Bipolar Flashcards
What are the symptoms of hypomania?
Present for 4 days Mild elevation or instability of mood Increased energy Mild overspending, risk-taking Increased sociability, overfamiliarity Distractibility Increased sexual energy Decreased need for sleep
What are the symptoms of mania?
Present for a week or be severe enough to necessitate inpatient admission Mood is elevated, expansive, irritable Increased activity Reckless behaviour Disinhibition Marked distractibility Markedly increased sexual energy Sleep severely impaired or absent Grandiosity Flight of ideas
What are the symptoms of mania and psychotic symptoms?
Often mood congruent
e.g. Inflated self-esteem and ideation can develop into fully-formed grandiose beliefs
e.g. Irritability and suspiciousness can develop into delusions of persecution
Hallucinations occur less frequently
How is bipolar diagnosed?
Need to elicit current symptoms and past episodes
Absolute numbers of symptoms are relatively unimportant
One episode of mania = Acute mania
Two episodes of mania = Bipolar affective disorder
One episode of mania, one episode of depression = Bipolar affective disorder
Two episodes of depression = Recurrent depressive disorder
What is Dysthymia?
Refers to the mood that is chronically low, where no episode justifies a diagnosis of a depressive disorder.
What is cyclothymia?
Persistent instability of mood with a number of periods of mild depressive symptoms or mild elation, where no episode meets the threshold for a depressive or a manic episode.
What is the epidemiology of bipolar?
Lifetime risk - 1%
Equal prevalence in men and women
Onset generally late teenage to early twenties
What is the aetiology of bipolar?
Genetics:
increased risk of bipolar disorder, unipolar depression and schizoaffective disorder
65% in identical twins, 10% risk in first degree relatives
Life events:
prolonged stressful circumstances or vulnerability factors can predispose to or preciptate episodes of affective disturbance
Substance misuse
What is the prognosis for bipolar?
The average length of a manic episode, whether treated or untreated, is 6 months
Following a manic episode, at least 90% will have a further episode of mood disturbance
Patients with bipolar disorder experience, on average, 10 episodes of mood disturbance, over a 25-year follow-up period
Recovery from acute episodes tends to be good, but the long term prognosis can be poor. Less than 20% achieve a period of 5 years of clinical stability, with good social/occupational performance
People with bipolar disorder are around 20-30 times more likely to die by suicide than are the general population
Why can relapse occur in bipolar?
Non-concordance with medication Life events, social stressors Disruption of circadian rhythm Substance misuse Childbirth (puerperal psychosis) Natural course of the illness
What is used for the management of acute mania?
Antipsychotic (haloperidol, olanzapine, risperidoen, quetiapine) Lithium or valprorate Consider benzodiazepines Stop antidepressants Low stimulus environment
What is the management for bipolar depression?
2nd line antipsychotic (olanzapine, quetiapine)
Antidepressant (needs to be used with anti-manic agent)
Mood stabiliser (lithium, valproate, lamotrigine)
CBT
What testing needs to be done when a patient is taking lithium?
Levels weekly whilst initiating and after any dose change and every 3 months thereafter; also need to check U&E and TFT every 6 months
For which medications does contraceptive advice need to be given?
folic acid if lithium, valproate, carbamazepine are prescribed to women of childbearing age.
What are the indications for mood stabilisers?
Prophylaxis for bipolar disorder
Single manic episode associated with significant risk
Illness with significant impact on functioning
Two or more acute episodes
Treatment of an acute mania/hypomania
Generally not first line
Treatment of bipolar depression
Augmentation for antidepressants in treatment-resistant depression
What is the therapeutic range for lithium?
narrow therapeutic range
essential to titrate lithium dosing and monitor lithium levels after a minimum of 5 days, aiming for a range of 0.4-1.2 mmol/L.
What are the side effects of lithium?
GI upset Fine tremor Polyuria Polydipsia Metallic taste in mouth Weight gain Oedema
What are the symptoms of lithium toxicity?
Diarrhoea
Course tremor
Ataxia
Dysarthria
Nystagmus
Confusion
Convulsions
Associated with ow sodium diets, dehydration, drug interactions (NSAIDS, ACE inhibitors, thiazide and loop diuretics), Addison’s
Occurs over 1.5mmol/L
Over 2.5mmol serious toxicity requiring harm-dialysis
Monitoring:
Lithium level (once every 3 months)
Urea & Electrolytes (once every 6 months)
Thyroid Function Test (once every 6 months)
What are the teratogenic effects of lithium?
malformations are cardiac defects (ASD and VSDs)
Ebstein’s anomaly (abnormality of the tricuspid valve), with lithium exposure in the first trimester the rate of Ebstein’s anomaly increases from 0.00005% to 0.1%.
What are the teratogenic effects of valproate?
Congenital Malformation: 8-10% Neural Tube defect: 3% Low verbal IQ: 30% Autism: 6% Valproate syndrome: 6%
What are the side effects of lamotrigine?
Dose needs to be titrated due to concerns with the development of Stevens-Johnson Syndrome.
Teratogenic (less): risk of cleft lip/palate
What are the psychotic symptoms?
Disordered thought form
- Loosening of associations
- Neologisms
- Thought blocking
Circumstantiality
- Over-inclusive details during speech and unnecessary asides and diversions
- Does eventually connect from starting point to desired destination
Tangentiality
- Speaker diverts from initial train of thought
- Never returns to original point
Flight of idea
Abnormal beliefs
- Grandiose delusions
- Persecutory delusions
Perceptual disturbance
- Sounds seem louder = hyperacusis
- Colours seem brighter/more vivid = hyperaesthesia
- Hallucinations - often mood congruent and second person auditory
Which conditions can cause an elevated/irritable mood?
Space occupying lesions - especially frontal ○ Temporal lobe epilepsy ○ Cushing’s disease ○ Huntington's disease ○ Hyperthyroidism ○ MD, Renal failure, SLE ○ Vitamin B12 Deficiency
Which drugs can cause symptoms?
Amphetamines Cocaine Hallucinogens Legal highs Anabolic steroids Antidepressants Corticosteroids Dopaminergic agents - L-Dopa
What is first line for acute mania?
Lithium and semi- sodium valproate
What is the management for an acute depressive episode?
Avoid routine use of antidepressants
Optimise prophylactic treatment:
○ Lithium
○ Lamotrigine
Olanzapine or Quetiapine as monotherapy or with Fluoxetine
Add an SSRI if there is no improvement after 4 weeks
What is the long term management for recurrent affective episodes?
Lithium
Atypical antipsychotics - Olanzapine, Quetiapine
Anti-epileptic medication - Sodium Valproate, Carbamazepine, Lamotrigine
