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Y4 Psychiatry: Conditions > Bipolar Affective Disorder > Flashcards

Bipolar Affective Disorder Flashcards

1
Q

What is bipolar affective disorder (BPAD)?

A

Bipolar affective disorder (previously known as ‘ manic depression ’) is a chronic episodic mood disorder, characterised by at least one episode of mania (or hypomania ) and a further episode of mania or depression.

Either one can occur first but the term bipolar also includes those who at the time of diagnosis have suffered only manic episodes, as all cases of mania will eventually develop depression.

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2
Q

Briefly describe the pathophysiology/ aetiology of BPAD

A

The cause of bipolar affective disorder (BPAD) involves both biological and environmental factors.

The monoamine hypothesis is applicable to elevated mood just as it is to depressed mood. It states that elevated mood is a result of increased central monoamines (noradrenaline and serotonin).

Dysfunction of the HPA axis (abnormal secretion of cortisol, as found in unipolar depression) and dysfunction of the hypothalamic– pituitary– thyroid axis may contribute to BPAD.

BPAD shows strong heritability with monozygotic twin studies showing a 40– 70% concordance rate. The lifetime risk of developing BPAD for 1st degree relatives of a BPAD patient is 5– 10%.

Stressful or significant life events may precipitate the onset of a first manic episode.

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3
Q

What is the mean age of onset of BPAD?

A

19 years of age.

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4
Q

Who is commonly affected by BPAD?

A

In the UK, the incidence of BPAD is higher in black and other minority ethnic groups than in the white population.

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5
Q

Are males or females more likely to be affected by BPAD?

A

The male to female affected ratio is 1:1.

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6
Q

What are the risk factors for BPAD?

A
  • Age (early 20’s)
  • Strong family history
  • Anxiety disorders
  • Substance misuse
  • After depression
  • Stressful life events
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7
Q

What are the symptoms of mania?

Note: I DIG FASTER

A
  • Irritability
  • Distractibility/ disinhibited (sexual, social and spending)
  • Insight impaired/ increased libido
  • Grandiose delusions
  • Flight of ideas
  • Activity/ appetite increased
  • Sleep decreased
  • Talkative (pressure of speech)
  • Elevated mood/ energy increased
  • Reduced concentration/ reckless behaviour and spending
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8
Q

What the the 3 types of mania?

A
  1. Hypomania
  2. Mania without psychosis
  3. Mania with psychosis
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9
Q

What is hypomania?

A

Mildly elevated mood or irritable mood present for ≥4 days.

Symptoms of mania, where present, are to a lesser extent than true mania.

Considerable interference with work and social life but not severe disruption.

Partial insight may be preserved.

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10
Q

What is mania without psychosis?

A

As with hypomania but to a greater extent.

Symptoms present for >1 week, with complete disruption of work and social activities.

May have grandiose ideas and excessive spending could lead to debts.

There may be sexual disinhibition and reduced sleep may lead to exhaustion.

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11
Q

What is mania with psychosis?

A

Severely elevated or suspicious mood with the addition of psychotic features such grandiose or persecutory delusions and auditory hallucinations that are mood congruent.

Patient may show signs of aggression.

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12
Q

Briefly differentiate between hypomania, mania without psychosis and mania with psychosis

A
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13
Q

Briefly differentiate between bipolar I, bipolar II and radpic cycling

A

Bipolar I: involves periods of severe mood episodes from mania to depression.

Bipolar II: milder form of mood elevation, involving milder episodes of hypomania that alternate with periods of severe depression.

Rapid cycling: more than four mood swings in a 12-month period with no intervening asymptomatic periods. Poor prognosis.

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14
Q

Briefly describe the ICD-10 Criteria for mania

A

Mania requires 3/9 symptoms to be present:

  1. Grandiosity/inflated self-esteem
  2. Decreased sleep
  3. Pressure of speech
  4. Flight of ideas
  5. Distractibility
  6. Psychomotor agitation (restlessness)
  7. Reckless behaviour, e.g. spending sprees, reckless driving
  8. Loss of social inhibitions (leading to inappropriate behaviour)
  9. Marked sexual energy
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15
Q

Briefly describe the ICD-10 Criteria for BPAD

A

Bipolar affective disorder requires at least two episodes in which a person’s mood and activity levels are significantly disturbed- one of which MUST be mania or hypomania.

ICD-10 divides bipolar disorder into five states:

  1. Currently hypomanic
  2. Currently manic
  3. Currently depressed
  4. Mixed Disorder
  5. In remission
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16
Q

Briefly describe the MSE for BPAD

A

Appearance: flamboyant/unusual combination of clothing, heavy makeup and jewellery. Personal neglect when condition is severe.

Behaviour: overfamiliar, disinhibited (flirtatious, aggressive), increased psychomotor activity, distractible, restless.

Speech: loud, ↑ rate and quantity, pressure of speech, uninterruptible, puns and rhymes, neologisms.

Mood: elated, euphoric, and/or irritable.

Thought: optimistic, pressured thought, flight of ideas, loosening of association, circumstantiality, tangentiality, overvalued ideas, grandiose/persecutory delusions.

Perception: usually no hallucinations. Mood-congruent auditory hallucinations may occur.

Cognition: attention and concentration often impaired. Fully oriented.

Insight: generally very poor.

17
Q

What are the investigations for BPAD?

A

Self-rating scales: e.g. Mood Disorder Questionnaire.

Blood tests: FBC (routine), TFTs (both hyper/hypothyroidism are differentials), U&Es (baseline renal function with view to starting lithium), LFTs (baseline hepatic function with view to starting mood stabilizers), glucose, calcium (biochemical disturbances can cause mood symptoms).

Urine drug test: illicit drugs can cause manic symptoms.

CT head: to rule out space-occupying lesions (can cause manic symptoms such as disinhibition).

18
Q

Briefly describe the management of BPAD

Note: CALMER

A
  • Consider hospitalisation
  • Antipsychotics (atypical)
  • Lorazepam
  • Mood stabilisers (e.g. lithium)
  • ECT
  • Risk assessment
19
Q

Briefly describe the bio-psychosocial approach to the management of BPAD

A

Biological: mood stabilisers, benzodiazepines, antipsychotics and ECT (for uncontrolled mania).

Psychological: psychoeducation and CBT.

Social: social support groups, self-help groups and encourage calming activities.

20
Q

When is hospitalisation required for BPAD?

A

The Mental Health Act is needed if the patient is violent or a risk to self. Hospitalisation will be required if there is:

  1. Reckless behaviour causing risk to patient or others
  2. Significant psychotic symptoms
  3. Impaired judgement
  4. Psychomotor agitation
21
Q

When is CBT needed in BPAD?

A

For bipolar depression, offer a high-intensity psychological intervention (e.g. CBT).

22
Q

When should ECT be offered?

A

ECT is not first-line, but it can be used when antipsychotic drugs are ineffective and the patient is so severely disturbed that further medication or awaiting natural recovery is not feasible.

23
Q

Briefly describe the follow up needed after an acute episode of BPAD

A

Patients who present with an acute episode should be followed-up once a week initially and then 2– 4 weekly for the first few months.

24
Q

Briefly describe the pharmacological management of acute manic episode/ mixed episode

A

First-line offer an antipsychotic such as olanzapine, risperidone or quetiapine (haloperidol is also effective). They have a rapid onset of action compared to mood stabilizers and are therefore used in severe mania.

If the first antipsychotic is not effective or poorly tolerated then a second is usually offered. Mood stabilizers namely lithium or if not suitable, valproate should be added as second-line treatment.

Benzodiazepines may further be required to aid sleep and reduce agitation.

Rapid tranquilization may be required with haloperidol and/or lorazepam .

25
Q

Briefly describe the pharmacological management of a bipolar depressive episode

A

Atypical antipsychotics are effective in bipolar depression. Options include olanzapine (combined with fluoxetine), olanzapine alone or quetiapine alone.

Mood stabilizer option is lamotrigine. Lithium is also effective.

Antidepressants alone are usually avoided- if used, they should be used with care in BPAD, even if depression is the main feature, as they have the potential to induce mania. They should be prescribed in conjunction with the cover of anti-manic medication.

26
Q

Briefly describe the long-term management of bipolar affective disorder

A

4 weeks after an acute episode has resolved, lithium should be offered first-line to prevent relapses.

If lithium is ineffective consider adding valproate. Olanzapine or quetiapine are alternative options.

27
Q

What is the role of lithium in managing BPAD?

A

Lithium is the standard long-term therapy in bipolar affective disorder. It minimizes the risk of relapse and improves quality of life.

28
Q

What parameters must be checked before starting lithium?

A

Before lithium treatment is started U&Es (lithium has renal excretion), TFTs, pregnancy status and baseline ECG should be checked.

Lithium has a narrow therapeutic window and so drug levels should be closely monitored and patients should be informed of potential side effects and toxicity.

29
Q

What are the side effects of lithium therapy?

A

Side effects include:

  • Polydipsia
  • Polyuria
  • Fine tremor
  • Weight gain
  • Oedema
  • Hypothyroidism
  • Impaired renal function
  • Memory problems
  • Teratogenicity (in 1st trimester)
30
Q

Briefly describe the presentation of lithium toxicity

A

Signs of toxicity (1.5– 2.0 mmol/L): nausea and vomiting, coarse tremor, ataxia, muscle weakness and apathy.

Signs of severe toxicity (>2.0 mmol/L): nystagmus, dysarthria, hyperreflexia, oliguria, hypotension, convulsions and coma.

31
Q

Briefly describe the monitoring of lithium use

A

Due to its side effect profile and risk of toxicity lithium is strictly regulated:

  • Lithium levels- 12 hours following first dose, then weekly until therapeutic level (0.5– 1.0 mmol/L) has been stable for 4 weeks
    • Once stable check every 3 months
  • U&Es- every 6 months
  • TFTs- every 12 months
32
Q

As well as lithium, what drug is used to treat rapid cycling BPAD?

A

A combination of lithium and sodium valproate is first-line treatment for rapid cycling.

33
Q

What differentials should be considered for BPAD?

A
  • Mood disorders
    • Hypomania, mania, mixed episode and cyclothymia
  • Psychotic disorders
    • Schizophrenia and schizoaffective disorder
  • Secondary to medical condition
    • Hyper/hypothyroidism, Cushing’s disease, cerebral tumour (e.g. frontal lobe lesion with disinhibition) and stroke
  • Drug related
    • Illicit drug ingestion (e.g. amphetamines, cocaine), acute drug withdrawal and side effect of corticosteroid use
  • Personality disorders
    • Histrionic and emotionally unstable

Y4 Psychiatry: Conditions (23 decks)

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