Friday, March 5, 2010

Good Roulette Numbers

NEW mood stabilizers in bipolar disorders.
(Part One)
Miguel Pérez Camacho Duque


Mood Disorders magnify everyday human experiences, they acquire a larger dimension. Its symptoms are exaggerations of sadness and exhaustion, joy and happiness, sensuality and sexuality, irritability and anger, energy and creativity that can happen in normal life. In the first descriptions found in a wide variety of cultures for thousands of years and is considered the manic-depressive mood disorder as the prototype.

What are depression and mania?

Ideally, we should first describe the mood or state of mind "normal." Despite the difficulty that entails, an operational definition may be that the humor "normal" is the state of not feeling particularly elated or sad, except in certain circumstances.
For example, if something is wrong, we feel sad and dejected at the time. The vast majority of people can be included in this definition. Superficially, depression and hypomania can be seen as ends of these normal fluctuations of mood. But clinical depression or mania are more than extremes of normal mood, represent syndromes in which, in addition to affecting mood, there are abnormal thinking, psychomotor status, behavior, motivation, physiology and psychosocial functioning.

The Hippocratic School an essential contribution to the scientific psychiatry: it was argued that diseases of the body, not related to magical or supernatural spirits. Hippocrates described the melancholy as a condition "associated with aversion to eating, depression, insomnia, irritability and restlessness, and mania as a state of high energy and euphoria.

Hippocrates also located the etiology of disorders mood in the brain:

Men should know that the brain and the brain only come our pleasures, joys, laughter and jokes, as well as our sorrows, grief, sorrow and tears ... so I say that the brain is the interpreter of consciousness. Hippocratic

This awareness was buried for two millennia under the humoral theory, established in medicine for Galen (second century AD), which held that melancholy was an excess of black bile and mania of an excess of yellow bile . The heart, rather than the brain, was also considered the organ of mood disorders for a long time.

In the first century BC, Greek doctors initially suggested a connection between melancholia and mania.

clinical acuity of this period culminated in Cappadocia Areteo :

According to Areteo , the classic form of bipolar mania was the way: the patient who previously was elated, happy, hyperactive, suddenly experienced tendency to melancholy, at the end of the crisis, going to feel listless, sad, silent, expressing concerns about their future, feeling ashamed. " When the depressive phase is complete, these patients return to be happy, laugh, joke, sing. In a severe form of mania, called the furor, the patient "sometimes kills and slaughters the servants", in milder forms, it exalts itself frequently, "without being cultivated, said to be a philosopher ... and the incompetent (say be them) ... others are good craftsmen suspicious and they feel persecuted, why are irascible. "

Age Media

clinical-empirical tradition survived in Greek early Middle Ages in the midst of Islam and Christianity , but later succumbed to religious intolerance. In the twelfth century, this tradition led to a more theological than empirical. So Roger Bacon , arguing that empirical observation was necessary to obtain the knowledge and mental illness had natural etiologies, was censured by the Church and condemned by his colleagues at the University of Oxford .
A similar tension in the Middle East instead. The Hippocratic tradition was exemplified by the Persian Rhazes , who represents the equivalent of Roger Bacon . Avicenna took a more diplomatic stance and prospered as a synthesizer moderate traditions of Greek, Roman and religious. Its synthesis care, the Canon of Medicine, raised suedogalénica consideration for centuries, conveying this vision in mood disorders: "undoubtedly, the substrate is produced by the mania of the same nature than that produced the blues.

At the beginning of the sixteenth and seventeenth centuries, the Enlightenment gave impetus to medical progress in Europe. The eighteenth century witnessed the resurgence of clinical and empirical tradition in medicine, with descriptions advanced on the mania and melancholy.

The turning of the nineteenth century French clinical psychiatry

In 1845, Jean Falret described cyclic disorder (folie circulaire) who first explicitly defined a disease that "the succession of mania and melancholia manifests itself continuously and almost regular." In the same year, Baillarger described essentially the same concept (folie a double forme), emphasizing that the manic and depressive episodes were not different access, but rather different phases of the same access. For the first time, the manic-depressive disorder was conceived as a single, clearly anticipating the subsequent synthesis of Kraepelin .

Mendel was the first to define hypomania, a "form of mania that typically only shown in the mild stages, abort, so to speak." At the same time, Kahlbaum described cyclic disorders and cyclothymia, characterized by episodes of depression and excitement, but that would permit a dementia, such as occurred with chronic mania or melancholia.

The twentieth century and the synthesis Kraepelinian

Emil Kraepelin in the twentieth century, distinguished from other psychoses diseases and clearly delineated manic-depressive.
emphasize those aspects of manic-depressive that most clearly differentiated from dementia praecox: the periodic or episodic course, more benign prognosis and a family history of manic-depressive illness. Karl Jaspers

argued that the clinical data collected need to be neutral, free of underlying theories, such as Freud free specific diagnostic paradigms, such as Kraepelin . The influence of Jaspers resulted in more thorough descriptions of the syndromes of humor, as exemplified in the highly influential textbook Fish's Clinical Psychopathology .

First twentieth century

In Europe, in the midst of academicians psychiatrist, Eugen Bleuler Kraepelin left to conceptualize the relationship between illness (affective) manic-depressive and demntia praecox (schizophrenia) as a continuous without a clear line marking. Bleuler

grew that the location of a patient in the spectrum depended on the number of schizophrenic features presented. In that sense, he believed that mood symptoms were not specific.

In 1933, Kasanin identified a number of patients with manic-depressive but also showed psychotic symptoms outside of affective episodes. These conditions appeared to be outside the dichotomy of Kraepelin, and led to the concept of schizoaffective disorder .

Bipolar-unipolar distinction

In 1957, Karl Leonhard noted that within the broad category of manic-depressive illness, some patients had a history of depression and mania, while others had only depression. He then pointed out that patients with a history of mania (which he called "bipolar") had a higher incidence of mania in their families when compared with those with depression alone (which he called "monopole"). Alonso Fernández

proposed in 1968 Fasotímicas Psychosis terminology and concept and I quote:

"In the mid-nineteenth century, French psychiatrists and Farlet Baillarger described the" la folie circulaire "and" folie double forme ", respectively, an entity that is characterized by an alternate course between the poles of exaltation and depression, with more or less prolonged periods of emotional stability.

corresponds to Kraepelin merit have grouped this set of circular psychosis or manic depressive psychosis exclusively a disease entity which he called manic-depressive insanity. Specht includes developments here too paranoid. Although this attempt did not prosper, it should be noted that there are many boxes mounted on a sad paranoid (especially self-referential delusions of persecution and jealousy) or vital exuberance (especially delusions litigants).
studies Dreyfus Kraepelin forced to finally including involutional depression in the "manic-depressive insanity." Piquer

Arrufat , illustrious English doctor eighteenth century, the English Hippocrates by some fans of his, describes in detail the condition of the English king Fernando VI and diagnosed as manic-melancholic. Diagnosis has been confirmed by modern psychiatrists. The first is to have established a link between mania nosological and melancholy, is a English psychiatric contribution truly exceptional and very little known, which anticipates the release of manic-depressive insanity by Kraepelin in more than one hundred years and Farlet circular insanity and madness double Baillarger formed by more than seventy-five years.

Any designation of the disease in containing the word "madness" I find it unacceptable. I base my position on two grounds: First

: this word is overloaded with derogatory meanings, so that should be excluded from psychiatric gazetteer.

Second, precisely because of the nature of the semantic burden, gives a wrong idea of \u200b\u200bwhat most of these patients are essentially emotional.

Moreover, the terms "circular", "dual form" and "manic depression" only encompass the patients at least once, have had a manic phase and a depressive. These names are inapplicable to the large contingent in one step (single) or several (multi). Unipolar depressive courses are much more common than bipolar courses (manic and depressive phases).

should therefore be reserved for the names "manic-depressive" and "psychosis circular" exclusively for bipolar affective psychotic disorders.

To Kretschmer, cyclothymia is one form of fluctuating temper, for his share diathetic, between joy and sadness, this temperamental type, as is familiar, is correlated positively with the fleshy body architecture. Alonso Fernández

means can only be resolved by appealing to the two basic characteristics apply to all the manic and depressive mood disorders: to be a vital dysthymia sad or elated, as primary and fundamental psychological symptoms, and the follow a phasic course.

faso thymic The term psychosis, I would propose, means etymologically "during phasic affective psychoses, in whose sector includes essentially forms affective (depressive, manic and manic-depressive).

Also, in 1968 Ian Gregory considered psychotic affective disorders characterized by serious deviations affect, mood or emotional tone. Affectivity may be predominant at the lower end of the scale (depression) or top (euphoria). Associated with severe depression or euphoria, may have also significant problems of perception, thinking or behavior, including hallucinations, delusions and suicidal or homicidal.
subtypes of mood disorders in DSM-IV

1. Disorder (unipolar) major depression is characterized by depressive episodes without manic or hypomanic states.
2. Affective disorder characterized by bipolar manic or mixed episodes of major depressive type (bipolar I according to DSM IV ) or hypomanic episodes and major depressive type (bipolar II), is now one of the psychiatric disorders that enjoy increased research interest both in its etiopathogenesis, pathological physiological, evolutionary, nosological and therapeutic.

The current diagnostic classification systems bipolar disorder face fairly similar. For the DSM IV ( APA, 1994) there are two forms of bipolar affective disorder differentiated by the intensity of manic symptoms (Bipolar I mania or mixed pure "dysphoric mania" more bipolar depression, bipolar II, hypomania, bipolar depression more), within which one can distinguish a subgroup of cicladotes too fast (four or more episodes per year of illness), more frequent young women and sometimes associated with subclinical hypothyroidism, and organic brain factors itself caused this farmacógne mania by antidepressants, particularly poor prognosis Give your poor response to conventional treatment, mood stabilizers and especially lithium carbonate. The DSM IV also recognizes another disorder called cyclothymia, characterized by episodes with depressive hypomanic phases that do not meet criteria for major depression.
In type II bipolar disorder tends to start in adolescence, ua times, in preadolescence. The average age of onset is 18 years. At first, it is common that misdiagnosed as unipolar depression as adjustment disorder or personality disorder, especially the limit. The fact that the disease starts with mild fluctuations in mood and its amplitude or frequency will increase over time until they reach the threshold is a common pattern. Keller et al., in a ten-year follow-up of childhood depression, observed that ultimately 33% met the criteria for bipolar I disorder and 15.3% for bipolar disorder type II.

The gender distribution appears to be midway between the patterns observed in unipolar disorder (preponderance of females) and bipolar disorder type I (equal sex ratios), although some studies support the non-existence of gender differences.

3. Dysthymia refers to more clinically significant depressive symptoms are present for 2 years or more but do not reach the threshold for major depressive disorder. Cyclothymia is a condition in which, as in dysthymia, depressive symptoms did not reach the threshold for a diagnosis of major depressive episode, and is present hypomania. The "hyperthymia" sometimes described chronic mild hypomania (decrease in sleep needs, expansive behavior, extraversion checked).

Regarding treatment, the mainstay is still the psychopharmacological, based on lithium carbonate in both manic and depressive mood stabilizer as maintenance therapy.

lithium salts enjoyed popularity in the nineteenth century to treat gout and other disorders, but fell into disuse by the alarming reports of toxicity. Its use in psychiatric disorders was first suggested by Cade in Australia in 1949. This author developed the idea of \u200b\u200busing lithium in the treatment of psychotic excitement, based on the experimental fact that lithium carbonate caused or short period of lethargy and lack of response to stimuli in guinea pigs, on the other hand, remained conscious. Cade

reported favorable response in manic without hypnotic effect, and from this first study have been published many others point to the efficacy of lithium salts in manic states. Schou et al., in Denmark, addressed a series of manic, alternatively, with lithium and a placebo. Rice, in a trial with a mixed group of patients, found a special sedative when the manic and schizophrenic patients were improved affective elements which influenced.

is generally agreed that the drug is effective only in manic states. Noack and Trautner found that the best responses were in acute cases and do not consider value in chronic. Schoou , in a review of the literature indicates that 80 100 of cures and improvements relating to manic. Andreani reported improvement in 10 of 24 depressed patients. However, recently it has been recognized the value of lithium for prophylactic use in the manic and depressive episodes (1950).

The therapeutic dose for an acute attack would be 600mg. three times a day, although a slow increase may be advised daily to avoid side effects. The maintenance or preventive dose of 300mg can be. three times daily. The lithium concentration in serum is an indicator of the effect of lithium. Using the criterion of Kalinowsky should not be less than 0.6 mEq. / L. not more than 1.6 mEq. / l. Increasingly

are the authors who advocate an indefinite treatment with this substance to the risk of relapse and resistance to lithium after deletion especially if it is done in a rough manner. Lithium has proved effective in both manic and depressive phase of bipolar disorder and prophylaxis of new affective decompensation. However, their efficiency is lower in dysphoric mania in the cicladotes fast and those individuals who attend organic disorders such as thyroid dysfunction, epilepsy or brain damage.

as alternatives to lithium we find the antiepileptic drugs, mainly carbamazepine and valproate, alone or in combination with the first. These drugs are apparently more effective than lithium in rapid cycling, dysphoric mania in the patients and epilepsy, although its use in bipolar disorder type I is associated with worse outcomes. In addition, follow-up studies to 5 years up to 70% speaks of relapses in patients treated with a combination of these drugs and their effect on maintenance therapy is more questionable in the case of lithium.

Other associations would be recommended for atypical antipsychotics in the manic phases of the disease because of its speed of action, preferably the newer atypical antipsychotics (olanzapine, risperidone, quetiapine, ziprasidone) or classical antipsychotic, perphenazine, before reaching atypical, solved many problems bipolar.

New antipsychotics:

conclusions are an alternative first-line treatment for acute mania ( Texas Consensus Conference Panel, 2002).

Data suggest its effectiveness in preventing new episodes.

Its use in prophylaxis can and should be done in combination with mood stabilizers such as lithium, lamotrigine or others.

In its continued use should choose those with better tolerability profile.

During the depressive phase, although this aspect is controversial because in principle it is recommended monotherapy with mood stabilizers may be used concomitantly antidepressant drugs recommended for this purpose reuptake inhibitors of serotonin by their lower risk of inducing a change manic, hypomanic or rapid cycling. The new atypical antipsychotics (olanzapine, risperidone) on their mechanism of action is less dependent on dopaminergic blockade and among their properties with serotonergic stimulation could also be used as a treatment for bipolar depression coadyudante.

Other pharmacological approaches (inhibitors of inositol, omega 3) are in the studio waiting for consistent results.


Post a Comment