Affective disorders - Bipolar disorder and Mania Flashcards
What is mania?
https://www.youtube.com/watch?v=zA-fqvC02oM
Mental illness marked by periods of great excitement or euphoria, delusions, and overactivity. Rarely a symptom, often associated with grandiose ideas, disinhibition, loss of judgment; with similarities to the mental effects of stimulant drugs (AMPH, cocaine)
How long must manic symptoms be present before a diagnosis of mania is made?
> 1 week
What is hypomania?
Hypomania has many of the same symptoms as mania, but without psychosis, impairment of daily functioning, or need for inpatient treatment
What are the psychotic symptoms of mania?
- Flight of ideas
- Delusions of grandure
- 2 person auditory hallucinations
What are the signs of mania with regard to mood?
- Irritability
- Euphoria
- Lability
What are behavioural signs of Mania?
- Hyperactive/increased energy/irritable
- Decreased need for sleep
- Hypersexual
- Extravagance/overspending
- Over-familiar
- Recklessness
What signs in terms of appearence might you see in someone with mania?
- Extravagant clothing
- Bizarrely dressed
In terms of speech, what might you observe in someone who is manic?
- Pressure of speech
- Increased rate
- Prolonged
In terms of thought form, what might you observe in a manic individual?
- Flight of ideas
- Racing thoughts
In terms of thought content, what might be observed in mania?
- Delusions of grandure
- Inflated self-esteem
- Persecutory delusions
In terms of perception, what might you observe in someone with mania?
- 2nd person auditory hallucinations
In terms of cognition, what might you see in mania?
- Grandiosity
- Distractibility/poor concentration
- Confusion
- Lack of insight
- Disinhibition
In terms of insight, what might you see in someone with mania?
Total lack of insight
In terms of risk, what might you find in someone with mania?
May be a risk to themselves or others due to reckless or deluded behaviours
What is the differential diagnosis for someone who presents with manic symptoms?
- Schizophrenia, schizoaffective, delusionsal disorder
- Cyclothymia
- Drugs/Alcohol
- ADHD/conduct disorder
- Endocrine - Cushing’s, hyperthyroidism
- SLE
- Stroke, MS, Tumour, epilepsy
- AIDS, neurosyphilis
What endocrine problems can cause manic symptoms?
- Cushing’s
- Hyperthyroidism
What neurological disorders can cause manic symptoms?
- Stroke
- MS
- Tumour
- Epilepsy
What infections can cause manic symptoms?
- AIDS
- Neurosyphilis
What systemic illness can cause manic symptoms?
SLE
What medications can cause manic symptoms?
- Steroids
- Antidepressants
What illicit substances can cause mania?
- Cocaine
- Amphetamines
How would you assess someone with manic symptoms?
- MSE
- Assessment tools
-
Exclude other causes
- Bloods
- Infection screen
- CT/MRI
- ECG
What routine blood tests would you to investigate treatable causes of mania in a patient?
- FBC
- U+E’s
- LFTS
- TFTs
- ESR
- Glucose
- Calcium
- Tox screen
- ANA
- HIV test
How would you treat someone with mania?
May need to be sectioned under mental health act
- Benzodiazepines/sedation
- Antipsychotics
- Consider stopping antidepressants
- Mood stabilisers
What are the commonly used mood stabilisers?
- Lithium
-
Anticonvulsants
- Valproic acid
- Carbemazepine
- Lamotrigine
What is the mechanism of action of lithium?
The mechanism of action of lithium is unknown. It may include alterations in transmembrane ion flux and / or reduction in phosphatidylinositide turnover, which lead to mood stabilization.
What are the indications for use of lithium?
- Treatment and prophylaxis of mania
- Bipolar disorder
- Recurrent depression
- Aggressive or self-mutilating behaviour (rarely used)
What are the side effects of lithium?
- Gastro intestinal disturbance
- Fine tremor
- ADH antagonism + tubulointerstitial damage -> nephrogenic diabetes insipidus
- Weight gain and oedema
- Exacerbation of psoriasis
- Goitre and thyroid dysfunction
- Reduced seizure threshold
- Toxicity
What are signs of lithium intoxication?
- Vomiting, diarrhea
- Ataxia
- Dizziness
- Slurred speech
- Nystagmus
What signs/symptoms would indicate severe lithium toxicity?
- Hyper-reflexia
- Convulsions
- Psychosis
- Syncope
- Renal insufficiency
What is the blood level that is aimed for when using lithium?
0.6-1.2mmol/L
When considering starting lithium, what should you do first?
- Baseline U+E and TSH
- Pregnancy test in woman
How long does it take for lithium to reach a steady state after first dose?
5 days
How often should lithium levels be checked once steady state is established?
3 months
When should you recheck U+E’s, creatinine and TSH in somoene on lithium?
6 months
What is the mechanism of action of sodium valproate/valproic acid?
Three separate methods:
- Increasing the amount of GABA in the brain
- Blocking Sodium Channels
- Blocking Calcium Channels
It increases the amount of GABA in the brain by inhibiting the enzyme GABA Transaminase, which normally breaks down GABA.
By blocking both sodium and calcium channels, Valproate prevents the depolarisation/firing of neurones
What are the side effects of sodium valproate/valrpoic acid?
- SEVERE - sudden onset of liver failure, acute pancreatitis and severe thrombocytopenia.
- Nausea and vomiting
- Diarrhoea
- Weight gain
- Oedema
- Hallucinations
When giving sodium valproate/valproic acid, what baseline tests should you do?
- LFTs
- Pregnancy test
- FBC
When is carbemazepine indicated for use?
- Acute mania
- Mania prophylaxis
What is the first line treatment for acute mania and mania prophylaxis?
Carbemazepine
What is the mechanism of action of carbemazepine?
Carbamazepine acts by binding to the sodium channels of neuronal membranes and prevents the influx of sodium into the cell which normally leads to an action potential. By preventing depolarisation of these neurones, there is not the repeated “firing” of action potentials that is responsible for epileptic seizures.
What are the side effects of carbemazepine use?
- Skin conditions
- SIADH
- Nausea and vomiting
- Dry mouth
- Peripheral Oedema, weight gain
- Dizziness
- Drowsiness and fatigue
- Headache
- Abnormal LFTs
- AV conduction delays
What serious skin conditions can occur with the use of carbemazepine and lamotrigine?
- SJS
- Toxic Epidermal Necrolysis
What baseline measurements should you take before starting someone on carbemazepine?
- FBC
- LFTs
- ECG
What is the mechanism of action of lamotrigine?
Acts as a sodium channel blocker, to reduce the influx of sodium ions into neurones, and therefore reduced action potentials. This effectively stops the neurones from repetitively “firing” and therefore prevents seizures.
What are the side effects of lamotrigine?
- Rashes
- Nausea, vomiting and diarrhoea
- Somnolence or insomnia
- Headache
- Dizziness
- Blurred vision or diplopia
- Ataxia
- Skin conditions
- Haematological abnormalities
What is biplar affective disorder?
A disorder characterised by repeated episodes of mania and depression:
- At least two episodes of mania
- (or) one episode of mania and one episode of depression
Characteristically, recovery is usually complete between episodes
How would you treat a severe/life-threatening manic episode?
ECT
How would you manage someone with bipolar disorder?
- Mood stabilisers
- Antipsychotics - even if not psychotic
- Antidepressants - so long as they have not induced mania for the patient in the past!
How would you treat someone with bipolar disorder who was having a severe/life-threatening episode of depression?
ECT
What long term prophylaxis is often used to control bipolar disorder?
After successful treatment of manic/depressive episode + baseline is normal:
Lithium carbonate
What are the concerns with lithium toxicity and pregnancy?
Developmental disorders
- Ebsteins anomaly
- Floppy baby syndrome
- Thyroid abnormalities
How long do typical manic episodes in bipolar disorder last for?
1-3 months
What percentage of those with bipolar disorder die by suicide?
10%
Which sex is bipolar disorder more common in?
Neither, both sexes are equal
What is the mean age of onset of bipolar disorder?
21
