Bipolar

Question 1

Symptoms of Bipolar Depression

Answer 1

Manic Episodes: 	• G - grandiosity 
	• S - sleep decreased 2-3h
	• T - talk is  pressured 
	• P - pleasurable activity w. painful consequences (e.g. impulsive spending) 
	• A - ↑activity 
	• I - ideas (flight of) 
	• D - distractible 

Hypomania Episode:

• mood isn’t severe enough to cause problems or require hospitalisation
• are never psychotic symptoms.

Depressive Episode: 
SIG E CAPS  + Mood 
	• S - sleep (↑/↓)
	• I - ↓interest (anhedonia) 
	• G - guilt 
	• E - ↓energy 
	• C - ↓concentration 
	• A - appetite (↓/↑)
	• P - psychomotor agitation / retardation 
          S - suicidal ideation (+ risk of harm to self / others)

Question 2

Describe the Classification of Bipolar Affective DIsorder?

Answer 2

1 - manic episode +/- depressive episode (no such thing as unipolar mania)

2 - at least 1 depressive episode and 1 hypomanic episode (mild manic)

3 - iatrogenic - hypomania on antidepressive treatments

4 - hypomania on substances

3/4 is relatively equivocal

cyclothymia - alternating periods of dysthymic with hypomanic moods.

Question 3

Treatment for Bipolar Affective Disorder?

Answer 3

1) psychological support
2) social support and rehab
3) start with mood stabiliser (ALWAYS) regardless of depressive or manic:
- lithium = used in pregnancy with close monitoring
- anticonvulsants = valproate, carbamazepine (teratogenic)
- 2nd gen antipsych = lamotrigine, olanzapine (faster onset)

4) consider others if indicated:
- antidepressants (very careful, trigger bipolar 3)
- ECT
- psychological treatment

Question 4

Prognosis of Bipolar Affective Disorder?

Answer 4

increased suicide rate with a relapsing remitting course

- an increased recurrence rate for mania with 90% recurrence in <5 years.

Question 5

Timeline for Diagnosis

Answer 5

• mania >1 week
• hypomania >2-4 days
• rapid cycling >4 episodes in 1 year
• Mixed states - mixture of depressive and manic symptoms 1-2 weeks

Question 6

Talk about some problems with using Lithium?

Answer 6

1) Toxicity: 
narrow therapeutic index (0.5-0.8 in mood, acute can go to 1.2) 
     Mild: 
     - nausea + vomiting
     - diarrhea 
     - fatigue 
     - fine tremor and hyperreflexia 

 Moderate: 

 - ataxia, dysarthria, delirium 
 - coarse tremor, myoclonus, hypertonia 

 Severe: 

 - stupor 
 - coma 
 - seizures 
 - paralysis, spasticity, rigidity
 - renal failure, CV collapse 

> 3mmol/L get dialysis

can get toxicity in OD and illness states e.g. dehydrated.

Other side effects:

• weight gain,
• memory problems
• tremor
• metallic taste
• drowsiness
• sexual problems.

Used in pregnant women as Sodium valproate is teratogenic and can cause irregular periods.

Question 7

What are some considerations for Bipolar Affective Disorder and Pregnancy?

Answer 7

1) NICE guidelines say mood stabiliser should cease in 1st trimester and replace with antipsychotics
2) change to lithium - least teratogenic. Does cause Epstein’s anomaly (TV displaced in heart)
3) postpartum psychosis more common in BPAD than schizophrenia. 4% infanticide, 5% suicide, medical emergency.