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1、Bipolar Disorder in DSM-IVBipolar I disorder: manic episode(s)or mixed episode(s) plus MDE(s)Bipolar II disorder: major depressive episode(s) plus hypomanic episode(s)Cyclothymia: hypomanic symptomsplus depressive symptomsBipolar Disorders: DSM-IV NosologyCriteriaManiaHypomaniaMajor depressionMixed
2、stateBPD IRequiredPossiblePossible PossibleBPD IINo Required Required NoCyclothymiaNoNo No NoManic Episode: Diagnostic Criteria Elevated, expansive, or irritable mood for 1 week or longer, plus 3 or more of the followingInflated self-esteem or grandiosityDecreased need for sleepPressured speechRacin
3、g thoughts/flight of ideasDistractibilityPsychomotor agitation/increased goal-directed activityExcessive involvement in high-risk activities Manic Episode: Differential DiagnosesDifferential diagnosisConsider if . . . Mood disorder due to a Mood disorder due to a general medical general medical cond
4、itionconditionSubstance-inducedSubstance-inducedmood disordermood disorderHypomanic episodeHypomanic episodeMixed episodeMixed episodeMajor medical condition present Major medical condition present First episode at 50 years of ageFirst episode at 50 years of ageSymptoms in context of intoxicationSym
5、ptoms in context of intoxicationor withdrawalor withdrawalHistory of treatment for depressionHistory of treatment for depressionMood disturbance not severeMood disturbance not severeenough to require hospitalizationenough to require hospitalizationor impair functioningor impair functioningManic epis
6、ode and MDE in 1 weekManic episode and MDE in 1 weekManic Episode: Differential Diagnoses (cont.)AD/HDAD/HDEarly childhood mood disturbance onset Early childhood mood disturbance onset Chronic rather than episodic courseChronic rather than episodic courseNo clear onsets and offsets No clear onsets a
7、nd offsets No abnormally elevated moodNo abnormally elevated moodNo psychotic features No psychotic features American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). 4th ed. 1994.Differential diagnosisConsider if . . . Depressed mood and/or loss of interest o
8、r pleasure 2 weeks durationAssociated symptomsPhysical: insomnia/hypersomnia, appetite/weight change, decreased energy, psychomotor changePsychological: feelings of guilt or worthlessness, poor concentration/indecisiveness, thoughts of death/suicidal intentions (SI)Major Depressive Episode: DSM-IV C
9、riteriaand 4 of the following symptomsPhysicalSleep disorderAppetite changeFatiguePsychomotor retardationPsychologicalLow self esteem/guiltPoor concentration/indecisivenessThoughts of death/SIMixed Episode: Diagnostic CriteriaCriteria met for both manic episode + MDE for 1 weekSymptoms Are sufficien
10、t to impair functioning orNecessitate hospitalization orAre accompanied by psychotic featuresCharacteristicsBPD I BPD IIPrevalence 1.6%0.5%Ethnic/racial differentialNoneNoneGender differentialM = FFM (?)Bipolar Disorders: EpidemiologyCharacteristicsBPD I BPD IIBipolar Disorders: EpidemiologyHypomani
11、c episodes in BPD II immediately precede or follow MDEs in 60% to 70% of casesFirst-degree relatives may have increased rates of BPD I, BPD II, and MDDRecurrent in 90% of casesFirst-degree relatives have increased rates of BPD I, BPD II, and MDDCourseFamilial patternEpidemiologyPeak age of onset: ad
12、olescence through early 20sOnset of first manic episode after age 40 years is“red flag to consider substance use or generalmedical conditionSeasonal variationDepression more common in spring and autumnMania more common in summerDiagnostic Dilemmas: Unipolar Versus BipolarNo evidence of hypomania, cy
13、clothymia, hyperthymic personality, or family history of BPD1 manic episodeRecurrent major depression with hypomania and/or cyclothymic temperamentRecurrent major depression without spontaneous hypomania but often with hyperthymic temperament and/or family history of BPDUnipolar BPD IBPD IIBPD NOSEt
14、iologyHeritabilityEvidence for heritability is much stronger for bipolar than for unipolar disordersSpecific genetic association has not been consistently replicatedEVIDENCE FOR HERITABILITY OF BIPOLAR DISORDERFamily Studies- First degree relatives are 8 to 18 times more likely to have Bipolar I2 to
15、 10 times to have MDD.Risk is 25% if one parent has illness, and 50% to 75% with both parents affectedFAMILY STUDIESThe majority of individuals with bipolar disorder have a positive family history of some type of mood disorderAbout 50% of all bipolar I patients have at least one parent with a mood d
16、isorderADOPTION STUDIESPrevalence of bipolar disorder in adopted away offspring corresponds to rates in biological, but not adoptive relativesTwin Studies- Concordance rate in MZ twins is 33 to 90%, in DZ is 5 to 25%Cognitive DeficitsWorking memorySustained attentionAbstract reasoningVisuomotor skil
17、lsVerbal memoryVerbal fluencyCognitive flexibilityGeneral cognitive functioningPotential Explanations for Cognitive DeficitsIatrogenic or Alcohol useTemporary functional changesDegenerative brain changesPermanent structural lesionsPermanent functional alterations of neural networks underlying affect
18、 and cognitionAlcohol UseAlcohol use occurs in 30-50% of casesImpairs memory and executive functioningGorp et al (1998)Compared BP only, BP + AD, ControlBP + AD BP only for cognitive impairmentNo difference between Control and BP onlyOther studies have reported cognitive deficits in non substance ab
19、using BP patientsIatrogenicLithium Memory and psychomotor functioningValproate and Carbemazepine Attentional deficitisNeurolepticsSustained attentionVisuomotor speed deficitsBenzodiazapinesMemoryCrews et al.Performance on WCST negatively related to years of exposure to antipsychotic drugsQuestionsSo
20、me evidence indicates that Lithium exerts a neuroprotective effect on neuronal tissueAre studies indicating adverse effects of lithium not accounting for complex combinations of meds?Could we even study this issue empirically?EthicsGeneralizabilityTemporal Functional DeficitsAre cognitive deficits s
21、pecific to depressive or manic states?DepressionDecreased dorsal prefrontal cortex and anterior cingulate gyrus activationIncreased ventral prefrontal cortex activationReductions in left hemisphere activityManiaOpposite patternDecreased ventral and increased dorsal activity of the prefrontal cortexR
22、eductions in right hemisphere activityRemission of depressive symptoms associated with increased blood flow to dorsolateral and medial prefrontal cortexDistractibility and behavioral dysregulation during maniaHeightened left hemisphere prefontal corticol activityAttentional deficits accompanying depressionRight hemisphere disturbance of dorsal prefrontal cortex, cingulate gyrus, parlimbic cortexSummaryAuthors contend (Savitz et al, 2005) that functional disturbances have a neurodevelopmental and possibly genetic etiology that may be exacerbated by mood disturbances
