Bipolar Flashcards
What are screening questions for mania
MOOD
o How’s your mood been lately - can do the score
- Have you ever had periods lasting several days of elevated energy, feeling on top of the world?
SLEEP
o Have you noticed anything happening with the number of hours you sleep?
ENERGY
o How are your energy levels with less sleep ?
THOUGHT/ SPEECH
- noticed any changes in how you think? speed of thinking and processing information ?
- how about speech ? anyone commented
GRANDIOSITY
- How’s your sense of self and how you like yourself self-esteem during these times? (did you feel like you had special talents or powers?)
- What about your sense of the future - any new interesting plans or projects?
What are screening for risks for mania
Driving
- how has driving been, faster than usual ? how is driving with people around them. Problems with speeding tickets
Finances
- how is financial situation recently, how has your spending been. have you had any interest in gambling recently
Sex
- any changes in terms of sex life or sex drive.
Aggressive behaviours
- have you had any fights lately.
Have people noticed you have been more in their face?
What about periods lasting several days of feeling unusually irritable and quick to argue or fight?
Screen for psychosis (delusions and hallucinations)
What are the additional questions to screening to ask for Bipolar affective disorder
o Ask impact on life
o Ask about depression sx
o Ask about substance abuse
Mental state findings for Bipolar affective disorder
Appearance & Behaviour - disheveled, poorly groomed, disinhibited, inappropriate, overly
familiar/aggressive, irritable, hostile
- Speech & Language - pressured (difficult to interrupt), fast rate, increased volume, increased amount
- Mood & Affect - elevated, euphoric, elated effect, affect congruent to mood
- Thought Form - disorganised, flight of ideas, derailment, loosening of associations
- Thought Content - grandiose delusions (often mood congruent)
- Perception - usually nil
- Cognition - usually intact
- Insight & Judgement - poor, unaware of recklessness and consequences of actions
- Safety - harm to others by actions, themselves in a depressive episode or vulnerability
Diagnostic criteria and differentials for bipolar (general)
Bipolar I
- At least one manic episode - doesn’t require depressive episodes
Bipolar II
- At least one hypomanic episode and one depressive episode
- Depression must cause significant impairment in functioning but not hypomania
- If psychotic features must exclude SCHIZOAFFECTIVE schizophrenia, delusional disorder, substances-induced
psychosis, brief psychotic disorder - Manic episode secondary to medication/illness
eg. steroids, BB
eg. cerebral illness - CVA,tumour, epilepsy, head injury dementia
eg. MS, AIDS, neurosyphillis, hyperthyroidism, Wilsons - Manic episode secondary to substance use eg. - amphetamines, cocaine, cannabis
Cyclothymic disorder
- Lower-grade depressive and hypomanic symptoms present for ≥2 years
- Depressive and manic episodes don’t meet DSM criteria
- No organic/substance-induced cause
- Causes significant distress or loss of
functioning
Definition/ diagnostic criteria for manic episodes
Manic episode
A. A distinct period of abnormally and persistently elevated/expansive/irritable mood and persistently increased activity/energy lasting ≥1 week and present for most of the day, nearly every day (can be less than one week if hospitalisation was
necessary)
B. ≥3 of the following symptoms (four if the mood is only irritable) present during the period of mood disturbance showing increased energy ; a change from their usual behaviour
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- More talkative than usual and/or pressured speech
- Flight of ideas, subjective experience that thoughts are racing
- Distractibility ( easily distracted) as reported/observed
- Increase in goal-directed activity or
psychomotor agitation
- Excessive involvement in activities that have a high potential for painful consequences
C. Marked impairment in social/occupational
functioning or requires hospitalisation to prevent harm to self/others or psychotic features
D. Not attributable to substances (e.g. drug of abuse, medication) or a medical condition
what are the specifiers for BPAD
Specifiers
- With - anxious distress, mixed features,
rapid cycling: - ≥4 episodes (mania,
hypomania, depression) within 12 months
melancholic features, atypical features,
psychotic features, catatonia, peripartum onset, seasonal pattern
- Psychotic features - mood congruent (e.g. grandiosity) vs. incongruent
- Degree of remission - partial vs.full (no symptoms for 2 months)
- Current severity of manic +/- depressive episode - mild vs. moderate vs. severe
Define hypomanic episode
- a distinct period of persistently elevated/expansive/irritable mood same as mania but lasting ≥4
days that is clearly different from the usual nondepressed mood - no psychotic symptoms
no marked impairment in social/ occupational fx
Initial management for mania / bpad
Acute treatment of mania/hypomania:
o Safety (to self, others, self-care +
finances / driving / fights / sexual behaviour
o Reduce external stimuli + collateral hx
o Limit access to cars, finances, phones,
etc. (due to risk of reckless behaviour)
o Medical Ix
- bhCG, FBC, U+Es, TFTs, urine tox
- baseline ECG
*IP treatment usually not required for hypomania
admit if no insight/ not cooperative
Biological treatment for Mania - acute and long term
Meds =
- start mood stabiliser (1st lithium , 2nd valproate + carbemazepine +
- atypical antipsychotics for imminent symptoms (olanzapine, quetiapine, apriprazole).
Both if severe.
- Acutely may need Benzos (lorazepam prn 1-2mg IMI for agitation)
- Zopiclone if not sleeping
(if pregnant - Haloperidol / ECT)
Stop antidepressants
Long term
- Mood stabilisers for at least 2 years after initial manic episode - withdraw the benzo and antipsychotics once the acute mania is over.
- Consider continuing antipsychotics if severe
- Antidepressants may be started After initiating mood stabilisers, avoided in rapid cycling
- IF severe mania + depression then consider ECT
- lamotrigine best for preventing depression and in bipolar 2 but not good in acute mania
- carbamazepine may be used for prophylaxis for pt unresponsive to other combinations and for rapid cyclers
Manage any comorbid substance abuse
What are the psychological and social management of BPAD / mania
o Psychoeducation,
o CBT for depressive episodes
- Supportive psychotherapy in long term follow up for relationships - family or marital
o Relapse Prevention Plan : Strategies for early intervention if early warning signs occur
o Bipolar disorder support groups
- Ideally continuity of care and therapeutic relationship
Social
o Discuss lifestyle issues and
interventions: stress-management,
drug and alcohol avoidance (ideally),
at-risk-period advance planning
o 24/7 contact options to get advice or a
review
o Educate patients about meds side effects and their management
Mobilise social supports - family and friends
- Work/school - work certificate, sickness
benefit, work finding or retraining
- Housing situation - social worker input
- Cultural/spiritual supports/services
