BipolarDisorderinDSM-IV-CenterforAddictions双相情感障碍在DSM-IV中心为成瘾.ppt

Bipolar Disorder in DSM-IV Bipolar 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 symptoms plus depressive symptoms Bipolar Disorders: DSM-IV Nosology Criteria Mania Hypomania Major depression Mixed state BPD I Required Possible Possible Possible BPD II No Required Required No Cyclothymia No No No No Manic Episode: Diagnostic Criteria Elevated, expansive, or irritable mood for 1 week or longer, plus 3 or more of the following Inflated self-esteem or grandiosity Decreased need for sleep Pressured speech Racing thoughts/flight of ideas Distractibility Psychomotor agitation/increased goal- directed activity Excessive involvement in high-risk activities Manic Episode: Differential Diagnoses Differential diagnosis Consider if . . . Mood disorder due to a Mood disorder due to a general medical general medical conditioncondition Substance-inducedSubstance-induced mood disordermood disorder HypomanicHypomanic episode episode Mixed episodeMixed episode Major medical condition present Major medical condition present First episode at 50 years of ageFirst episode at 50 years of age Symptoms in context of intoxicationSymptoms in context of intoxication or withdrawalor withdrawal History of treatment for depressionHistory of treatment for depression Mood disturbance not severeMood disturbance not severe enough to require hospitalizationenough to require hospitalization or impair functioningor impair functioning Manic episode and MDE in 1 weekManic episode and MDE in 1 week Manic Episode: Differential Diagnoses (cont.) AD/HDAD/HDEarly childhood mood disturbance onset Early childhood mood disturbance onset Chronic rather than episodic courseChronic rather than episodic course No clear onsets and offsets No clear onsets and offsets No abnormally elevated moodNo abnormally elevated mood No 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 or pleasure 2 weeks duration Associated symptoms Physical: insomnia/hypersomnia, appetite/weight change, decreased energy, psychomotor change Psychological: feelings of guilt or worthlessness, poor concentration/indecisiveness, thoughts of death/suicidal intentions (SI) Major Depressive Episode: DSM-IV Criteria and 4 of the following symptoms Physical Sleep disorder Appetite change Fatigue Psychomotor retardation Psychological Low self esteem/guilt Poor concentration/ indecisiveness Thoughts of death/SI Mixed Episode: Diagnostic Criteria Criteria met for both manic episode + MDE for 1 week Symptoms Are sufficient to impair functioning or Necessitate hospitalization or Are accompanied by psychotic features CharacteristicsBPD I BPD II Prevalence 1.6%0.5% Ethnic/racial differentialNoneNone Gender differentialM = FFM (?) Bipolar Disorders: Epidemiology CharacteristicsBPD I BPD II Bipolar Disorders: Epidemiology Hypomanic episodes in BPD II immediately precede or follow MDEs in 60% to 70% of cases First-degree relatives may have increased rates of BPD I, BPD II, and MDD Recurrent in 90% of cases First-degree relatives have increased rates of BPD I, BPD II, and MDD Course Familial pattern Epidemiology Peak age of onset: adolescence through early 20s Onset of first manic episode after age 40 years is “red flag” to consider substance use or general medical condition Seasonal variation Depression more common in spring and autumn Mania more common in summer Diagnostic Dilemmas: Unipolar Versus Bipolar No evidence of hypomania, cyclothymia, hyperthymic personality, or family history of BPD 1 manic episode Recurrent major depression with hypomania and/or cyclothymic temperament Recurrent major depression without spontaneous hypomania but often with hyperthymic temperament and/or family history of BPD Unipolar BPD I BPD II BPD NOS Etiology Heritability Evidence for heritability is much stronger for bipolar than for unipolar disorders Specific genetic association has not been consistently replicated EVIDENCE FOR HERITABILITY OF BIPOLAR DISORDER Family Studies- First degree relatives are 8 to 18 times more likely to have Bipolar I 2 to 10 times to have MDD. Risk is 25% if one parent has illness, and 50% to 75% with both parents affected FAMILY STUDIES The majority of individuals with bipolar disorder have a positive family history of some type of mood disorder About 50% of all bipolar I patients have at least one parent with a mood disorder ADOPTION STUDIES Prevalence of bipolar disorder in adopted away offspring corresponds to rates in biological, but not adoptive relatives Twin Studies- Concordance rate in MZ twins is 33 to 90%, in DZ is 5 to 25% Cognitive Deficits Working memory Sustained attention Abstract reasoning Visuomotor skills Verbal memory Verbal fluency Cognitive flexibility General cognitive functioning Potential Explanations for Cognitive Deficits Iatrogenic or Alcohol use Temporary functional changes Degenerative brain changes Permanent structural lesions Permanent functional alterations of neural networks underlying affect and cognition Alcohol Use Alcohol use occurs in 30-50% of cases Impairs memory and executive functioning Gorp et al (1998) Compared BP only, BP + AD, Control BP + AD BP only for cognitive impairment No difference between Control and BP only Other studies have reported cognitive deficits in non substance abusing BP patients Iatrogenic Lithium Memory and psychomotor functioning Valproate and Carbemazepine Attentional deficitis Neuroleptics Sustained attention Visuomotor speed deficits Benzodiazapines Memory Crews et al. Performance on WCST negatively related to years of exposure to antipsychotic drugs Questions Some evidence indicates that Lithium exerts a neuroprotective effect on neuronal tissue Are studies indicating adverse effects of lithium not accounting for complex combinations of meds? Could we even study this issue empirically? Ethics Generalizability Temporal Functional Deficits Are cognitive deficits specific to depressive or manic states? Depression Decreased dorsal prefrontal cortex and anterior cingulate gyrus activation Increased ventral prefrontal cortex activation Reductions