Demystifying The Bipolar Spectrum: What Is It and Why Is It Important?

what's up everybody I'm Dr Garrett Rossi and I'm a board-certified psychiatrist who makes mental health content here on YouTube if you're new to the Channel please consider joining the community it really helps me to know that this information is valuable to you and if you're a returning viewer thank you so much for all the support so today's topic is a good one it's going to be on bipolar disorder now bipolar disorder is a controversial diagnosis some people say we diagnose it too often other people say we miss this diagnosis all the time in clinical practice so what is the deal is this some diabolical plan by the pharmaceutical companies to make patients take stronger medications and charge them more money or is there really something to these bipolar diagnosis and is there something called the bipolar Spectrum and what I want to do in this video is I want to clear up this mystery that is the bipolar Spectrum so today's video is going to be demystifying the bipolar Spectrum what is it and why is it important I feel like I have to set the frame a little bit here with bipolar disorder so when we think about bipolar disorder we're largely thinking about bipolar one disorder and bipolar 2 disorder because that's what the DSM-5 tells us we should be thinking about now if we really break that down this accounts for about 16 percent of depressed patients but in 2013 when the DSM-5 came out it added a bunch of other things it added this idea of mixed features specifier and also antidepressant-induced Mania and hypomania when we combine that with the bipolar one M bipolar II diagnoses we can account for almost 50 percent of depressed patients in the bipolar Spectrum so what we end up seeing is that a lot of times when a patient comes to us and they're depressed or they come in primarily for depression up to 50 percent of those people could actually be bipolar or in the bipolar Spectrum which we're going to get to and not necessarily unipolar depression and thus they won't respond to the same treatments that somebody with a pure unipolar depression is going to respond to now that may be surprising to some of you out there but to be clear being in the bipolar spectrum is not necessarily the same thing as having bipolar 1 or bipolar II disorder there is variability in the expression of meaning and hypomania inpatient populations and the symptoms of mood disorders should not be split this is partially my opinion but also partially what the data tells us the mood disorders should not be split into clear-cut categories as it misses many of the patients we're going to talk about in this very video now having done this job for a while and haven't seen quite a few patients I'm convinced that there's far more people that fit into the bipolar Spectrum than we previously believed and then I was taught in my training and by recognizing these individuals we can begin to refine our treatment approaches and make better decisions for our patients making the diagnosis of bipolar disorder this seems incredibly easy if you're in inpatient psychiatrist but when you start to work out patiently start to see a different picture and one of our first tasks is making that diagnosis identifying those individuals with bipolar disorder and making accurate diagnosis now 75 percent of patients with bipolar disorder will manifest the illness before or at the age of 25. so in North America this is much earlier than places like Europe and several factors may be in play in the United States we have increased exposure at an earlier age to elicit drugs and alcohol so that might be one explanation there's also increased exposure to antidepressants in North America including the United States and Canada another possibility has to do with reproductive choices so patients with bipolar disorder are more likely to have two parents with severe mental illness increasing the likelihood that their offspring will also have severe mental illness and the one last point that I want to make and it always comes back to this in one form or another and that is trauma specifically childhood trauma 30 to 70 percent of patients with bipolar illness have a history of childhood trauma and they have an earlier age of onset as a result of the childhood trauma so early onset childhood trauma so we have a couple different things at play here one people in the United States and North America seem to be exposed to drugs and alcohol at much earlier ages number two we have increased exposure to antidepressants and treatment at younger ages number three we have reproductive choices and number four we have childhood trauma now there is a difference in the brain structure between individuals with bipolar disorder and healthy controls and this comes up all the time where people say well there's no like there's no there's nothing biological there's no blood test well there are things right people with bipolar disorder again have Progressive loss of brain tissue as the number of episodes of mania increase and this has been shown in studies that looked at neuroimaging so I can show that diagram here and give you an idea of what's going on so there are real structural changes it's just to do one of these Imaging studies in every individual that presents with bipolar disorder is not really practical from a financial standpoint or from a clinical practice standpoint so this is why we don't do them all the time now this may be why patients with bipolar illness actually tend to have more mixed episodes and more depression as the disease progresses to the later stages so we see more anxiety more depression predominating as the number of episodes increases so this for this disorder what I want to highlight here is a bipolar disorder is highly Progressive over time it gets worse as the number of episodes increases now there are two common misconceptions about people with bipolar disorder one misconception is that people with bipolar disorders spend most of their time euphoric feeling amazing right and they spend most of that time Manic and that the second misconception is that people with bipolar 2 disorder have a milder form of bipolar disorder and don't require as much treatment and we shouldn't focus on them as much because again they don't have that outward Mania that we see in bipolar one patients so this all again couldn't be further from the truth patients with bipolar disorder spend 70 to 80 percent of their time depressed so that's a lot let that sink in for a second so even though there are manic episodes 70 to 80 percent of that time is spent depressed and patients with bipolar 2 disorder actually have higher rates of comorbidity increase rates of Rapid Cycling and higher suicide completion rates than those with bipolar 1 Disorder so bipolar 2 disorder is again it's not a milder form of bipolar and we should keep that in mind so it's important that we keep in mind that patients who present with depression might be better explained not as unipolar depression but as bipolar disorder so I just want to go through a quick approach to recognizing bipolar disorder clinically and some of the things we should be looking for so the clinical factors we should be looking for are number one a family history so we know bipolar disorder is highly genetic and if the first degree relative has bipolar disorder we should be suspecting it in a patient that presents to us with depression for example the onset of depression before the age of 25 so the earlier onset of depression we know that most people with bipolar disorder are going to present at or before the age of 25 so we want to see when those symptoms originally started the number of Lifetime episodes as the number of Lifetime episodes increases obviously the severity increases and as I said the brain structural changes also increase the number of hospitalizations again a measure of severity the more time somebody is hospitalized the more severe the episodes likely were and of course the greater and greater severity of depressive episodes so when the person does present with depression is the severity much greater the second factor is treatment history and the thing we're going to look for the most there is their response to antidepressants so if that person's taking antidepressants and has had antidepressant induced Mania or hypomania it's a good indication that you should be thinking about bipolar disorder the second one is a little bit harder to tease out but that is the person either has a worse response say they become destabilized with the use of antidepressants that would be another case that might indicate the person is more in the bipolar Spectrum and then finally the symptoms psychotic features more common in bipolar atypical depression and then impulsivity aggression hostility so anger aggression impulsivity and substance use disorder are also common in bipolar disorder and should start again pushing you in that direction of thinking about it and at least screening for and questioning bipolar disorder the more of these factors a patient has the more likely you are to suspect bipolar disorder may be an option for the diagnosis so let's start our discussion about these bipolar Spectrum States we're going to start with depression and mixed States so this is the patient with depression with mixed features now many patients with mixed episodes of depression will present as saying this is the worst depression of My Life Dr Rossi I'm really just so damn depressed I can't get over it right what makes me start thinking about mixed features is the presence of other things though I'm looking for for irritability I'm looking for anxiety I'm looking for racing thoughts as I've said before in other videos manic symptoms always matter and we need to be thinking about them when depression is the primary complaint to be diagnosed with mixed features of course you need to have three or more manic symptoms present and the patient must not meet criteria for bipolar disorders depression with mixed features the typical symptoms are an increase in directionless and disorganized activity coupled with distressing racing thoughts that the patient just wants to get out of their head right the symptoms of depression with mixed features translate slightly differently than typical manic symptoms present in bipolar disorder the increase in energy that we see is not that euphoric energy that typically presents in Mania it's more of an uncomfortable restlessness that the patient just wants to stop the impulsivity in mixed States usually involves irritability and aggression patients may drive aggressively they may break things in their home or self-harm impulsive spending eating or other vices are often explained Away by the patient as therapy for the depression it's a way of them feeling making themselves feel better and sort of treating that depressive State sleep may be decreased but the patient will often feel like they still need to sleep due to the fatigue associated with depression the reason thoughts are not pleasurable in any way they are often take the the form of depressive themes so these racing thoughts are not like enjoyable racing thoughts like I'm excited about the new business I'm forming and I can't wait for it to start etc etc it's more of those depressive themes so again it presents differently in mixed States so let's talk about the treatment of mixed episodes right treatment for these individuals is going to be vastly different than patients with pure unipolar depression if you are going to use an antidepressant in these patients you want to be very careful because it is likely to destabilize their mood and possibly worsen their symptoms the current recommendations and the current guidelines will tell you to start an atypical dopamine blocking medication such as aripiprazole a centipine lorazidone Quetiapine enzaprasodium so again atypical second generation dopamine blocking medications we can also put in there are second line options chloripazine or lanzapine fluoxetine combination and lumeteperon I would consider in there as well mood stabilizers such as lithium and Lamotrigine are also good options and recommended as adjunctive Therapies in some cases antidepressants most importantly antidepressants are not recommended alone and should only be used in combination with inadequately titrated mood stabilizer so monotherapy with antidepressants is not a good idea in these individuals many of these individuals unfortunately though will already be on an antidepressant so your first step in the treatment might be to taper them off of the antidepressant safely right you want to do it over time and then while simultaneously starting one of the options listed above so for patients whose symptoms are made worse by the antidepressant you want to taper it off relatively quick probably over a one to two week period for patients whose symptoms are not really that bad or they really haven't had any response to the antidepressant you can taper it more slowly personally I believe antidepressants may be helpful in a minority of patients so in a small number of patients but they are best left as third line options after all the other options for treatment have been explored and of course there are multiple sides of this story and many also caution the use of dopamine blocking medications in mixed depression due to the metabolic risk factors some have said using lithium and Lamotrigine are safer long-term options with lower side effect burden lithium does have the risk of interfering with thyroid function and kidney function although I've talked previously in videos about ways to reduce the risk of kidney defunction kidney dysfunction when starting lithium so there are ways to reduce the risks with lithium and prescribe it more safely so that patients do not have these problems long term Psychotherapy such as cognitive behavioral therapy should be initiated in mixed depression and of course lifestyle modification including healthy diet regular sleep patterns and weight patterns as well as routine exercise our standard recommendations in all cases something that doesn't nearly get discussed enough in Psychiatry is the idea of temperaments and one of the temperaments that somebody can have is what's called a cyclothymic temperament so with cyclothymic temperament what we see is it consists of emotional ups and downs so they're not as Extreme as those seen in bipolar 1 or bipolar II disorder but they are ups and downs that fluctuate often and usually more often than even a bipolar one or two disorder these ups and downs can interfere with the patient's ability to form a stable sense of self and there are often comorbidities like borderline personality disorder in these patients now if you believe you're working with somebody with a cyclothymic temperament and you want to know what to do the foundation of treatment is going to be Psychotherapy including DBT so dialectical behavioral therapy commonly used in borderline personality disorder is a good way to go for patients with this problem and it's really kind of makes sense given the overlap with cluster B personality disorders if medications are used you're going to want to start with something like Lamotrigine which does have the best evidence in cyclothymic disorder and has some efficacy in the treatment of borderline personality disorder as well you're going to again want to stay away from antidepressants and stimulant medications as when antidepressants and stimulants are used in this group they tend to be mood destabilizing and cause more problems than they do provide helpful benefits so stay away from antidepressants and stimulant medications in this population the next scenario I want to take you guys through is what happens when you have a patient who presents with Manic or hypomanic symptoms but it only lasts two or three days and I think we have to talk about the arbitrary nature of this four-day specifier and seven day specifier when you're talking about bipolar disorder and hypomania and Mania why is it four days why is it seven days is that scientifically valid and I think asking those questions here is very very important so why did they come up with that is it scientifically valid from the research I've seen and the things that I've been reading this doesn't seem to be the case at all the decision to use four days instead of say two or three days should really be reconsidered because again I think if somebody has manic episodes or manic symptoms for two or three days it matters and it changes the way you're going to treat that person so what do you do with a patient who has manic symptoms for two or three days well in my mind these patients clearly fall into this bipolar spectrum they are certainly not pure unipolar depression they may not meet criteria for full-blown bipolar one or bipolar bipolar II disorder but they are within the bipolar spectrum and unfortunately there isn't much research in this area and the DSM has basically said that these cases are areas of further interest or areas of needed that need further study so we really don't have a lot of clarity here however in my mind you would be treating these patients the same way that you retrieve mixed depression possibly or other patients in the bipolar Spectrum there is some evidence again that Lamotrigine is effective in these cases but I would also consider the dopamine blocking medications that have evidence for use in bipolar depression as well as potentially the other mood stabilizing agent lithium here One Thing Remains true here as it does in all the other cases that I'm going to be describing today and that is antidepressants are not a good option it is not recommended to start antidepressants in these cases because again they can be mood destabilizing the next case is the patient who has had multiple antidepressant trials and antidepressants never work in this person now I've seen a lot of cases where the patient presents after multiple Trials of different antidepressant medications and they have either made the person feel worse or they've worked for a short period of time and then pooped out so this is the so-called antidepressant poop out effect the technical terms that we're using here and this is usually going to be a patient who has had a distant manic episode so this is going to be somebody who had a manic episode but doesn't recall the manic episode so we know that majority of bipolar patients spend most of their time depressed about 70 to 80 percent of their time is spent depressed and because the criteria for bipolar disorder is the presence of a single manic episode in one's lifetime you could make this diagnosis and the persons might simply not remember that manic episode things that I found to complicate this diagnosis a little bit is a person who is using substances so or at a substance use disorder potentially or with abusing recreational drugs this can really complicate the picture because the patient might not be able to distinguish what are what is true manic episodes and what is substance induced right and especially if someone's using something like stimulants or cocaine that can be very difficult to tease out so if you have a history in a patient a poor response to antidepressants or short duration of improvement followed by destabilizing effects look for a distant history of mania and consider the possibility of the bipolar Spectrum again there are no clear guidelines on how to treat these individuals but similar medication choices would be reasonable including Lamotrigine lithium and the second generation dopamine blocking medications are all good places to potentially start if medication is indicated and severity is high okay so what about the person that you suspect will develop bipolar but they're not quite presenting with those symptoms or maybe RN are a child adolescent patient that you don't want to diagnose bipolar disorder in right away now these individuals will usually have a very strong family history a bipolar disorder meaning that one of their first degree relatives maybe a mother or father is going to have bipolar illness they typically present with severe depression irritability and inattention they are often misdiagnosed with a major depressive disorder or ADHD but when these patients are treated with medication the medications either do not work at all and do not help or they work for a very short duration and then stop working so what we're starting to recognize is that there may be this prodromal phase of bipolar disorder where symptoms are present there's severe depression their severe anxiety there's behavioral problems in these individuals but and they have a first degree relative with bipolar disorder this should make you suspicious for the possibility of bipolar disorder now in this group you're going to want to again avoid antidepressants this is very important if you catch only one theme from this whole talk it's avoid antidepressants and you're going to want to start Psychotherapy and family therapy now Psychotherapy can help teach behavioral techniques and family therapy can help decrease expressed emotion and these are first-line interventions medications for these individuals should only be offered if symptoms are severe and they impact the person's function to conclude the video I want to say that when you work in the inpatient unit you assume that every patient that comes in with a bipolar disorder is going to be grossly manic and the diagnosis is so obvious that even your brand new third year medical student just starting clinical rotations can make the diagnosis but what we're seeing here is that the diagnosis of bipolar disorder is highly nuanced and difficult to make and that bipolar disorder is very very complex and that there is a spectrum of presentations that are possible and you won't fully see this usually until you move into the outpatient setting and start seeing patients in that setting what we should be doing is we should be re-evaluating the use of antidepressants and bipolar disorder and bipolar Spectrum we should largely avoid that process and only do it if we've tried other options first and we have reached the conclusion that nothing else works and we should either consider a stopping all antidepressant use or we should consider using them very sparingly in rare cases you never want to prescribe an antidepressant to a patient with bipolar disorder without a mood stabilizer on board first and being adequately titrated to an appropriate dose so you want to be sure you do not prescribe these medications without the proper mood stabilizing medication first and for mixed depression you might also consider the dopamine blocking medications discussed above so I'm going to go ahead and hold the video there guys if you have questions or comments please drop them below love to hear them and I will get to them as soon as I can if you haven't subscribed to the Channel please consider doing so right now it really helps me to know that this stuff works for you

Channel: Shrinks In Sneakers

Views: 4,276

Keywords: Psychiatry, Psychiatrist, Bipolar Disorder, Bipolar Depression, Bipolar Spectrum

Id: GnSzOfLAl0c

Length: 24min 18sec (1458 seconds)

Published: Tue Oct 11 2022