Bipolar Disorder and Special Populations Adam T Kaul

Bipolar Disorder and Special Populations Adam T. Kaul M. D.

Vincent van Gogh The painter suffered from incredible highs and lows throughout his apparent struggle with mental illness. During his lifetime, van Gogh’s disease wouldn’t have been known as bipolar disorder, but today the symptoms are clearly recognizable. “When van Gogh's health and spirits were up, he painted with confidence and energy amounting almost to fury, ” a Washington Post art critic wrote in 1998. “When he was down. . . he was virtually paralyzed with doubt and fear. ”

Bipolar Disorder • Also known as manic depression, a mental illness that causes a person’s moods to swing from extremely happy and energized (mania) to extremely sad (depression) • Chronic illness; can be life-threatening • Most often diagnosed in adolescence (age 15 -25)

Epidemiology of Bipolar Disorder • Prevalence: 1% of population Adults and Adolescents • Males = Females • 2 -3 million American adults are diagnosed with bipolar disorder

Genetics • Strong genetic correlation: • 30 -70% • 75% Identical twins Both parents bipolar

Assessment/Diagnosis of Bipolar Disorder • Often very complicated; it mimics many other disorders and has comorbidity (presents with other disorders) • Alphabet soup diagnosis • Half of bipolar children have relatives with bipolar disorder

Assessment/Diagnosis of Bipolar Disorder with Substance Abuse • Overlap with Bipolar Symptoms: “manic” symptoms, such as euphoria, rapid speech, altered states of consciousness can be direct effects of substances. • Substance abuse is very common in bipolar disorder, in both the depressive and the manic poles of the illness.

Assessment/Diagnosis of Bipolar Disorder in Elderly • It is rare, but bipolar disorder can manifest in the elderly as new onset. Usually, it is an exacerbation of a chronic condition • May get mislabeled as being dementia, although dementia may cause acute mania. • A thorough medical work up is indicated if any new bipolar symtoms are noted. Delirium should be ruled out.

Assessment/Diagnosis of Bipolar Disorder with Intellectual Disability • Overlap with ASD symptoms (e. g. extreme hyperfocus) • May get mislabeled as being only behavioral • Limited insight with an illness that already limits insight.

Other Organic Diagnoses • It is important to first rule out the possibility of any other organic diagnosis: – Thyroid disorder – Seizure disorder – Multiple sclerosis – Infectious, toxic, and drug-induced disorders

Pediatric-Onset Bipolar Disorder: Differential Diagnosis with ADHD Talkativeness Physical hyperactivity Distractibility • ADHD confusion although identifying presence of mood disorder helpful in guiding treatment

• ADHD criteria does not include a mood component (usually comorbid ODD) • Look for family history data to help with diagnosis of bipolar disorder • Nonverbal learning disorders overlap

Winston Churchill The twice-over Prime Minister of the United Kingdom who achieved victory during World War II was diagnosed with bipolar disorder in middle age. Winston Churchill often referred openly to his depression, calling it his “black dog. ” He was known for making the best of his situation and often capitalized on episodes of sleeplessness by directing his energy into his work. He published 43 books during his time as prime minister. He went on to win the Nobel Prize in Literature in 1953.

Mood history • Mania – Giddy, goofy, laughing fits, class clown – Explosive (how often, how long, how destructive and aggressive) – Irritable, cranky, angry, disrespectful, threatening – Grandiosity may present as EXTREME defiance and oppositionality • Depression – Low frustration tolerance, self-destructive, no pleasure, lower level of irritability

DSM Criteria • A distinct period of abnormally and persistently elevated, expansive, or irritable mood • DIGFAST acronym (at least 3 of 7 symptoms)

DIGFAST – Mental Status Exam • • Distractible Increased activity/psychomotor agitation Grandiosity/Super-hero mentality Flight of ideas or racing thoughts Activities that are dangerous or hypersexual Sleep decreased Talkative or pressured speech

Bipolar II Disorder • Bipolar II similar to Bipolar I except that people have hypomanic episodes, a milder form of mania. – Less intense manic episodes results in less “damage” (e. g. need for hospitalization) – The chronic depression can be very debilitating and difficult to treat

Catherine Zeta-Jones After a stressful year watching her husband, Michael Douglas, grapple with a cancer diagnosis, Catherine Zeta-Jones checked herself into a mental health facility for treatment of bipolar II. Bipolar II is a type of bipolar disorder that’s marked by longer bouts of depression and less elevated “up” periods. Zeta-Jones sought treatment briefly to help balance her mental health before going back to work. She has been very outspoken about managing her disorder. She advocates for de -stigmatizing mental illness and hopes that she can inspire others to seek treatment and support.

Rapid Cycling Bipolar Disorder • Depression and manic states alternate rapidly – Can be over a period of hours • Can be exacerbated/caused by certain medications

Mixed State Bipolar Disorder • Depression and manic states co-exist • Can be exacerbated/caused by certain medications • Can be a very dangerous condition due to depressive mood with manic energy.

Effects of Bipolar Disorder • Significant functional impairment • Bipolar I people go through cycles of major depression and mania: – Often require lifelong treatment – High risk behaviors – Frequent hospitalizations – Poor lifestyle habits • Bipolar II people go through chronic difficult depression

Effects of Bipolar Disorder: The IMPACT Study • Impact on wellbeing • As well as affecting work lives and relationships, bipolar I disorder can also have a profound impact on the wellbeing of people with the condition. 1 • 76% of participants reported a decrease in their own expectations of success in life because of their bipolar I disorder while 79% said it has had a negative impact on their physical health. 2

Impact of Bipolar Disorder • Discrimination • A stigma is often associated with bipolar I disorder so participants were asked if they believed they had ever experienced discrimination. Nearly half (45%) claimed they had experienced discrimination because of their condition. 1

Graham Greene English novelist Graham Greene led a hedonistic life—he would swing from periods of elation or irritability to despair, and was guilty of repeated infidelities. He was an alcoholic who abandoned his wife and children in favor of a series of affairs with married women. He was a devout Catholic who was tormented by his behavior, and expressed the moral struggle between good and evil in his novels, plays, and films.

Impact of Bipolar Disorder • Communication • People with bipolar I disorder often find it difficult to talk to people about their condition. In this study, only 14% of participants said they felt able to discuss their condition openly with other people. 1

Impact of Bipolar Disorder • Work Life • Often people with bipolar I disorder find that their work life is hindered. 1 Almost half of participants (45%) in the study lost their job because of their bipolar I disorder and more than half (55%) chose not to tell their employer or manager about their diagnosis. 2

Impact of Bipolar Disorder • Work Life • Often people with bipolar I disorder find that their work life is hindered. 1 Almost half of participants (45%) in the study lost their job because of their bipolar I disorder and more than half (55%) chose not to tell their employer or manager about their diagnosis. 2

Impact of Bipolar Disorder • Personal Life • Bipolar I disorder can have a profound effect on relationships. 1 Participants were asked to record how their personal lives had been affected and 38% said they had been divorced or separated because of their bipolar I disorder. 2 • 67% of participants also reported feeling isolated and alone during a period of mania. 2

Treatment Guidelines 1. Early diagnosis and intervention is ideal 2. Utilize a biopsychosocial approach 3. Prioritize Symptoms

Nina Simone The famous singer of “I Put a Spell on You” was a prodigious jazz artist. Simone was also a political activist vocal during the Civil Rights movement of the 1960 s. She was prone to fits of rage and was labeled a “difficult diva” in the music industry at the time. She experienced greater freedom of expression and authenticity than a lot of the women of her time. She also ignored pressures to conform to “normal” social conventions. Her biographers explore her bipolar and borderline personality disorder symptoms in the books “Princess Noire: The Tumultuous Reign of Nina Simone” and “Break It Down and Let It All Out. ”

Biopsychosocial Treatment • • Education, compliance is a primary goal Hospitalize for acute loss of functioning Outpatient treatment is rehabilitative Psychoanalysis, exploratory therapies have limited value. CBT and supportive therapies are usually better as primary treatments. • Families should be involved. • Multidisciplinary Treatment approach

Prioritizing Target Symptoms 1. Treat mania and/or psychosis 2. Treat depression 3. Anxiety and ADHD

Medications • Mood Stabilizers • Lithium • Divalproex Sodium (Depakote) • Carbamezapine

Lithium • An elemental salt • Came into common medical usage around 1971 • Levels need to be monitored due to a narrow therapeutic window • Can cause kidney problems if too high – Need to hydrate well

Carrie Fisher Actress Fisher, 54, best known for her role as Princess Leia in the Star Wars trilogy, has experienced plenty of turbulence in her life —and not just aboard the Millennium Falcon. After years of struggling with mania and depression, Fisher was diagnosed with bipolar disorder when she was 28. Fisher told USA Today in 2002 that she now leads a normal life and her behavior is much more predictable, thanks to the lithium prescribed by her doctor. But it wasn’t always so easy. “I hacked off my hair, got a tattoo, and wanted to convert to Judaism, " she said of her most recent manic episode.

Anti-epileptic medications • Depakote (Divalproex/Valproic acid) – Effective as a solo treatment – Levels need to be checked – Liver toxicity can occur • Tegretol (Carbamazepine) – Less commonly used, sometimes as adjuvant – Levels need to be checked

Anti-epileptic medications • Trileptal – Similar to Tegretol – Does not require levels to be monitored – Can cause low sodium • Topamax (Topiramate) – Often used as adjuvant – Sedation/slow cogntitive processing is common

Anti-epileptic medications • Lamictal (lamotrigine) – Has the benefit of improving depressive symptoms – Not as good for preventing mania – Monitor for a dangerous rash

Anti-epileptic medications • Others – Neurontin (gabapentin), and many other AEM’s (Dilantin, Zonegran, Keppra, Vimpat, Lyrica, Onfi, etc) – Not very good data on these for bipolar monotherapy. Most do not work at all, and are probably being used for other conditions. – Not as good for preventing mania. – May be used as adjuvant treatments (Neurontin, Vimpat)

Bipolar Disorder: Antipsychotics • Antipsychotic Agents: (Also called neuroleptics) Typical: Also called first generation Atypical: Also called second generation

Typical Antipsychotics • Low potency: – Chlorpromazine – Thioridazine – Mesoridazine • High potency: – – Haloperidol Fluphenazine Thiothixene Loxapine (mid) • Efficacy is predominantly due to blocking the effect of Dopamine.

Typical Antipsychotics • Older, more difficult side effects • Not as effective for mood stabilization or monotherapy as Lithium and Depakote • Often used for adjuvant treatment of psychotic symptoms • Often also used for acute mania treatment – Often referred to as “tranquilizers” when used this way.

Typical Neuroleptics: Side Effects • • • Acute dystonia Parkinsonian side effects (EPS) Akathisia Tardive dyskinesia Sedation, orthostasis, QTC prolongation, anticholinergic, lower seizure threshold, increased prolactin

Demi Lovato Child actor turned Billboard Top 40 chart-topper Demi Lovato was diagnosed with bipolar disorder in 2011 at the age of 19. She entered a treatment program at the insistence of her family. Like many, Lovato struggled to accept her diagnosis at first, believing that she wasn’t sick and that many people were far worse off than she was. Through hard work she says she’s gradually come to understand manage her illness. Lovato spoke openly about her experiences in an MTV documentary titled “Stay Strong. ” She said it was her obligation to share her story to help inspire others in the same situation. She also wanted to encourage compassion for those learning to cope with the disorder.

Atypical Antipsychotics: • • • Risperidone (Risperdal) Olanzapine (Zyprexa) Quetiapine (Seroquel) Clozapine (Clozaril) Ziprasidone (Geodon) Aripiprazole (Abilify) Paliperidone (Invega) Lurasidone (Latuda) Asenapine (Saphris) Iloperidone (Fanapt) Cariprazine (Vraylar) Brexpiprazole (Rexulti)

Atypical antipsychotics: • Newer, better tolerated • Some can be used in monotherapy for bipolar disorder • Broader spectrum of receptor activity (Serotonin, dopamine, GABA) • May be better at alleviating depressive symptoms and cognitive dysfunction • Can also be used as adjuvant treatment for targeted symptoms or overall stabilization.

Atypical Antipsychotics (ctd. ) • Increasingly used because they can cause rapid patient stabilization • Many can help with depression, mania and psychosis – “best of all worlds. ” • Weight gain and metabolic syndrome. • Akathisia can occur and mimic manic symptoms

Monitoring of Antipsychotic Agents • Monitor for EPS and TD, Akathisia • Monitor for metabolic syndrome • Monitor for Sedation • Monitor WBC in Clozaril • Monitor for interactions with other medications • Prolactin, QTc intervals

Key Point • Just because a person improves on a medication does not prove the diagnosis. Mood stabilizers are also effective in symptoms of agitation/aggression in many psychiatric conditions.

Additional Treatment Options • Mood Charting • Assistance with medication compliance • Teach Good Sleep Hygiene, monitor sleep patterns • Support groups • Family Counseling • Legal intervention • Hope

Vincent Van Gogh “It isn’t possible to get values and color. You can’t be at the pole and the equator at the same time. You must choose your own line, as I hope to do, and it will probably be color. ”

Bipolar Disorder and Special Populations Questions and Comments