BipolarDisorderinDSMIVCenterforAddictions雙相情感障礙在DSMIV中心為成癮

BipolarDisorderinDSM-IVBipolarIdisorder:manicepisode(s)

ormixedepisode(s)plusMDE(s)BipolarIIdisorder:majordepressiveepisode(s)plushypomanic

episode(s)Cyclothymia:hypomanicsymptoms

plusdepressivesymptomsBipolarDisorders:DSM-IVNosologyCriteriaMania

Hypomania

Majordepression

MixedstateBPDIRequired

Possible

Possible

PossibleBPDIINo

Required

Required

NoCyclothymiaNo

No

No

NoManicEpisode:DiagnosticCriteria

Elevated,expansive,orirritablemoodfor

1weekorlonger,plus

3ormoreofthefollowingInflatedself-esteemorgrandiosityDecreasedneedforsleepPressuredspeechRacingthoughts/flightofideasDistractibilityPsychomotoragitation/increasedgoal-directedactivityExcessiveinvolvementinhigh-riskactivities

ManicEpisode:

DifferentialDiagnosesDifferentialdiagnosisConsiderif...MooddisorderduetoageneralmedicalconditionSubstance-induced

mooddisorderHypomanicepisodeMixedepisodeMajormedicalconditionpresentFirstepisodeat>50yearsofageSymptomsincontextofintoxication

orwithdrawalHistoryoftreatmentfordepressionMooddisturbancenotsevere

enoughtorequirehospitalization

orimpairfunctioning ManicepisodeandMDEin1weekManicEpisode:

DifferentialDiagnoses(cont.)AD/HDEarlychildhoodmooddisturbanceonsetChronicratherthanepisodiccourseNoclearonsetsandoffsetsNoabnormallyelevatedmoodNopsychoticfeaturesAmericanPsychiatricAssociation.DiagnosticandStatisticalManualofMentalDisorders

(DSM-IV).4thed.

1994.DifferentialdiagnosisConsiderif...Depressedmoodand/orlossofinterest

orpleasure

2weeksdurationAssociatedsymptomsPhysical:insomnia/hypersomnia,appetite/weightchange,decreasedenergy,psychomotorchangePsychological:feelingsofguiltorworthlessness,poorconcentration/indecisiveness,thoughts

ofdeath/suicidalintentions(SI)MajorDepressiveEpisode:

DSM-IVCriteria…and

4ofthefollowingsymptomsPhysicalSleepdisorderAppetitechangeFatiguePsychomotorretardationPsychologicalLowselfesteem/guiltPoorconcentration/

indecisivenessThoughtsofdeath/SIMixedEpisode:DiagnosticCriteriaCriteriametforbothmanicepisode+MDEfor

1weekSymptomsAresufficienttoimpairfunctioning

orNecessitatehospitalization

orAreaccompaniedbypsychoticfeaturesCharacteristics BPDI BPDIIPrevalence

1.6% 0.5%Ethnic/racial

differential None NoneGender

differential M=F F?M(?)BipolarDisorders:EpidemiologyCharacteristics BPDI BPDIIBipolarDisorders:EpidemiologyHypomanicepisodesinBPDIIimmediatelyprecedeorfollowMDEsin60%to

70%ofcasesFirst-degreerelativesmayhaveincreasedratesofBPDI,BPDII,andMDDRecurrentin>90%ofcasesFirst-degreerelativeshaveincreasedratesofBPDI,BPDII,andMDDCourseFamilialpattern

EpidemiologyPeakageofonset:adolescencethroughearly20sOnsetoffirstmanicepisodeafterage40yearsis

“redflag”toconsidersubstanceuseorgeneral

medicalconditionSeasonalvariationDepressionmorecommoninspringandautumnManiamorecommoninsummerDiagnosticDilemmas:

UnipolarVersusBipolarNoevidenceofhypomania,cyclothymia,hyperthymicpersonality,orfamilyhistoryofBPD

1manicepisode Recurrentmajordepressionwithhypomaniaand/orcyclothymictemperament Recurrentmajordepressionwithoutspontaneoushypomaniabutoftenwithhyperthymictemperament

and/orfamilyhistoryofBPDUnipolar

BPDI

BPDII

BPDNOS EtiologyHeritabilityEvidenceforheritabilityismuchstrongerforbipolarthanforunipolardisordersSpecificgeneticassociationhasnotbeenconsistentlyreplicatedEVIDENCEFORHERITABILITYOFBIPOLARDISORDERFamilyStudies-Firstdegreerelativesare8to18timesmorelikelytohaveBipolarI2to10timestohaveMDD.Riskis25%ifoneparenthasillness,and50%to75%withbothparentsaffectedFAMILYSTUDIESThemajorityofindividualswithbipolardisorderhaveapositivefamilyhistoryofsometypeofmooddisorderAbout50%ofallbipolarIpatientshaveatleastoneparentwithamooddisorderADOPTIONSTUDIESPrevalenceofbipolardisorderinadoptedawayoffspringcorrespondstoratesinbiological,butnotadoptiverelativesTwinStudies-ConcordancerateinMZtwinsis33to90%,inDZis5to25%CognitiveDeficitsWorkingmemorySustainedattentionAbstractreasoningVisuomotorskillsVerbalmemoryVerbalfluencyCognitiveflexibilityGeneralcognitivefunctioningPotentialExplanations

forCognitiveDeficitsIatrogenicorAlcoholuseTemporaryfunctionalchangesDegenerativebrainchangesPermanentstructurallesionsPermanentfunctionalalterationsofneuralnetworksunderlyingaffectandcognitionAlcoholUseAlcoholuseoccursin30-50%ofcasesImpairsmemoryandexecutivefunctioningGorpetal(1998)ComparedBPonly,BP+AD,ControlBP+AD>BPonlyforcognitiveimpairmentNodifferencebetweenControlandBPonlyOtherstudieshavereportedcognitivedeficitsinnonsubstanceabusingBPpatientsIatrogenicLithiumMemoryandpsychomotorfunctioningValproateandCarbemazepine

Attentional

deficitisNeurolepticsSustainedattentionVisuomotorspeeddeficitsBenzodiazapinesMemoryCrewsetal.PerformanceonWCSTnegativelyrelatedtoyearsofexposuretoantipsychoticdrugsQuestionsSomeevidenceindicatesthatLithiumexertsaneuroprotectiveeffectonneuronaltissueArestudiesindicatingadverseeffectsoflithiumnotaccountingforcomplexcombinationsofmeds?Couldweevenstudythisissueempirically??EthicsGeneralizabilityTemporalFunctionalDeficitsArecognitivedeficitsspecifictodepressiveormanicstates?DepressionDecreaseddorsalprefrontalcortexandanteriorcingulate

gyrusactivationIncreasedventralprefrontalcortexactivationReductionsinlefthemisphereactivityManiaOppositepatternD