Bipolar and Cyclothymia Flashcards
If a patient has bipolar with psychotic features. . .
. . . they need a mood stabilizer AND an antipsychotic
Presentation of bipolar in children
Often presents with a mixed or dysphoric picture characterized by short periods of intense mood lability and irritability.
Alternatively, it is often misdiagnosed as depression, as a major depressive episode often precedes the onset of manic episodes in adolescents with bipolar I.
Labile mood
A mood or affect that switches rapidly from one extreme to another
For example, laughing and euphoric one minute, intense anger followed by extreme sadness moments later, often over the course of minutes during an interview
Rapid-cycling bipolar disorder
- Occurrence of at least 4 mood episodes (depression or mania/hypomania) within 1 year
- Separated by either a full or partial remisson of at least 2 months duration
- OR
- Full switch from one pole to the other (full mania to major depression)
Concordance rate of identical vs dizygotic twins for bipolar disorder
Identical: 69%
Dizygotic: 19%
In other words, there is a strong genetic component
Diagnostic criteria for manic episode
- Period of abnormally and persistently elevated or irritable mood and increased energy
- Lasts at least 1 week OR any duration if hospitalization is required OR any duration if manic psychosis is present
- 3 or more of the manic symptoms (DIGFAST)
- Must cause impaired functioning
- Not better explained by another dx or substance/medical condition
In adolescence, episodes of mania are often accompanied by. . .
. . . psychotic features
Hospitalization is often necessary for these patients
When making a diagnosis of bipolar in children or adolescents. . .
. . . at least 1 week of mania and 2 weeks of major depression should be present in the history to ensure accurate diagnosis
Major ddx for bipolar I and manic symptoms in children
ADHD in combination with ODD or CD
These patients can present with a pattern of distractability, motor agitation, and impulsive angry outbursts.
Note that bipolar is extremely uncommon in school age children while ADHD and ODD/CD are common at this time.
First-line therapies for bipolar without psychotic features
- Mood stabilizers:
- Lithium
- Divalproex
- Carbamazepine
OR
- Atypical antipsychotics:
- Risperidone
- Olanzapine
- Quetiapine
Divalproex and age
Divaporex has well established safety for children younger than age 12, and so it is first-line for bipolar disorder in these patients.
For age 12 or older, lithium is often the drug of choice.
All mood stabilizers require. . .
. . . regular monitoring of blood levels
Just like many antiepileptics
Monitoring for lithium
Regular blood level of lithium
Thyroid function tests
Kidney function tests
Monitoring for carbamazepine
CBC for aplastic anemia or agranulocytosis
Before prescribing any mood stabilizer, you should obtain. . .
. . . a pregnancy test (from female patients)
Since they are basically all teratogenic in some way/shape/form
In contrast, atypical antipsychotics for treating mania have no teratogenic effects.
Monitoring for divalproex
Liver function tests
Platelet levels
“Unmasking” of mania
Many antidepressants are believed to be able to trigger or “unmask” mania
As a consequence, they should be avoided or used carefully in patients with mania. If a patient does start one, they should be carefully observed for emergent manic symptoms.
Criteria for a hypomanic episode
- Essentially the same criteria as a manic episode, but shorter duration and less intense
- Elevated, expansive, or irritable mood with increased energy/activity
- Lasts for 4 days or more with 3 or less associated symptoms (DIGFAST)
Symptoms for manic episode (mnemonic)
Symptoms for major depressive episode (mnemonic)
Criteria for major depressive episode
- Depressed mood and/or anhedonia
- Lasts for 2 weeks or more
- With tour or more other associated symptoms (SIGECAPS)
Diagnostic criteria for cyclothymia
- Fluctuating hypomanic and depressive symptoms
- Never meeting full criteria for hypomanic, manic, or depressive episodes
- History of at least 2 years for which symptoms are present at least half of the time without any aymptomatic periods > 2 months
- Symptoms lead to significant distress and/or impaired functioning
Common medical therapies or drugs of abuse that mimic cyclothymia’s “mood swings”
Steroids
Stimulants
“Mixed state” in bipolar disorder
Exhibiting elements of both depression and (hypo)mania
The presence of ___ rules out cyclothymia
The presence of psychotic features rules out cyclothymia
___ also often presents with mood lability and relationship difficulties and may co-occur with cyclothymic disorder
Borderline personality disorder also often presents with mood lability and relationship difficulties and may co-occur with cyclothymic disorder
Medications for cyclothymia are. . .
. . . the same as for run of the mill bipolar
Lithium and valproate are first-line as mood stabilizers. Lamotrigine can be used to address depressive symptoms.
Similarly, anti-depressants should be avoided due to the possibility of inducing (hypo)mania.
Education is a very imporant component for these patients.
What do you do if someone fails conventional mood stabilizer therapy for bipolar?
Combination therapy with mood stabilizer and atypical antipsychotic
ex, valproate and quetiapine
