Bipolar Affective Disorder (BPAD) Flashcards
Define
A disorder characterised by ≥2 episodes, 1 must be manic associated (hypomania/mania/mixed; the other can be depressive); AND
- Mania lasts ~4m
- Depression lasts ~6m
> > 90% of people with mania go on to have depressive episodes
- Complete recovery between 2 episodes
An elevation of mood and increased energy and activity (hypomania and mania)
A lowering of mood and decreased energy and activity (depression).
SIDE NOTE: time between episodes doesn’t matter but as progresses, length of time between episodes might narrow
Bipolar Type I- episodic mood disorder defined by the occurrence of ≥ 1 manic or mixed episodes
Bipolar Type II- episodic mood disorder defined by the occurrence of ≥ 1 hypomanic and ≥ 1 depressive episode
Definition of mania/ hypomania
Mania a distinct period of abnormally and persistently elevated, expansive or irritable mood with ≥3 characteristics of mania, lasting at least 7 days (ICD-10)
* impair occupational/social functioning ± psychosis
* 1st rank symptoms are not likely to persist past the acute episode (if they do, think schizophrenia) - hallucinations, thought insertion etc.
Hypomanic- >3 characteristic symptoms of mania lasting ≥4 days -> does not impair occupational/social functioning / no psychosis or delusions (and do NOT cause any psychotic features)
- Think of this like slightly less exaggerated mania symptoms as seen above
- I.E. a mildly elevated mood; feeling of well-being, mental, or physical efficiency
Mixed episode- mixed or very rapid alteration (usually within a few hours) between prominent manic and depressive symptoms on most days during a period of at least 2 weeks
- Depression plus over-activity/pressure of speech
- Mania plus agitation and reduced energy/libido
- Dysphoria plus manic symptoms (not elevated mood)
Rapid cycling (fluctuating between mania and depression – 4 or more episodes per year)
- Psychotic symptoms such as delusions or hallucinations can also occur with either depressed or manic episode
Rapid-cycling bipolar disorder- the experience of at least 4 depressive, manic, hypomanic or mixed episodes within a 12 month period
Cyclothymia- instability of mood involves only mild elation and depression over a period of atleast 2 yrs (not severe enough to meet a hypomanic or depressive episode)
Epidemiology
1.5% prevalence (lower than depression)
- Mean age of onset = 18 - 20
- More common in younger age groups (16-24 year olds)
- Bipolar I may be slightly more common than Bipolar II
- Suicide risk is x15-18 higher than general pop
- 10% who get a depressive episode develop mania later
- Upper social class is more common
- F=M
- Ethinicitis are all the same
First degree relatives = 7 times more common
Aetiology
- Genetic – 1st degree relative to 7x inc. risk
- Anatomical – decreased grey matter mass in emotional regulation areas; increased ventral limbic area activity
- Transmitters – increased NA, DA, serotonin trigger mania
- Stressful life events (i.e. pregnancy)
Environmental factors/ triggers that have been associated with the onset or relapses:
* Early life stress, maternal death before a child is 5 years, childhood trauma, childhood abuse, emotional neglect/ abuse
* Toxoplasma gondii exposure
* Cannabis use, cocaine exposure
* Higher social classes
Symptoms
Hypomanic/ Manic
* Euphoria
* Irritability
* Expansiveness
* Excessive psychomotor activation
* Increased energy
* Inflated self-esteem and confidence
* Over-optimistic ideation
* Reduced social inhibitions -> Inappropriate social behaviour
* Increased tendency for pleasurable, risky behaviour, with disregard for consequences
* Spending recklessly
* Inappropriate sexual encounters
* Preoccupation with extravagant, impracticable schemes
* Increased appetite
* Raised libido
* Grandiosity
* Decreased need for sleep
* Pressured speech
* Reduced attention/ increased distractibility
Flight of ideas – links are evident (clang associations, circumnstantial
- Increased talkativeness
- Increased activity/ physical restlessness
- Distractibility
- Impulsive or reckless behaviours lasting for at least several days
Manic- symptoms of hypomania lasting ≥ 1 week (unless severe enough for hospital admission) and have marked impairment on function (and can have rapid changes in mood (i.e. mood lability))
Mania
- Lasts for at least 7 days - Causes severe functional impairment in social and work setting
- May require hospitalization due to risk of harm to self or others
- May present with psychotic symptoms
Hypomania
- A lesser version of mania
- Lasts for < 7 days, typically 3-4 days
- Can be high functioning and does not impair
functional capacity in social or work setting
- Unlikely to require hospitalization
- Does not exhibit any psychotic symptoms
Therefore, the length of symptoms, severity and presence of psychotic symptoms (e.g. delusions of grandeur, auditory hallucinations) helps differentiates mania from hypomania.
Depressive
- Persistent feelings of sadness and low mood
- Loss of interest in activities (for at least 2 weeks) or pleasure
- Low energy
- Changes in appetite
- Change in sleep
- Psychomotor agitation or retardation
- Fatigue
- Feelings of worthlessness
- Excessive or inappropriate guilt
- Feelings of hopelessness
- Difficulty concentrating
- Suicidality
- Psychotic symptoms - usually mood congruent
(may get first rank-symptoms like thought insertion in an acute episode but these symp are usually leaning towards schizophrenia/ schizoaffective disorder)
- Total loss of insight
- Hallucinations
- Delusions
- Grandiose - special powers or religious content
- Persecutory - due to suspicion
- Incomprehensible speech: pressured speech is so great that the clear associations
are lost hence cannot understand the resulting speech. - Self neglect: preoccupation with their own thoughts and extravagant themes and
their distractibility may lead to self neglect, so patients may not eat or drink and
results in poor living conditions. - Catatonic behaviour- manic stupor
REMEMBER STILL AT A RISK OF SUICIDE EVEN DURING A MANIC EPISODE
And don’t assume that racing thoughts and plenty of energy is always enjoyable - pts may find them distressing or overwhelming
Investigations
- Collateral history
- Physical examination (establish baseline state)
- Bloods: FBC, TSH, U&E, LFT, ECG Urine drug screen
- Rule out organic causes:
- Bloods- FBC, TFT (hyperthyroid), CRP, U&Es
- Urine drug screen (esp stimulants)
- CT/ MRI- if really indicated (esp in r. hemisphere - more common in elderly)
- Meds - levo-dopa, corticosteroids
- Rating scale: Young Mania Rating Scale
- N.B. most BPAD present in their depressive episodes, so always ensure you ask about manic symptoms
ICD-10 criteria for Mania:
- At least three of the following symptoms (4 if mood only irritable) must be present:
- Inflated self-esteem or grandiosity
- Increased activity or physical restlessness
- Decreased need for sleep
- Increased talkativeness (‘pressure of speech’)
- Flight of ideas or the subjective experience of thoughts racing
- Loss of normal social inhibitions: resulting in behaviour which is inappropriate to the circumstances
- Distractibility or constant changes in activity or plans
- Reckless behaviour whose risks the subject does not recognize e.g. spending sprees, foolish enterprises, reckless driving
- Marked sexual energy or sexual indiscretions
- The absence of hallucinations or delusions, although perceptual disorders may occur
- Exclusion criteria: the episode is not attributable to psychoactive substance use or any organic mental disorder
ICD-10 criteria for mania with psychotic symptoms
- Episode meets mania criteria, except the absence hallucinations/delusions
- Does not meet schizophrenia or schizoaffective disorder criteria
- Delusions or hallucinations are present
- Not attributable to psychoactive substance use or organic disorder
Diagnosed in children ONLY after a period of intensive longitudinal monitoring by a doctor/MD team in collaboration with the patient’s carers/ family
Differentials
- Schizophrenia
- Schizoaffective disorder
- Alcohol or drug induced – stimulants, opiates , cocaine
- Delusional disorder
- Medications / iatrogenic:
1. Antidepressants
2. Other ychotropic medication: benzodiazepines, lithium – toxicity, antipsychotics (olanzapine/risperidone), anticonvulsants
3. Parkinson’s medication: amantadine, probocriptine, levodopa
4. Steroids: beclomethasone, corticosteroids, dexamethasone, hydrocortisone, prednisolone - ADHD / conduct disorder
- Physical illness: hyper/hypothyroidism(myxoedema ‘madness’), Cushing’s, brain tumour, head injury, MS complication (hypomania + depression)
Management
- If in Primary Care: refer to Specialist Mental Health Service to confirm the diagnosis, treat the acute episode, and establish a care plan
- Symptoms of hypomania -> routine referral to CMHT
- Symptoms of mania or severe depression -> urgent referral to CMHT / admission to psychiatric ward
RISK ASSESSMENT!- Crisis Resolution Team/ Home Treatment Team if needed
Factors to consider when deciding if they need to go to Inpatient instead of HTT : Risk to self; Risk to others (especially her child); Lack of insight (which would affect adherence with treatment plan); Lack of support at home; Capacity of the patient; Wishes of the patient
In children < 14 years – refer to CAMHS
Acute Manic Episode
- Gradually taper off and stop inducing medications (i.e. SSRIs)
- Monitor fluid/food intake
- Sedation may be required (clonazepam, lorazepam)
- ECT only if mania is not responsive to treatments below
- If not on treatment… aim is to stabilise them before starting lithium
- 1st Line: PO Antipsychotic
1. Haloperidol
2. Olanzapine
3. Quetiapine
4. Risperidone - 2nd Line: Alternative antipsychotic- if first antipsychotic is not tolerated or ineffective
- 3rd Line: Addition of Lithium
- If lithium is INEFFECTIVE or unsuitable, consider adding Sodium valproate
-Do not offer valproate to women or girls of childbearing potential (including young girls who are likely to need treatment into their childbearing years) for long-term treatment
If on antidepressants as monotherapy:
- STOP the antidepressant
- Offer an antipsychotic
- (If on antidepressant + antipsychotic, then stop the antidepressant)
If already on lithium:
- Check plasm lithium levels
- Consider adding antipsychotic
If already on mood stabilisers:
- Check levels
- Consider increasing dose (if necessary, to maximum level)
- Consider adding antipsychotic
Short-term Benzodiazepine use (e.g. Lorazepam)- useful if agitated/insomnia
ECT is rarely used if unresponsive to all other medication and severely manic during pregnancy
Bipolar Depression
Psychological Therapy
- Psychological intervention- specifically for bipolar depression
- High-intensity psychological intervention : CBT/ IPT
- Behavioural couples therapy
Biological Therapy
- Moderate-Severe
- 1st Line: Fluoxetine + Olanzapine OR Quetiapine
If patient preference: consider Olanzapine or Lamotrigine on its own
- 2nd Line: Lamotrigine (if 1st line combination or quetiapine ineffective)
Long Term Treatment
- Biological Therapy
- 4 weeks after resolution of symptoms, changes to medication for long term treatment can be reviewed
- Can continue acute treatment for mania OR start long-term treatment with mood stabilisers described below:
1st Line: Lithium+/- Sodium Valproate (if Lithium ineffective)
2nd Line: If Lithium poorly tolerated or unsuitable, consider:
Sodium Valproate OR Olanzapine OR Quetiapine if effective during mania episodes or bipolar depression
Unsuitable e.g. Of childbearing age
Meds aren’t started in the GP setting
Psychological Therapy
- Offer family intervention
- Offer structured psychological intervention (individual, group, family) designed for BPAD
- NOTE: this is effective for the depressive phases, NOT the manic episodes. It may help with relapse recognition in some patients in remission
- It can help improve concordance with medication
Monitoring
- When starting antipsychotics, the following should be measured:
1. BMI, pulse, BP
2. HbA1c/ fasting glucose, lipid profile
3. ECG- may be needed if drug indication, patient risk factors
When taking antipsychotics, monitor:
1. Pulse + BP- after each dose change
2. BMI- weekly for first 6 weeks, then at 12 weeks
3. Blood glucose or HbA1c, lipid profile- at 12 weeks
Prior to commencing lithium, the following should be checked:
1. BMI
2. U&Es (inc. calcium + GFR)
3. TFTs
4. FBC
5. ECG- if CVD or CV risk factors
Measure plasma lithium levels 1 week after starting or changing dose and monitor weekly until stable levels reached. It should then be measured at least every 3 months thereafter in the first year
Aim: 0.6-0.8mmol/L- if first time use
Aim: 0.8-1mmol/L- if relapse whilst taking or subthreshold symptoms with functional impairment
If taking lithium, monitor:
1. U&Es (inc. calcium + GFR) and TFTs- every 6 months
If stopping pharmacological treatment:
1. Stop treatment gradually
2. Lithium:
- Reduced gradually over at least 4 weeks, preferably up to 3 months
- During dose reduction and for 3 months after stopped, monitor for signs of mania or depression
3.Antipsychotics:
- Reduce gradually over at least 4 weeks to minimise risk of relapse
- Monitor for signs of relapse
- Continue monitoring mood and mental state for 2 years after medication has stopped entirely
4.Social Interventions
- Family support and therapy as well aiding return to education or work
- Advise not to drive during acute illness and insurance may not be valid and must inform DVLA about their illness
Additional Information: Bipolar UK, MIND, Rethink- have local self-help groups
British Association for Supported Employment (BASE.uk.org) is the National Trade Association representing agencies that can help securing employment for people with disabilities
Women of Childbearing Age & Pregnancy- Discuss with Specialist Perinatal Mental Health
- Sodium valproate should NOT be prescribed to female children, adolescents and women of childbearing potential or pregnant women unless the illness is severe and all other options are ineffective or not tolerated + Pregnancy Prevention Programme is in place
- If on sodium valproate, dose should be reduced over 4 weeks to minimise risk of relapse (MHRA safety advice due to teratogenicity)
In Primary Care
- If known bipolar disorder and there are symptoms of hypomania or deterioration in depressive symptoms, liaise with or refer to secondary care
- Symptoms of hypomania or non-severe depression routine referral to CMHT
- Symptoms of mania or severe depression URGENT referral to CMHT
- Do NOT start sodium valproate in primary care for treatment of BPAD
In children and young people
- Aripiprazole can be used for moderate-severe manic episodes in BPAD type 1 in children ≥ 13 years
- Otherwise, same as adult treatment above
Complications
- Suicide and deliberate self-harm
- Consequences of disinhibition and impaired social functioning
- Other psychological and physical illnesses
- Lithium toxicity: Life-threatening
- Mild tremor, GI effects- N+V, polyuria, polydipsia, arrhythmia, hypothyroidism, weight gain, renal failure, CNS symptoms- drowsiness, ataxia, coarse tremor, fits, coma, death
- Triggers: salt balance changes (e.g. dehydration, D+V), drugs interfering with excretion (e.g. diuretics), accidental or deliberate OD
- Management:Check lithium level, STOP lithium dose
WARNING: stopping lithium abruptly could precipitate symptoms of mania/ depression
- Transfer to medical care- rehydration, osmotic diuresis
- If OD is severe, patient may need gastric lavage or dialysis
- Lithium can also precipitate a benign leukocytosis
Mood stabilisers are teratogenic in pregnancy
1. Lithium- Ebstein’s anomaly
2. Valproate and Olanzapine- spina bifida
Prognosis
Manic episodes often begin abruptly and are normally shorter than depressive episodes (last between 4-5 months)
Recovery is usually complete between episodes
Remissions become shorter with age and depressions become more frequent
Long-term treatment with lithium reduces risk of suicide to the same levels as the general population
> 90% of those who have a manic episode will eventually have a depressive episode
2-3 increased risk in diabetes, CVD and COPD
