressors Combined pharmacotherapy and psychotherapy Improved medication compliance Better monitoring of clinical status Decreased number and length of hospitalizations Decreased risk of relapse Improved social and occupational functioning 30

31. Pharmacotherapy DIVISION  Acute Phase  Maintenance Phase 31

32. Treatment of Acute Mania Lithium Carbonate – the prototypical “mood stabilizer – Therapeutic lithium levels are between 0.6 and 1.2 mEq/L  Controls acute mania and prevents relapse in about 80% of persons with bipolar I disorder  Has a relatively slow onset of action when used and exerts its antimanic effects over 1-3 weeks  Thus a benzodiazepine, dopamine receptor antagonist, serotonin- dopamine antagonist, or valproic acid is usually administered for the first few weeks. Caution:  Nephrotoxic (request Creatinine/BUN, monitor Blood levels)  Teratogen (Pregnancy Test)  Hypothyroidism 32

33. Treatment of Acute Mania Valproate  only indicated for acute mania; has prophylactic effects  Typical dose levels of valproic acid are 750 to 2,500 mg per day, achieving blood levels between 50 and 120 µg/mL Carbamazepine and Oxcarbazepine  Typical doses of carbamazepine to treat acute mania range between 600 and 1,800 mg per day associated with blood levels of between 4 and 12 µg/mL 33

34. Treatment of Acute Mania Clonazepam and Lorazepam – effective and are widely used for adjunctive treatment of acute manic agitation, insomnia, aggression, and dysphoria, as well as panic – Adjuvant to Lithium, may result in an increased time between cycles and fewer depressive episodes Lamotrigine – Prevent recurrences of manic episodes ECT – Effective in acute mania – Reserved for rare refractory mania or with medical complications 34

35. Treatment of Acute Bipolar Depression Combination of Antidepressants and Mood Stabilizer  Olanzepine and Fluoxetine Electroconvulsive Therapy Calcium Channel Blocker  Verapamil  Has acute antimanic efficacy 35

36. 36 Table 15.1-37 US Food and Drug Administration (FDA)-Approved Medications for the Treatment of Bipolar Disorders Mania Maintenance Aripiprazole (Abilify)Yes (2004)No Carbamazepine XR (Equetro) Yes (2004)No Divalproex (Depakote)Yes (1996)No Lamotrigine (Lamictal)NoYes (2003) Lithium (Lithobid)Yes (1970)Yes (1974) Olanzapine (Zyprexa)Yes (2000)Yes (2004) Risperidone (Risperdal)Yes (2003)No Quetiapine (Seroquel)Yes (2004)No Ziprasidone (Geodon)Yes (2004)No

37. Maintenace Treatment of Bipolar Disorder MOOD STABILIZERS – Lamotrigine – Lithium – Olanzapine Ameliorate affective and psychotic symptoms during acute manic episodes Improve depression episodes during acute bipolar depressive episodes Prevent future mood episodes with sustained treatment at therapeutic levels (prophylactic benefit) 37

38. Psychotherapy Patients taking lithium or other treatments for bipolar I disorder are usually medicated for an indefinite period of time to prevent episodes of mania or depression Most psychotherapists insist that patients with bipolar I disorder be medicated before starting any insight-oriented therapy. Without such premedication, most patients with bipolar I disorder are unable to make the necessary therapeutic alliance. 38

39. Psychotherapy When those patients are depressed, their abulia seriously disrupts their flow of thoughts, and the sessions are nonproductive. When they are manic, their flow of associations can be rapid, and their speech can be so pressured that the therapist may be flooded with material and may be unable to make appropriate interpretations or to assimilate the material into the patient's disrupted cognitive framework. 39

40. Psychotherapy American Psychiatric Association (APA) practice guideline for bipolar disorder  Recommends combined therapy as the best approach  It increases compliance, decreases relapse, and reduces the need for hospitalization 40

41. Thank you. 41

42. Major Depressive Episode Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations. 42

43. Major Depressive Episode 1. depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood. 2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others) 43

44. Major Depressive Episode 3. significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. 4. insomnia or hypersomnia nearly every day 5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) 44

45. Major Depressive Episode 6. fatigue or loss of energy nearly every day 7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) 8. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) 45

46. Major Depressive Episode 9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide The symptoms do not meet criteria for a Mixed Episode The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 46

47. Major Depressive Episode The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. 47

48. Manic Episode A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: 48

49. Manic Episode 1. inflated self-esteem or grandiosity 2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep) 3. more talkative than usual or pressure to keep talking 4. flight of ideas or subjective experience that thoughts are racing 5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) 49

50. Manic Episode 6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation 7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) 50

51. Manic Episode The symptoms do not meet criteria for a Mixed Episode The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). 51

52. Mixed Episode The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). 52

53. Schizophrenia – Criterion A Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): - delusions - hallucinations - disorganized speech - frequent derailment or incoherence - grossly disorganized or catatonic behavior - negative symptoms - affective flattening, alogia, or avolition 53

54. Schizophrenia – Criterion A Only one symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other. 54