Bipolar and Related Bipolar and Related Disorders, Depressive Disorders, Depressive

Disorders, Schizophrenia Disorders, Schizophrenia SpectrumSpectrum

Trisha EconomidisTrisha Economidis

Marilee EliasMarilee Elias

Lake-Sumter State CollegeLake-Sumter State College

Fall, 2014Fall, 2014

MoodMood

Also called pervasive and sustained Also called pervasive and sustained emotion that may have a major emotion that may have a major influence on a person’s perception of influence on a person’s perception of the world.the world.

DepressionDepression JoyJoy ElationElation AngerAnger AnxietyAnxiety

Bipolar DisorderBipolar Disorder

A psychobiological disorder A psychobiological disorder characterized by alternating mood characterized by alternating mood disturbances of mania, hypomania, disturbances of mania, hypomania, depression and mixed episodesdepression and mixed episodes

Etiology of Bipolar DisorderEtiology of Bipolar Disorder

Strong genetic linkStrong genetic link May be related to hormone May be related to hormone

imbalancesimbalances Neurotransmitter levels definitely Neurotransmitter levels definitely

implicatedimplicated

Mania SymptomsMania Symptoms

Racing thoughts, increased energy, Racing thoughts, increased energy, less need for sleepless need for sleep

TalkativeTalkative More self-confident than usualMore self-confident than usual Focused on getting things done, while Focused on getting things done, while

accomplishing littleaccomplishing little Risky or unusual activities to the Risky or unusual activities to the

extremeextreme

Depression - SymptomsDepression - Symptoms

Sadness, anhedoniaSadness, anhedonia Feeling worthless, hopeless, guiltyFeeling worthless, hopeless, guilty Sleep disturbancesSleep disturbances Appetite/weight changesAppetite/weight changes AnergiaAnergia RestlessnessRestlessness Problems concentrating or making decisionsProblems concentrating or making decisions Thoughts of death or suicideThoughts of death or suicide

Bipolar Disorder TreatmentBipolar Disorder Treatment

LithiumLithium Must be at therapeutic level – Must be at therapeutic level –

1-1.5mEq/L for acute mania; 1-1.5mEq/L for acute mania; 0.6-1.2 mEq/L for maintenance0.6-1.2 mEq/L for maintenance

Can easily become toxicCan easily become toxic Many side-effectsMany side-effects

Other pharmacological Other pharmacological treatmentstreatments

Anticonvulsant (antiepileptic) meds Anticonvulsant (antiepileptic) meds often first-line treatment as well – often first-line treatment as well – Valproic Acid (Depakote), Lamotrigine Valproic Acid (Depakote), Lamotrigine (Lamictal), Carbamazepine (Tegretol)(Lamictal), Carbamazepine (Tegretol)

Antipsychotics may be used alone or in Antipsychotics may be used alone or in combination with lithium; Risperidone combination with lithium; Risperidone (Risperdal), Olanzepine (Zyprexa), (Risperdal), Olanzepine (Zyprexa), Aripiprazole (Abilify)Aripiprazole (Abilify)

Antidepressants used VERY cautiouslyAntidepressants used VERY cautiously AnxiolyticsAnxiolytics

Tips for Preventing Manic Tips for Preventing Manic EpisodesEpisodes

Get plenty of sleepGet plenty of sleep Set reasonable work hoursSet reasonable work hours Join a support groupJoin a support group Take meds as prescribedTake meds as prescribed Track history of episodes, looking for Track history of episodes, looking for

triggerstriggers Avoid destabilizers (alcohol, drugs, Avoid destabilizers (alcohol, drugs,

caffeine)caffeine)

Consider psychotherapyConsider psychotherapy Get regular check-ups with primary Get regular check-ups with primary

care physiciancare physician Have someone you trust monitor Have someone you trust monitor

your behavior and moods. Bipolar your behavior and moods. Bipolar disorder often attacks insight firstdisorder often attacks insight first

Depressive DisordersDepressive Disorders Major Depressive DisorderMajor Depressive Disorder Persistent Depressive DisorderPersistent Depressive Disorder

(Dysthymia)(Dysthymia) Premenstrual Dysphoric DisorderPremenstrual Dysphoric Disorder Depressive Disorder due to Depressive Disorder due to

another medical conditionanother medical condition Substance/Medication-induced Substance/Medication-induced

Depressive DisorderDepressive Disorder

DepressionDepression

Depression and anxiety are most Depression and anxiety are most common psychiatric disorders seen common psychiatric disorders seen in primary carein primary care

Less than 50% of those with Less than 50% of those with depression actually ask for helpdepression actually ask for help

It is a potentially lethal illnessIt is a potentially lethal illness

Risk Factors for DepressionRisk Factors for Depression

Family historyFamily history Personal historyPersonal history Female genderFemale gender Life stressorLife stressor Loss of parents at young ageLoss of parents at young age Childhood abuseChildhood abuse

Risk factors, cont.Risk factors, cont.

Alcohol or substance abuseAlcohol or substance abuse Anxiety disordersAnxiety disorders Neurologic or medical disordersNeurologic or medical disorders Primary sleep disordersPrimary sleep disorders ElderlyElderly Post-partumPost-partum

Treatment for DepressionTreatment for Depression

Individual PsychotherapyIndividual Psychotherapy Group and/or family therapyGroup and/or family therapy PsychopharmacologyPsychopharmacology

SSRI’sSSRI’s SNRI’sSNRI’s Atypical antidepressants (Mirtazapine Atypical antidepressants (Mirtazapine

(Remeron), Bupropion HCL (Welbutrin))(Remeron), Bupropion HCL (Welbutrin)) Others as discussed with anxiety Others as discussed with anxiety

treatmenttreatment

SuicideSuicide 1111thth leading cause of death in the U.S. leading cause of death in the U.S. Males successful 4 times more often Males successful 4 times more often

than femalesthan females Females attempt suicide 3 times more Females attempt suicide 3 times more

often than malesoften than males Firearms are most commonly used by Firearms are most commonly used by

malesmales Poisoning is most common method by Poisoning is most common method by

femalesfemales

Suicide Myths or FactsSuicide Myths or Facts

People who commit suicide always People who commit suicide always leave a noteleave a note

Myth or FactMyth or Fact

People who die from suicide don’t People who die from suicide don’t warn otherswarn others MythMyth OrOr FactFact

Myth or FactMyth or Fact

People who talk about suicide are People who talk about suicide are only trying to get attention. They only trying to get attention. They won’t really do it.won’t really do it. MythMyth OrOr FactFact

Myth or FactMyth or Fact

Don’t mention suicide to someone Don’t mention suicide to someone who’s showing signs of severe who’s showing signs of severe depression. It will plant the idea in depression. It will plant the idea in their minds, and they will act on it.their minds, and they will act on it. MythMyth OrOr FactFact

Myth or FactMyth or Fact

If a person attempts suicide and If a person attempts suicide and survives, they will never make a survives, they will never make a further attempt.further attempt. MythMyth OrOr FactFact

Myth or FactMyth or Fact

Suicide is painless.Suicide is painless.

MythMyth

OrOr

FactFact

Myth or FactMyth or Fact

MYTH: Many suicide methods are MYTH: Many suicide methods are very painful.very painful.

Warning Signs of Suicidal Warning Signs of Suicidal Thoughts or IntentThoughts or Intent

Recent suicide or death of a Recent suicide or death of a friend/relativefriend/relative

Previous suicide attemptPrevious suicide attempt Preoccupation with deathPreoccupation with death DepressionDepression Giving away prized possessionsGiving away prized possessions Major change in sleep patternsMajor change in sleep patterns Changes in eating patternsChanges in eating patterns

Warning Signs, cont.Warning Signs, cont.

Withdrawal from friends/familyWithdrawal from friends/family Dropping out of group activitiesDropping out of group activities Personality changesPersonality changes Irritability or unexplained cryingIrritability or unexplained crying Expressions of failureExpressions of failure Lack of interest in the futureLack of interest in the future

Warning Signs, cont.Warning Signs, cont. Frequent school absence, poor Frequent school absence, poor

performanceperformance Expressions of self-destructive Expressions of self-destructive

behavior, verbal hintsbehavior, verbal hints SUDDEN cheerfulness after a SUDDEN cheerfulness after a

period of depression as though period of depression as though there is relief from the sufferingthere is relief from the suffering

SAD PERSONS SCALESAD PERSONS SCALEA Suicide Risk AssessmentA Suicide Risk Assessment

S – Sex – 1 pt if maleS – Sex – 1 pt if male A – Age – 1 pt if 25-44, or 65+A – Age – 1 pt if 25-44, or 65+ D – Depression – 1 pt if presentD – Depression – 1 pt if present P – Previous attempt – 1 ptP – Previous attempt – 1 pt E – Ethanol use – 1 ptE – Ethanol use – 1 pt R – Rational thinking loss – 1 pt if R – Rational thinking loss – 1 pt if

psychoticpsychotic

SAD Person Scale, cont.SAD Person Scale, cont.

S – Social supports lacking – 1 ptS – Social supports lacking – 1 pt O – Organized plan – 1 ptO – Organized plan – 1 pt N – No spouse – 1 ptN – No spouse – 1 pt S – Sickness – 1 ptS – Sickness – 1 pt 0-2 Send home with follow-up0-2 Send home with follow-up 3-4 Closely follow or hospitalize3-4 Closely follow or hospitalize 5-6 Strongly consider hospitalization5-6 Strongly consider hospitalization 7-10 Hospitalize or commit7-10 Hospitalize or commit

Interventions for Outpatient Interventions for Outpatient Client Client

Don’t leave client aloneDon’t leave client alone Establish a no-suicide contractEstablish a no-suicide contract Make sure environment is safeMake sure environment is safe Establish frequent appt scheduleEstablish frequent appt schedule Establish therapeutic relationshipEstablish therapeutic relationship Be directBe direct

Interventions, cont.Interventions, cont.

Be aware that antidepressant use Be aware that antidepressant use may increase risk of suicide in 1-3 may increase risk of suicide in 1-3 weeks after they’ve been started. weeks after they’ve been started. Level of energy increases and they Level of energy increases and they are more able to carry out a plan.are more able to carry out a plan.

Schizophrenia Spectrum Schizophrenia Spectrum and other Psychotic and other Psychotic

DisordersDisorders Now viewed as a spectrum of Now viewed as a spectrum of

disorders from least severe to most disorders from least severe to most severesevere

Brief Psychotic DisorderBrief Psychotic Disorder Delusional Disorder Delusional Disorder Psychotic Disorder due to another Psychotic Disorder due to another

medical conditionmedical condition SchizophreniaSchizophrenia

SchizophreniaSchizophrenia

Affects more than 2 million people in Affects more than 2 million people in the USthe US

1 in every 100 people, across 1 in every 100 people, across culturescultures

Chronic, severe, disabling brain Chronic, severe, disabling brain disease that has no known disease that has no known singlesingle causecause

Schizophrenia EtiologySchizophrenia Etiology

Current theory is Variable Current theory is Variable Combination of:Combination of: Genetic PredispositionGenetic Predisposition Biochemical DysfunctionBiochemical Dysfunction Physiological FactorsPhysiological Factors Psychosocial StressPsychosocial Stress

Are you Positive about those Are you Positive about those Symptoms?Symptoms?

Common Symptoms – Content Common Symptoms – Content of Thoughtof Thought

Delusions:Delusions: Delusion of PersecutionDelusion of Persecution Delusion of GrandeurDelusion of Grandeur Delusion of ReferenceDelusion of Reference Delusion of ControlDelusion of Control

ReligiosityReligiosity

ParanoiaParanoia

Symptoms – Form of Symptoms – Form of ThoughtThought

Associative LoosenessAssociative Looseness NeologismsNeologisms Concrete ThinkingConcrete Thinking Clang associationsClang associations Word SaladWord Salad TangentialityTangentiality PerseverationPerseveration

Symptoms - PerceptionSymptoms - Perception

HallucinationsHallucinations AuditoryAuditory VisualVisual TactileTactile GustatoryGustatory OlfactoryOlfactory

IllusionsIllusions

Symptoms – Sense of SelfSymptoms – Sense of Self

EcholaliaEcholalia EchopraxiaEchopraxia DepersonalizationDepersonalization

How can you be so How can you be so Negative?Negative?

Symptoms - AffectSymptoms - Affect

Inappropriate AffectInappropriate Affect Flat or blunted affectFlat or blunted affect ApathyApathy

Symptom - VolitionSymptom - Volition

Ambivalence – Conflicting ideas, Ambivalence – Conflicting ideas, emotions, ideas at the same time emotions, ideas at the same time about a particular person, situationabout a particular person, situation

Symptoms – Impaired Symptoms – Impaired Interpersonal FunctioningInterpersonal Functioning

Autism – living in a fantasy worldAutism – living in a fantasy world Deteriorated appearance – lack of Deteriorated appearance – lack of

self-careself-care

Symptoms – Psychomotor Symptoms – Psychomotor BehaviorBehavior

Pacing and rockingPacing and rocking Anergia – lack of energyAnergia – lack of energy

Symptoms – Associated Symptoms – Associated featuresfeatures

AnhedoniaAnhedonia RegressionRegression

Positive Symptoms (Something Positive Symptoms (Something present that shouldn’t be present that shouldn’t be

there)there) DelusionsDelusions HallucinationsHallucinations Disorganized thinking and Disorganized thinking and

speechspeech Disorganized behaviorsDisorganized behaviors

Negative Symptoms Negative Symptoms (Something missing that (Something missing that

should be there)should be there) Flat or blunted affectFlat or blunted affect AlogiaAlogia Avolition/apathyAvolition/apathy AnhedoniaAnhedonia Social IsolationSocial Isolation

TreatmentTreatment

Psychoanalytic psychotherapy?Psychoanalytic psychotherapy? Why NOT?Why NOT?

Treatment ProgramsTreatment Programs PsychopharmacologyPsychopharmacology Teaching Client to manage symptomsTeaching Client to manage symptoms Supportive Family TherapySupportive Family Therapy Reality Oriented PsychotherapyReality Oriented Psychotherapy

PsychopharmacologyPsychopharmacology

AntipsychoticsAntipsychotics Side effects make compliance difficultySide effects make compliance difficulty Up to 75% of schizophrenics smoke – Up to 75% of schizophrenics smoke –

the nicotine decreases the effectiveness the nicotine decreases the effectiveness of the medicationof the medication

Dopamine believed to be the Dopamine believed to be the neurotransmitter most closely linked to neurotransmitter most closely linked to schizophreniaschizophrenia

Atypical AntipsychoticsAtypical Antipsychotics

Block both serotonin and dopamine Block both serotonin and dopamine receptorsreceptors

Treat positive and negative symptomsTreat positive and negative symptoms Have fewer side effects by still have Have fewer side effects by still have

unpleasant onesunpleasant ones Clozapine (Clozaril), Respiridone Clozapine (Clozaril), Respiridone

(Risperdal), Olanzepine (Zyprexa), (Risperdal), Olanzepine (Zyprexa), Quietapine (Seroquel), Ziprasidone Quietapine (Seroquel), Ziprasidone (Geodon), Aripiprazole(Abilify)(Geodon), Aripiprazole(Abilify)

Typical or Conventional Typical or Conventional AntipsychoticsAntipsychotics

Many side effects including Extrapyramidal Many side effects including Extrapyramidal symptoms:symptoms: DystoniasDystonias AkathesiaAkathesia ParkinsonismParkinsonism Tardive dyskinesiaTardive dyskinesia Life-Threatening Side Effect: Neuroleptic Life-Threatening Side Effect: Neuroleptic

Malignant SyndromeMalignant Syndrome Haloperidol (Haldol), Fluphenazine (Prolixin), Haloperidol (Haldol), Fluphenazine (Prolixin),

Chlorpromazine (Thorazine), Thioridazine Chlorpromazine (Thorazine), Thioridazine (Mellaril)(Mellaril)

Coming AttractionsComing AttractionsIt’s All Psych The End Class It’s All Psych The End Class

55 Personality D/OsPersonality D/Os Eating D/OsEating D/Os D/Os common in Children & D/Os common in Children &

AdolescentsAdolescents Pharmacological & Non-Pharmacological & Non-

pharmacological management of pharmacological management of these D/Osthese D/Os