Bipolar and OAP

Question 1

Bipolar disorder: Hypomanic episode

Answer 1

Ssymptoms lasting for at least several days
* persistent elevated mood
* persistent irritability
* increase activity/energy
* increase talkativeness
* rapid/racing thoughts
* increase self-esteem
* decrease need for sleep
* distractibility
* impulsive/reckless behaviour
* Significant change from usual mood, energy and behaviour but no impairment in functioning

Question 2

Bipolar type 2 disorder

Answer 2

• Lifetime prevalence 0.4% in adults
• Onset: late adolescent to mid-20s. Often with one or more depressive episodes which might be unrecognised before symptoms of hypomania emerged.
• 15% may subsequently develop episodes of mania – change diagnosis to Bipolar I= (always review diagnosis at each patient contact)
• Significant FH of Bipolar Disorders
• Increase suicide risk esp during depressive episodes
• Recurrent panic attacks may indicate greater severity of illness, poorer response to treatment & higher risk of suicide
• Increase risk of developing medical condition eg cardiovascular diseases, metabolic syndrome due to the effect of medications used to treat Bipolar II Disorders.
• Higher rates of Anxiety/Fear Related Disorders and Disorders of Substance Use.

Question 3

Risks in bipolar affective disorder

Answer 3

• Overspending, debts
• Disinhibition (incl. promiscuity, pregnancy)
• Exploitation – financial, relationship,
• Driving
• Family/Children
• Violence – self & others
• Self-neglect – personal care, physical health
• Suicide: 15x higher then the general population
• Alcohol and Recreational substances

Question 4

What is mania/hypomania

Answer 4

• both terms relate to abnormally elevated mood or irritability
• with mania, there is severe functional impairment or psychotic symptoms for 7 days or more
• hypomania describes decreased or increased function for 4 days or more
• from an exam point of view the key differentiation is psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) which suggest mania

Question 5

Management of bipolar disorder

Answer 5

• psychological interventions specifically designed for bipolar disorder may be helpful
• lithium remains the mood stabilizer of choice. An alternative is valproate
• management of mania/hypomania= consider stopping antidepressant if the patient takes one; antipsychotic therapy e.g. olanzapine or haloperidol
• management of depression= talking therapies (see above); fluoxetine is the antidepressant of choice
• address co-morbidities= there is a 2-3 times increased risk of diabetes, cardiovascular disease and COPD

Question 6

Bipolar disorder: primary care referral

Answer 6

• if symptoms suggest hypomania then NICE recommend routine referral to the community mental health team (CMHT)
• if there are features of mania or severe depression then an urgent referral to the CMHT should be made

Question 7

Bipolar disorder: diagnostic challenges 1

Answer 7

• Clinically difficult to diagnose Bipolar Disorders in a single assessment.
• Diagnostic criteria for depressive episodes: identical in bipolar disorder and depressive disorder. Bipolar disorder is often misdiagnosed as depressive disorder
• Bipolar II is difficult to distinguish from depressive disorder because of the frequent depressive episodes and absence of full-blown mania
• Depressive symptoms are common in bipolar disorders and their prevalence is higher than that of hypomanic or manic symptoms

Question 8

Bipolar disorder: diagnostic challenges 2

Answer 8

• Mixed mood episodes are more common that previously thought in bipolar disorder. These episodes might obscure detection of mania and hypomania due to patients’ reporting bias (some patients prefer to be in hypomanic state as they can get more things done)
• Subthreshold symptoms of hypomania are common in depression
• A subset of patients with treatment-resistant depressive disorder might have misdiagnosed bipolar disorder

Question 9

Examples of rating scales in mood disorders: self reported

Answer 9

• Mood Disorder Questionnaire (MDQ) – brief screen – 12 or 3 item
• Young Mania Rating Scale (YMRS)
• Patient Health Questionnaire (PHQ)
• Beck Depression Inventory – BDI, most commonly used in clinical diagnosis
• Quick Inventory Depressive Symptomatology-Self Report (QIDS-SR)

Question 10

Examples of rating scales in mood disorders: interview with physician

Answer 10

• Hamilton Depression Rating Scale (HAMD)
• Montgomery and Asberg Depression Rating Scale (MADRS)
• Quick Inventory Depressive Symptomatology – Clinician (QIDS-C)

Question 11

Biological management of bipolar disorder: first episode (manic or hypomanic)

Answer 11

• If the individual is on antidepressant (as treatment for depression), consider stopping antidepressant.
• Start antipsychotics – choice of risperidone, olanzapine, haloperidol, quetiapine. Titrate dose carefully.
• Monitor for side-effects – acute dystonia, akathisia, EPSE
• If first antipsychotic is poorly tolerated or if no response, choose another antipsychotic
• Benzodiazepine – short term use only & if necessary Review daily. Long term use of benzodiazepine cause dependence & potential withdrawal symptoms
• Other options: choice of Lithium, Valproate, Aripiprazole. Sodium valproate cant be given to women of child bearing age due to teratogenicity

Question 12

Biological management of bipolar disorder: acute depressive episode (moderate to severe bipolar depression)

Answer 12

• If not on treatment for bipolar disorder:
• Fluoxetine plus Olanzapine or Quetiapine on its own
• Can offer either Olanzapine or Lamotrigine on its own
• If no response to combination of fluoxetine plus Olanzapine or Quetiapine, offer Lamotrigine on its own

Question 13

Treatment for acute depressive episode (moderate to severe bipolar disorder): if already on lithium

Answer 13

• Check Li level & adjust dosage appropriately. If Lithium is at max, based on patient’s preference & previous experience, offer combination of Lithium with:
• Fluoxetine + Olanzapine or Quetiapine
• Can add Olanzapine (without Fluoxetine)
• Stop if no response to combination of Fluoxetine + Olanzapine or adding Quetiapine
• Consider combination of Lamotrigine to Lithium

Question 14

Treatment for acute depressive episode (moderate to severe bipolar disorder): if already on valproate

Answer 14

• Consider increasing the dose within therapeutic range to maximum tolerated dose. If already at max, based on patient’s preferences & experience, offer combination of Valproate with
• Fluoxetine + Olanzapine or Quetiapine
• Can add Olanzapine (without Fluoxetine)
• Stop if no response to Fluoxetine + Olanzapine or adding Quetiapine
• Consider combining Lamotrigine to Valproate

Question 15

Long term management of bipolar disorder: biological

Answer 15

• Shared decision making. Discuss what pharmacological intervention that worked in the past, potential benefits and risks of medications in the shorter & longer term, medication concordance, side-effects & drug interactions inc over the counter preparation. Risks of relapse without meds.
• First Line: Lithium, If Li ineffective, offer Valproate (Not of women of child bearing age)
• Alternative consider Olanzapine, Quetiapine

Question 16

Long term management of bipolar disorder: Psychological

Answer 16

• Educate patients and carers (with patients’ consent) about nature & severity of illness.
• The aim is to empower patients to manage their illness – self-monitoring, recognition of early warning signs eg decrease need for sleep may trigger a manic relapse.
• Discuss about future management according to patients’ preferences inc advance directive
• Offer CBT/Interpersonal Therapy/Family Intervention according to patients’ needs & preferences.

Question 17

Long term management of bipolar disorder: social

Answer 17

• The aim is to return to premorbid functioning level in terms of education & employment.
• Lifestyle advice on smoking/alcohol/recreational substances/exercise/diet
• Support group: Bipolar UK

Question 18

Bipolar disorder issues in treatment: Lithium

Answer 18

• Narrow therapeutic index – initially measure weekly till levels stable, monitor levels 3 monthly thereafter.
• Renal and thyroid dysfunction – renal function + TFTs 6 monthly
• Sudden discontinuation – 50% risk of mania
• Pregnancy= Avoid, if possible, particularly in the first trimester (risk of teratogenicity, including cardiac abnormalities - Ebstein anomaly. Dose requirements increased during the second and third trimesters (but on delivery return abruptly to normal). Close monitoring of serum-lithium concentration advised in pregnancy (risk of toxicity in neonate).

Question 19

Bipolar disorder issues in treatment: Valproate and Lamotrigine

Answer 19

• Valproate: not for women of child bearing age. Reduced IQ (10-15 points), teratogenicity (neural tube), polycystic ovary. Levels if ineffective, poor adherence or toxicity
• Lamotrigine: risk of Stevens-Johnson syndrome, slow dose titration
  Combination of antidepressant and antipsychotic are indicated for the treatment of depressive disorder with psychotic symptoms. For example, Sertraline and Ariprazole

Question 20

Neurostimulation

Answer 20

• ECT
• Transcranial magnetic stimulation (TMS)
• Others: Vagus nerve stimulation, Transcranial direct current stimulation (tDCS), Deep brain stimulation

Question 21

Electroconvulsive therapy

Answer 21

• Indications: severe depression, mania, catatonia, psychosis
• Contraindications: relatively few (space occupying lesion). Cautions: MI, Cardiac surgery, AAA, valvular
• Anaesthetic Risks – especially for individuals with pre-existing illness eg COPD. May need to liaise with Anaesthetists/Physicians if there are concerns
• Short term – headaches, myalgia, nausea, retrograde/anterograde memory loss
• Long term - ?memory loss. Patients report 1/3 autobiographical/retrograde memory loss - research studies shows memory loss is temporary but research measures anterograde memory. Most ECT clinics conduct cognitive assessments pre & post treatment.

Question 22

Transcranial magnetic stimulation (rTMS)

Answer 22

• Commonly used method= Involves placing electrodes directly against the head (rTMS)
• Placing electrodes against the head & passing a small current between them (tDMS)
• Aim is to stimulate neurons in the brain
• Currently used in the treatment of depression. Less robust evidence for others eg OCD, anxiety/fear related disorders
• Not available on the NHS

Question 23

Special considerations in presentations and management of old age psychiatry

Answer 23

• Many older people suffer from multiple illnesses & significant disability.
• Have greater medical complexity & Vulnerability.
• May suffer major cognitive, affective and functional problems.
• The illness presentations maybe atypical.
• Elderly population are often socially isolated.
• They maybe particularly vulnerable to iatrogenic health problems.
• Potential for increased sensitivity to medication.
• Requires particular attention to assessment, treatment and discharge planning

Question 24

Mental disorders in old age: Organic vs Functional

Answer 24

• Organic: dementia, delirium, substance misuse
• Functional: depressive disorder, Manic/BPAD, late onset psychosis, anxiety disorders, personality disorders

Question 25

Depression in older adults

Answer 25

• Most common mental health problem in later life.
• F>M
• F more recurrent depressive episodes
• Men less likely to present
• Prevalence (major depression) in older adults varies with setting: Highest in institutional settings (e.g. Care Homes), Often unrecognised & untreated.
• Burden of depression is higher in the elderly, increased mortality if untreated
• Increased morbidity, healthcare utilisation and economic costs

Question 26

Depression in older adults: risk factors

Answer 26

• Physical illness= sensory impairment, reduced mobility, impaired ADL and social function, chronic and disabling treatment for physical health problems (steroids). I.e. myocardial infraction, hypothyroidism, Parkinsons, rheumatoid arthritis
• Psychosocial= loneliness, lack of social support, financial hardship, role change, bereaverment and loss of independence
• Age related changes= change in endocrine, cardiovascular and inflammatory system etc. Normal ageing process and changes to sleep (insomnia), sleep disturbance
• Other= past history of depression, presence of subthreshold depression, family history of depression, female gender
  Depression in older adults clinical features: Core symptoms the same (ICD-11) but reduced complaints of sadness.

Question 27

Mood disorders in ICD-11

Answer 27

• Single episode depressive disorder: one depressive episode only
• Recurrent depressive disorder: a history or at least two depressive episodes separated by at least several months without significant mood disturbance
• Bipolar type I disorder: episodic mood disorder defined by the occurrence of one or more manic or mixed episodes
• Bipolar type II disorder: episodic mood disorder defined by the occurrence of one or more hypomanic episodes and at least one depressive episode

Question 28

Depressive episode: symptoms in older adults

Answer 28

• A depressive episode is characterised by a period of depressed mood or diminished interest in activities (anhedonia)
• Activity: change in appetite, change in sleep, reduced energy or fatigue
• Cognition: difficult concentrating, recurrent thoughts of death or suicide, psychomotor agitation or retardation
• Emotion: feelings of worthlessness, excessive or inappropriate guilt, hopelessness
• Time course: occurring most of the day, nearly every day, during a period lasting at least 2 weeks
• Significant impairment in functioning
• Categorised based on intensity of symptoms and functional impairment, not number of symptoms

Question 29

Depression in older adults: presentation

Answer 29

• Reporting of physical symptoms ( pain, dizziness, weakness, constipation)
• Apathy & Poor motivation.
• Psychological symptoms are more frequent: guilt, anxiety, suicidal ideation – risk factor for suicide
• Irritability & agitation
• Psychomotor retardation & risk of self neglect.
• Psychotic features: Hallucinations & delusions (nihilistic delusion)
• Cognitive deficits are characteristic (‘pseudodementia’)

Question 30

Relationship between depression and dementia

Answer 30

The presence of depressive symptoms:
* Often occurs in patients with dementia
* Maybe a reaction to early cognitive deficit
* Can impair cognitive function (pseudo dementia) with difficulties in concentration and memory
* Maybe risk factor for developing dementia

Question 31

Suicide in the elderly: associated risk factors

Answer 31

• Male gender
• Older age
• Living alone / Social isolation.
• Bereavement
• Poor physical health (up to 80%)
• Psychiatric illness & alcohol misuse.
• Recent discharge from general hospital
• High rates of contact with primary care.
• Recent life events
• Previous self harm.

Question 32

Management of depression in the elderly

Answer 32

• Bio-psycho social approach for risk assessment and formulation (e.g. Self neglect, physical health decline, psychosis, suicide).
• Rule out physical cause
• Role & Indications for Electroconvulsive therapy (ECT) including Psychomotor retardation, Severe depression.
• Consideration for appropriate psychopharmacological options and potential side effects ( e.g. SSRI & Hyponatraemia), and low dose antipsychotic medication in psychotic depression.
• Psychosocial interventions to include collateral history gathering, psychological interventions (e.g. CBT), supportive therapies, IAPT (improving access to psychological therapies), social interventions(occupational therapy assessments), social care packages, carers assessment.
• Role of 3rd Sector / Voluntary services.

Question 33

Bipolar affective disorder in older adults

Answer 33

New episode is uncommon in older adults. Suspicion of an underlying physical cause for the symptoms, especially if there is no history of mood disorder (i.e. brain damage, hyperthyroidism, temporal lobe epilepsy).

Question 34

Bipolar affective disorder in older adults management

Answer 34

• Bio-psycho social approach for risk assessment and formulation including consideration for use of Mental Health Act as appropriate.
• Use of appropriate pharmacological interventions including mood stabilisers – e.g. lithium, anticonvulsants & antipsychotic medication.
• Lithium monitoring & lithium toxicity ( diarrhoea, vomiting, coarse tremor etc.). Beware dehydration & polypharmacy.
• Risk assessment & formulation to include risk of exploitation, sexual inhibition etc.
• Psychological interventions including cognitive behavioural therapy, family therapy.
• Role of GP, Community psychiatric nurses, psychiatrists review & social services.

Question 35

Commo causes of psychosis in the elderly

Answer 35

• Long standing psychotic illness
• Mood disorder
• Dementia
• (Very) late onset schizophrenia
• Psychosis does not mean presence of psychiatric illness, physical causes including delirium and medication side effects especially in the elderly

Question 36

Risk factors for late onset schizophrenia

Answer 36

• Female gender.
• Social isolation.
• Sensory impairments (sight, hearing).
• Other associations: History of poor adjustment & unusual personality / Schizoid personality traits ( paranoia, lack of interest in social relationships, secretiveness, restricted expression of emotions).

Question 37

Late onset schizophrenia: clinical features

Answer 37

• Persecutory delusions and auditory hallucinations
• Less common are thought disorder, negative symptoms i.e. deficits in emotional response and motivation) or cataonia
• If patient presents with visual hallucinations, consider the following: Delirium, Lewy body dementia, Anti-Parkinson drugs, Charles Bonnet syndrome

Question 38

Management of late onset schizophrenia

Answer 38

• Bio-psycho social approach is useful in risk assessment (risk to self & others) including consideration for use of Mental Health Act.
• Important to exclude organic causes ( physical illness, medication side effect, dementia).
• Use of antipsychotic medication, lower dose & need for annual physical health monitoring ( e.g. blood pressure, pulse rate, weight, blood glucose, ECG, EPSE etc.). Atypical vs Typical.
• Treatment of other associated conditions e.g. depression.
• Review of sensory deficits, address social isolation
• Appropriate psychological approaches including counselling, cognitive behavioural therapy & family therapy.
• Role of GP, Community psychiatric nurses, psychiatrists review & social services (carers assessment, social care package, respite) & Role of voluntary / 3rd Sector services.

Question 39

Anxiety disorders in older adults

Answer 39

• New onset of primary anxiety disorder in older age is uncommon: think dementia, depression and physical
• Common physical causes of anxiety include heart disease (myocardial infarction, arrhythmias), lung disease (COPD and pneumonia) and hyperthyroidism
• Sigs of anxiety can be mistaken for physical health problems

Question 40

Management of anxiety disorders in older adults

Answer 40

• Psychological treatments are often the main stay of therapy in anxiety disorders –CBT commonly used (Also effective in older people despite difficulties with sensory impairment, mobility, memory or physical health).
• Use of appropriate psychopharmacological interventions e.g. antidepressants SSRI especially when co existing mood symptoms.
• Beware Side effects of medications and risk of falls in elderly.

Question 41

Personality disorders in older adults

Answer 41

• Prevalence around 10%
• Challenges in diagnosing in older adult
• Symptoms persist as with younger age group, though maybe ‘less dramatic’
• ? Functional impairment due to underlying personality impairment or effects of ageing.
• Increased risk of self harm

Question 42

Management of personality disorders in older adults

Answer 42

• Management is with use of biological, psychological & social approach with treatment aimed primarily at any co- morbid disorder (e.g. depression), though presence of depression may negatively impact on outcomes of treatment options.
• Treatment modalities include psychological interventions such as supportive psychotherapy, CBT, cognitive analytic therapy, psychodynamic therapy & family therapy

Question 43

Other terms re disordered eating

Answer 43

• Bigorexia – muscle dysmorphia
• Drunkorexia – restricting dietary intake to drink alcohol without consuming extra calories
• Orthorexia – “healthy” “clean” diets
• Diabulimia – omitting insulin to lose weight/compensate for binges

Question 44

Aetiology- eating disorders

Answer 44

• Genetics: risk of developing an eating disorder is increased in first degree relatives of those with AN/BN. Some patients with AN have gene mutations controlling metabolism, particularly blood sugar levels and body fat
• Gender- more common in females
• Early puberty
• Type 1 diabetes
• Psychological: Temperament traits, early experiences and attachment, early feeding behaviours, life events, low self esteem, weight/shape concerns
• Social= dieting culture, profession (models, gymnasts, ballet, fashion, acting, boxing), family dynamics, bullying, social media

Question 45

Types of delirium

Answer 45

• Hyperactive: increased sympathetic activity, agitation. Restless and disturbed sleep cycle. Rapid mood changes and hallucinations, most easily recognised
• Hypoactive underdiagnosed: poor oral intake, need feeding and supervision with meds. Worse prognosis, prone to malnutrition and dehydration. Inactivity or reduced motor activity
• Mixed (most common): fluctuates, hyperactivity at night and lack of insight, recollection in the day

Question 46

Assessment and diagnosis of delirium

Answer 46

-MSE, clinical features (+ assessment tests e.g. CAM, 4AT), collateral history
- Physical + neuro examination
- Other tests – bloods, urine, neuroimaging…

Question 47

CAM: delirium

Answer 47

Must have 1 + 2 + 3/4
(1) Acute onset and fluctuating course – change from baseline
(2) Inattention – difficulty focusing on tasks
(3) Disorganized thinking – rambling, irrelevant conversation, illogical flow of ideas
(4) Altered level of consciousness – alert/vigilant/lethargic/stupor/coma

Question 48

Management of delirium

Answer 48

• Awareness & risk factor assessment
• Treat underlying cause
• Prevention – calm, well-lit environment, hearing aids and spectacles if needed, avoid restraints, meds review, pain management, sleep hygiene…
• Effective communication & reorientation
• Nonverbal de-escalation techniques
• CAUTION with antipsychotic meds used for distressing sx
• Residual sx may take up to 6 months to resolve

Question 49

Self-harm definition

Answer 49

An intentional act of self-poisoning or self-injury irrespective of the motivation or apparent purpose of the act and is an expression of emotional distress.

Question 50

Assessing risk of violence

Answer 50

• History of violence: a person should be asked: “have you ever been in prison for a violent offence?” If the answer is yes, then ask for more details. A further question to ask is “have you ever attacked any one?” If yes again, request more detail, “Was this in a fight? Was someone seriously hurt? Did they require hospital treatment? Were any weapons used? Did you kick someone when they were down?”
• Current risk of violence: “Do you have any violent thoughts at present?” If the answer is yes, this requires further exploration. Consider whether the individual has access to potential victims, this is particularly important in individuals identified with mental state abnormalities. You should also ask if they carry any weapons.