Bipolar and related disorders

Question 1

What is the difference between Bipolar I, Bipolar II, and Cyclothymic disorder?

Answer 1

Bipolar I has Manic episodes followed by severe depressive episodes

Bipolar II has Hypomanic episodes followed by severe depressive episodes

Cyclothymic disorder has Hypomanic episodes followed by mild depressive episodes

Question 2

What is the broad diagnostic criteria for Bipolar I

Answer 2

Current or past manic state AND a current or past depressive episode

Question 3

What it the broad diagnostic criteria for Bipolar II

Answer 3

Current or past hypomanic state AND a current or past depressive episode

Question 4

What is the duration for manic and hypomanic states

Answer 4

One week for manic

four days for hypomanic

Question 5

What are the 7 criterion B symptoms for diagnosing mania / hypomania?

Answer 5

Three or more (four or more if the mood is only irritable) of the following to a significant degree, and where they are a change from usual behaviour:

1. Inflated self-esteem or grandiosity
2. Decreased need for sleep (feels rested after 3h)
3. More talkative than usual or pressure to keep talking
4. Flight of ideas or subjective experience that thoughts are racing
5. Distractibility
6. Increase in goal-directed activity (or purposeless non-goal-directed activity like pacing)
7. Excessive involvement in activities that have high potential for painful consequences (spending, unsafe sex, etc.)

Question 6

What distinguishes Mania from Hypomania?

Answer 6

Marked impairment

Hospitalisation

Psychosis

Question 7

When does psychosis occur in Bipolar I and II

Answer 7

In mania for Bipolar I

In depression for Bipolar II

Question 8

What is the most common presentation for Bipolar?

Answer 8

Depression. Most don’t present in mania

Family may initiate consultation for mania (particularly aggressive mania)

Question 9

What are some screening questions for Bipolar?

Answer 9

Do you have periods when you feel more energised or wired?

So you have never experienced any highs or mood overshoots, then?

Question 10

How will patients describe manic / hypomanic states?

Answer 10

More productive
Highly energised
Playful
Impatient
Talking over people
Feeling invincible
Verbally indiscrete (criticising boss)
Need less sleep
Risk taking
Increased libido

Question 11

What are the typical delusions associated with Mania?

Answer 11

Delusions of grandeur: Special powers, special person, famous person, Jesus

Question 12

What is the management of acute mania in bipolar disorder?

Answer 12

First line:
Olanzapine (5mg)
Risperidone (0.5-1mg)

Second line:

Antispychotics:
Haloperidol (1.5mg)
Aripiprazole (10mg)
Asenapine (5mg twice per day)
Paliperidol (3mg)
Quetiapine (50mg twice per day)
Ziprasidone (40mg twice per day)

Mood stabilisers:
Lithium carbonate (750-100mg, check levels after 5-7 days)
Sodium valproate (200-400mg, check serum level after 3 days)
Carbamazapine (100-200mg, check serum level after 5-7 days)

If not responsive to treatment:
Combine antipsychotic with lithium
ECT

Question 13

What is the management of depression in Bipolar

Answer 13

An antidepressant + a recommended prophylactic medication (Olanzapine + fluoxetine most common)

Quetiapine monotherapy

Question 14

What is the prophylactic management of Bipolar?

Answer 14

OSCE / non-pham stuff:

• Broadly based treatment program (therapeutic alliance, specialist referral, case management, compliance therapy)
• Manage comorbidities
• Maintain physical health
• Work with family / carers

Pharmacological:
First line:
Lithium *** (most common)
Aripiprazole
Asenapine
Olanzapine
Paliperidone
Risperidone depot
Ziprasidone
Lamotrigine (***if depression is prominent)
Carbamazepine
Sodium valproate