Bipolar Affective Disorder

Question 1

What is Bipolar type 1

Answer 1

this type presents with manic episodes (most commonly interspersed with major depressive episodes). Manic episodes are severe and result in impaired functioning and frequent hospital admissions.

Question 2

What is Bipolar type 2

Answer 2

Patients do not meet the criteria for full mania and are described as HYPOMANIC. Hypomania, unlike mania, has no psychotic symptoms and results in less associated dysfunction. Type 2 is also often interspersed with depressive episodes.

Question 3

What is cyclothymia?

Answer 3

“Less intense Bipolar disorder’ usually including hypomania

Question 4

Who has a higher lifetime risk of type 1 bipolar disorder?

Answer 4

Males

Question 5

Who has a higher lifetime risk of type 2 bipolar disorder?

Answer 5

Females

Question 6

What other disorders is Bipolar affective disorder commonly associated with?

Answer 6

Anxiety and substance misuse

Question 7

Is there a genetic aetiology?

Answer 7

• Relatives of people with bipolar disorder are 5-10x more likely to have a bipolar disorder themselves.

Question 8

What is the presentation at a manic phase?

Answer 8

Characterised by elevated mood and increased quantity of speed of both physical and mental activity. Some patients may be excessively angry; others may be irritable and easily angered.

Question 9

what are symptoms of mania?

Answer 9

• Grandiose ideas
• Pressure of speech
• Excessive amounts of energy
• Racing of thoughts and flight of ideas
• Over activity
• Needing little sleep, or altered sleeping pattern
• Easily distracted – start many activities and leaving them unfinished
• Bright clothes or unkempt
• Increased appetite
• Sexual disinhibition
• Reckless with money

Question 10

What are severe symptoms of mania?

Answer 10

• Grandiose delusions
• Auditory hallucinations
• Persecutory delusions
• Lack of insight – this is very dangerous as patients wil not see they need to change their behaviour

Question 11

What symptoms may be experienced in depressive phase?

Answer 11

• Low mood – usually worse in mornings and is disproportionate to circumstance
• Reduced energy
• Psychomotor retardation
• No joy in daily activities – anhedonia
• Negative thoughts
• Lack facial expressions – blunting of affect, apathy
• Poor eye contact
• Maybe tearful
• Unkempt
• Feelings of despair, low self-esteem and guilt which may have no clear reason
• Weight loss, reduced appetite
• Altered sleep pattern – early morning wakening
• Loss of libido
• May have suicidal ideation or thoughts of self-harm

Question 12

What symptoms may be seen in severe depressive stages?

Answer 12

• Persecutory delusions
• Hypochondriacal delusions
• Delusion of impending death

Question 13

What does the ICD-10 require for a diagnosis?

Answer 13

ICD-10 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.

Question 14

What is bipolar further divided into within the ICD-10?

Answer 14

• Currently hypomanic
• Currently manic
• Currently depressed
• Mixed disorder
• In remission

Question 15

What is meant by rapid cycling?

Answer 15

defined as four or more cycles of depression and mania a year, with no intervening asymptomatic episodes

Question 16

What percentage of people with bipolar affective disorder have rapid cycling?

Answer 16

10-20%

Question 17

What are organic Ddx of BAD?

Answer 17

• Hyperthyroidism or hypothyroidism
• Cerebrovascular event
• Dementia
• CKD
• Acute drug withdrawal
• Illicit drug ingestion e.g. cocaine intoxication
• Cerebral insults – e.g. neoplasm, infarcts

Question 18

What are psychiatric DDx of BAD?

Answer 18

• Schizophrenia
• Schizoaffective disorder
• Cyclothymia

Question 19

What medications may be a Ddx of BAD?

Answer 19

• Steroids
• Isoniazid
• L-dopa
• Sympathomimetic amines

Question 20

What is the management of first manic episode?

Answer 20

Manic episodes require urgent control and patients may be violent, and hospital admission should be considered when definite risk to the patient or others. Oral preparations are preferable to IM drugs as absorption is variable for IM and harder to assess response.
• Anipsychotic: olanzapine, Haloperidol, quetiapine, Risperidone
• Stop any antidepressant – as can make mania worse
• RAPID TRANQUILISATION – rarely needed
• Valproate

Question 21

What is the management of a subsequent manic episode?

Answer 21

• Antipsychotic: Olanzapine, Haloperidol, Quetiapine, Risperidone (if one antipsychotic at max dose is poorly tolerated, offer an alternative, if this isn’t effective at max. dose either, then consider adding lithium)
• Valproate – but avoided in females of childbearing age, but if is used need to be counselled on alternative forms of contraception.
• Lithium
• Stop any antidepressant

Question 22

Management of an acute depressive episode?

Answer 22

• NEED RISK ASSESSMENT OF SUICIDAL IDEATION
• Antidepressants – use carefully as can cause mania, hypomania or rapid cycling (SHOULD BE PRESCRIBED WITH A ANTI-MANIC MEDICATION)
• Moderate to Severe: Fluoxetine combined with olanzapine OR quetiapine/lamotrigine on its own (can combine the combination with either of the singles if the combi is not enough)

Question 23

What is the long-term Tx to prevent relapse or recurrence of BAD?

Answer 23

• Lithium – FIRST LINE
• Valproate – SECOND LINE– if lithium is not tolerated or suitable (can be added to lithium if lithium alone is ineffective)
• Olanzapine – if lithium is not suitable or not tolerated
• Quetiapine – if it has been effective during an episode of mania or bipolar depression

Question 24

What psychological Tx may be offered for someone with BAD?

Answer 24

• Psychotherapy – CBT, cognitive interpersonal therapy, behavioural couples therapy
• Psychoeducation

Question 25

What social Tx may be offered?

Answer 25

• Self-help groups
• Support groups
• Telephone support
• Coping strategies