Bipolar affective disorder Flashcards
What is bipolar I disorder?
Episodic mood disorders characterised by episodes of mania, hypomania or mixed
Charaterised by one or more episodes of above
What does a patient experience in a manic episode
Euphoria, irritability, expansiveness
Increased activity/increase energy
Increase self-esteem/grandiosity
Rapid/pressure of speech
Flight of ideas
Decrease need for sleep
Distractibility
Impulsive/Reckless behaviour
Rapid changes between mood states (labile mood)
What is the difference between type I and II bipolar?
type I - manic episode
II - hypomanic episode
How long do manic symptoms have to last to be classed as an episode?
1 week
How long does a mixed episode have to last to be official?
2 weeks
What does a patient experience in a mixed episode presentation?
Several prominent manic symptoms and several prominenet depressive symptoms occuring for most of the day nearly every day
lifetime prevalence of bipolar
1% general pop
How does bipolar I presnetation differ with gender?
Males earlier onset and more diabling manic symptoms
Females - more depressive symptoms
Equal occurence
When is risk of suicide in bipolar I esp high?
Fallout after manic episode eg spending, relationship breakdwon realisation
Type II - depressive episodes
What often cooccurs with bipolar I disorder?
Substance use disroder
Panic disorder
What does co-occurence of panic disorder with bipolar I suggest?
More severe illness, poorer response to treatment and higher risk of suicide
How long do depressive symptoms need to alst to be an episode in bipolar?
2 weeks
How liong does hypomania have to last to be an epsiode?
Severeal days
How is Bipolar II charactereised?
1 or more hypomanic episode AND ar least one depressive episode
No prev hisotry of manic or mixed episodes
Hypomanic episode symptoms
persistent elevated mood
persistent irritability
increase activity/energy
increase talkativeness
rapid/racing thoughts
increase self-esteem
decrease need for sleep
distractibility
impulsive/reckless behaviour
Hypomanic episode symptoms
persistent elevated mood
persistent irritability
increase activity/energy
increase talkativeness
rapid/racing thoughts
increase self-esteem
decrease need for sleep
distractibility
impulsive/reckless behaviour
How does a patient present in a hypomainic episode?
Significant change from usual mood, energy and behaviour but no impairment in funcitoning
Depressive episode symptoms
period of low mood
diminished interest in activities
changes in appetite
changes in sleep
psychomotor agitation/retardation
fatigue
feelings of worthlessness/inappropriate guilt
hopelessness
difficulty in concentrating
suicidality
Onset of bipolar II disorder
Late adolescent to mid 20s
Often with one or more depressive episodes - unrecognised before symptmos hypomania emerge
Why review diagnosis of type II bipolar at each patient contact
15% develop episodes of mania - change to typt I
Why do people with bipolar have a higher risk of developing medical conditions?
CVD diseases, metabolic syndrome due to effect of medicaitons
Risks in bipolar affective disorder
Overspending, debts
Disinhibition (incl. promiscuity, pregnancy)
Exploitation – financial, relationship,
Driving
Family/Children
Violence – self & others
Self-neglect – personal care, physical health
Suicide
Alcohol and Recreational substances
How much higher are rates of suicide in bipolar than normal pop?
15 x
Why do antidepressants often not help in bipolar?
Can cause manic switch - from depression to mania
What is bipoilar often misdiagnosed as?
Depression - depressive episodes have same criteria, esp type II
Why can it be difficult to diagnose manic episodes?
Patients reporting bias - prefer to be in manic/hypomanic state, get more done
Mixed mood episodes are quite common, obscure mania
Why is hypomania often difficult to diagnose?
Subthreshold symptoms common in depressive illness
30-55% patients have hypomanic symtpoms in depressive episode and common in dperessive disorder
What group of patients should be treated as sus bipolar?
Treatment resistant depression
Self reported scales for bipolar
Mood Disorder Questionnaire (MDQ) – brief screen – 12 or 3 item
Young Mania Rating Scale (Patient Health Questionnaire (PHQ)
YMRS)
Beck Depression Inventory – BDI
Quick Inventory Depressive Symptomatology-Self Report (QIDS-SR)
Interview rating scales in mood disorders
Interview with physician:
Hamilton Depression Rating Scale (HAMD)
Montgomery and Asberg Depression Rating Scale (MADRS)
Quick Inventory Depressive Symptomatology – Clinician (QIDS-C)
What syndrome does lamotrigine increase the risk of
Steven Johnson
Why do you titrate lamotrigine slowly?
Risk of steven johnson syndrome - severe skin condition (erythema multiforme)
Factors when deciding treatment
Prev experience of meds
Comorbid physical illness
Patients preference
Adverse effects of meds
Acute management first episode of manic or hypomanic episode
1-Consider stop antidepressants
2-Start antipsycjotics, titrated carefully and monitor side effects
3-Potential benzodiazapine if needed
4-Lithium, valproate, arpiprazole
first line antipsychotics
risperidone, olanzapine, haloperidol, quetiapine
Side effects of antipsychotics to monitor for?
Acute dystonia, akathasia, extrapyramidal symptoms
How often review benzodiazapine when acute use manic episode?
Daily
Relapse of bipolar disorder management
Optimise current treatment
Check complaince
Antipsychotic - start with what worked before
Mood stabilisers - choice of lithium, valproate, carbamazapine (NOT LAMOTRIGINE)
use of alcohol/recreational substances
Relapse of bipolar disorder management
Optimise current treatment
Check complaince
Antipsychotic - start with what worked before
Mood stabilisers - choice of lithium, valproate, carbamazapine (NOT LAMOTRIGINE)
use of alcohol/recreational substances
What drug do you not offer in relapse of manic episodes in bipolar
lmaotrigine
Acute depressive episode management if not being treated for bipolar
Fluoxetine + olanzipine
Quetiapine on own
Can offer olanzapine or lamotrigine on own patient preference
If no repsonse -> fluoxetine + olanzapine or quetiapine, lamotrigine on own
First line treatment for long term management of bipolar
lithium
2nd line for long term management bipolar
Valproate
alternatives - olanzapine, quetiapine
Psychological management of bipolar
Educate patients and carers (with patients’ consent) about nature & severity of illness.
The aim is to empower patients to manage their illness – self-monitoring, recognition of early warning signs eg decrease need for sleep may trigger a manic relapse.
Discuss about future management according to patients’ preferences inc advance directive
Offer CBT/Interpersonal Therapy/Family Intervention according to patients’ needs & preferences
Social treatment of bipolar
The aim is to return to premorbid functioning level in terms of education & employment.
Lifestyle advice on smoking/alcohol/recreational substances/exercise/diet
Support group: Bipolar UK
Management of acute depressive episode if already on lithium for bipolar
Check Li level and adjust dose appropriately
If lithium at amx offer in combination
-Fluoxetine + olanzipine or quetiapine
-olanzapine on own
Stop if no repsonse to combination of fluoxetine + olanzapine or adding quetiapine
Lamotrigine
Management of acute depressive episode if already on valproate for bipolar
Increase dose to max tolerated in therapeutic range
Patient preference combine with
-Fluoxetine + olanzapine or quetiapine
-Olanzapine
-Stop if no response to above
Consider lamotrigine
Why monitor lithium weekly?
Narrow therapeutic index
How often do yuo monitor lithium levels
weekly until stable then 3 monthly
What are problems with lithium?
Narrow therapeutic index - toxicity
Leukocytosis
Nausea, vomitting, diarrhoea
Renal and thyroid dysfunction
CVS disease
Muscle weakness and tremor
Sudden discontinuation – 50% risk of mania
Acne
Dry motuh
Pregnancy
What monitor on lithium
Renal function and TFTs (thryoid) 6 monthly
What is the risk with sudden discontinuation of lithium?
50% increase risk of mania
Risks ass with lithium in pregnancy
Teratogenicity
Cardiac abnormalities
Ebstein anomaly
What is required with lithium treatment in pregnancy?
Dose requirements increased during the second and third trimesters (but on delivery return abruptly to normal).
Close monitoring of serum-lithium concentration advised in pregnancy (risk of toxicity in neonate
What can valproate cause in pregnancy?
Reduced IQ - 10-15
Teratogenicity (neural tube)
Polycystic ovary
What symptoms constitutes mania?
Abnormally and persistent elevated or irritable mood
Increased energy
Inflated self esteem or grandiosity
Decreased need for sleep
Pressured speech
Racing thoughts or flight of ideas
Distractability
Increased activity
Excess pleasurabe or risky activity
How long must symptoms go on for to class as a manic episode?
Must have
abnoramlly and persistent elevated or irritable mood and increased energy plus any other 3 symptoms
forat least 1 week, with functional impairemtn
What is the minimum duration for hypomania?
4 days
What episodes normally predominate/come first in bipolar?
Depressive - why its often misdiagnosed
Bipolar I vs II
I - patient has had at least one manic episode
II - patient has had hypomanic episodes byt never a manic one
Bipolar I vs II
I - patient has had at least one manic episode
II - patient has had hypomanic episodes byt never a manic one
Bipolar I vs II
I - patient has had at least one manic episode
II - patient has had hypomanic episodes byt never a manic one
What is the most dangerous episode in bipolar? (Highest risk of suicide)
Mixed episodes - symptoms of opposite pole present
What is rapid cycling in bipolar?
4+ episodes of any type per year
What is cyclothymia?
Sub syndromal ups and downs
CF dysthmia = just downs
