The Bipolar Disorders

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The Bipolar Disorders

• BIPOLAR DISORDERS
• AIS School Counsellors Conference
• June 1, 2006. Leura

Gordon Parker (propped up by Topo Rodriguez)
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Setting the Scene

• An historical story and a vignette.

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Objectives

• Describe Bipolar Disorder (BPD) and the Bipolar
  Spectrum (BP-I, BP-II and BP-III) and their
  manifestations (and consequences) particular in
  secondary school children
• Note problems in detection
• Review high (and increasing prevalence) of
• BPII and why.

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Once

• There was a condition called Manic Depressive
  Psychosis that affected about 0.5 of the general
  community over their lifetime.

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New Bipolar Spectrum Model and Prevalence
Implications

• Bipolar spectrum held to comprise
• I manic-depression
• II depression hypomania
• III hypomania in association with
  Antidepressant drugs (start up or on withdrawal
  switching)
• IV depression superimposed on hyperthymic
  temperaments
• V and VI other more temperament concepts.
• We estimate that 1 in 10 individuals in the
  community either has bipolar disorder or is at
  risk for it Akiskal.

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Now..

• BP-II conditions comprise some 50 of the
  depressed patients observed in a general
  out-patient setting
• Highest rate in those under the age of 30 years
• A condition that commonly emerges in mid to late
  adolescence.

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Lifetime Prevalence of BP Disorders in Two
Depressive Samples A Cohort Effect?
Proportion of each sample diagnosed with BP, by
age.
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Bipolar I and Bipolar II
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Relationship between Depression and Highs an
Isomer Model
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Features of the (Melancholic) Depression

• Profound lack of energy (eg hard to get out of
  bed and bathe), worse in a.m.
• Lose the light in their eyes
• Become asocial and reclusive
• Life without pleasure and not (or minimally able
  to be cheered up)
• Suicidal
• May have atypical features
• (i.e. sleep more, eat more).

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Detection is Poor and Delayed

• Onset to diagnosis 10-12 years in US, and some
  15-20 years in Australia
• Diagnosis often made too late
• Principal reasons lack of awarenesss of the
  condition and sufferers only present when
  depressed (not when high).

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Such a Diagnosis Can Be a Threat for Many
Individuals

• People often describe the highs as enjoyable
• Thoughts and ideas come rapidly
• As if new energy reserves are discovered, new
  projects started bubbling with plans and
  enthusiasm
• The world seems a wonderful place, extremely
  positive outlook on life
• In essence, if there was a drug that created such
  states, it would be commercially viable.

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Detecting/Suspecting Bipolar Disorder

• Periods when neither normal or depressed - but
  more energised and wired, that commenced at a
  certain age (usually late adolescence or later)
  before and after depressive episodes. Thus,
  TREND BREAK
• Highs may last only hours or a couple of days
• Usually but not always observable
• Family history (Bipolar or depression) in some
  individuals
• During such times, notice a number of features..

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Detecting/Suspecting Bipolar Disorder

• Classic clinical features
• Wired and energised
• Talk more and over people
• Be verbally and socially indiscrete
• Need less sleep and not feel tired
• Libido increased and nature more beautiful
• Spend money (often unable to afford)
• Feel creative, the world is their oyster,
  oceanic feelings with everything linking with
  everything else.
• NOTE a subjective state at low levels and not
  always observable

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www.blackdoginstitute.org.au
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Our Online Self-test
CREATIVITY
MYSTICISM

• More confident
• See things in new light
• Creative ideas plans
• Things vivid/crystal clear
• Spend more money
• Increased libido

• Lots of coincidences
• Feel at one with nature
• See special meaning
• in things
• Mystical experiences

DISINHIBITION
IRRITABILITY

• Say outrageous things
• Feel high as a kite
• Laugh more
• Do outrageous things

• Talk over people
• Feel angry
• Thoughts race
• Feel irritated

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Detecting/Suspecting Bipolar Disorder

• Can commence in childhood however rare. BP-II
  usually in years 10 12 (high or depression can
  be first, other phase often follows rapidly)
• Mixed episodes (ie high and depressed) not
  uncommon
• Pre-onset, often forme fruste presentations, with
  over-representation of all anxiety disorders,
  anorexia nervosa.

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Comorbidity and Hidden Bipolar Disorder

• Drug and alcohol misuse around 40 of patients
  with Bipolar Disorder (distinct
  over-representation of alcohol when high drink,
  when low drink)
• Concurrent anxiety disorders (social phobia,
  panic disorder, generalised anxiety disorder and
  OCD) around 50 of patients with Bipolar
  Disorder
• Mood instability often diagnosed as personality
  style (e.g borderline)
• Impulsivity and distractibility can attract a
  false diagnosis of ADHD
• Suicide rate 15 (just as high as BP-I or manic
  depression, higher than schizophrenia). A
  killer condition.

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Is the Incidence of Bipolar II Disorder
Increasing?

• If the incidence is increasing, does it reflect a
  change in the true incidence/prevalence or does
  it reflect a referral bias?
• Thus, is it real or an artefact?

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If an Artefact

• Could be referral bias as a consequence of
  destigmatisation and other issues
• Could be observational error, reflecting changed
  practitioner skills
• Could reflect changes in diagnostic methods
• Could reflect the redefinition of bipolar risking
  bringing in false positives.

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If Real

• Host issue?
• Genetic change
• Behavioural change
• Environmental issue?
• E.g., Weather?
• External agent?
• Drugs/toxins/stimulant drinks/the party scene
• Diet (the omega 3 story).

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My Speculation

• Some of the suggested increase
• reflects awareness, redefinition and
• artefactual factors
• But also a true increase.

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Key points about treatment

• Bipolar Disorder usually requires long-term
  pluralistic management (ie drug therapy plus
  other strategies akin to diabetes)
• Charting moods will help to assess the impact of
  medication (and improve medication compliance).
  Available on our website
• Differing medications may be used to treat acute
  episodes and prevent further episodes or augment
  acute treatments
• Psychological therapies by themselves are
  unlikely to be effective but are useful adjuncts
  to physical therapies
• Compliance with medications is important for
  long-term stability.

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Psychological Treatments for Bipolar Disorder

• Cognitive Behavioural Therapy May focus on a
  number of issues including identifying and
  challenging dysfunctional thoughts and beliefs,
  the identification and management of stressful
  life events, and the development of practical
  skills to modify mood instability
• Family Focused Therapy improves family
  functioning, communication skills,
  problem-solving and coping strategies
• Psychoeducation including understanding the
  causes of Bipolar Disorder, likely course of the
  illness, information on medication use and
  managing side-effects, recognition of early
  warning signs of relapse and the role of mood
  monitoring, tools to improve self-management of
  life stressors

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Preventing Relapse and Developing Stay Well Plans

• Developing a stay well plan is a relatively new
  strategy but seemingly beneficial and views as
  highly cogent by sufferers
• Involves recognising the triggers and early
  warning signs for relapse and developing a
  lifestyle that is conducive to mental wellness.

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Developing Stay Well Plans

• Such plans help people to maintain mental and
  physical equilibrium in the short- and long-term
• May include developing specific strategies for
  coping with potentially stressful situations such
  as social events, overseas travel or high levels
  of work stress
• May also include lifestyle changes and
  modifications such as practicing meditation and
  relaxation strategies, exercising regularly, and
  implementing a regular routine for meals, sleep
  and recreational activities that will help people
  stay well in the long-term
• Avoidance of excessive caffeine, alcohol, and
  recreational drugs can also be part of stay well
  plans
• Family and friends can help in developing and
  implementing stay well plans school counselors
  have a unique capacity to assist in vivo.

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Online Black Dog Bipolar Education Program
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Conclusion
Theres a new game in town

• BP disorders are more prevalent than previously
  conceded. We need to improve their detection and
  management.
• School counsellors may be the best group
  available to detect the early manifestations.