bipolar Flashcards
general bipolar
- lifelong, cyclical mood disorder
- recurrent fluctuations in mood, energy, behaviour -> severe mood swings
differences in 1st episode presentation by gender
- males: manic episode
- females: depressive episode
progression of bipolar disorder by age
10 - 20: mild bipolar mood swing
20: first major depression
20 - 30: first mania and post-mania depression
30: depression
30 - 40: rapid cycling between mania and depression
tldr risk factors for bipolar
1) genetics
2) treatment induced
3) medical conditions
4) history of trauma
5) physical stressors
6) seasonal change
genetic risk factors for bipolar
- family history
- loci on genes and X chromosomes: 18, 11p15, 21
treatment induced bipolar
1) ECT
2) drug abuse, intoxication
3) drug withdrawal state
4) antidepressant (increased NE or DA transmission)
5) DA-augmenting agents (CNS stimulants increase DA transmission)
6) NE-augmenting agents (alpha-2 antagonist, increase NE transmission)
7) steroids
8) thyroid preparations
9) herbal products
10) pseudoepinephrine
general medical conditions that cause bipolar
1) CNS disorders (Stroke, head injuries, multiple sclerosis)
2) CNS infections
3) electrolyte/metabolic imbalance
4) endocrine/hormonal dysregulation
history of trauma that cause bipolar
perinatal trauma, head trauma, physical abuse
pathophysiology of bipolar
excessive NE or DA neurotransmission -> manic episode
clinical presentation of bipolar
1) history of mania/hypomania not caused by other conditions or substances
2) high mood (manic) symptoms
- abnormal and persistently elevated, expansive, irritable mood + 3 other symptoms in 1 wk period (DIGFAST)
** distractability and easily frustrated
** irresponsible and erratic uninhibited behaviour
** grandiosity
** flight of ideas
** activity increased, psychomotor agitation
** sleep need decreased
** talkativeness
3) depressive symptoms (In.SAD.CAGES)
description of bipolar mood episodes
1) major depressive episodes
- symptoms > 2 wks with functional impairment
2) manic episodes
- symptoms >/= 1 wk with functional impairment
3) hypomanic episodes
- symptoms >/= 4 days, no functional impairment, no psychosis
DSM-5 classification for bipolar
1) bipolar I = mania +/- depressive episodes
2) bipolar II = hypomania + depressive episodes
how diagnosis for bipolar normally recorded
bipolar (Type) disorder with (Type of current/most recent episodes) (severity/psychotic/remission specifier)
general assessment of bipolar
similar to schizophrenia
non-pharmaco for bipolar
1) psychoeducation
- recognise early signs and symptoms
- chart mood changes
- identify stressors that precipitate episodes
- strategies for coping
- development crisis intervention plan
2) psychotherapy
- interpersonal therapy, CBT, behavioural couples therapy
3) stress reduction techniques
4) sleep hygiene
5) nutrition: protein rich, essential fatty acids, supplementation
6) exercise
initiation of bipolar therapy
1) short course PRN benzodiazepine
- help patient relax and sleep
- onset of effectiveness within hours
- taper off when condition improved and mood stabiliser optimised
2) start mood stabilisers
- acute and maintenance
what to do when poor response to initial bipolar treatment?
1) Switch agent
- if no response after 2 - 4 wks then switch to 2nd 1st line agent
- if partial response after 2 - 4 wks then add on 2nd 1st line agent
2) ECT
- for severe, treatment resistant
3) antidepressant
- recurrent episodes need long term lithium and antidepressant
4) bipolar disorder and rapid cycling (>/=4 mood episodes per year)
- X antidepressant/stimulant
- treat underlying cause instead
tldr type of mood stabilisers
1) mania
- lithium
- olan, quet, risp, ari, halo
- valproate
- combination of each
2) bipolar depression
- lithium
- quet, olan + fluoxetine
- lamotrigine
- combination
lithium MOA
1) normalise/inhibit secondary messenger systems
2) maybe reduce PKC
3) reduce 5-HT reuptake and DA release
lithium PK
- not affected by liver, kidney clearance
lithium lab values monitoring
- TFT, electrolytes w Ca2+ and renal function, FBC, urinalysis, EKG, pregnancy test
- taking samples
** 12 hrs after previous dose
** 5 - 7 days after initiation/titration cuz steady state after 5 days
lithium SE
- fine - coarse tremor, polyuria, hypothryoidism, cardiac effect (ECG change), N, weight gain, fatigue, cognitive impairment, diabetes insipidus
lithium DDI
lithium toxicity
- STAND
1) sodium depletion: body reuptake more Na but reuptake Li instead cuz both Li and Na monovalent cation
2) thiazide: promote water loss -> increase concentration in blood
3) ACEi/ARB
4) NSAIDs
5) Dehydration - toxicity categories
1) mild
** serum levels 1.5-2
** GI SE: N/V, loose stools
** CNS SE: lethargy, confusion, coarse hand tremors
2) moderate
** serum level 2 - 2.5
** GI SE: severe N/V, diarrhoea
** CNS SE: slurred speech, worsening confusion, ataxia, blurred vision, profound lethargy, tinnitus, apathy
3) severe
** serum level > 3
** GI SE: severe N/V, diarrhoea
** CNS SE: very impaired consciousness, increased deep tendon reflexes, stupor, coma, seizure, death
valproate MOA
- increase GABA levels
- decrease DA turnover and PKC
- normalise Na and Ca channels
- antikindling properties
