Bipolar Flashcards
Difference between bipolar 1 and 2?
Bipolar I Disorder
- at least one manic episode has occurred
- if manic symptoms lead to hospitalization, or if there are psychotic symptoms, the diagnosis is BP I
- commonly accompanied by at least 1 MDE but not required for diagnosis
Bipolar II Disorder
- at least 1 MDE, 1 hypomanic and no manic episodes
Bipolar II is often missed due to the severity and chronicity of depressive episodes and low rates of spontaneous reporting and recognition of hypomanic episodes
DSM critera for manic episode?
A. A period of abnormally elevated mood, lasting at least 1 week and present most of the day nearly every day
B. >3 of the following symptoms are present to a significant degree:
- inflated self esteem/grandiosity
- decreased need for sleep
- more talkative than usual/pressure of speech
- flight of ideas, racing thoughts
- distractability
- increase in goal-directed activity
- excessive involvement in activities that have a high potential for painful consequences (eg. sexual indiscretions, foolish business investments)
C. significant mood disturbance to cause marked impraiment in social/occupational/etc functioning or requires hospitilisation, or other psychotic features
D. not attributable to substances/other medical condition
DSM criteria for hypomanic episode?
A. A period of abnormally elevated mood, lasting 4 days
B. >3 of the following symptoms are present to a significant degree:
- inflated self esteem/grandiosity
- decreased need for sleep
- more talkative than usual/pressure of speech
- flight of ideas, racing thoughts
- distractability
- increase in goal-directed activity
- excessive involvement in activities that have a high potential for painful consequences (eg. sexual indiscretions, foolish business investments)
C. the episode is associated with an unequivocal change in funcitoning that is uncharacteristic of the individual when not symptomatic
D. the change in mood is observable by others
E. the episode is not severe enough to cause marked impairment, doesn’t require hospitalisation
F. not attributable to substances/other medical condition
Treatment of acute mania?
First line
- olanzapine
- risperidone
Second line
- haloperidol
- Zuclopenthixol
- aripiprazole
- asenapine
- paliperidone
- quetiapine
- ziprasidone
- lithium carbonate
- sodium valproate
- carbamazepine
Treatment of “behavioural emergency”
Use oral route wherever possible
- diazepam
- lorazepam
- if not working, use the patients current antipsychotic + dose, olanzapine, risperidone, chlorpromazine or haloperidol
IV:
- diazepam
- midazolam
Droperidol or olanzapine can be used in combination with diazepam or midazolam, or as a single drug in patients who are tolerant of benzodiazepines or if there is a failure of benzodiazepines
- droperidol
- olanzapine
IM
- midazolam
- if failure of midaz, use droperidol or olanzapine
if tranquillisation lasting 2 to 3 days is required, zuclopenthixol acetate can be used
- should not be used for first-line treatment of behavioural emergencies
- should only be administered after specialist psychiatric assessment has confirmed the presence of a primary psychotic disorder or there is clear evidence of a psychotic illness, and there is a high likelihood of recurrent agitation and aggression
- can cause extrapyramidal adverse effects.
Non-pharm treatment of bipolar
Lifestyle:
- psychoeducation regarding cycling nature of illness
- develop early warning system
- emergency plan for manic episodes
- promote stable routine - sleep/meals/exercise
- ensure regular check ins
Psychological:
- supportive or psychodynamic therapy
- CBT
- IPT
- family therapy
Pharmacological:
- lithium
- anticonvulsants
- antipsychotics
- ECT
Following the first episode of mania, how long should pharmacological treatment be continued?
12 months at least
What is the recurrence rate of manic episode?
90% within 5 yrs
First line pharmacotherapy for prophylactic treatment of bipolar?
- lithium carbonate
- aripiprazole
- asenapine
- olanzapine
- paliperidone
- quetiapine
- risperidone
- ziprasidone
- lamotrigine
SECOND LINE
- carbemazepine
- sodium valproate
Effects of lithium toxicity?
ataxia, vomiting, coarse tremor, neurological signs (including hemiplegia), disorientation, dysarthria, muscle twitches, impaired consciousness, acute kidney failure and death.
Prolonged toxic concentrations may lead to irreversible brain damage.
At what concentration does lithium toxicity usually occur?
Toxicity usually occurs at concentrations more than 1.5 mmol/L, but may develop at lower concentrations, especially in older people.
What are some common adverse effects of lithium?
- Leucocytosis
- Increased calcium
- T wave changes, Tremor
- Hypothyroidism
- Increased PTH
- Ugly - acne, weight gain, psoriasis
- Metallic taste
metallic taste, nausea, diarrhoea, epigastric discomfort, weight gain, fatigue, headache, vertigo, tremor, acne, psoriasis, leucocytosis, nephrotoxicity, hypothyroidism (usually asymptomatic), hypercalcaemia, hyperparathyroidism, benign T wave changes on ECG
Name some first + second gen antipsychotics. What is the difference?
Distinction between typical/atypical groups is not clearly defined byt rests on:
- receptor profile
- incidence of extrapyramidal side effects (less in atypical group)
- efficacy in ‘treatment resistant’ groups - specific to clozapine
- efficacy against negative symptoms
FIRST GEN (typical)
- chlorpromazine
- haloperidol
- droperidol
- fluphenazine
- flupentixol
- clopentixol
SECOND GEN (atypical)
- clozapine
- olanzapine
- risperidone
- sertindole
- quetiapine
- amisulpride
- paliperidone
- aripiprazole
- ziprasidone
Common adverse effects of sodium valproate
- Vomiting
- Appetite increase
- Loss of hair
- Parasthesia
- Really sleepy
- Ovaries - PCOS/irregularity
- Ataxia
- Tremor
- Elevated aminotransferases
nausea, vomiting, increased appetite, weight gain, tremor (dose-related), thinning or loss of scalp hair (usually temporary), paraesthesia, drowsiness, dizziness, memory impairment, ataxia, elevated aminotransferase concentrations (dose-related), asymptomatic hyperammonaemia, thrombocytopenia (dose-related), menstrual irregularities, polycystic ovaries, hyperandrogenism in females
Suicide risk in patients with bipolar?
15 x higher than the general population
