Stephanie’s Presentation on 5/22/2007 Part II

 

Affect/mood
Depressed episode: Sadness dominates the affect of individuals experiencing a depressed episode. They feel sad, depressed, lost, vacant, and isolated. The "2 Hs" often accompany their mood, hopeless and helpless. When in the presence of such patients, one comes away feeling sad and down.

Hypomanic episode: Their mood is up, expansive, and often irritable.

Manic episode: The mood is inappropriately joyous, elated, and jubilant. They are euphoric. They also may demonstrate annoyance and irritability, especially if the mania has been present for a significant length of time.

Mixed episode: The patient exhibits both depression and mania within a brief period (1 wk or less).

Thought content
Depressed episode: Patients experiencing a depression have thoughts that reflect their sadness. They are preoccupied with negative ideas and nihilistic concerns, and they metaphorically see "the glass as half empty." They likely are to focus on death and morbid persons. Many think about suicide.

Hypomanic episode: Patients in this state are optimistic, forward thinking, and have a positive attitude.

Manic episode: During the manic phase, patients have very expansive and optimistic thinking. They may be excessively self-confident and/or grandiose. They often have a very rapid production of ideas and thoughts. They perceive their minds as being very active and see themselves as being highly engaging and creative. They are highly distractible and quickly shift from one person to another.

Mixed episode: Patients in this state can oscillate dramatically between depression and euphoria, and often they demonstrate marked irritability.

Perceptions
Depression episode: Two forms of a major depression are described. One has psychotic features and the other does not. With psychosis, the patient experiences delusions and hallucinations that are either consistent or inconsistent with the mood. In the former, the patient’s delusions of having sinned are accompanied by guilt and remorse or the patient feels he or she is utterly worthless and should live in total deprivation and degradation. Hence, the delusional content remains consistent with the depressed mood.
In contrast, some patients experience delusions that are inconsistent with the depression, such as paranoia or persecutory delusions.

Hypomanic episode: Patients in this state do not experience perceptual disturbances.

Manic episode: Approximately three fourths of patients in the manic phase have delusions. As in major depression, the delusional content is either consistent or inconsistent with the mania. Manic delusions reflect perceptions of power, prestige, position, self-worth, and glory.

Mixed episode: Patients might exhibit delusions and hallucinations consistent with either depression or mania or congruent to both.

Suicide/self-destruction
Depressed episode: Depressed patients have a very high rate of suicide. They are the individuals who attempt and succeed at killing themselves. Query patients to determine if they have any thoughts of hurting themselves (suicidal ideation) and any plans to do so. The more specific the plan, the higher the danger. As patients emerge from a period of depression, their suicide risk may increase. This may be because, as the illness remits, executive functions are improved such that the person is again capable of making and carrying out a plan while the subjective feeling of depression and accompanying suicidal thoughts may persist.

Hypomanic episode: Incidence of suicide is low.

Manic episode: Incidence of suicide is low.

Mixed episode: The depressed phases put the patient at risk for suicide.

Homicide/violence/aggression
Depressed episode: Generally, suicide remains the paramount issue. However, certain persons in the depths of a depression not only see the world as hopeless and helpless for themselves but also for others. Frequently, that perspective can create and lead to a homicide followed by a suicide. One example of this occurred when a 42-year-old mother of 2 was experiencing a significant depression as part of her bipolar disorder. She believed the earth was doomed and was a terrible place to dwell. Furthermore, she thought that if she died, her children would be left in a wretched place. Because of this view, she planned to kill her 2 children and then herself. Fortunately, her family recognized the state of affairs, which led to an emergency intervention and her hospitalization.

Hypomanic episode: Patients who are hypomanic frequently show evidence of irritability and aggressiveness. They can be pushy and impatient with others.

Manic episode: Persons in mania can be openly combative and aggressive. They have no patience or tolerance for others. They can be highly demanding, violently assertive, and highly irritable. The homicidal element particularly emerges if these individuals have a delusional content to their mania. They are acting out of the grandiose belief that others must obey their commands, wishes, and directives. If their delusions become persecutory in nature, they may defend themselves against others in a homicidal fashion.

Mixed episode: Persons in a mixed episode may exhibit aggression, especially in the manic phases.

Judgment/insight
Depressed episode: Depression clouds and dims these individuals’ judgment and colors their insights. They fail to make important actions because they are so down and preoccupied with their own plight. They see no tomorrow; therefore, planning for it is very difficult. Frequently, persons in the middle of a depression have done things such as forgetting to pay their income taxes. At that time, they have little insight into their behavior. Often, others have to persuade them to seek therapy because of their lack of insight.  

Hypomanic episode: Generally, these people have good but expansive judgment. They may take on too many tasks or become over-involved. Often, their distractibility impairs their judgment, and they have little insight into their driven qualities. They see themselves as productive and conscientious, not as hypomanic.

Manic episode: The hallmark of this phase is seriously impaired judgment. They make terrible decisions in their work and family. They may invest the family fortune in very questionable programs. They may become professionally over-involved in work activities or with coworkers. They start a series of dramatic very unsound fiscal or professional ventures. They do not listen to any feedback, suggestions, or advice from friends, family, or colleagues. They have no insight into the extreme nature of their demands, plans, and behavior. Often, commitment proves the only way to contain them.  

Mixed episode: Major shifts in affect during short lengths of time severely impair their judgment and interfere with their insight.

Cognition

Impairments in orientation and memory are seldom observed in patients with bipolar disorder unless they are very psychotic. They know the time and their location, and they recognize people. They can remember immediate, recent, and distant events. In some cases of hypomanic and even manic episodes, their ability to recall information can be extremely vivid and expanded. In extremes of depression and mania, they may experience difficulty in concentrating and focusing.


Causes

Bipolar disorder has a number of contributing factors, including genetic, biochemical, psychodynamic, and environmental elements.

Genetics:

Bipolar disorder, especially BPI, has a major genetic component. The evidence indicating a genetic role in bipolar disorder takes several forms.
First-degree relatives of people with BPI are approximately 7 times more likely to develop BPI than the general population. Remarkably, offspring of a parent with bipolar disorder have a 50% chance of having another major psychiatric disorder.
Twin studies demonstrate a concordance of 33-90% for BPI in identical twins.
Adoption studies prove that a common environment is not the only factor that makes bipolar disorder occur in families. Children whose biologic parents have either BPI or a major depressive disorder remain at increased risk of developing an affective disorder, even if they are reared in a home with adopted parents who are not affected.
Numerous genetic studies of BPI suggest multiple different genetic loci, but, as yet, no genes have been definitively identified. This is, in part, because many genes contribute small effects to the disorder in different individuals and, partly, because no objective means of identifying a particular genetic subtype is available. However, studies are ongoing, and technological and statistical advances may lead to a breakthrough in the next decade.

A very interesting new finding in psychiatric genetics heralds the future revision of DSM-IV-TR according to an etiological rather than descriptive basis. Using probands from the Maudsley Twin Register in London, Cardno and colleagues showed that schizophrenic, schizoaffective, and manic syndromes share genetic risk factors and that the genetic liability for schizoaffective disorder was entirely shared in common with the other two syndromes. This finding suggests an independent genetic liability for psychosis shared by both mood and schizophrenia spectrum disorders as Berrettini previously speculated.

A recent study by Tsuang et al further indicates the genetic contribution to manic-depressive illness with psychotic features. Their findings show the link between schizophrenia and bipolar disorder (Tsuang, 2004).

As discussed above, gene expression studies also demonstrate that persons with bipolar disorder, major depression, and schizophrenia share similar decreases in the expression of oligodendrocyte-myelin–related genes and abnormalities of white matter in various brain regions.

Biochemical causes:

 Multiple biochemical pathways likely contribute to bipolar disorder, which is why detecting one particular abnormality is difficult.

A number of neurotransmitters have been linked to this disorder, largely based on patients’ responses to psychoactive agents.

For instance, the blood pressure drug reserpine, which depletes catecholamines from nerve terminals, was noted incidentally to cause depression. This led to the catecholamine hypothesis, which holds that an increase in epinephrine and norepinephrine causes mania and a decrease in epinephrine and norepinephrine causes depression.

Drugs like cocaine, which also act on this neurotransmitter system, exacerbate mania.
Other agents that exacerbate mania include L-dopa, which implicates dopamine and serotonin-reuptake inhibitors, which, in turn, implicate serotonin.

Calcium channel blockers have been used to treat mania, which also may result from a disruption of calcium regulation in neurons. The proposed disruption of calcium

regulation may be caused by various neurologic insults such as excessive glutaminergic transmission or ischemia. Interestingly, valproate specifically up-regulates expression of a calcium chaperone protein, GRP 78, which may be one of its chief mechanisms of cellular protection.

Hormonal imbalances and disruptions of the hypothalamic-pituitary-adrenal axis involved in homeostasis and the stress response also may contribute to the clinical picture of bipolar disorder.

Psychodynamic:

 Many practitioners see the dynamics of manic-depressive illness as being linked through one common pathway.

They see the depression as the manifestation of the losses, ie, the loss of self-esteem and the sense of worthlessness. Therefore, that mania serves as a defense against the feelings of depression. (Melanie Klein was one of the major proponents of this formulation.)

Environmental
In some instances, the cycle either may be directly linked to external stresses or the external pressures may serve to exacerbate some underlying genetic or biochemical predisposition.

Pregnancy is a particular stress for women with a manic-depressive illness history and increases the possibility of postpartum psychosis (Chaudron, 2003).
Because of the nature of their work, certain individuals have periods of high demands followed by periods of few requirements. For example, one person was a landscaper and gardener. In the spring, summer, and fall, he was very busy. During the winter, he was relatively inactive except for plowing snow. Thus, he appeared manic for a good part of the year, and then he would crash and hibernate for the cold months.

 

 

 

 

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