Bipolar Affective Disorder Flashcards
What is Bipolar?
Part of the ‘mood/affective disorders’
Episodes of mania/hypomania and depression
Interspersed by periods of normal mood and functioning
Aspects of BPAD
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Epidemiology - BPAD
- Sex ?
- Average age of onset …. years
- 90% before … years
- Life time prevalence: 1-3% general population
- Lifetime competed suicide rates 10 – 15%
- Sex: ♀ = ♂
- Average age of onset 20 years
- 90% before 30 years
- Life time prevalence: 1-3% general population
- Lifetime competed suicide rates 10 – 15%
Epidemiology - BPAD
- Sex: ♀ = ♂
- Average age of onset 20 years
- ….% before 30 years
- Life time prevalence: …-…% general population
- Lifetime competed suicide rates 10 – 15%
- Sex: ♀ = ♂
- Average age of onset 20 years
- 90% before 30 years
- Life time prevalence: 1-3% general population
- Lifetime competed suicide rates 10 – 15%
Epidemiology - BPAD
- Sex?
- Average age of onset 20 years
- 90% before 30 years
- Life time prevalence: 1-3% general population
- Lifetime competed suicide rates … – ….%
- Sex: ♀ = ♂
- Average age of onset 20 years
- 90% before 30 years
- Life time prevalence: 1-3% general population
- Lifetime competed suicide rates 10 – 15%
Epidemiology - BPAD
- Sex: ♀ = ♂
- Average age of onset … years
- 90% before … years
- Life time prevalence: ..-..% general population
- Lifetime competed suicide rates 10 – 15%
- Sex: ♀ = ♂
- Average age of onset 20 years
- 90% before 30 years
- Life time prevalence: 1-3% general population
- Lifetime competed suicide rates 10 – 15%
Aetiology of Bipolar
- Strong genetic component
- Increased risk if 1st degree relative affected (up to 10%)
- MZ twin concordance: …%
- DZ twin concordance: …%
- Heritability 60%
- TRIGGERS
- … stress
- … disturbance
- Strong genetic component
- Increased risk if 1st degree relative affected (up to 10%)
- MZ twin concordance: 60%
- DZ twin concordance: 20%
- Heritability 60%
- TRIGGERS
- Psychosocial stress
- Sleep disturbance
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Aetiology of Bipolar
- Strong … component
- Increased risk if 1st degree relative affected (up to …%)
- …Z twin concordance: 60%
- …Z twin concordance: 20%
- Heritability 60%
- TRIGGERS
- Psychosocial stress
- Sleep disturbance
- Strong genetic component
- Increased risk if 1st degree relative affected (up to 10%)
- MZ twin concordance: 60%
- DZ twin concordance: 20%
- Heritability 60%
- TRIGGERS
- Psychosocial stress
- Sleep disturbance
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Aetiology of Bipolar
- Strong genetic component
- Increased risk if 1st degree relative affected (up to 10%)
- MZ twin concordance: 60%
- DZ twin concordance: 20%
- Heritability …%
- TRIGGERS
- Psychosocial …
- Sleep …
- Strong genetic component
- Increased risk if 1st degree relative affected (up to 10%)
- MZ twin concordance: 60%
- DZ twin concordance: 20%
- Heritability 60%
- TRIGGERS
- Psychosocial stress
- Sleep disturbance
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Aetiology of Bipolar
- Strong genetic component
- Increased risk if … degree relative affected (up to 10%)
- MZ twin concordance: 60%
- DZ twin concordance: 20%
- Heritability …%
- TRIGGERS
- Psychosocial stress
- Sleep disturbance
- Strong genetic component
- Increased risk if 1st degree relative affected (up to 10%)
- MZ twin concordance: 60%
- DZ twin concordance: 20%
- Heritability 60%
- TRIGGERS
- Psychosocial stress
- Sleep disturbance
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DSM-V criteria - BPAD
- BPAD Type I:
- 1+ manic episode (>… days)
- (With or without major depressive episode)
- BPAD Type II:
- 1+ hypomanic episode (>… days)
- 1 major depressive episode
- (NO episodes of …)
- BPAD Type I:
- 1+ manic episode (>7 days)
- (With or without major depressive episode)
- BPAD Type II:
- 1+ hypomanic episode (>4 days)
- 1 major depressive episode
- (NO episodes of mania)
DSM-V criteria - BPAD
- BPAD Type I:
- …+ manic episode (>7 days)
- (With or without … … episode)
- BPAD Type II:
- 1+ … episode (>4 days)
- 1 … … episode
- (NO episodes of mania)
- BPAD Type I:
- 1+ manic episode (>7 days)
- (With or without major depressive episode)
- BPAD Type II:
- 1+ hypomanic episode (>4 days)
- 1 major depressive episode
- (NO episodes of mania)
DSM-V criteria - BPAD
- BPAD Type I:
- 1+ manic episode (>…. days)
- (With or without major depressive episode)
- BPAD Type II:
- 1+ …. episode (>… days)
- 1 major depressive episode
- (…. episodes of mania)
- BPAD Type I:
- 1+ manic episode (>7 days)
- (With or without major depressive episode)
- BPAD Type II:
- 1+ hypomanic episode (>4 days)
- 1 major depressive episode
- (NO episodes of mania)
ICD-10 - BPAD
- …+ episodes
- Manic
- Hypomanic
- Major depressive
- 2+ episodes
- Manic
- Hypomanic
- Major depressive
DIG FAST medical mnemonic – symptoms of mania
- D…
- I….
- Grandiosity
- Flight of Ideas / racing thoughts
- Action Increase – Excess Energy
- S… changes – … need for …
- Talkativeness – Pressure of Speech
- DIGFAST
- Distractibility
- Indiscretion (Risk Taking Behaviour)
- Grandiosity
- Flight of Ideas / racing thoughts
- Action Increase – Excess Energy
- Sleep changes – Decreased need for sleep
- Talkativeness – Pressure of Speech
DIG FAST medical mnemonic – symptoms of mania
- Distractibility
- Indiscretion (… Taking Behaviour)
- G….
- F…
- Action Increase – … Energy
- Sleep changes – Decreased need for sleep
- Talkativeness – … of Speech
- DIGFAST
- Distractibility
- Indiscretion (Risk Taking Behaviour)
- Grandiosity
- Flight of Ideas / racing thoughts
- Action Increase – Excess Energy
- Sleep changes – Decreased need for sleep
- Talkativeness – Pressure of Speech
Hypomania
- Elevated/irritable mood >… days
- 3+ of: (4+ if mood …)
- Increased activity/restlessness
- Increased talkativeness/pressure of speech
- Increased sociability
- Distractibility
- Insomnia
- Increased sexual energy, overfamiliarity
- Mild reckless, irresponsible behaviour
- Leading to some interference with personal function
- Elevated/irritable mood >4 days
- 3+ of: (4+ if mood irritable)
- Increased activity/restlessness
- Increased talkativeness/pressure of speech
- Increased sociability
- Distractibility
- Insomnia
- Increased sexual energy, overfamiliarity
- Mild reckless, irresponsible behaviour
- Leading to some interference with personal function
What does DIG FAST stand for?
- Distractibility
- Indiscretion (Risk Taking Behaviour)
- Grandiosity
- Flight of Ideas / racing thoughts
- Action Increase – Excess Energy
- Sleep changes – Decreased need for sleep
- Talkativeness – Pressure of Speech
Acronym for Bipolar manic episodes
Define Hypomania
- Elevated/irritable mood >4 days
- 3+ of: (4+ if mood irritable)
- Increased activity/restlessness
- Increased talkativeness/pressure of speech
- Increased sociability
- Distractibility
- Insomnia
- Increased sexual energy, overfamiliarity
- Mild reckless, irresponsible behaviour
- Leading to some interference with personal function
Hypomania
- Elevated/irritable mood >4 days
- 3+ of: (4+ if mood irritable)
- Increased activity/restlessness
- Increased …/… of …
- Increased …
- Distractibility
- I…
- Increased … energy, overfamiliarity
- Mild reckless, irresponsible behaviour
- Leading to some interference with personal function
- Elevated/irritable mood >4 days
- 3+ of: (4+ if mood irritable)
- Increased activity/restlessness
- Increased talkativeness/pressure of speech
- Increased sociability
- Distractibility
- Insomnia
- Increased sexual energy, overfamiliarity
- Mild reckless, irresponsible behaviour
- Leading to some interference with personal function
Hypomania
- Elevated/irritable mood >4 days
- 3+ of: (4+ if mood irritable)
- Increased …/…
- Increased …/pressure of speech
- Increased sociability
- D…
- Insomnia
- Increased sexual energy, overfamiliarity
- Mild …, … behaviour
- Leading to some interference with … …
- Elevated/irritable mood >4 days
- 3+ of: (4+ if mood irritable)
- Increased activity/restlessness
- Increased talkativeness/pressure of speech
- Increased sociability
- Distractibility
- Insomnia
- Increased sexual energy, overfamiliarity
- Mild reckless, irresponsible behaviour
- Leading to some interference with personal function
Hypomania
- …/… mood >4 days
- …+ of: (4+ if mood …)
- Increased activity/restlessness
- Increased talkativeness/pressure of speech
- Increased sociability
- Distractibility
- Insomnia
- Increased sexual energy, overfamiliarity
- Mild reckless, irresponsible behaviour
- Leading to some interference with personal function
- Elevated/irritable mood >4 days
- 3+ of: (4+ if mood irritable)
- Increased activity/restlessness
- Increased talkativeness/pressure of speech
- Increased sociability
- Distractibility
- Insomnia
- Increased sexual energy, overfamiliarity
- Mild reckless, irresponsible behaviour
- Leading to some interference with personal function
Define Mania
- >1 week (or any duration if hospitalised)
- Predominantly elevated/irritable mood
- 3+ of: (4 if mood irritable)
- Increased activity/restlessness
- Foolhardy/reckless behaviour
- Distractibility
- Talkativeness/pressure of speech
- Reduced need for sleep
- Flight of ideas/subjective feeling of racing thoughts
- Increased self esteem or grandiosity
- Psychotic symptoms
- Leading to severe interference with personal function
Mania
- >… … (or any duration if hospitalised)
- Predominantly elevated/irritable mood
- 3+ of: (4 if mood irritable)
- Increased activity/restlessness
- Foolhardy/reckless behaviour
- D…
- Talkativeness/pressure of speech
- … need for sleep
- Flight of ideas/subjective feeling of racing thoughts
- Increased self esteem or grandiosity
- … symptoms
- Leading to severe interference with personal function
- >1 week (or any duration if hospitalised)
- Predominantly elevated/irritable mood
- 3+ of: (4 if mood irritable)
- Increased activity/restlessness
- Foolhardy/reckless behaviour
- Distractibility
- Talkativeness/pressure of speech
- Reduced need for sleep
- Flight of ideas/subjective feeling of racing thoughts
- Increased self esteem or grandiosity
- Psychotic symptoms
- Leading to severe interference with personal function
Mania
- >1 week (or any duration if hospitalised)
- Predominantly …/…. mood
- …+ of: (… if mood irritable)
- Increased activity/restlessness
- Foolhardy/reckless behaviour
- Distractibility
- Talkativeness/pressure of speech
- Reduced need for sleep
- Flight of ideas/subjective feeling of racing thoughts
- Increased self esteem or grandiosity
- Psychotic symptoms
- Leading to severe interference with personal function
- >1 week (or any duration if hospitalised)
- Predominantly elevated/irritable mood
- 3+ of: (4 if mood irritable)
- Increased activity/restlessness
- Foolhardy/reckless behaviour
- Distractibility
- Talkativeness/pressure of speech
- Reduced need for sleep
- Flight of ideas/subjective feeling of racing thoughts
- Increased self esteem or grandiosity
- Psychotic symptoms
- Leading to severe interference with personal function
Psychotic symptoms in mania
- Delusions - usually mood-…
- Grandiose (fame, wealth, power…)
- Persecutory (if irritable)
- Hallucinations
- … person auditory
- Formal … disorder
- Circumstantiality
- Tangentiality
- … of ideas
- Communication may be difficult!
- Delusions - usually mood-congruent
- Grandiose (fame, wealth, power…)
- Persecutory (if irritable)
- Hallucinations
- 2nd person auditory
- Formal thought disorder
- Circumstantiality
- Tangentiality
- Flight of ideas
- Communication may be difficult!
Psychotic symptoms in mania
- Delusions - usually mood-congruent
- … (fame, wealth, power…)
- … (if irritable)
- Hallucinations
- 2nd person auditory
- … thought disorder
- Circumstantiality
- T…
- Flight of ideas
- Communication may be difficult!
- Delusions - usually mood-congruent
- Grandiose (fame, wealth, power…)
- Persecutory (if irritable)
- Hallucinations
- 2nd person auditory
- Formal thought disorder
- Circumstantiality
- Tangentiality
- Flight of ideas
- Communication may be difficult!
Hypomania vs mania
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DSM-V criteria - BPAD
- BPAD Type I:
- ….+ manic episode
- (With or without major depressive episode)
- BPAD Type II:
- ….+ hypomanic episode
- 1 major depressive episode
- (NO episodes of mania)
- BPAD Type I:
- 1+ manic episode
- (With or without major depressive episode)
- BPAD Type II:
- 1+ hypomanic episode
- 1 major depressive episode
- (NO episodes of mania)
DSM-V criteria - BPAD
- BPAD Type I:
- 1+ manic episode
- (With or without major depressive episode?)
- BPAD Type II:
- 1+ hypomanic episode
- (with or without major depressive episode?)
- (NO episodes of mania)
- BPAD Type I:
- 1+ manic episode
- (With or without major depressive episode)
- BPAD Type II:
- 1+ hypomanic episode
- 1 major depressive episode
- (NO episodes of mania)
DSM-V criteria - BPAD
- BPAD Type I:
- 1+ … episode
- (With or without major depressive episode)
- BPAD Type II:
- 1+ … episode
- 1 major depressive episode
- (NO episodes of mania)
- BPAD Type I:
- 1+ manic episode
- (With or without major depressive episode)
- BPAD Type II:
- 1+ hypomanic episode
- 1 major depressive episode
- (NO episodes of mania)
DSM-V criteria - BPAD
- BPAD Type …:
- 1+ manic episode
- (With or without major depressive episode)
- BPAD Type …:
- 1+ hypomanic episode
- 1 major depressive episode
- (NO episodes of mania)
- BPAD Type I:
- 1+ manic episode
- (With or without major depressive episode)
- BPAD Type II:
- 1+ hypomanic episode
- 1 major depressive episode
- (NO episodes of mania)
ICD-10 - BPAD
- •2+ episodes
- •Manic
- •Hypomanic
- •Major depressive
BPAD II
- Which gender more prevalent?
- More difficult to Diagnose
- Needs more careful history
- … symptoms may not be spontaneously reported
- May need collateral
- Important to Dx:
- … alcohol, substance misuse
- ^frequency and severity of depressive episodes
- May need different treatment – … …
- BPAD II can progress to BPAD I
- F >M
- More difficult to Diagnose
- Needs more careful history
- Hypomanic symptoms may not be spontaneously reported
- May need collateral
- Important to Dx:
- Increased alcohol, substance misuse
- ^frequency and severity of depressive episodes
- May need different treatment – mood stabilisers
- BPAD II can progress to BPAD I
BPAD II
- Which gender more prevalent?
- More difficult to Diagnose
- Needs more careful history
- … symptoms may not be spontaneously reported
- May need collateral
- Important to Dx:
- … alcohol, substance misuse
- ^frequency and severity of … episodes
- May need different treatment – … …
- BPAD II can progress to BPAD I
- F >M
- More difficult to Diagnose
- Needs more careful history
- Hypomanic symptoms may not be spontaneously reported
- May need collateral
- Important to Dx:
- Increased alcohol, substance misuse
- ^frequency and severity of depressive episodes
- May need different treatment – mood stabilisers
- BPAD II can progress to BPAD I
Subtypes of BPAD
- Rapid cycling BPAD
- ….+ episodes in single year
- … prognosis
- Cyclothymia
- Chronic, >2 years
- Periods of mild elation and depression
- Rapid cycling BPAD
- 4+ episodes in single year
- Poor prognosis
- Cyclothymia
- Chronic, >2 years
- Periods of mild elation and depression
Subtypes of BPAD
- Rapid cycling BPAD
- ….+ episodes in single year
- … prognosis
- Cyclothymia
- Chronic, >… years
- Periods of mild … and …
- Rapid cycling BPAD
- 4+ episodes in single year
- Poor prognosis
- Cyclothymia
- Chronic, >2 years
- Periods of mild elation and depression
What is rapid cycling BPAD?
- 4+ episodes in single year
- Poor prognosis
What is Cyclothymia?
- Chronic, >2 years
- Periods of mild elation and depression
Differential diagnosis of mania
- …
- Secondary to medical condition
- Eg thyroid disease, MS, brain lesions
- Delirium
- Secondary to substance misuse
- Secondary to medication eg steroids, levodopa
- Secondary to medical condition
- …
- Schizoaffective disorder
- Schizophrenia
- …
- BPAD
- cyclothymia
- …
- EUPD
- Organic
- Secondary to medical condition
- Eg thyroid disease, MS, brain lesions
- Delirium
- Secondary to substance misuse
- Secondary to medication eg steroids, levodopa
- Secondary to medical condition
- Psychotic
- Schizoaffective disorder
- Schizophrenia
- Affective
- BPAD
- cyclothymia
- Personality
- EUPD
Differential diagnosis of mania
- Organic
- … to medical condition
- Eg thyroid disease, MS, brain lesions
- Delirium
- Secondary to … misuse
- Secondary to … eg steroids, levodopa
- … to medical condition
- Psychotic
- … disorder
- Schizophrenia
- Affective
- …
- cyclo..
- Personality
- E…
- Organic
- Secondary to medical condition
- Eg thyroid disease, MS, brain lesions
- Delirium
- Secondary to substance misuse
- Secondary to medication eg steroids, levodopa
- Secondary to medical condition
- Psychotic
- Schizoaffective disorder
- Schizophrenia
- Affective
- BPAD
- cyclothymia
- Personality
- EUPD
Treatment of acute manic episodes: General principles
- Reduce … stimuli
- Assess for possible contributing substances
- Recreational/prescribed drugs
- … … screen
- Limit potential … behaviour
- Eg Limit access to cars, bank accounts, credit cards
- Consider consequences of reckless behaviour
- Sexual health - emergency contraception/STI screen
- Reduce external stimuli
- Assess for possible contributing substances
- Recreational/prescribed drugs
- Urine drug screen
- Limit potential reckless behaviour
- Eg Limit access to cars, bank accounts, credit cards
- Consider consequences of reckless behaviour
- Sexual health - emergency contraception/STI screen
Treatment of acute manic episodes: General principles
- Reduce external stimuli
- Assess for possible contributing substances
- …/… drugs
- Urine drug screen
- Limit potential … behaviour
- Eg Limit access to cars, bank accounts, credit cards
- Consider consequences of … behaviour
- … health - emergency contraception/STI screen
- Reduce external stimuli
- Assess for possible contributing substances
- Recreational/prescribed drugs
- Urine drug screen
- Limit potential reckless behaviour
- Eg Limit access to cars, bank accounts, credit cards
- Consider consequences of reckless behaviour
- Sexual health - emergency contraception/STI screen
Treatment of acute manic episodes
- STOP any …
- 1) Antipsychotic- 1 of:
- O…
- H…
- QUETIAPINE
- RISPERIDONE
- N.B. NICE guidance – there may be better choices for your individual patient
- 2) Alternative antipsychotic (AP)
- 3) Lithium + AP
- 4) Valproate + AP
- Short term benzodiazepine for sedation
- STOP any antidepressant
- 1) Antipsychotic- 1 of:
- OLANZAPINE
- HALOPERIDOL
- QUETIAPINE
- RISPERIDONE
- N.B. NICE guidance – there may be better choices for your individual patient
- 2) Alternative antipsychotic (AP)
- 3) Lithium + AP
- 4) Valproate + AP
- Short term benzodiazepine for sedation
Treatment of acute manic episodes
- STOP any antidepressant
- 1) Antipsychotic- 1 of:
- OLANZAPINE
- HALOPERIDOL
- Q…
- R…
- N.B. NICE guidance – there may be better choices for your individual patient
- 2) Alternative antipsychotic (AP)
- 3) … + AP
- 4) Valproate + AP
- Short term … for sedation
- STOP any antidepressant
- 1) Antipsychotic- 1 of:
- OLANZAPINE
- HALOPERIDOL
- QUETIAPINE
- RISPERIDONE
- N.B. NICE guidance – there may be better choices for your individual patient
- 2) Alternative antipsychotic (AP)
- 3) Lithium + AP
- 4) Valproate + AP
- Short term benzodiazepine for sedation
Treatment of acute manic episodes
- STOP any antidepressant
- 1) Antipsychotic- 1 of:
- OLANZAPINE
- H..
- QUETIAPINE
- R…
- N.B. NICE guidance – there may be better choices for your individual patient
- 2) Alternative antipsychotic (AP)
- 3) Lithium + AP
- 4) … + AP
- Short term benzodiazepine for …
- STOP any antidepressant
- 1) Antipsychotic- 1 of:
- OLANZAPINE
- HALOPERIDOL
- QUETIAPINE
- RISPERIDONE
- N.B. NICE guidance – there may be better choices for your individual patient
- 2) Alternative antipsychotic (AP)
- 3) Lithium + AP
- 4) Valproate + AP
- Short term benzodiazepine for sedation
Treatment of acute manic episodes
- … any antidepressant
- 1) Antipsychotic- 1 of:
- OLANZAPINE
- HALOPERIDOL
- Q…
- RISPERIDONE
- N.B. NICE guidance – there may be better choices for your individual patient
- 2) Alternative antipsychotic (AP)
- 3) Lithium + AP
- 4) Valproate + AP
- Short term … for sedation
- STOP any antidepressant
- 1) Antipsychotic- 1 of:
- OLANZAPINE
- HALOPERIDOL
- QUETIAPINE
- RISPERIDONE
- N.B. NICE guidance – there may be better choices for your individual patient
- 2) Alternative antipsychotic (AP)
- 3) Lithium + AP
- 4) Valproate + AP
- Short term benzodiazepine for sedation
BPAD - If already taking lithium or valproate:
- Check …
- … dose
- .. level?
- May add …
- Check compliant
- Optimise dose
- Li level?
- May add AP
Management – BPAD
- M… …
- … antipsychotics
- E…
- Psychological – CBT, psychoeducation, psychodynamic, family therapy, relapse prevention
- Antidepressants? - risk of manic switch
- Mood stabilisers
- Atypical antipsychotics
- ECT
- Psychological – CBT, psychoeducation, psychodynamic, family therapy, relapse prevention
- Antidepressants? - risk of manic switch
Management – BPAD
- Mood …
- Atypical …
- E…
- Psychological – CBT, psychoeducation, psychodynamic, family therapy, relapse prevention
- Antidepressants? - risk of … switch
- Mood stabilisers
- Atypical antipsychotics
- ECT
- Psychological – CBT, psychoeducation, psychodynamic, family therapy, relapse prevention
- Antidepressants? - risk of manic switch
Psychiatric history outline in BPAD
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