Bipolar

Question 1

EPIDEMIOLOGY

i) does it affect females or males more?
ii) what is the average age of onset? what age do 90% present before?
iii) what is lifetime prevalence and lifetime completed suicide rates?

Answer 1

i) F=M

ii) average age of onset is 20yrs
- 90% present before 30yrs

iii) lifetime prev is 1-3%
lifetime suicide rates are 10-15%

Question 2

AETIOLOGY

i) is there a strong genetic component? what can be increased risk if 1st degree relative is affected?
ii) what is monozygotic twin concordance? what is dizygotic?
iii) name two potential triggers

Answer 2

i) yes
- 10% increased risk of 1st degree relative affected

ii) mono concord is 60%
di concord is 20%

iii) potential triggers are psychosocial stress and sleep disturbance

Question 3

DEFINITIONS

i) what does DSM-V define BPAD type 1 as? (2)
ii) what does DSM-V define BPAD type 2 as? (3)
iii) what does ICD10 define it as? (3)
iv) what is a symptom and what is a sign? give eg

Answer 3

i) type 1 - one or more manic episodes (lasting >7 days) with or without a depressive episode
ii) type 2 - 1 or more hypomanic episode (4+ days) and one major depressive episode, no episodes of mania
iii) 2 or more episodes of manic, hypomanic or major depressive

iv) symptom = subjective experience described by patient (depressed, poor conc)
sign = objective finding observed by clinician (psychomotor retard, restricted affect)

Question 4

KEY FEATURES

i) what are the key features of bipolar? DIGFAST
ii) what else is needed? (2)
iii) what is hypomania? name three things needed? what does it lead to?

Answer 4

Distractability
Indiscretion (risk taking behavs)
Grandiosity
Flight of ideas/racing thoughts
Action increase (excess energy)
Sleep change (decreased need for sleep)
Talkative (pressure of speech)

ii) also need elevated mood or irritability

iii) hypomania is elevated/irritable mood for more than 4 days
- inc activity, restless, increased talk, pressure of speech, inc social, distracted, insomnia, inc sexual energy, mild reckless or irresponsible behavs
- leads to some intference with personal function

Question 5

MANIA

i) what duration of symptoms is required to define mania?
ii) name four symptoms of which three are needed for mania
iii) what does it lead to?
iv) name the three key psychotic symptoms that may be seen in mania
v) what is the key difference between hypo and mania?

Answer 5

i) elevated or irritable mood >7 days or any duration if hospitalised
ii) three of - increased acitivity, restless, reckless, distracted, pressure of speech, less sleep, flight of ideas, grandiosity, psychotic symptoms
iii) leads to severe interference with personal function

iv) key psych symptoms:
- delusions = usually mood congruent (grandiose, persecutory)
- hallucinations = 2nd person auditory
- formal thought disorder = circumstantiality, tangential, flight of ideas

v) intensity of symptoms

Question 6

BIPOLAR TYPE II

i) does it affect females or males more?
ii) why is it more difficult to diagnose?
iii) name two things that are important to ask about in diagnosis? what can it progress to?

Answer 6

1+ hypomania episodes, 1 major depressive episode

i) F > M
ii) difficult to dx due to hypomanic symp may not be spont reported, may need collateral

iii) ask about increased alcohol, substance misuse, freq/severity of depress episodes
- can progress to BPAD 1

Question 7

SUBTYPES OF BPAD

i) what is rapid cycling BPAD? what is the prognosis?
ii) what is cyclothymia? how long does it last for?
iii) name two organic, psychotic, affective, personality differetial dx for mania?

Answer 7

i) 4+ episodes in a single year with poor prognosis

ii) ‘mini bipolar’ > subthreshold
- chronic for >2 years
- periods of mild elation and depression (doesnt reach thresh for hypomania or depression)

iii) organic = thyroid, MS, delirium, substance misuse, meds eg levodopa
psychotic = schizoaffective, schizophrenia
affective = BPAD, cyclothymia
personality = EUPD

Question 8

TREATMENT OF ACUTE MANIC EPISODES

i) name three general things that should be done?
ii) what should be screened? (2)
iii) what needs to be stopped?
iv) name an antipsychotic that may be started first?
v) what is given 2nd, 3rd and 4th line? what can be given short term for sedation?

Answer 8

i) reduce external stimuli
- assess for contributing substances eg rec/prescribed drug
- limit reckless behaviour by limiting access to cars, bank account
- consider consequences of reckless behaviour

ii) do a urine drug screen and sexual health
iii) stop any anti depressants
iv) start olanzapine, haloperidol, quetiapine, risperidone

v) 2nd - alternative AP
3rd - lithium + AP
4th - valproate + AP
- short term benzo for sedation

Question 9

MANAGEMENT OF BIPOLAR

i) which two main drug classes are used?
ii) what can be done if medical therapy isnt working?
iii) name three psych interventions that may be useful?

Answer 9

I) mood stabilisers and atypical APs

ii) if med therapy isnt working > ECT can be considered
iii) CBT, psychoeducation, psychodynamic, family therapy