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Psychiatry > Bipolar Affective Disorder > Flashcards

Bipolar Affective Disorder Flashcards

1
Q

What is Bipolar disorder?

A

A disorder characterised by at least 2 episodes of long-term changes in mood at least one of which has to be hypomanic, manic or a mixed episode. 90% of those who have manic episodes will develop depression at some point.

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2
Q

What is the epidemiology of bipolar disorder?

A

1-2% in the population usually beginning typically aged 15-19 for boys and 20-24 for girls. There is an equal distribution within the two genders. People with Bipolar disorder have 20x the normal risk of suicide.

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3
Q

What causes bipolar disorder?

A

Genetic
Neurologic illness – infection, stroke, neoplasm, epilepsy, and multiple sclerosis
Metabolic disturbance
Childhood experiences
Personality traits
Drugs – illicit, steroid and antidepressants

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4
Q

Describe the symptoms of hypomania

A 
Hypomania
Mildly elevated mood or irritable mood
Increased energy and activity
Increased self esteem
Sociability, talkativeness and over familiarity
Increased libido
Reduced sleep
Difficulty concentrating on one thing
No psychotic symptoms
No impairment of daily living and so no need for inpatient treatment
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5
Q

Describe the symptoms of mania

A 
Mania
Elevated mood for a week
Increased energy
Grandiosity and increased self esteem
Pressure of speech
Flight of ideas/racing thoughts
Distractible
Reduced need for sleep
Increased libido
Social inhibitions lost
Can include psychotic symptoms
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6
Q

What is a mixed effective state?

A

Mixed affective state = rapid alternation between hypomania, mania and depression.

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7
Q

What are dysthymia and cyclothymia?

A

Dysthymia – chronic low mood not fulfilling criteria for depression
Cyclothymia – mild periods of elation/depression with early onset/chronic course and commonly seen in relative of those with bipolar disorder, present for more than 2 years.

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8
Q

What is the difference between Bipolar I and II in the DSM cefinitions?

A

Bipolar I – Mania +/- Depression

Bipolar II – Depression and Hypomania

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9
Q

What is a mood disorder with psychosis?

A

Mood Disorder with Psychosis = a single instance of a mood disorder with psychotic symptoms only present during the mood change.

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10
Q

What is schizoaffective disorder?

A

Schizoaffective Disorder – combination of Schizophrenia and mood disorder, Often the symptoms of schizophrenia predate the mood changes.

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11
Q

What investigations should be completed in someone suspected of being manic/hypomanic?

A

FBC
Us and Es
ECG
CT

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12
Q

How is acute mania managed?

A

Acute mania – Atypical antipsychotic e.g. Quetiapine, risperidone or Sodium Valproate. Stop any antidepressants and urgent referral to community mental health team

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13
Q

How is an acute depressive episode managed in someone with known bipolar affective disorder?

A

Acute depressive episode – Fluoxetine and olanzapine, Quetiapine alone, olanzapine alone or lamotrigine alone. Talking therapies

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14
Q

How is an acute hypomanic episode managed?

A

Hypomania – referral to community mental health team

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15
Q

How is Bipolar disorder/mood disorders managed long term?

A

Following treatment of an acute episode and diagnosis of Bipolar disorder they should have a long-term management plan which is usually a mood stabiliser – Lithium or sodium valproate but can be continuation of treatment for mania.

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16
Q

When is ECT indicated in mood disorders?

A

ECT for prolonged severe manic episodes or depressive symptoms

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17
Q

What pschotherapy should be offered in Bipolar disorders and what specifically are they used to treat?

A

Psychotherapy – CBT, Psychodynamic, mindfulness and psychoeducation. Most affective in those with insight. These should target dealing with a cycling disorder, anxiety about whether they are just having a good time or recurrence and other problems caused by manic episodes e.g. hypersexuality, overspending etc.

18
Q

Why is lithium used in mood disorders?

A

Unknown mechanism of action, but notably lowers noradrenaline and increases serotonin synthesis. Has a very narrow therapeutic window. Lithium reduces suicide rates, has a license for reduction of self-harm and can be used to augment antidepressants.

19
Q

What monitoring should take place in a patient on/starting lithium?

A
  • At baseline – FBC, U&E including calcium, BMI, TFTs and and optional pregnancy test. ECG if any cardiovascular disease or risk factors for it
  • After starting – check lithium levels weekly until it has been stable for 4 weeks.
  • Check Li levels one week after any dose change.
  • Measure lithium levels every 3 months for the next year and then every 6 months after that. If unstable, old, on diuretic, NSAIDs or ACE-I (all 3 increase Li) or previous lithium levels were high then test every 3 months. Minimum effective dose is 0.4mmol/l but we aim for 0.6-0.8mmol/l
  • Every 6 months check weight, U&Es including calcium, TFTs (more often if renal impairment)
20
Q

What side effects should be looked out for with lithium use?

A

Side effects – fine tremor, GI symptoms, T wave flattening, weight gain, idiopathic intracranial hypertension, leucocytosis, and nephrogenic diabetes insipidus
Long term side effects – Hypothyroidism and Nephrotoxicity
Gently rising Li levels suggests progressive nephrotoxicity

21
Q

What are the signs of lithium toxicity?

A

Signs of lithium toxicity – reduced vision, D&V, reduced potassium, ataxia, coarse tremor, dysarthria, and coma.

22
Q

How is lithium toxicity managed?

A

Treated with supportive measure and sometimes dialysis. Should drink lots of water to avoid risk of toxicity.

23
Q

Can lithium be stopped suddenly?

A

Abrupt cessation of lithium can induce a manic episode so must be gradual.

24
Q

If lithium doses are altered what needs to be monitored?

A

After a change in dose lithium levels should be taken a week later and 12 hours after the last dose.

25
Q

What are the risk factors for suicide in bipolar disorder?

A

Previous attempt, family history, early onset, extent of depressive symptoms, increasingly bad affective signs, mixed affective states, rapid cycling, abuse of alcohol or drugs

26
Q

What is sodium valproate?

A

GABA mediated inhibition

27
Q

What are the side effects of sodium valproate?

A

Sedation, ataxia, tremor, alopecia, pancreatitis and weight gain

Liver damage so monitor LFT’s due to hepatotoxicity risk

Teratogen: neural tube defects

28
Q

How do antidepressants and anti-psychotics affect sodium valproate?

A

Antidepressants inhibit action of valproate. Antipsychotics antagonise valproate by lowering seizure threshold.

29
Q

How does aspirin affect sodium valproate?

A

Aspirin competitive binding causing valproate increase

30
Q

What is lamotrigine?

A

VGNa Channel Blockers

31
Q

What are the side effects of lamotrigine?

A

Dizziness, drowsiness, ataxia, numbness, and tingling

Serious skin rashes – Steven’s Johnson syndrome

32
Q

How does lamotrigine interact with sodium valproate?

A

Valproate increased concentrations due to competitive binding

33
Q

What must you be careful about when prescribing lamotrigine with contraceptives?

A

Oral contraceptives reduce lamotrigine concentrations.

34
Q

What is carbamazepine?

A

VGNa Channel Blockers

35
Q

What are the side effects of carbamazepine?

A

CNS: dizziness, drowsiness, ataxia, numbness and tingling.
GI upset and vomiting
Rashes, hyponatraemia, and severe bone marrow suppression

36
Q

How do antidepressants interact with carbamazepine?

A

Antidepressants all interfere with its action

37
Q

How does carbamazepine effect CYP450?

A

Strong CYP450 inducer so much so that is reduces its own half-life. Also affects contraceptives and warfarin

38
Q

Can antidepressants be used alongside lithium?

A

Antidepressants during Lithium treatment may be required, recommended to use SSRIs or venlafaxine. TCAs are contraindicated as they can cause iatrogenic mania.

39
Q

How do mood stabilisers/anti-convulsants effect platelets?

A

Note all anti-convulsant can cause thrombocytopenia so check FBC after starting.

40
Q

Can lithium be combined with other mood stabilisers?

A

Yes and is often trialed

Psychiatry (11 decks)

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