Understanding People Who Have Bipolar Disorders

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 peopleNational Alliance on Mental Illnesses. Bipolar Disorder FACT SHEET. Retrieved 11/13/13 from

http://www.nami.org/factsheets/bipolardisorder_factsheet.pdf

http://www.nimh.nih.gov/statistics/1bipolar_adult.shtml

http://www.nami.org/factsheets/bipolardisorder_factsheet.pdf

Bipolar IA. Must have at least one manic episode lasting at

least 1 weekB. During manic episode must have 3 or more out

of 7 behavioral manifestations of mania(next slide)

C. Major impairment in life functioningD. Cannot be explained by medications or drugs for

another medical conditionMay 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.

Behaviors of Mania1. Grandiosity, increased self esteem2. Insomnia3. Pressured or continuous talking4. Expresses that thoughts are racing or expressed thoughts

jump rapidly from one topic to another, called flight of ideas

5. Distractibility6. Increase in goal-directed or non-goal-directed activity,

called psychomotor activity7. Activities are of increased risk: pain, excessive spending,

hypersexuality…

May include psychotic behaviorAmerican 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 daysB.Uncharacteristic for usual behaviors of the

personC.Others notice the increased/expansive

behaviorsD.Not severe enough for major impairment in

life functioningAmerican 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 riskAmerican 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 personC.Observable by othersD.Does not significantly interfere with functioning

nor require hospitalizationMust include at least one major depressive episode, present or past


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 treatmentAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.

Bipolar II• Prevalence – 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 IAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed. ). Washington D.C.: American Psychiatric Publishing.

Mania _____________________________________

Hypomania _____________________________________

Normal Mood - Eupnea

_____________________________________

DysthymicCyclothymic

_____________________________________

Depressed _____________________________________

Bipolar MoodsTime -----------------------------------------------

Comparison

Bipolar I1 week elevated mood3/7 characteristics (4 if

mood irritable)Marked impairment ADLsPsychosis when present

defines BP I

May have major depression


Bipolar II4 days elevated mood3/7 Characteristics (4 if mood

irritable)ADLs NOT markedly affected.

Hospitalization not necessary.

Behaviors noted by othersMust 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


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/distressC. Not due to another medical condition or effects

of a substanceAmerican 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 Depression6. 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 planThe above may be subjective or observed by

others. The above may not be normal reactions to significant loss


Depression

Major depressive SX are the most common first presentation for which people with BP II disorder seek medical attention, particularly hospitalization.


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• ThreatsALWAYS 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)

PsychosisBPI 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….


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.


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 adequateNational 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

http://www.nimh.nih.gov/statistics/1bipolar_adult.shtml

MedicationsMood 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 functionNational Institute for Mental Health. National Institutes for Health. Retrieved 11/8/13 from

http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml




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





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 defectsNational Institute for Mental Health. National Institutes for Health. Retrieved 11/8/13 from




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-JonesBhatia, 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

http://www.everydayhealth.com/bipolar-disorder-pictures/famous-people-with-bipolar-disorder.aspx



Famous People Who may have had or have BPDs

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

• 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

http://famouspeoplewithbipolardisorder.blogspot.com/2012/12/bipolar-famous-people.html

http://famouspeoplewithbipolardisorder.blogspot.com/2012/12/bipolar-famous-people.html

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

http://www.nami.org/

References• 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-program-on-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.

Documents

Understanding People Who Have Bipolar Disorders