Treatment of trichotillomania and subthreshold bipolar disorder with lithium (original) (raw)

Bipolar Disorder for Family Physicians Part 1: Diagnosis

2012

Identification and optimal management of bipolar disorder (BD) can be a challenging proposition. Distinguishing the symptoms of the depressed phase of the disorder from those of unipolar major depression represents perhaps the most significant obstacle to diagnosis. 1 Furthermore, comorbidities with anxiety disorders, substance-use disorders and Attention Deficit Hyperactivity Disorder (ADHD) may further hinder a correct diagnosis of a bipolar mood disorder. 2 This review (Part 1 in a series of two articles) briefly outlines the epidemiology and natural history of BD. It then explores in some depth the most effective ways to distinguish between the various presentations of mood, anxiety and somatic symptoms, to help differentiate between BD and unipolar depression. Part 2 of the review (later in this issue) includes a discussion of treatment options for patients diagnosed with BD. Epidemiology and Natural History of Bipolar Disorder Epidemiologic data from a variety of sources suggest that BD is more common than once believed. 4-11 Data from Canada (published in 1988), suggested a prevalence of 0.5%. 5 American data indicate that lifetime prevalence rates of bipolar I disorder, bipolar II disorder and sub-threshold BD are 1.0%, 1.1% and 2.4%, respectively. 12 Overall, the prognosis associated with BD can be further improved upon; this is a disorder characterized by frequent recurrences. In fact, studies published by Judd et al in 2002 and 2003 showed that after having been diagnosed, followed prospectively and treated, patients with BD spent half of their lives being symptomatic (Figure 1). 13,14 Comorbidities are very common among patients with BD. Anxiety disorders are the most common psychiatric comorbidities, present in at least 93% of BD patients. 16 Perhaps the most menacing non-psychiatric comorbidities include metabolic syndrome and cardiovascular disease, for which bipolar patients are at higher risk compared to the general population. 3,17 Specifically, the authors of the 2009 Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) Collaborative guidelines 3 list obesity, type 2 diabetes, cardiovascular disease, migraine, hepatitis C, HIV, dementia, lower back pain, chronic obstructive pulmonary disease, asthma and allergies as non-psychiatric conditions seen at elevated rates in patients with BD. Of particular note, data have emerged since the previous (2007) CANMAT guidelines were published to further support reports of high rates of metabolic syndrome in patients with BD. One analysis showed that up to 30% of 60 consecutive patients (all but seven being treated with antipsychotic

Electroconvulsive therapy for trichotillomania in a bipolar patient

Bulletin of the Menninger Clinic, 2019

A recent review on the use of electroconvulsive therapy (ECT) in obsessive-compulsive–related disorders (OCRDs) identified reports of trichotillomania (TTM) in only three patients, but it did not describe the specific effect of ECT on hair-pulling behaviors. The authors present a case report of Mrs. A, a 77-year-old widowed housewife with a lifelong history of episodic TTM and bipolar disorder who was effectively treated with ECT. However, on each attempt to withdraw ECT, her condition deteriorated. Eventually, a decision was made to maintain ECT (one session every week), which resulted in no further relapse over the followup period. ECT shows some potential promise for reducing hair-pulling behaviors in the context of severe depression.

Diagnosis and treatment of bipolar disorder in pregnant women

Primary care update for Ob/Gyns, 2000

Bipolar disorder is relatively rare in obstetrics and gynecology (ob/gyn) practice compared with depressive and anxiety disorders, but there is a high risk for poor outcomes for patients and their offspring. Ob/Gyn physicians are assuming increasing responsibility for the care of these patients in today's managed care environment, working independently or in collaboration with a psychiatrist. The clinical presentation of bipolar patients may include mania and/or depression, in addition to more minor mood fluctuations that accompany the emotional and physical changes of pregnancy. The key issue in the differential diagnosis is to rule out medical, surgical, medication, and substance etiologies of mania that are potentially reversible. Indications for routine, urgent, and emergent referrals to a psychiatrist are reviewed. Treatment for bipolar women considering pregnancy includes prepregnancy planning education, involving the patient, family, psychiatrist, ob/gyn physician, and ma...

Managing bipolar disorder during pregnancy: weighing the risks and benefits

Canadian journal of psychiatry. Revue canadienne de psychiatrie, 2002

Challenges for the clinical management of bipolar disorder (BD) during pregnancy are multiple and complex and include competing risks to mother and offspring. We reviewed recent research findings on the course of BD during pregnancy and postpartum, as well as reproductive safety data on the major mood stabilizers. Pregnancy, and especially the postpartum period, are associated with a high risk for recurrence of BD. This risk appears to be limited by mood-stabilizing treatments and markedly increased by the abrupt discontinuation of such treatments. However, drugs used to treat or protect against recurrences of BD vary markedly in teratogenic potential: there are low risks with typical neuroleptics, moderate risks with lithium, higher risks with older anticonvulsants such as valproic acid and carbamazepine, and virtually unknown risks with other newer-generation anticonvulsants and atypical antipsychotics (ATPs). Clinical management of BD through pregnancy and postpartum calls for ba...

Treatment of Bipolar Disorder in Pregnancy and Postpartum Period

Turk Psikiyatri Dergisi, 2010

The prevalence of bipolar disorder (BD) in males and females is almost equal. The onset of BD in females typically occurs during the reproductive years, complicating its treatment. Although it was once believed that pregnancy prevents recurrence, studies have shown that recurrence is common and severe during pregnancy. On the other hand, the effects of pharmacological treatment on obstetrical outcome are not well known and some of these agents are considered teratogenic. Thus, the decision to treat pregnant patients with psychotropic agents requires solving an ethical dilemma. Risk-benefit decisions should be made while considering both the risk of relapse of BD and its morbidity, and the risk of fetal exposure to psychotropic medications. Moreover, the risk of recurrence increases dramatically in the postpartum period. It is well known that all of the psychotropic medications studied enter the breast milk. Thus, their effects on infants should be considered while prescribing for a breastfeeding mother.

The use of lithium and management of women with bipolar disorder during pregnancy and lactation

PubMed, 1998

The introduction of lithium salts almost a century ago and the subsequent approval of lithium carbonate for the treatment of patients with bipolar disorder represent one of the cornerstones of modern psychopharmacology. The onset of bipolar disorder in women often occurs during the childbearing years, which complicates the treatment decisions secondary to the possibility of conception while taking medication. The establishment of the lithium registry for fetal teratogenesis in the late 1960s ushered in a heightened level of concern for the use of lithium during the reproductive years; although, in the years to come, it has become apparent that alternative pharmacologic treatments for bipolar disorder may exceed the teratogenic risk of lithium monotherapy. In this paper, the available data on the use of antimanic medications during pregnancy and lactation are reviewed with an emphasis on providing a realistic risk/benefit assessment for medication selection and management of these patients. Treatment strategies are discussed for (1) women who are contemplating pregnancy (2) women who inadvertently conceive while taking medications (3) women who choose to become pregnant while taking medication, and (4) women who intend to breastfeed while taking medications.