[4] Bipolar Disorder Flashcards
What is bipolar disorder?
A chronic episodic mood disorder, characterised by at least one episode of mania (or hypomania), and a further episode of mania or depression.
What occurs first in bipolar disorder, depression or mania?
Can be either
What might mania be accompanied by in bipolar disorder?
Psychosis
What does the cause of bipolar disorder involve?
Biological and environmental factors
How can the monoamine theory of depression be applied to elevated mood?
It states that elevated mood is a result of increased central monoamines (noradrenaline and serotonin)
What hormonal pathways may be dysfunctional in bipolar disorder?
The HPA and HPT axis
What is the lifetime (happy now elliot????) - no you didn’t change the answer card -heritability of bipolar disorder?
Strong heritability, with the lifestyle risk of developing bipolar disorder when you have a first degree relative with the condition being 5-10%
What might precipitate the onset of the first manic episode?
Stressful and significant life events
What are the symptoms of mania?
- Irritability
- Disinhibition
- Impaired insight
- Increased libido
- Grandiose delusions
- Flight of ideas
- Appetite increased
- Sleep decreased
- Pressure of speech
- Elevated mood
- Energy increase
- Reduced concentration
What is hypomania?
Hypomania is slightly elevated mood or irritable mood, present for 4 or more days.
Symptoms of mania are present, but too a lesser extent.
How much does hypomania interfere with life?
There is considerable interference with work and social life, but not severe disruption
Do people with hypomania have insight?
Partial insight may be maintained
What is mania?
As with hypomania, but to a greater extent. Symptoms are present for at least 1 week, with complete disruption of work and social activities
How might mania cause significant disruption to life?
- May have grandiose ideas and excessive spending, which can lead to debts
- May be sexual disinhibition
- Reduced sleep may need to exhaustion
What is mania with psychosis?
A severely elevated or suspicious mood, with the addition of psychotic features such as grandiose delusions and auditory hallucinations that are mood congruent. Patients may show signs of aggression
What is the ICD-10 diagnostic criteria of bipolar?
Mania requires at least 3-9 symptoms to be present;
- Grandiosity/inflated self esteem
- Decreased sleep
- Pressure of speech
- Flight of ideas
- Distractibility
- Psychomotor agitation
- Reckless behaviour
- Loss of social inhibitions
- Marked sexual energy
Bipolar disorder requires at least two episodes in which a person’s mood and activity levels are significantly disturbed, one of which must be mania or hypomania.
What states does the ICD-10 divide bipolar disorder?
- Currently hyopmanic
- Currently manic
- Currently depressed
- Mixed disorder
- Remission
What investigations are done into bipolar disorder?
- History
- MSE
- Self-rating scales
- Blood tests to rule out oraganic causes
- Urine drug test
- CT head
What are the differential diagnoses of bipolar disorder?
- Psychotic conditions such as schizophrenia
- Medical conditions such as hyper/hypothyroidism, Cushing’s disease, cerebral tumour, or stroke
- Drug related - illicit drug ingestion, acute drug withdrawal, side effects of corticosteroid use
- Personality disorders, particularly histrionic or emotionally unstable
How is bipolar disorder managed?
- Full risk assessment, including suicidal ideation and risk to self
- Consider need for hospitalisation under the Mental Health Act
- Pharmacological management
- High-intensity psychological intervention, e.g. CBT
- ECT
Why do you need to ask about driving in bipolar patients?
DVLA has guidelines about driving when manic, hypomanic, or severely depressed
What are the indications for hospitalisation under the Mental Health Act in bipolar disorder?
- Reckless behaviour causing risk to the patient or others
- Significant psychotic symptoms
- Impaired judgement
- Psychomotor agitation
What pharmacological agents are first line in the acute manic/mixed episode?
Anti-psychotics such as olanzapine, risperidone, or quetiapine
What pharmacological agents are second line in the acute manic/mixed episode?
Lithium or sodium valproate
What is the advantage of the use of anti-psychotics over mood stabilisers in the acute manic/mixed episodes?
They have a rapid onset action compared to mood stabilisers, and therefore can be used in severe mania
What is done if the first-line antipsychotic in bipolar is not effective or poorly tolerated?
A second is usually offered
When might benzodiazepines be used in the acute manic/mixed episode?
To aid sleep and reduce agitation
How can rapid tranquilisation be achieved if required in the acute manic/mixed episode?
Haloperidol and/or lorazepam
What pharmacological agents are first line in the management of a bipolar depressive episodes?
Atypical antipsychtiocs, including olanzapine (with or without fluoxetine) or quetiapine
What pharmacological agents are second line in the management of a bipolar depressive episode?
Lamotrigine and lithium
Why should antidepressants alone be avoided in the management of a bipolar depressive episode?
They have the potential to induce mania
What should be done if antidepressants are prescribed in a bipolar depressive episode?
Caution should be exercised, and an anti-manic medication should be use for cover
What pharmacological agents are used in the long term management of bipolar?
4 weeks after the resolution of an acute episode, lithium should be offered as first-line to prevent relapse. If this is ineffective, cosnider sodium valproate
What effect does lithium have in the long-term management of bipolar disorder?
It minimises the risk of relapses, and improves the quality of life
How affective is lithium in treating patients with mania and hypomania?
Effectiveness of 60-80%
What is the first-line treatment for rapid-cycling bipolar?
A combination of lithium and sodium valproate
What is the mechanism of action of lithium in bipolar?
Although many cellular processes are altered by treatment with lithium, notably lowering noradrenaline release and increasing serotonin synthesis, the mode of action is unknown
What is the result of lithium having a narrow therapeutic index?
- Drug levels should be closely monitored
- Patients should be informed about the side effects and risk of toxicity
What should be checked before lithium treatment is started?
- U&Es
- TFTs
- Pregnancy status
- Baseline ECG
What are the side effects of lithium?
- Polydipsia
- Polyuria
- Fine tremor
- Weight gain
- Oedema
- Hypothyroidism
- Impaired renal function
- Memory problems
- Teratogenicity in 1st trimester
At what levels does lithium toxicity occur?
1.5-2.0mmol/L
When does the potential for lithium toxicity increase?
- Dehydration
- Some drugs can interact to produce dangerously high levels, e.g. NSAIDs, thiazide diuretics, and ACE inhibitors
What are the early symptoms of lithium toxicity?
- Coarse tremor
- Ataxia
- Muscle weakness
- Apathy
At what levels does severe lithium toxicity occur?
>2.0mmol/L
What are the symptoms of severe lithium toxicity?
- Nystagmus
- Dysarthria
- Hyperreflexia
- Oliguria
- Hypotension
- Convulsions
- Coma
How is lithium administered?
Orally
How is the lithium ion excreted?
By the kidney
What is the mechanism of action of sodium valproate?
It is unknown, however proposed mechanisms include affecting GABA levels, blocking voltage-gated sodium channels, and inhibiting histone deactylases
What are the indications for treatment with sodium valproate?
- Bipolar disorder
- Epilepsy
- Migraine headache prevention
What are the adverse effects of sodium valproate?
- Nausea
- Drowsiness
- Dizziness
- Vomiting
- Weakness
- Bleeding
- Encephalopathy
- Suicidal behaviour and thoughts
Why does sodium valproate have a black box warning
Due to the risk of hepatotoxicity, pancreatitis, and fetal abnormalities
How can sodium valproate be administered?
Orally or IV
What formulations of sodium valproate exist?
Long and short acting
Where is sodium valproate metabolised?
The vast majority occurs in the liver
What is the major excretion pathway of sodium valproate?
Via urine, as glucuronide conjugate or mitochondrial beta-oxidation
What are the indications for ECT in bipolar disorder?
ECT is not the first line treatment, but can be used when antipsychotic drugs are ineffective, and the patient is so severly disturbed that further medication or awaiting natural recovery is not feasible
How often should patients be followed up after an acute episode of bipolar?
Once a week initially, them 2-4 weekly for the first few months
