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Understanding People Who Have
Bipolar Disorders
Mary Bittle, PhD, RN, LMFTA
Objectives
• Recognize characteristics of bipolar disorders.
• Differentiate DSM-IV-TR and DSM-V characteristics,
effective 1/1/14.
• Differentiate between mania and hypomania
• Recognize contributing factors of genetics and brain
chemistry.
• Recognize common treatments
• Recognize challenges of managing
• Recognize famous people who have/had
• Acknowledge people with successful management
can lead successful lives
What are Bipolar Disorders?
• Disturbances of mood that significantly
interfere with the daily functioning of an
individual. DSM IV-TR mood DO. DSM V
places in separate category
• Two types: Bipolar I and Bipolar II
• 19th century called manic-depressive, no
longer a correct term.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.:
American Psychiatric Publishing.
Bipolar Disorders U.S.
• Prevalence: 2.6%
• Classified Severe: 82.9% (2.6%) = 2.2%
National Institute for Mental Health. National Institutes for Health. (2005). Bipolar disorder among adults.
Retrieved 11/13/13 from http://www.nimh.nih.gov/statistics/1bipolar_adult.shtml
• Some 10 million people
National Alliance on Mental Illnesses. Bipolar Disorder FACT SHEET. Retrieved 11/13/13 from
http://www.nami.org/factsheets/bipolardisorder_factsheet.pdf
Bipolar I
A. Must have at least one manic episode lasting at
least 1 week
B. During manic episode must have 3 or more out
of 7 behavioral manifestations of mania(next
slide)
C. Major impairment in life functioning
D. Cannot be explained by medications or drugs for
another medical condition
May also be followed or preceded by hypomania
and/or major depression. Hypomania/MD not
necessary for BPI DO.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American
Psychiatric Publishing.
1.
2.
3.
4.
Behaviors of Mania
Grandiosity, increased self esteem
Insomnia
Pressured or continuous talking
Expresses that thoughts are racing or expressed thoughts
jump rapidly from one topic to another, called flight of
ideas
5. Distractibility
6. Increase in goal-directed or non-goal-directed activity,
called psychomotor activity
7. Activities are of increased risk: pain, excessive spending,
hypersexuality…
May include psychotic behavior
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric
Publishing.
Behaviors of Hypomania
Same as for mania except:
A. Lasts at least 4 days
B. Uncharacteristic for usual behaviors of the
person
C. Others notice the increased/expansive
behaviors
D. Not severe enough for major impairment in
life functioning
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
Bipolar I
• Typical age of onset ~18 years old
• Prevalence:
– US 0.6%
– 11 other countries 0.0% - 0.6%
• Male to female occurrence 1.1:1
• More common in countries with higher
incomes
• Higher rates in separated, widowed
• Suicide risk 15 X that of general population
• 36.3% Lifetime risk
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ).
Washington D.C.: American Psychiatric Publishing.
Bipolar II
Same as Bipolar I EXCEPT:
A. Elevated mood of at least 4 days.
B. Not characteristic of person
C. Observable by others
D. Does not significantly interfere with functioning
nor require hospitalization
Must include at least one major depressive
episode, present or past
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
Other Characteristics of Bipolar II
• Common impulsive behaviors troublesome.
• Suicide ideation and risk increased
– 1/3 have suicide attempt in lifetime, 32.4 %
– Use more lethal means , so success greater
• Substance abuse
• Value of increased creativity leads to denial and
aversion to treatment
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
• Prevalence
Bipolar II
– 0.8% US
– 0.3% Internationally
• Typical age for development mid 20s
• Usually begins with a depressive episode
• Once there is ever a hypomanic episode, DX = BP II
and not MDD
• More lifetime episodes than BP I
• May be rapid cycling, females more likely, poorer
prognosis
• Once there is a manic episode, DX changes to BP I
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
Bipolar Moods
Time -----------------------------------------------
Mania
_____________________________________
Hypomania
_____________________________________
Normal Mood -
_____________________________________
Eupnea
Dysthymic
_____________________________________
Cyclothymic
Depressed
_____________________________________
Comparison
Bipolar I
1 week elevated mood
3/7 characteristics (4 if
mood irritable)
Marked impairment ADLs
Psychosis when present
defines BP I
May have major depression
American Psychiatric Association. (2013). Diagnostic and statistical
manual of mental disorders. (5th ed. ). Washington D.C.:
American Psychiatric Publishing.
Bipolar II
4 days elevated mood
3/7 Characteristics (4 if mood
irritable)
ADLs NOT markedly affected.
Hospitalization not
necessary.
Behaviors noted by others
Must include Major
Depression
DSM V Coding
• 296. for Bipolar I
• Codes following decimal:
– Mild, Moderate, Severe
– Most current episode Mania, Hypomania,
Depressed
– Psychotic feature present
– Partial or Full Remission
• 296.89 for Bipolar II
– Further modifiers are written in words
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
Major Depression
A. For at least a period of 2 weeks, 5 of 9
symptoms (next slide) have occurred.
Depressed mood or anhedonia (loss of pleasure)
Represents change from usual.
The symptoms are not due to another medical
condition.
B. Major impairment in life functioning/distress
C. Not due to another medical condition or effects
of a substance
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
Behaviors of Depression
1. Depressed mood (sadness, emptiness,
hopelessness, crying) most all day, most every day.
2. No or nearly no interest in pleasure or activities,
most all day, most every day. (Anhedonia)
3. Significant loss of appetite with unplanned weight
loss (=/>5%)
4. Too much or too little sleep, insomnia or
hypersomnia
5. Significant activity slowing or irritability
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
Behaviors of Depression
6. Continuous low energy and/or fatigue
7. Feeling of excessive guilt (may be delusional)
or worthlessness.
8. Less ability to concentrate or make decisions
most all day, most every day.
9. Thoughts of death: suicidal ideation with or
without a plan
The above may be subjective or observed by
others. The above may not be normal
reactions to significant loss
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
Depression
Major depressive SX are the most common first
presentation for which people with BP II
disorder seek medical attention, particularly
hospitalization.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
Suicide Ideation
• Thoughts of
– Death
– Wanting relief
– The world will be better off w/o me
– Significant others will be better off w/o me
• Contemplation
– Plan
– Means and lethality
– Energy with which to carry out
Clues to Suicide and Interventions
• Verbalizing the future w/o oneself
• Giving things away
• Threats
ALWAYS take any clue to suicide seriously.
• ADDRESS person openly
• Do want to harm yourself?
• Do you have a plan?
• What is you plan?
• Notify significant others and /or authorities
• Offer HOPE.
• Things NOT to say: guilt, shame, false reassurance, can
“snap out of it.”
Suicide Prevention?
• Research does not support effectiveness of
“Suicide Contracts.” American Psychiatric Association. (2003). Practice guidelines for the
assessment and treatment of patients with suicidal behaviors. American Journal of Psychiatry, 160(11Suppl.),
1-60.
• Use written “Plan for Life” (positive approach)
– When I feel______________ (describe)
– I will ___________________ (activities)
– I will call ________________ (support persons)
– I will call ________________ (Suicide Contact
ph. #s, 911)
Psychosis
BPI may have psychotic features
Psychoses of BPD are usually of the type of
Delusions – strongly held/fixed beliefs that defy
evidence or reality
Examples: grandiosity, persecutory, referential,
erotomanic, somatic, nihilistic….
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington
D.C.: American Psychiatric Publishing.
Bipolar Typical Characteristics
• People who have mania or hypomania frequently
do not recognize/deny that their behaviors are
abnormal.
• They may enjoy their elevated moods.
• They may value ability to accomplish goals.
• If behaviors are serious enough, persons may
have to be hospitalized. Usually they are
resistant to hospitalization resulting in
involuntary admission.
• Behaviors, particularly delusional, may result in
illegal transgressions.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
Co Morbidity
• Drug and Substance use, abuse, and
addictions are common
– Alcohol
– Marijuana
• Persons desperately want to relieve symptoms
Etiology – Multiple - Complex
• Familial
– Relatives of those with Bipolar Disorders are more likely to
have. 10X the risk.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.
-Both parents: 50-75% chance for children; one parent 27%
-Identical Twins 78-80% concordance
-Familial Twins 17-19% Concordance
Snow, D. (2009). Bipolar lecture. University of Texas at Arlington College of Nursing.
- White matter reduction
Sprooten, E. et al. (2013). Reduced white matter integrity in sibling pairs discordant for bipolar disorder. Am J Psychiatry 2013;170:1317-1325
• Multiple genes involved
– Polymorphisms at the G72/G30 gene locus, on L13q33
Hattori, E. et al. (2003). Polymorphisms at the G72/G30 gene locus, on L13q33, are associated with bipolar disorder in two independent pedigree series. American Journal of Human
Genetics, 72(5), 1131-1140.
– Corticotropin receptor and subunit of G protein genes on C-18
•
Snow, D. (2009). Bipolar lecture. University of Texas at Arlington College of Nursing.
• Environmental
Neurobiological Correlates
• Brain areas: prefrontal cortex (executive
function),medial temporal lobe (memory functions),
via PET & MRI evidence
• Neurotransmitters:
norepinephrine, dopamine, serotonin
- decreased availability associated with mood
lowering
• Endocrine – thyroid:
– Low thyroid– risk for depression , and rapid cycling
Varcarolis, E. (2006). Mood disorders: Bipolar. In Foundation of Psychiatric Mental Health Nursing : A Clinical Approach. St. Louis, MO. Saunders. 359-393.
Treatment Options
• Medications
• Talk or Psychotherapy
• Electroconvulsive Therapy (ECT)
Every person is different with presentation of
BPD. Since multiple causal and environmental
factors are involved, the management is
challenging and often takes much trial and
error and readjustment.
Treatment Estimates
• ~48.8% receive
• ~38.8% minimally adequate
National Institute for Mental Health. National Institutes for Health. (2005). Bipolar disorder among
adults. Retrieved 11/13/13 from http://www.nimh.nih.gov/statistics/1bipolar_adult.shtml
Parody of psychiatric and medical treatment
access could increase these
Medications
Mood Stabilizers
• Lithium is classic (Eskalith or Lithobid)
– Long term necessary
– Therapeutic and toxic levels are close
– Lab tests closely monitor levels
– Acts like salt, so balance /w table salt important
– Decreased levels of salt can raise levels of lithium
– Can cause dry mouth, sensitivity to cold,
muscle/joint pain, brittle nails/hair, acne,
indigestion, restlessness
– Need monitoring of kidney and thyroid function
National Institute for Mental Health. National Institutes for Health. Retrieved 11/8/13 from
http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
Varcarolis, E. (2006). Mood disorders: Bipolar. In Foundation of Psychiatric Mental Health Nursing : A Clinical Approach. St. Louis,
MO. Saunders. 359-393.
Medications
Mood Stabilizers
Anticonvulsants - FDA approved
• Valproic acid or divalproex sodium (Depakote)
• Lamotrigine (Lamictal)
• Gabapentin (Neurontin)
• Topiramate (Topamax)
• Oxcarbazepine (Trileptal)
National Institute for Mental Health. National Institutes for Health. Retrieved 11/8/13 from
http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
Varcarolis, E. (2006). Mood disorders: Bipolar. In Foundation of Psychiatric Mental Health Nursing : A Clinical
Approach. St. Louis, MO. Saunders. 359-393.
Medications
Mood Stabilizers
Side and/or Untoward Effects
• Warnings of increased risk for suicide
• GI: Diarrhea/constipation/heartburn
• Nasal: Stuffy/runny nose
• Neuro: Headache, drowsiness/dizziness
• Potentially fatal skin rash from
Lamotrigine (Stevens-Johnson syndrome)
• Young women & Valproic acid, risk for polycystic
ovaries/birth defects
National Institute for Mental Health. National Institutes for Health. Retrieved 11/8/13 from
http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
Varcarolis, E. (2006). Mood disorders: Bipolar. In Foundation of Psychiatric Mental Health Nursing : A
Clinical Approach. St. Louis, MO. Saunders. 359-393.
Having Bipolar Disorders are serious life altering
challenges to individuals who have them and
to their families.
Can be managed successfully to have productive
life.
Requires tremendous insight in individual and
supportive understanding by those closest to
them .
Famous People
Who may have had or have BPDs
• Vivien Leigh
• Carrie Fisher
• Jean-Claude Van
Damme
• Linda Hamilton
• Sinéad O'Connor
•
•
•
•
•
Vincent van Gogh
Virginia Woolf
Jane Pauley
Mariette Hartley
Catherine Zeta-Jones
Bhatia, J. (2011). 10 Famous people with bipolar
disorder: The price of fame? Retrieved 11/14/13
from http://www.everydayhealth.com/bipolardisorder-pictures/famous-people-with-bipolardisorder.aspx#/slide-1
Famous People Who may have had or have
BPDs
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Author. (2012). Retrieved 11/13/13 from http://famouspeoplewithbipolardisorder.blogspot.com/2012/12/bipolar-famous-people.html
Jack Nicholson
Jim Carey
Rowan Atkinson
Robert Pattinson
Ben Stiller
Hugh Laurie
Craig Manning
Rapper "DMX'“
Kurt Cobain
Alfred Hitchcock
Salvador Dali‘
Kim Novak
Richard Dreyfuss
Margot Kidder
Demi Lovato
Sir Winston Churchil
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Macy Gray
Jimi Hendrix
Madonna
Buzz Aldrin
Abraham Lincoln
Charley Pride
Kristy McNichol
Connie Francis
Ozzie Osbourne
Sir Isaac Newton
Ludwig Van Beethoven
John Forbes Nash Jr.
Rita Lee
Pete Wentz
Patti Duke
Pablo Picasso
Resources
• Skywriting: A Life Out of the Blue, a book by
Jane Pauley
• National Alliance on Mental Illness
http://www.nami.org
• National Institute for Mental Health. National
Institutes for Health www.nimh.nih.gov
• www.mayoclinic.com/health/bipolar-disorder
References
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American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ).
Washington D.C.: American Psychiatric Publishing.
American Psychiatric Association. (2003). Practice guidelines for the assessment and treatment of patients with
suicidal behaviors. American Journal of Psychiatry, 160(11Suppl.), 1-60.
Author. (2012). Famous people with bipolar disorder. Retrieved 11/13/13 from
http://famouspeoplewithbipolardisorder.blogspot.com/2012/12/bipolar-famous-people.html
Bhatia, J. (2011). 10 Famous people with bipolar disorder: The price of fame? Retrieved 11/14/13 from
http://www.everydayhealth.com/bipolar-disorder-pictures/famous-people-with-bipolar-disorder.aspx#/slide-1
Hattori, E. et al. (2003). Polymorphisms at the G72/G30 gene locus, on L13q33, are associated with bipolar disorder
in two independent pedigree series. American Journal of Human Genetics, 72(5), 1131-1140.
National Alliance on Mental Illnesses. Bipolar Disorder FACT SHEET. Retrieved 11/13/13 from
http://www.nami.org/factsheets/bipolardisorder_factsheet.pdf
National Institute for Mental Health. National Institutes for Health. (2005). Bipolar disorder among adults.
Retrieved 11/13/13 from http://www.nimh.nih.gov/statistics/1bipolar_adult.shtml
National Institute for Mental Health. National Institutes for Health. (2006). Retrieved 11/8/13 from
http://www.nimh.nih.gov/news/science-news/2006/early-findings-from-largest-nimh-funded-research-programon-bipolar-disorder-begin-to-build-evidence-base-on-best-treatment-options.shtml
National Institute for Mental Health. National Institutes for Health. Retrieved 11/8/13 from
http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
Snow, D. (2009). Bipolar lecture. University of Texas at Arlington College of Nursing.
Sprooten, E. et al. (2013). Reduced white matter integrity in sibling pairs discordant for bipolar disorder. Am J
Psychiatry 2013;170:1317-1325.
Varcarolis, E. (2006). Mood disorders: Bipolar. In Foundation of Psychiatric Mental Health Nursing : A Clinical
Approach. St. Louis, MO. Saunders. 359-393.
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