BIPOLAR AFFECTIVE DISORDER Flashcards
What is the lifetime risk of developing bipolar affective disorder?
1%
What is the average age of onset for bipolar affective disorder?
20
Which gender is more affected by bipolar affective disorder?
Affected equally
Patients with a family history of which disorders are more at risk of developing bipolar disorder?
Bipolar disorder
Schizophrenia
Schizoaffective disorder
What is the most important environmental risk factor for a patient with untreated bipolar disorder?
Giving birth - there is a 50% risk of mania postpartum in those with untreated bipolar affective disorder.
What are the neurotransmitters most closely associated with mania?
Mono amines
Are manic episodes always associated with elation and euphoria?
No. Some patients will experience irritability and or extreme suspicion during a manic episode. This is not uncommon. Patients actually experience irritability more often than euphoria.
What are some of the biological symptoms of mania or manic episodes?
Decreased need for sleep - very important early warning sign
Increased energy - initially in goal directed activities. Patients may go on excessive spending sprees or engage in reckless promiscuity.
Why is increased energy dangerous as a symptom in someone experiencing a manic episode?
Can lead to physical exhaustion, dehydration and subsequent death
In a mental state exam, what might you notice in a manic patient with increased energy?
Psychomotor excitation:
Patient is unable to sit still
Frequently stands up
Pacing around the room
Gesticulating expansively
What are the cognitive symptoms associated with mania?
Elevated sense of self esteem or grandiosity
Poor concentration
Accelerated thinking
Impaired judgement and insight
What are the psychotic symptoms associated with mania and manic episodes?
Disordered thought form Circumstantiality and tangentiality Flight of ideas Abnormal beliefs Perceptual disturbance
What are the three degrees of severity of manic episodes as set out by the ICD-10?
Hypo mania
Mania without psychotic symptoms
Mania with psychotic symptoms
Are psychotic symptoms more commonly associated with depressive episodes or manic episodes?
2/3rds of patients in a manic state will report psychotic symptoms whereas only 1/3rd of patients in a depressive episode will.
How are diagnoses of mania distinguished from hypo mania?
The level of interference with work or social activities. Mania is a complete disruption, whereas hypomania is only a considerable interference.
What are mixed affective episodes?
Episodes where the patient presents with rapidly alternating manic and depressive symptoms.
What is bipolar affective disorder?
Most patients who present with a hypomanic, manic or mixed affective episode will have experienced a previous episode of mood disturbance. In this case they should be diagnosed with bipolar affective disorder.
What do we classify patients who only have manic or hypomanic episodes with no intervening depressive episodes?
These patients are still classified as bipolar affective disorder.
What is cyclothymia?
Characterised by instability of mood resulting in alternating periods of periods of mild elation and others of mild depression, none of which are severe enough to be classified as hypomanic or depressive episode.
Why might someone with a diagnosis of unipolar depression have a manic episode?
a) Agitated depression - prominent irritable mood which when coupled with psychomotor agitation can be difficult to distinguish from mania.
b) Depressives responding to treatment (either antidepressants or ECT)
c) Patient with recently resolved depressive disorder might misidentify euthymia for hypomania.
Identify A to D.
Insert algorithm on page 60
A - Consider no mental illness, clyclothymia or other differentials
B - Hypomania
C - Mania
D - Mania with psychotic features
What substances are known to cause manic episodes?
Amphetamines
Cocaine
Hallucinogens
Legal highs
What medications have manic episodes as a possible side effect?
Anabolic steroids
Antidepressants
Corticosteroids
Dopaminergic agents (eg L-dopa, selegiline, bromocriptine)
What medical conditions are known possible causes of manic episodes?
Organic cerebral problems (SOLs, infarcts, infection) Cushing's disease Huntington's disease Hyperthyroidism Multiple sclerosis Renal failure SLE Epilepsy (temporal lobe) B12 and niacin deficiency
What investigations should be done for someone experiencing a manic episode?
FBC U+Es TFTs Antibodies Bloods - looking for substances Brain scan - looking for organic changes
What are the mood stabilisers that we commonly use to treat bipolar affective disorder?
Lithium
Sodium valproate
Lamotrigine - when depressive episodes are dominant symptom
Carbamazepine - not first line
How do you manage someone currently suffering an acute manic or hypomanic episode?
- Stop antidepressants (may need to be gradual, to avoid symptoms)
- Offer short term benzodiazepine - lorazepam
- NICE recommends antipsychotics - haloperidol, olanzepine, quetiapine, risperidone
- Try different antipsychotic
- Add lithium - Mood stabilisers may be restarted if they have been used before with success - these take longer to work though
Mood stabiliser can be increased if they are already on it or another added. Do not offer lamotrigine.
How do you manage someone currently suffering acute depression in the context of bipolar disorder?
Antidepressants need to be co-prescribed with antimanic agents IF the depression is moderate-serious.
Doses should start low and increase very gradually.
Drugs of choice is SSRI’s (eg sertraline) or quetiapine (antipsychotic with antidepressant properties)
Long-term antidepressants should be avoided
Not everyone who has had a manic episode requires maintenance therapy. Who does NICE recommend is commenced on long term mood stabilisers?
Those who have had a manic episode associated with serious adverse risk or consequences
Those who have had a manic episode and another disordered mood episode
Those who have had repeated hypomanic episodes or depressive episodes with significant functional impairment or risk.
What is the side effect of all mood stabilisers that all women of child bearing age should take into consideration?
They are all teratogenic, so they should be advised to use contraception.
What monitoring tests need to be done in someone using sodium valproate as a mood stabiliser?
LFTs
FBC
Both for at least the first 6 months
In what patients should lamotrigine be considered as maintenance therapy of bipolar affective disorder?
Those in whom the majority of episodes are depressive.
Why is lithium a dangerous drug to give patients?
Because of the very small therapeutic window.
How is lithium excreted?
Via the kidneys
What can affect lithium clearance from the body and lead to a build up of lithium to toxic levels?
Renal impairment
Sodium depletion - the kidney will hold onto lithium in place of sodium
Diuretics
NSAIDs
ACE-inhibitors
Antipsychotics can synergistically increase lithium induced neurotoxicity
What are the side effects of lithium, a mood stabiliser used in bipolar disorder?
Thirst Polydipsia Polyuria Weight gain Oedema Coarse tremor Muscle weakness Precipitates skin problems Problems with concentration and memory Hypothyroidism Impaired renal function Cardiac: T-wave flattening or inversion Leucocytosis Teratogenicity Note: Lithium can be transferred in breast milk
What monitoring tests are needed for someone starting on lithium as treatment for bipolar affective disorder?
FBC U+Es TFTs Pregnancy test ECG Lithium levels are monitored weekly until stable for 4 weeks, and then every 3 months
What are the contraindications for using lithium as a mood stabiliser?
Pregnancy Breastfeeding Impaired renal function Thyroid disease Cardiac conditions Neurological conditions (eg Parkinson's or Huntington's disease)
