Affective disorders

Question 1

1) What is the main feature of an affective disorder?
2) Give a basic description of the general course of an affective disorder.
3) What does a unipolar mood disorder describe?
4) What does a bipolar mood disorder describe?

Answer 1

1) excessively high or low mood.
2) Mood disorders generally follow a relapsing and remitting course.
3) recurrent episodes of depression.
4) episodes of mania and depression.

Question 2

1) What is the most common affective disorder?
2) Who is depression more common in?
3) Who is bipolar affective disorder more common in?

Answer 2

1) Depression.
2) Females (2:1)
3) Equally common in males and females (1:1)

Question 3

1) Briefly describe the genetic aetiology for mood disorders.
2) Briefly describe the familial risk of inheriting mood disorders.
3) What do adoption studies show about genetic aetiology of mood disorders?
4) With regards to mood disorders, what model has superseded the nature/nurture debate?

Answer 3

1) It is thought that a combination of genes probably increases the risk for mood disorders.
2) Relatives of depressed people are at an increased risk of depression. Relatives of those with BPAD are at a higher risk of both BPAD and depression.
3) children of depressed parents have a higher rate of depression. even when raised in ‘depression-free’ adoptive families.
4) Complex models of genetic and environmental interactions.

Question 4

1) Name one gene which is an example of genetic susceptibility to stress.
2) Describe the theory behind susceptibility to mood disorders in relation to this gene.

Answer 4

1) Serotonin transporter gene.
2) The promoter region of the serotonin transporter gene has 2 versions –> an S (short) allele and an L (long) allele. If someone with the S allele suffers 3 of more significant life events then their risk of depression trebles. This has no effect on the depression risk for someone with the L allele.

Question 5

1) Name 4 childhood experiences which might increase the risk of depression.
2) Name 4 vulnerability factors which might increase the risk of depression.
3) How do vulnerability factors increase the risk of depression?

Answer 5

1) early childhood abuse, relentless criticism, parental loss and perceived lack of affection.
2) Unemployment, lack of a confiding relationship, lower SES status and social isolation.
3) By reducing resilience to adverse situations.

Question 6

1) Briefly describe the relationship between life events and risk of depression.
2) List life events according to their degree of stressfulness (most to least) according to the Holmes- Rahe social adjustment scale.
3) Which types of life events are particularly important in depression?
4) Aside from bereavement, name 2 other examples of loss events.

Answer 6

1) Risk of depression increases 6 fold in the 6 months following life events.
2) Death of a spouse, divorce, marital separation, jail term and death of a close relative.
3) Loss events.
4) loss of a role (for example, following retirement) and loss of autonomy ( for example, following physical or mental ill health).

Question 7

1) Which types of life events can precipitate mania?
2) As BPAD evolves over time, which types of triggers become less important?
3) Name 3 things which can all trigger manic episodes.

Answer 7

1) Both negative and positive life events.
2) Environmental triggers become less important.
3) Puerperium, sleep deprivation and flying across time zones.

Question 8

Name 6 physical illnesses which directly cause depression.

Answer 8

1) Cushing’s syndrome
2) Hypothyroidism
3) Stroke
4) Parkinson’s disease
5) Multiple sclerosis
6) Hyperparathyroidism

Question 9

1) What physical symptom may precipitate depression and is linked with an increased suicide risk?
2) Can physical illness be associated with depression?
3) Name 3 types of medications which can cause depression.
4) Which types of illicit drugs can cause depression?

Answer 9

1) Chronic pain
2) Yes.
3) Steroids, beta-blockers and antihypertensives.
4) Stimulants such as cocaine.

Question 10

1) Name 3 physical disorders which can cause mania.

2) Name 3 classes of drugs which can cause mania.

Answer 10

1) Cushing’s syndrome, head injury and multiple sclerosis.

2) Steroids, antidepressants and stimulants.

Question 11

Give 4 main aetiological categories for affective disorders.

Answer 11

1) Genetics
2) ACEs
3) Life events
4) Physical causes

Question 12

Name the 4 groups of theories behind the aetiology of affective disorders.

Answer 12

1) Behavioural and cognitive theories.
2) Psychoanalytical theories.
3) Neurochemical theories
4) Endocrine abnormalities

Question 13

Name 2 behavioural/ cognitive models of depression and describe these.

Answer 13

1) Learned helplessness model of depression: depressed people learn that they cannot change their situation and effectively give up trying.
2) Beck’s negative cognitive triad: shows how negative thinking can depress mood, which generates negative thoughts, resulting in a downward spiral into depression.

Question 14

Describe the psychoanalytical theory of depression.

Answer 14

Psychoanalysis believes that early experience, particularly the quality of early relationships, determines the risk of later depression.

Question 15

Describe the monoamine hypothesis of depression.

Answer 15

The monoamine hypothesis states that depression is the result of a deficiency in brain monoamine neurotransmitters.

Question 16

Name the 3 neurotransmitters implicated in the monoamine hypothesis of depression and state what these neurotransmitters affect.

Answer 16

1) Noradrenaline: affects mood and energy.
2) Serotonin: affects sleep, appetite, memory and mood.
3) Dopamine: Affects psychomotor activity.

Question 17

Name 3 biochemical findings in depression relating to the monoamine hypothesis of depression.

Answer 17

1) Decreased plasma tryptophan (a 5-HT precursor)
2) Decreased CSF levels of 5-HIAA (a 5-HT precursor)
3) Decreased CSF homovanillic acid (a dopamine metabolite)

All of the above suggest monoamine deficiency in depression.

Question 18

State one factor which does not support the monoamine theory of depression.

Answer 18

The hypothesis does not explain the 4-6 week delay in mood elevation by antidepressants.

Question 19

1) What biochemical abnormality might mania be related to?
2) Name 3 drugs which increase dopamine levels and can induce manic symptoms.
3) What class of drugs are generally used to treat mania?

Answer 19

1) Dopamine overactivity.
2) Bromocriptine (dopamine agonist), amphetamine and cocaine.
3) Dopamine antagonists.

Question 20

1) Describe the potential relationship between cortisol and depression.
2) In 50% depressed patients, what does dexamethasone fail to do?
3) Why is the dexamethasone suppression test not diagnostically useful for depression?

Answer 20

1) Cortisol is the main stress hormone and may mediate between stressful life events and the biological changes in depression, possibly by damaging hippocampal neurons.
2) Fails to suppress cortisol secretion.
3) Because non-suppression also occurs in mania, schizophrenia and old age, so the test is not specific for depression.

Question 21

1) How many weeks of symptoms are required for a diagnosis of depression?
2) What are the 3 core symptoms of depression?
3) What is diurnal variation of mood?
4) What is psychomotor retardation and which core symptom is it related to?

Answer 21

1) 2 weeks
2) Low mood, anergia and anhedonia.
3) Where symptoms at one part of the day may feel worse, classically mornings.
4) Where movements are obviously slowed and is an example of anergia.

Question 22

List 6 cognitive symptoms of depression.

Answer 22

1) Feeling worthless, useless and unlovable.
2) Guilty feelings and dwelling on past misdeeds.
3) Pessmistic view of the future and loss of self-confidence.
4) Suicidal ideation and thoughts of self-harm.
5) Poor concentration and memory
6) Memory impairment and slow thinking

Question 23

List 4 biological symptoms of depression.

Answer 23

1) Altered sleep pattern.
2) Suppressed appetite leading to weight loss.
3) Lack of sex drive putting strain on relationships.
4) Physical symptoms such as constipation, aches, pains, dysmenorrhoea.

Question 24

Describe the change in sleep habits in patients with depression.

Answer 24

Typically there is initial insomnia (difficulty falling asleep) or early morning wakening (waking at least 2 hours earlier than normal).

Hypersomnia is less common, but this can co-exist with hyperphagia and weight gain.

Question 25

1) In severe depression, what types of auditory hallucinations might be experienced?
2) In severe depression, what type of visual hallucinations might be experienced?
3) In severe depression, what types of delusions might be experienced?
4) What are the 4 gradings of depression?

Answer 25

1) Often unpleasant derogatory voices.
2) Scenes of destruction or evil spirits may be seen.
3) Nihilistic, persecutory or delusions of guilt.
4) Mild, moderate, severe, severe with psychotic features.

Question 26

1) What factors influence what severity of depression a patient is diagnosed with?
2) When do biological symptoms tend to emerge?
3) Give the 4 most worrying features of depression.

Answer 26

1) Number and severity of symptoms as well as effect on functioning.
2) As the severity of the depression increases, with psychotic symptoms only being seen in the most severe of cases.
3) Suicidality, psychotic symptoms, severe self-neglect and ceasing to eat/ drink.

Question 27

In the context of depression:

1) Describe nihilistic delusions.
2) Describe persecutory delusions.
3) Describe delusions of guilt.

Answer 27

1) Follow the theme of ‘nothingness’ - the world has ended, the patient is dead, the organs are blocked or decomposing.
2) The patient may feel that they deserve persecution or punishment, linking with feelings of guilt.
3) Guilt can progress to a delusional level, even to the extent that the patient may think that they have committed a terrible crime, despite being blameless.

Question 28

List 4 subtypes of depression and give a basic description of these.

Answer 28

1) Seasonal affective disorder: Presents predictably with low mood in the winter. Usually reversed biological symptoms of overeating and oversleeping.
2) atypical depression: no seasonal variation, shows reversed biological symptoms and may retain mood reactivity.
3) Agitated depression: depression with psychomotor agitation (instead of retardation) - restlessness, pacing, hand-wringing.
4) Depressive stupor: when psychomotor retardation is so profound that the person grinds to a halt. They become mute and stop eating, drinking or moving.

Question 29

Give 8 differential diagnoses for depression.

Answer 29

1) Physical causes: hypothyroidism, head injury, cancer, quite delirium.
2) Adjustment disorder: unpleasant but mild affective symptoms following a life event, but do not reach the severity required to diagnose depression.
3) Normal sadness: try not to medicalise, it is normal to be sad sometimes.
4) Bereavement: normal grief should not be diagnosed as depression.
5) BPAD/ schizoaffective disorder/ schizophrenia: look for previous manic or psychotic features.
6) substance misuse: alcohol and drugs may cause depression or be a form of self medication.
7) postnatal depression/ puerperal illness
8) Dementia: depression can affect memory so badly that the patient appears to have dementia (pseudodementia). Dementia can also begin with affective changes.

Question 30

List the 4 normal stages of grief.

Answer 30

1) Numbness
2) Pining
3) Depression
4) Recovery

Question 31

Give 4 symptoms of a normal grief reactions.

Answer 31

1) People may feel that they are ‘going mad’ or that they will never recover.
2) May see or hear the dead person.
3) Experiences of immense anger, guilt, anxiety or sadness.
4) May feel overwhelmed by sudden ‘pangs’ of guilt.

Question 32

Give 3 characteristics of an abnormal grief reaction.

Answer 32

1) Extremely intense: reaching the level for depression and disabling the person.
2) Prolonged: >6 months without relief
3) Delayed: no sign of an emotional response

Question 33

Name investigations that you may wish to carry out for a patient with suspected depression.

Answer 33

1) Collateral Hx.
2) Physical examination.
3) Bloods: TFT (rule out hypothyroidism), FBC (rule out anaemia), Glucose of HbA1c (rule out diabetes).
4) Rating scales to measure severity (Beck depression inventory/ HADS)

CT or MRI are never routine but may help to rule out suspected cerebral pathology.

Question 34

Describe some of the steps taken to manage mild depression.

Answer 34

1) Mild depression often resolves spontaneously so a ‘watchful waiting’ approach is often assumed.
2) Supportive counselling or problem solving therapy.
3) CMHT can provide support at home.
4) Advice on sleep hygiene, exercise and self help.
5) Access to CBT.
6) Address social stressors.
7) Interventions including time off work, respite for carers, refuge from abusers, debt advice, support groups.

Question 35

1) What is the first step in treating mild depression?

2) Name 3 psychological treatment techniques which are useful in depression.

Answer 35

1) Psychological treatment.

2) CBT, Psychodynamic psychotherapy, interpersonal therapy.

Question 36

1) In CBT for depression, what does the therapist help the patient to notice?
2) What are these NATs triggered by and what do they result in?
3) What does CBT target and what is the aim?
4) Describe the vicious cycle set up in depression.

Answer 36

1) Negative automatic thoughts.
2) Triggered by day-to-day situations and result in unhelpful moods and behaviours.
3) Targets thoughts and behaviours, with the aim of making changes which will have a knock-on effect on mood. The aim is to challenge negative beliefs and increase the patient’s daily exposure to positive stimulating activities.
4) A negative perception of events leads to lowered mood and unhelpful behaviour which withdraws the person from the world around them, further confirming their view that they are useless and unlovable.

Question 37

1) What does activity scheduling help?
2) In CBT for depression, what does the patient have to practice?
3) What does relapse prevention focus on?

Answer 37

1) Helps the patient to engage in behaviours that will enhance energy levels, develop interests and provide a sense of achievement.
2) Challenging their NATs as and when they arise.
3) Ensuring that old thinking and behavioural habits do not re-emerge.

Question 38

What are 2 common thinking errors in patients with depression?

Answer 38

1) Generalisation: ‘I always mess everything up’.

2) Minimisation: ‘I only passed that exam by chance, it doesn’t mean that I am good enough’.

Question 39

Give 2 ways that distorted beliefs are tested in depression.

Answer 39

1) Discussion during sessions: ‘How do you know for sure that nobody cares about you?’
2) Behavioural experiments between sessions: inviting a friend to dinner to test out the idea that nobody wants to spend time with them.

Question 40

1) What is the key issue in psychodynamic psychotherapy?
2) What does psychodynamic psychotherapy allow the patient to realise?
3) What is the primary focus of psychodynamic psychotherapy?

Answer 40

1) The developing relationship between therapist and patient.
2) Putting words into feelings allows the patient to recognise their hidden beliefs and re-evaluate them in the light of current reality.
3) To reveal the unconscious content of a client’s psyche in an effort to alleviate psychic tension.

Question 41

Give the 4 main themes that interpersonal therapy focuses on.

Answer 41

1) Unresolved loss.
2) Psychosocial transitions.
3) Relationship conflict.
4) Social skills deficit.

Question 42

1) What is the common purpose of antidepressants?
2) How do they achieve this?
3) What is thought to account for the 4-6 week delay in antidepressant effects?

Answer 42

1) Increase the overall level of monoamines in the synapse.
2) Either by reuptake or breakdown.
3) Because overtime the serotonin and central beta-adrenergic receptors become down regulated and decrease in number.

Question 43

1) What severities of depression are antidepressants usually indicated for?
2) What other drug might be added in psychotic depression?
3) Why are SSRIs usually the first choice of antidepressant?

Answer 43

1) Usually indicated for moderate to severe depression, alongside psychotherapy.
2) An antipsychotic.
3) Because they have relatively mild side effects and are relatively safe in overdose compared with other drugs.

Question 44

1) How long should treatment with antidepressants be continued for?
2) How long should treatment with antidepressants for recurrent episodes of depression last?
3) What should the maintenance dose of antidepressant be equal to and why?

Answer 44

1) Treatment should continue until the patient is no longer depressed and then for 6 months to prevent relapse.
2) Treatment should continue for much longer (about 2 years).
3) The maintenance dose of the antidepressant should be the same as for acute treatment, since lower doses are rarely effective.

Question 45

1) What 2 side effects do all antidepressants cause?
2) What adverse effect do most antidepressants cause?
3) In which conditions should antidepressants be avoided in?
4) What should patients be advised not to do when taking antidepressants and why?

Answer 45

1) All antidepressants cause hyponatraemia or some degree of sexual dysfunction.
2) Most antidepressants lower the seizure threshold, so use them with care in epilepsy.
3) Avoid them in people with mania or hypomania.
4) Do not drink alcohol when on antidepressants because of increased sedation. Never to drive if feeling drowsy on antidepressants.

Question 46

1) Give a basic description of what SSRIs do.
2) Briefly describe the mechanism of action of tricyclic antidepressants.
3) Why should use of tricyclic antidepressants be avoided when there is risk of suicide?

Answer 46

1) Enhance serotoninergic neurotransmission by blocking the reuptake of serotonin into the pre-synaptic terminal.
2) Inhibit reuptake of 5-HT and NA.
3) Because due to cardiotoxicity, they can be lethal in overdose.

Question 47

Give a brief overview of how to treat childhood depression.

Answer 47

Treated psychologically - antidepressants should only be prescribed by specialists and are only indicated for the most severely depressed children.

Question 48

1) How do MAOIs work?
2) Why are MAOIs rarely used now?
3) What should MAOIs not be combined with?

Answer 48

1) Inhibit metabolism of monoamines, increasing their synaptic levels.
2) Because of the dangers of a hypertensive crisis due to a build up of noradrenaline when eating tyramine rich foods (mature cheese/ yeast extract/ fermented soya beans).
3) Should not be combined with other antidepressants.

Question 49

1) What herbal remedy can be used to treat mild depression?

2) What is a negative of this herbal remedy?

Answer 49

1) St. John’s wort
2) It can induce metabolising enzymes, risking drug interactions. For example, can make the oral contraceptive pill ineffective.

Question 50

1) Why should SSRIs not suddenly be stopped?
2) Describe this effect.
3) Name 2 different ways that antidepressants can be swapped.
4) What might happen if 2 antidepressants are given at once?

Answer 50

1) Because if suddenly stopped they can cause unpleasant discontinuation symptoms.
2) The symptoms can include: flu-like symptoms, electric shock sensations, headaches, vertigo, irritability.
3) Cross-tapering/ drug-free washout period.
4) Serotonin syndrome might develop which is caused by excess serotonin. It is life-threatening and symptoms include: restlessness, sweating, myoclonus, confusion and fits.

Question 51

1) What is treatment resistant/ refractory depression?
2) What proportion of depressed patients might be treatment resistant?
3) Give 4 things which might be tried if you suspect treatment resistant depression.

Answer 51

1) Failure to respond to 2 adequate trials of different classes of antidepressants bat adequate doses for a period of up to 6-8 weeks.
2) Up to 30% of patients may be treatment resistant.
3) Increase dose, change drug, change class of drug, employ augmentation strategies (should also re-examine the diagnosis and check compliance).

Question 52

Name the 3 drugs which might be used in order to augment the effects of antidepressants.

Answer 52

1) Lithium
2) Tri-iodothyronine (T3) or levothyroxine (T4)
3) Busiprone (anxiolytic which might have synergistic effects when combined with SSRIs).

Question 53

1) When might ECT be considered for use in depression?
2) What is the basic delivery method of ECT?
3) What is the main concern with ECT?

Answer 53

1) In severe or psychotic depression as a fast and life-saving treatment.
2) Electrodes are used to produce a generalised tonic-clonic seizure with the patient under anaesthesia.
3) Some people experience a degree of memory loss after the seizure.

Question 54

1) What method of treatment might be used to treat SAD?

2) Why is this thought to be beneficial?

Answer 54

1) A light box.

2) Used to compensate for the fewer hours of daylight in the winter which is thought to be responsible for the disorder.

Question 55

1) What proportion of patients will have at least one more episode of depression after recovery?
2) What is the average length of time for a depressive episode, and what can treatment reduce this length to?
3) What type of depression has a poorer prognosis?
4) What proportion of people with depression eventually take their own lives?

Answer 55

1) Approximately 50%.
2) 8-9 months is the average length of time for a depressive episode, but treatment can reduce this to 2-3 months.
3) Psychotic depression has a poorer prognosis, but shows a better response too ECT.
4) 15% of people with major depression eventually take their own lives.

Question 56

1) In order to diagnose a manic episode, what must occur?
2) What might lead to a diagnosis of hypomania?
3) Why might hypomanic episodes be quite productive?

Answer 56

1) Symptoms should last for at least a week and prevent work and ordinary social activities.
2) Less severe symptoms, not entirely disrupting the patient’s ability to function may lead to a diagnosis of hypomania.
3) Because thoughts, energy and confidence are overflowing, but not so chaotically as not to be put to creative use.

Question 57

1) Name 3 factors which are all raised in mania.
2) What 2 more negative emotions can replace uncontrollable excitement in mania?
3) What does labile mood mean?
4) Give 6 other characteristic core symptoms of a manic patient.

Answer 57

1) Mood, energy and enjoyment are all raised.
2) Irritability and aggression can replace uncontrollable excitement.
3) Labile mood means switching quickly between emotions.
4) Boundless energy, overactive, busy, restless, talkative, increased enjoyment and interest.

Question 58

Give 5 cognitive symptoms mania.

Answer 58

1) Inflated self-esteem and confidence
2) Optimism making the future look hopeful and full of opportunity.
3) Distractable easily but patient feels that they can think more clearly than ever.
4) Speech becomes pressured and topics change rapidly (flight of ideas).
5) Exciting ideas abound, thoughts race and concentration dissolves.

Question 59

1) Describe the effect of mania on sleep.
2) Name 4 other biological symptoms of mania.
3) Name 2 types of delusion which may occur in mania.
4) What type of perceptional abnormalities might a patient with mania experience?

Answer 59

1) Sleep is dramatically reduced and people may be up all night without feeling tired.
2) Voracious appetite for food and sex, behaviour which is reckless, disinhibited and inappropriate, raised libido, excessive spending, reckless driving or gambling. Drugs and alcohol can become a new interest making the person more disinhibited.
3) Grandiose delusions and persecutory delusions (patients often believe that others are jealous of them).
4) Auditory hallucinations may reflect the elevated mood.

Question 60

When can a diagnosis of bipolar affective disorder be made?

Answer 60

Diagnosis can be made when a patient has suffered a manic episode and any other affective episode (depressed, hypomanic, manic or mixed - elements of both depression and mania at once).

Question 61

Describe the 3 different types of bipolar affective disorder.

Answer 61

1) Type 1 BPAD: manic episodes interspersed with depressive episodes.
2) Type 2 BPAD: mainly recurrent depressive episodes with less prominent hypomanic episodes.
3) Rapid cycling BPAD: 4 or more affective episodes in a year, more common in women, may respond better to sodium valproate.

Question 62

Give 4 differential diagnoses for mania.

Answer 62

1) Organic cause (drug-induced states, dementia, frontal lobe disease, delirium, cerebral HIV, myxoedema madness)
2) Schizophrenia/ schizoaffective disorder: psychotic symptoms precede and outweigh affective symptoms.
3) Cyclothymia: persistent mood instability with many episodes of mild low mood and mild elation. None of the episodes are sufficiently severe or prolonged to meet the criteria for even mild depression or hypomania.
4) Puerperal disorders.

Question 63

List 5 investigations you might want to do for a person with mania.

Answer 63

1) Collateral Hx.
2) Physical examination.
3) Bloods: FBC, TFTs, CRP, others that are indicated (E.G. U&E?)
4) UDS.
5) CT/MRI to exclude organic causes if indicated.

Question 64

1) What are the 3 broad categories that management is organised into?
2) What is the main class of drugs used to treat BPAD?
3) What is the aim of these drugs?

Answer 64

1) Pharmacological Rx, Psychological Rx and social interventions.
2) Mood stabilisers.
3) Mood stabilisers aim to ‘even out’ the extreme highs of mania and the profound lows of depression, although they tend to be most effective against mania.

Question 65

1) What are the 3 main mood stabilisers that are used?
2) What is the mechanism of action of these drugs?
3) What is the therapeutic range for lithium?

Answer 65

1) Lithium, Sodium Valproate, Carbamazepine.
2) MoA is currently uncertain, but it is thought that anticonvulsants act on sodium channels or GABA.
3) 0.6-1.0mmol/L, but there is a narrow therapeutic index.

Question 66

1) What is a negative to the use of lithium?
2) When should Lithium levels be measured?
3) As well as lithium level, what other blood tests need to be done to monitor a patient on Lithium and why?

Answer 66

1) Narrow therapeutic index, so large risk of toxicity.
2) Lithium levels should be monitored 12 hours post dose, a week after starting or changing the dose, weekly until a steady therapeutic level has been achieved and then every 3 months.
3) U&Es and TFTs every 3-6 months as lithium can cause renal impairment and hypothyroidism.

Question 67

1) Why does care need to be taken when switching between Lithium citrate (liquid) and lithium carbonate (tablet)?
2) What class of drug is sodium valproate?
3) What is the active drug of sodium valproate and why must it be administered as a salt?
4) Why do plasma levels of sodium valproate not need monitoring?

Answer 67

1) Because they contain different amounts of lithium.
2) Anticonvulsant.
3) Valproic acid and must be administered as a salt in the hope of lessening side effects.
4) There is generally no accepted therapeutic range and dose-related toxicity is not usually a problem.

Question 68

1) What class of drug is carbamazepine?
2) What can carbamazepine cause at high doses?
3) Why is it essential to monitor carbamazepine levels closely?
4) What line of treatment is carbamazepine?

Answer 68

1) An anticonvulsant.
2) Can cause toxicity at high doses.
3) It induces liver enzymes which metabolise many drugs (including itself) so it is essential to monitor levels closely and check for drug interactions before prescribing.
4) 2nd line for BPAD after Lithium, as it is less effective than lithium.

Question 69

1) Above what level is classed as lithium toxicity?
2) Give 7 clinical presentations of lithium toxicity.
3) How do you manage lithium toxicity?

Answer 69

1) Levels >1.2mmol/L
2) GI disturbance, sluggishness, giddiness, ataxia, gross tremor, fits and renal failure.
3) Stop lithium and transfer for medical care (rehydration and osmotic diuresis).

Question 70

Give 3 factors that might trigger lithium toxicity.

Answer 70

1) Salt balance changes due to dietary variation, dehydration, diarrhoea or vomiting.
2) Drugs interfering with lithium excretion (NSAIDs, diuretics, ACE inhibitors).
3) Accidental or deliberate overdose.

Question 71

Which 2 psychological treatments can be used for BPAD?

Answer 71

CBT and psychodynamic psychotherapy.

Question 72

1) In CBT, what do therapist and patient work together to identify?
2) What does CBT help BPAD patients to identify, and what is done about this?
3) Give 3 positive effects of CBT in patients with BPAD.

Answer 72

1) Relapse indicators such as insomnia and uncomfortably increased energy.
2) Helps to identify the excessively positive thoughts that occur in mania.
3) Can help to reduce relapse, shorten episodes of illness and decrease the length and number of hospitalisations.

Question 73

Identify 6 relapse prevention strategies that can be established in CBT for BPAD.

Answer 73

1) Developing routine.
2) Ensuring good quality sleep.
3) Promoting a health life style.
4) Avoiding excessive stimulation/ stress (easier said than done).
5) Addressing substance misuse.
6) Ensuring drug compliance.

Question 74

1) When is psychodynamic psychotherapy useful?
2) Describe the duration of manic episodes.
3) What happens to remissions in BPAD with increasing age?
4) What percentage of people with BPAD will die by suicide?
5) Why does BPAD carry a significant risk of suicide?

Answer 74

1) When mood has been stabilised.
2) Manic episodes often begin abruptly and are normally shorter than depressive episodes, lasting between a fortnight and 5 months.
3) Recovery is usually complete between episodes, although remissions become shorter with age and depressions become more frequent.
4) 15%, but long-term treatment with lithium reduces this to the same levels as the general population.
5) Risks due to poor judgement, increased impulsivity, irritability and sexual disinhibition. Affective lability seen in mania can cause extreme sudden distress or sadness. Psychotic symptoms also increase risk.