Bipolar

Question 1

dsm 5 criteria for manic episode of bipolar disorder:

Answer 1

Abnormally and persistently elevated, expansive, or irritable mood for at least 1 week*
Inflated self-esteem or grandiosity
Decreased need for sleep
Pressured speech (not where you’re from- from nj and talking fast)
Flight of ideas or racing thoughts
Distractibility
Increase in goal-directed activity or psychomotor agitation
Excessive involvement in pleasurable activities that have a high potential for painful consequences (high sex, gambling)

Question 2

narrow age range:

Answer 2

15-25-30 (if 60s or later, it may be brain tumor or other disorder): half are diagnosed by 25

Question 3

with bipolar, it is all too often:

Answer 3

misdiagnosed, alcohol and drug use comorbidities, people can have difficulties in their work or schooling

Question 4

Bipolar I disorder:

Answer 4

Must have a manic episode : elevated, expansive, irritable mood with accompanying DIGFAST symptoms for at least a week
Manic episode leads to marked impairment in function or there are psychotic features

Question 5

DIGFAST:

Answer 5

Distractibility: poorly focused, multitasking
Insomnia: decreased need for sleep
Grandiosity: inflated self-esteem
Flight of ideas: complaints of racing thoughts
Activities: increased goal-directed activities
Speech: pressured or more talkative
Thoughtlessness: “risk-taking” behavior—sexual, financial, travel, driving

Question 6

32 yr old woman is brought to the ed by police after being found standing in the middle of a busy highway, naked, commanding traffic to stop. In the emergency room. she is agitated and restless, with pressured speech, and an affect that alternates between euphoric and irritable. Her father is contacted and states that this kind of behaviour runs in the family

Answer 6

bipolar, manic

Question 7

bipolar I occurs ______ and bipolar II occurs ______; ___ include some substance abuse

Answer 7

equally in males and females, females more than males; 60% (self medicating- possibly smoking week, anxiety, etc)

Question 8

treatment options for bipolar include:

Answer 8

Psychotherapy: cognitive-behavioral, interpersonal
Acute mild-moderate
Not indicated alone for mania, severe depression
Helps prevent recurrence

Mood stabilizers +/- antipsychotics, benzodiazepines:
Patient preference/choice
Benefit must outweigh their perceived (or/experience of) risks

ECT for severe depression, psychosis

Combination psychotherapy + medications: faster response, better compliance, higher quality of life

Question 9

Cyclothymia

Answer 9

For at least 2 years, hypomanic symptoms and depressive symptoms. Depressive symptoms don’t qualify for Major Depression

Question 10

Bipolar Disorder II

Answer 10

Onset to proper diagnosis: 3-10 year lag (35% wait >10 years for correct diagnosis)
Misdiagnoses: unipolar depression (60%); anxiety disorders (26%); schizophrenia (18%); personality disorder (17%); alcohol/substance abuse (14%)
Significant co-morbidities (e.g., 60% lifetime prevalence of alcohol and drug use disorders)
Significant complications: cognitive, personal and occupational functioning

Question 11

lithium side effects:

Answer 11

thyroid, renal issues

Question 12

valproate side effects:

Answer 12

weight gain

Question 13

carbamazapine side effects:

Answer 13

agranulocytosis, anemia, make sure they have basic blood work

Question 14

before prescribing any medication, it is important to:

Answer 14

check liver, kidney, thyroid, wbc, etc
all baseline labs:
Urine toxicology
Serum creatinine 
24 hour urine creatinine if concerned about renal status)
Electrolyte screen-SMA-6
Fasting glucose and lipids
Thyroid function tests-Total serum thyroxine concentration-T4, resin triiodothyronine uptake (T3RU), free T4 index and thyroid stimulating hormone (TSH) 
Complete blood count
EKG (definite if patient is over 40)
Pregnancy test

Question 15

the 5 atypical antipsychotic drugs are:

Answer 15

olanzapine (Zyprexa)		high
quetiapine (Seroquel)		moderate
risperidone (Risperdal)		moderate
zisprasidone (Geodon)		low
aripiprazole (Abilify)		low

Question 16

the 5 atypical antipsychotics can leaad to:

Answer 16

metabolic syndrome, obesity, weight gain, diabetes,

Question 17

TEST: metabolic syndrome:

Answer 17

Metabolic syndrome is a cluster of conditions — increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels — that occur together, increasing your risk of heart disease, stroke and diabetes.
can occur with treatment

Question 18

____ is an extrapyramidal symptom that results in a subjective feeling of restlessness

Answer 18

akathisia (can you sit still? no, I can’t)

Question 19

_____ is an extrapyramidal symptom that results in abrupt onset muscular spasms of the neck, eyes, trunk, and extremities

Answer 19

acute dystonic reactions

Question 20

______ is an extrapyamidal symptom (EPS) that results in stiffness, tremor, and imparied gait

Answer 20

parkinsonism

Question 21

NMS:

Answer 21

Neuroleptic Malignant Syndrome (NMS)
Idiosyncratic (0.01%) reaction to dopamine antagonists
Hyperthermia, hypertension, profuse diaphoresis
Lead pipe rigidity, rhabdomyolysis, tremor
Creatinine kinase levels 4x upper limit of normal
10-20% mortality if unrecognized
Reported with essentially every D1 or D2 antagonist including non-psychotropics such as metoclopramide (Reglan)

Question 22

Tardive Dyskinesia

Answer 22

A movement disorder that may occur following long-term treatment with antipsychotic medications.

Movements may include:
mouth and tongue movements, such as lip smacking, sucking and puckering as well as facial grimacing
irregular movements of the limbs, particularly choreoathetoid-like movements of the fingers and toes and slow, writhing movements of the trunk

Mild- disabling

Often irreversible.

Question 23

a 54 yr old with a chronic mental illness seems to be constantly chewing, he does not wear dentures his tongue darts in and out, and grimaces, frowns, and blinks excessivley:

Answer 23

tardive dyskinesia; an extra pyramidal symptom assocaited with typical antipsychotics bc they work by blocking D2 dopamine receptors in the mesolimbic and mesocortical areas of the brain. However, these same medications also bind to dopamine receptors in other areas of the brain, such as the nigrostriatal pathway, thereby causing a variety of eps.

Question 24

tardive dyskinesia is charactecterised by_____ and results from:

Answer 24

involuntary choreoathetoid movements of the face, trunk, and extremities. Associated with prolonged use of medications that block dopamine receptors, most commonly antipsychotic medications.

Question 25

a 24 yr old with chronic schizophrenia is brought to the ed after his parents found him in his bed and were unable to communicate with him. On examination, the man is confused and disoriented. He has severe muscle rigidity, a temp of 39.4C his bp is elevated,, and he has a leucocytosis.

He is suffering from ____ and should be given ______

Answer 25

The patient has neuroleptic malignant syndrome NMS a life-threatening complication of antipsychotic treatment.

Question 26

a life-threatening complication of antipsychotic treatment, the symptoms include muscular rigidity, dystonia, akinesia, mutism, obtundation, and agitation:

Answer 26

neuroleptic malignant syndrome (NMS)

Question 27

27 yr old woman has been feeling lue fo the past 2 weeks. Has little energy and trouble concentrating. She states that 6 weeks ago she had been feeling very good, with lots of energy and no need for sleep. She says that this pattern has been occurring for at least the past 3 years though the episodes have never been so severe that she couldn’t work

Answer 27

cyclothymic disorder

Question 28

recurrent periods of mild depression alternating with periods of hypomania. This pattern must be present for at least 2 years (1 year for children or adolescents) before the diagnosis can be made. During these 2 years, the symptom-free intervals should not be longer than 2 months. ______ usually starts during adolescence or early adulthood and ends to have a chronic course. There is a marked shift in mood that can be confused with the affectives instability of borderline personality disorder or may suggest a substance abuse problem.

Answer 28

Cyclothymic disorder

Question 29

35 yo man is brought to office by his wife. He had previously suffered a major depressive episode 2 years prior and ceased medications 6 months ago. More recently, the patient had been working many overtime hours for several weeks to complete a project at work, and had slept much less than normal without apparent ill effect. When the project was completed, the patient continued to sleep little, shifted his activities to socializing and drinking with his colleagues. The patient admits he has not drunk this heavily since college. For the past few days the patient has crashed back into depression:

Answer 29

bipolar: pattern of decreased need for sleep, yet with no decrease in eergy level. Increased goal directed activity and excessive pleasure-seeking activity (drugs, alcohol), Need lithium

Question 30

33yr old writer is brought to ed by sister who voices concern that her sibling is acting “out of control.” The patinet laughs at sister’s accusation and rapidly retorts, “I feel great! She’s the one with something wrong.” The patient paces around the room, speaking rapidly. The ER MD attempts to redirect the interview several times, but the patient keeps talking. Her sister reports that the patient was like this several months ago, but otherwise has been normal. She remembers that both episodes seemed to occur around the time of her sister’s period. The patient responds by chanting, “yes, yes! I’ve got the PMS!” The patient has no known medical problems, substance abuse or fam history of psychiatric illlness.

Answer 30

bipolar: the patient presents in a manic state with elevated mood, irritability, psychomotor agitation, and rapid, pressured speech. Need lithium

Question 31

Patient does not use drugs, symptoms appear episodically and otherwise normal functioning. Behavior seems strange, but no overt signs of psychosis. Reports having pms:

Answer 31

bipolar. Pms or pmdd does not account for manic symptoms. Need lithium

Question 32

23 yr old graduate student presents with severe abdominal cramps, bloating, difficulty concentrating. BF says that she’s been extremely mean the past few days and anything he says sets her off. He does not recall any other changes in behavior:

Answer 32

Need SSRI (fluoxetine). Lithium has no known benefits in PMDD but would be gold standard for bipolar.