Bi Polar disorder

Question 1

What is it?

Answer 1

Bipolar disorder is a cyclical mood disorder that fluctuates between episodes of mania and depression.

Bipolar disorder is characterised by a significant disruption in mood and behaviour, which includes both periods of elated and depressed mood. It is a serious long-term condition with a much higher risk of suicide compared to the average population (0.4% annual risk).

Patients with bipolar experience episodes of both mania and depression.

Mania: elevated, expansive, or irritable mood. May be features of psychosis. Lack of insight with significant impairment in functioning.
Depression: low mood or loss of interest/pleasure in nearly all activities coupled with other depressive symptoms. Causes significant distress and impairs normal function.

Question 2

Clinical features?

Answer 2

Mania
Mania is characterised by an abnormal and persistently elevated, expansive or irritable mood, which leads to impairment in social and/or occupational function. There are numerous features suggestive of mania:

Elevated mood
Extreme irritability and/or aggression
Increased energy
Restlessness
Decreased need for sleep
Flight of ideas
Racing thought
Pressure of speech
Increase libido and disinhibition
Distractibility, poor concentration
Psychotic features: delusions (fixed belief contradictory to reality or rational argument) or hallucinations

Depression
Depression is characterised by a persistently low mood or loss of interest/pleasure in normal activities.

Low mood
Loss of interest or pleasure
Significant weight change
Insomnia or hypersomnia (sleep disturbance)
Psychomotor agitation or retardation
Fatigue
Feelings of worthlessness
Diminished concentration
Suicidal thoughts: recurrent thoughts of death/suicide, or a suicide attempt, or a specific plan for committing suicide

Question 3

Differential?

Answer 3

Mental health disorders: schizophrenia, unipolar depression, personality disorder or anxiety disorder.
Substance misuse: cocaine, ecstasy or amphetamines
‘Organic’ causes: thyroid disorder, multiple sclerosis, Cushing’s, Addison’s, cerebrovascular disease, dementia, epilepsy, systemic lupus erythematosus, encephalitis.
Iatrogenic causes: antidepressants, corticosteroids, levodopa or dopamine agonists.

Question 4

Management

Answer 4

Antipsychotics: used as a therapeutic trial to treat mania. May be switched to mood stabiliser once the acute episode resolved. Options can include haloperidol, olanzapine or quetiapine. Newer antipsychotics associated with fewer side effects.

Lithium: used for many years, still unclear mechanism. Often referred to as the ‘gold-standard’. Used in acute mania, recurrent depressive episodes or long-term maintenance. Its narrow therapeutic window increases the risk of toxicity and it is teratogenic. Patients on lithium require close monitoring.

Antiepileptics: also used as mood stabilisers in bipolar. Options include sodium valproate, lamotrigine or carbamazepine. May be used alone or in combination. It can help prevent depression relapses.

Antidepressants: may be restricted due to the risk of inducing mania or rapid-cycling (frequent, distinct episodes). The selective-serotonin reuptake inhibitor fluoxetine is commonly used.

CBT