Bipolar Flashcards
Bipolar 1 disorder criteria
- One manic episode->May have been preceded or followed by hypomanic or major depressive episode
- The occurrence of mania/depression is not better explained by schizoA, schizophrenia, schizophreniform, delusional or other unspecified schizophrenia spectrum/psychosis
Bipolar 2 criteria
- Current or past hypomanic and current/past major depressive episode
- There has never been a manic episode
- Episodes not better explained by another schizo/psychosis
Criteria for manic episode (A, B7, C, D)
A. Distinct period of abnormally ++mood/expansile or irritable with ++goal oriented activity, present for at least a week, for most of the day nearly every day
B. 3 + of the following during change present to a significant degree
1. Inflated self esteem, grandiosity
2. Decreased need for sleep
3. More talkative, pressured speech
4. Flight of ideas, subjective experience thoughts racing
5. Distractability
6. +Goal oriented activity
7. Excess involvement in activities with potential for painful consequences
C. Mood disturbance significant enough to cause marked impairment in function
D. Not attributable to anything else
Criteria for hypomanic episode
A. Distinct period of abnormally ++mood/expansile or irritable with ++goal oriented activity, present for 4 consequetive days, for most of the day nearly every day
B. 3 + of the following during change present to a significant degree
1. Inflated self esteem, grandiosity
2. Decreased need for sleep
3. More talkative, pressured speech
4. Flight of ideas, subjective experience thoughts racing
5. Distractability
6. +Goal oriented activity
7. Excess involvement in activities with potential for painful consequences
C. Unequivocal change in function that is uncharacteristic
D. Change in functioning observable by others
E. Episode not severe enough to cause marked impairment to necessitate hospitalisation, if there is psychosis= mania
F. Not due to psychological effects of a substance
Criteria for major depressive episode
A. 5+ symptoms in same 2 week period, change from previous, at least one depressed mood or loss of pleasure/interest
1. Depressed mood nearly all day every day
2. Loss of interest pleasure
3. Insomnia/hypersomnia
4. Appetite/weight loss
5. Concentration
6. Loss of energy
7. Feelings of worthlessness/++inappropriate guilt
8. Psychomotor agitation/retardation
9. Recurrent thoughts of deatj/suicide
B Significant distress/impairment
C. Not attributable to psychological effects of medication/other medical consition
Sub-categories of bipolar
classified as without psychotic features, with psychotic features, with catatonic features, with postpartum onset, with seasonal pattern, with rapid cycling (at least 4 episodes of a mood disturbance in the previous 12 months)
Treatment overview
- Pharmalogical:lithium, anticonvulsants, antipsychotics, antidepressants, ECT
- Psychological: supportive psychodynamic psychotherapy, CBT, ITP
- Social: vocational rehabilitation, leave of abscence, substitute decision maker for finances, alcohol and drug cessation, social skills training, education for family
Course and prognosis
High suicide 15%
Relapsing and remitting->depressive episodes seem to last longer
90% recurrence of mania within 5 years
Highest risk of suicide
When switching from mani episode to depression, especially when realisae consequences of actions while manic
Etiology
- Genetic->69% concordance in monozygotic twins
- Neurotransmitters->+Serotonin, NE, dopamine in mania, reduction in depression
- PsychoD->mania serves as defense for depression
- Neuroanatomical: +activation of cortical-cognition, +ventral limbic
- Environmental->stressors
Common causes of manic relapse
- Treatment non-adherence
- Life stressors
- Substance misuse
- Anti-depressant use
- Medication below therapeutic levels
Management of acute mania
- Admission
2. Risperidone or olanzapine (second line= second generation, carbamazepine, valproate)
Management when treatment resistant acute mania
- Admission
- ensure that maximum tolerable drug concentration has been achieved.
- switch to a different drug (eg from a second-generation antipsychotic to lithium)
- combine drugs (eg a second-generation antipsychotic plus lithium)
- electroconvulsive therapy (ECT)—this is a proven treatment for mania and may be extremely effective even when patients fail to respond to one or more antimanic drugs
Overview of prophylaxis for bipolar
- Following acute mania, treatment for at least 12 months. May be required long term
- Broad treatment approach->psychological, social, employment
- Manage comorbidities->including substance
- Maintain physical health
- Work with families and carers
Pharmacological options for prophylaxis
- Lithium
- Second-generation antipsychotic
- Lamotrogine
Differential diagnoses for elevated or irritable mood
1. Mood disorders Mania, mixed, bipolar Depression with irritable mood 2. General medical condition 3. Substance 4. SchizoA/Schizophrenia 5. Personality/developmental 6. Delirium/dementia
Medical conditions causes of mania
Cerebral neoplasms, infarcts, trauma Cushing's Huntington's Hyperthyroid MS Renal failure SLE Temporal lobe epilepsy Vitain B 12 deficiency
Substance causes of mani
Amphetamine
Cocaine
Hallucinogens
Legal high
Anabolic steroids
Antidepressant
Corticosterois
Dopaminergic->L dope, bromocriptine
Comparison b/w mania and schizoP->thought form, delusions, speech, biological, psychomotor
1. Mania Circumstantial, tangential, FOI Mood congruent delusions Pressured speech -ve need for sleep, +energy Agitation
2. SchizoP LOA, neologisms, thought bloking Unrelated to mood, passivity, insertion, withdrawal Hesitant, halting Sleep less disturbed, less hyperactive Agitation, catatonic, negative symptoms
History when presenting with ++mood
Particularly happy Too much energy Exciting ideas Thoughts racing Special powers Sleep Delusions, hallucinations Past depressive/mani episodes Substances Medical history Impairment
Examination of irritable++mood
General
Endocrinological
Neurological
Investigations when elevated mood
Social: collateral, home, work, children
Psychological->mood diary?
- Exclude medical/substance causes
UDS
Vitamin B12, folate
CT, EEG if indicated - Establish baseline before administering medication
FBC, UEC, Cr/BUN, LFTs, TSH, pregnancy test, ECG
Prevalence of bipolar affective disorder
0.5-1%, men and women affected equally
