_disorder inhima双相情感障碍的课件

Diagnosing Bipolar Disorder “Were all a little that way” MH Disorders in OP Psychiatry 25% “Other” = Schiz, Anx, ADHD, PD 25% Depression -(often treatment resistant) 25% Bipolar disorder 25% “Bipolar Spectrum” Complicated, confusing, comorbid, poor treatment outcome Diagnosis of Mood Disorders The possibilities: Bipolar I = Mania with or w/o depression Bipolar II = Hypomania with depression Cyclothymia = hypomania with “minor” depression Major Depression = depression “Bipolar spectrum” = Depression + other complexities Bipolar NOS or Mood DO NOS Always consider these: Significant medical condition Depression due to general med condition History of many physical symptoms Secondary depression Significant recent substance use Meth and cocaine and pot = mania/psychosis Alcohol and cocaine withdrawal = depression Diagnosis of BPAD Assessment of cross sectional symptoms inadequate for dx One session = “One cut of an MRI” Assessment of longitudinal course essential Collateral info = other providers, admits, family history and input, follow-up visits “The whole MRI” “Biography” Diagnosis DSM IV TR criteria for mania Distinct period of abnormally and persistently elevated or irritable mood lasting a week or requiring hospitalization, or with psychosis Three or more of: grandiosity, decreased need for sleep; talkative; flight of ideas; distractibility; increase in goal directed activity; excessive involvement in pleasurable activities = buying sprees, sexual indiscretions, foolish business investments DSM 4TR criteria for depression(MDD) Depressed mood most of the day almost every day Diminished interest or pleasure Appetite and wt changes Sleep changes Agitation or slowness of movement Fatigue Guilt or “worthlessness” Poor concentration Thoughts of death or suicide Other features of Depression Psychosis-paranoia or hallucinations Seasonal component = SAD Postpartum onset Catatonic features=marked psychomotor disturbance, immobility or stupor Melancholic features = worse in a.m., anorexia or wt loss, marked guilt Mixed Bipolar Episode Meet criteria for both mania and depression Often most severely ill High suicide rate Looks like agitated depression Depression: Bipolar vs MDD More common in Bipolar Early age of onset Recurrence Postpartum Rapid cycling Brief duration Baseline hyperthymic personality Bubbly,outgoing, extroverted, etc Symptoms: Bipolar vs Unipolar More common in Bipolar “Atypical” sx Increased sleep & appetite, rejection sensitivity, mood reactivity, leaden paralysis Psychotic depression Anxious/agitated depression Irritability and anger Treatment response: BPAD vs MDD More common in BPD Antidepressant induced mania Antidepressant induced psychosis, mixed states or suicidality,dysphoria (ACID syndrome) Nonresponse to good med trial Tolerance to medication = poop out effect Rapid cycling, including only w/in depressed range Differences between BPAD I & II BP-IBP-II Atypical features + + Mixed state/agitation + + Anxiety disorder + + Mood lability + + Social anxiety + + Female/Male ratio 1:1 2/1 The Galaxy of Possibilities Single MDE *Atyp MDD *(PD) *Chronic MDD *Recurrent MDD *Psychotic MDD * *Dysthymia *“Bipolar Spectrum DO” *Bipolar NOS *Bipolar II *Bipolar I *(Psychosis) *(ANXIETY) *(Psychosocial Stress)(ADHD) Comorbid Illness Substance dependence ETOH, etc. = 45% lifetime Anxiety DO GAD, PD, PTSD = 45% lifetime ADHD Shared cognitive deficits when euthymic Personality Disorders Cluster B = BP, NPD, ASPD Bipolar Spectrum Disorder, proposed for DSM V At least one MDE No spontaneous hypomania or mania Family Hx of BPD in 1st degree relative or AD induced hypomania/mania Ancillary criteria: Hyperthymic personality Recurrent MDE Brief MDEs ( 80%) of misdx” 50% of BPAD I present with depression 50% of BPAD II present with depression Up to 10 years of rx for MDD prior to dx of BPAD ? Bipolar Spectrum Ill defined intermittent sx, etc Misdx: patient factors Lack of insight with regard to mania Impaired memory for past depression Failure to report manic sx or behavior Experiencing hypomania as “normal good times” Cultural positive feedback for hypomanic/manic sx Misdx: clinician factors Failure to include family in eval Structure of DSM = “begins by separating bipolar from all depressions” Inadequate knowledge of mania criteria Intuitive “prototype” approach to dx Practical desire to make dx which is more palatable and more treatable STIGMA Lack of awareness of prevalence of bipolar Misdx: Illness factors First episode of illness often depression May be recurrent for many years Dysphoric depression is not conceptualized as a mixed state Depressive episodes last longer than often fleeting hypomanic states “There is no such thing as unipolar depresion” How much bipolarity? BPD: Treated vs Untreated Mortality ratios p100 Quetiapine 300mg - 600mg Olanzapine 5mg - 20mg Olanzapine/fluoxetine (Symbiax) Lamotrigine 50mg - 200 mg Lithium* Antidepressants and BPDep -No Prospective DB RCT adequately powered study in BP I or II (Olanzapine/fluoxetine combo) -Recent NEJM article (NIMH Sept 07) = depressive sx improve at same rate with and without AD -Treatment emergent affective switch (TEAS) -TCAVenSSRIBup -Treatment emergent rapid cycling -AD associated chronic irritable dysphoria “ACID” (STEP-BD study) Unrelenting dysphoria Severe agitation Refractory anxiety Unendurable sexual excitement Intractable insomnia Suicidal obsessions and impulses “histrionic demeanor” Social, occupational, marital dysfunction Improvement with stopping ADs Antidepressants in BPD Bipolar Treatment Centers 30% of patients on AD Community psychiatrists 50-60% of patients on AD Primary care providers 70-80% of patients on AD Treatment of BP Spectrum Agitated Depression Add mood stabilizer Lamotrigine- Oxcarb Lithium Depakote Taper and DC antidepres