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CP2 - Psychiatry - Kinsky > Bipolar affective disorder > Flashcards

Bipolar affective disorder Flashcards

1
Q

What is the lifetime risk of developing bipolar affective disorder?

A

1%

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2
Q

What is the average age of onset for bipolar affective disorder?

A

20

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3
Q

Which gender is more affected by bipolar affective disorder?

A

Affected equally

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4
Q

Patients with a family history of which disorders are more at risk of developing bipolar disorder?

A
  • Bipolar disorder
  • Schizophrenia
  • Schizoaffective disorder
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5
Q

What is the most important environmental risk factor for a patient with untreated bipolar disorder?

A

Giving birth - there is a 50% risk of mania postpartum in those with untreated bipolar affective disorder.

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6
Q

What are the neurotransmitters most closely associated with mania?

A

Mono amines:

  • Dopamine
  • Noradrenaline
  • Seratonin

(Adrenaline and histamine are also monoamines)

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7
Q

Are manic episodes always associated with elation and euphoria?

A

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.

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8
Q

What are some of the biological symptoms of mania or manic episodes?

A
  • 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 (impaired judgement)
    • O/E unable to sit still
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9
Q

Why is increased energy dangerous as a symptom in someone experiencing a manic episode?

A

Can lead to physical exhaustion, dehydration and subsequent death

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10
Q

In a mental state exam, what might you notice in a manic patient with increased energy?

A

Psychomotor excitation:

  • Patient is unable to sit still
  • Frequently stands up
  • Pacing around the room
  • Gesticulating expansively
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11
Q

What are the cognitive symptoms associated with mania?

A
  • Elevated sense of self esteem or grandiosity
  • Poor concentration
  • Accelerated thinking
    • May present with flight of ideas and pressure of speech
  • Impaired judgement and insight
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12
Q

What are the psychotic symptoms associated with mania and manic episodes?

A
  • Disordered thought form
    • Circumstantiality
    • Tangentiality
    • Flight of ideas
    • Secondary delusional thinking
  • Abnormal beliefs
  • Perceptual disturbance
    • Altered intensity of perceptions
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13
Q

What are the three degrees of severity of manic episodes as set out by the ICD-10?

A
  1. Hypo mania
  2. Mania without psychotic symptoms
  3. Mania with psychotic symptoms
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14
Q

Are psychotic symptoms more commonly associated with depressive episodes or manic episodes?

A

2/3rds of patients in a manic state will report psychotic symptoms whereas only 1/3rd of patients in a depressive episode will.

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15
Q

How are diagnoses of mania distinguished from hypo mania?

A

The level of interference with work or social activities.

Mania is a complete disruption, whereas hypomania is only a considerable interference.

Mania you get grandiose beliefs

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16
Q

What are mixed affective episodes?

A

Episodes where the patient presents with rapidly alternating manic and depressive symptoms.

17
Q

What is bipolar affective disorder?

A

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.

  • One episode of mania and one episode of depression
  • Two episodes of mania
18
Q

What do we classify patients who only have manic or hypomanic episodes with no intervening depressive episodes?

A

These patients are still classified as bipolar affective disorder.

19
Q

What is cyclothymia?

A

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.

20
Q

Why might someone with a diagnosis of unipolar depression have a manic episode?

(3)

A
  1. Agitated depression - prominent irritable mood which when coupled with psychomotor agitation can be difficult to distinguish from mania
  2. Depressives responding to treatment (either antidepressants or ECT)
  3. Patient with recently resolved depressive disorder might misidentify euthymia for hypomania.
21
Q

What substances are known to cause manic episodes?

A
  • Amphetamines
  • Cocaine
  • Hallucinogens
  • Legal highs
22
Q

What medications have manic episodes as a possible side effect?

A
  • Anabolic steroids
  • Antidepressants
  • Corticosteroids
  • Dopaminergic agents (eg L-dopa, selegiline, bromocriptine)
23
Q

What medical conditions are known possible causes of manic episodes?

A
  • Neurological:
    • Organic cerebral problems (SOLs, infarcts, infection)
    • Epilepsy (temporal lobe)
    • Huntington’s disease
    • Multiple sclerosis
  • Thyroid:
    • Cushing’s disease
    • Hyperthyroidism
  • Other:​
    • Renal failure
    • SLE
    • B12 and niacin deficiency
24
Q

What investigations should be done for someone experiencing a manic episode?

A
  • FBC
  • U+Es
  • TFTs
  • Antibodies
  • Bloods - looking for substances
  • Brain scan - looking for organic changes
25
Q

What are the mood stabilisers that we commonly use to treat bipolar affective disorder?

A

Lithium

Sodium valproate

Lamotrigine - when depressive episodes are dominant symptom

Carbamazepine - not first line

26
Q

How do you manage someone currently suffering an acute manic or hypomanic episode?

A
  1. Stop antidepressants (may need to be gradual, to avoid symptoms)
  2. Offer short term benzodiazepine - lorazepam
  3. NICE recommends antipsychotics - haloperidol, olanzepine, quetiapine, risperidone
  4. Try different antipsychotic
  5. Add lithium - Mood stabilisers may be restarted if they have been used before with success - these take longer to work though
  6. Mood stabiliser can be increased if they are already on it or another added. Do not offer lamotrigine.
27
Q

How do you manage someone currently suffering acute depression in the context of bipolar disorder?

A
  1. Antidepressants need to be co-prescribed with antimanic agents IF the depression is moderate-serious.
    1. Doses should start low and increase very gradually.
    2. Drugs of choice is SSRI’s (eg sertraline) or quetiapine (antipsychotic with antidepressant properties)

Long-term antidepressants should be avoided

28
Q

Not everyone who has had a manic episode requires maintenance therapy. Who does NICE recommend is commenced on long term mood stabilisers?

A
  • 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.
29
Q

What is the side effect of all mood stabilisers that all women of child bearing age should take into consideration?

A
  • They are all teratogenic, so they should be advised to use contraception
30
Q

What monitoring tests need to be done in someone using sodium valproate as a mood stabiliser?

A

LFTs

FBC

Both for at least the first 6 months

31
Q

In what patients should lamotrigine be considered as maintenance therapy of bipolar affective disorder?

A

Those in whom the majority of episodes are depressive.

32
Q

Why is lithium a dangerous drug to give patients?

A

Because of the very small therapeutic window.

33
Q

How is lithium excreted?

A

Via the kidneys

34
Q

What can affect lithium clearance from the body and lead to a build up of lithium to toxic levels?

(6)

A
  • 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
35
Q

What are the side effects of lithium, a mood stabiliser used in bipolar disorder?

A
  • 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 (majority defects are cardiogenic - ASD & VSDs)
  • Lithium can also be transferred in breast milk
36
Q

What are toxicity signs of lithium?

A
  • Course tremor (different from fine tremor is side effects)
  • Nausea
  • Vomiting
  • Nystagmus
  • Apathy
  • Ataxia
  • Muscle weakness
  • Impaired conscoiusness
  • Dysarthia
  • Oliguria
  • Hypotension
  • Convulsions
  • Coma
37
Q

What monitoring tests are needed for someone starting on lithium as treatment for bipolar affective disorder?

A
  • FBC
  • U+Es
  • TFTs
  • GFR
  • Pregnancy test (tetrogenic)
  • ECG
  • Lithium levels are monitored weekly until stable for 4 weeks, and then every 3 months
38
Q

What are the contraindications for using lithium as a mood stabiliser?

(6)

A
  1. Pregnancy
  2. Breastfeeding
  3. Impaired renal function
  4. Thyroid disease
  5. Cardiac conditions
  6. Neurological conditions (eg Parkinson’s or Huntington’s disease)

CP2 - Psychiatry - Kinsky (18 decks)

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