Bipolar Disorder Flashcards
What did bipolar disorder used to be called?
Formerly known as manic depression
What types of bipolar disorder are there?
- Bipolar 1 disorder
- Bipolar 2 disorder
- Rapid cycling bipolar
What happens in /characterises each of the types of bipolar disorder?
Bipolar 1 disorder – there is underlying depression, interspersed with episodes of mania (usually depressive and manic episodes occur in the ratio 1:1)
Bipolar 2 disorder – the depression is more predominant, and the RATIO of depressive to manic episodes is about 5:1. Manic episodes may only be slight (i.e. HYPOMANIA), or precipitated by anti-depressant medication
Rapid cycling bipolar – a new classification, where there are >4 episodes/YEAR of mania + depression. Important because the treatment is different from other types of bipolar disorder
How common is bipolar disorder and who gets it?
- Prevalence of 1-1.5%
(1% is bipolar 1
0.5% is bipolar 2) - More common in women
- Usual onset in teenage years
- First incidence is usually before at the age of 30
- If first incidence is after 45, suspect organic cause
- The first presentation can involve any/all of the following; depression, hypomania, mania
5-10% ↑ risk if family member has depression / bipolar
↑ risk in those with a tendency to have rapid mood changes (cyclothymia) or unusual periods of elated feelings (hyperthymia)
COMT gene associated with rapid cycling bipolar disorder.
Life effects, drugs etc can precipitate
What is mania vs hypomania?
Mania – this is an elated mood lasting 1-2 weeks (or more), with PSYCHOTIC symptoms. Affects social functioning.
Hypomania – there are no psychotic symptoms, and generally, it does not last as long. Must last >4 DAYS to be classed as hypomania
What features also accompany a manic episode?
- Feelings of ↑ self worth
- Inappropriate social behaviour (compulsive spending, dangerous driving etc)
- General increase in activity (and less sleep)
- Delusions and Hallucinations
- Very fast speech (fast thoughts, speech cant keep up)
- Altered perceptions (brighter colours, louder noise)
What questions could you ask to see is someone has a history of manic episodes?
Have you ever felt especially happy or cheerful? How long does it last? How often does it occur?
Do you feel you lose your temper more easily than usual?
Do you feel you have more energy than usual?
If the patient answers yes to any of these, ask about:
- sleep patterns,
- restlessness,
- opinion of the self,
- libido (↑↑),
- spending habits.
What would an MSE of manic episode likely sound like?
Appearance – bright coloured clothes, eccentric
Behaviour – over friendly, perhaps inappropriate
Speech – fast, and difficult to interrupt
Mood – elated/irritable
Thought – fast, sentences may be logical, but linked by puns and similar sounding words, and not by ideas, patient may be very self important and have grandiose ideas.
Perception – Hallucinations – usually occur with elated mood
Cognition – distractability
DSM-V diagnostic criteria for bipolar?
ELATED or IRRITABLE mood for at least one week, PLUS at least THREE of:
- Inflated self esteem
- Decreased need for sleep
- Accelerated speech
- Racing thoughts / flight of ideas
- Distractibility (reported or observed)
- Increased goal directed activity or psychomotor agitations
- Excessive activity
What differential diagnoses should you have when considering bipolar disorder?
- unipolar depression (regular depression)
- schizophrenia
- borderline personality disorder (more chronic, less episodic)
- endocrine (thyroid, pituitary, adrenal)
- neurological (MS, CVA, epilepsy, tumour, esp in frontal / subcortical areas)
- drugs (steroids, stimulants, anti-depressants)
What investigations might you do to rule out organic causes of mania?
Bloods: FBC, U&E, LFTs, TSH
Urinary drug screen
Neurochemistry, Neuroimaging and Neuropathology might show:
- PET scan: excessive post synaptic dopamine 2 activity in mania
- Increased serotonin and noradrenaline levels: during episodes of mania (but the evidence is not conclusive)
- Inositol phosphate: a chemical that increases the metabolism of lithium is increased in mania
- Cortisol: in mania, there is increase cortisol release/response to stress
- White-matter hyper-intesities: the presence of these is related to poor prognosis, increased frequency of manic episodes, and cognitive impairment
What is first and second line for acute mania?
First line:
Atypical antipsychotic – e.g. Olanzapine, risperidone, quetiapine, Clozapine (Be weary of Agranulocytosis!)
Second line:
try Valporate, lamotrigine (anticonvulsants), or Lithium
What are some pharmacological treatments for a bipolar depressive episode?
AVOID ANTIDEPRESSANTS! – these can cause rapid cycling mood
Try an atypical antipsychotic – such as quetiapine or olanzapine.
If this doesn’t work, try adding the anticonvulsant lamotrigine or possible lithium adjunct
In some cases, SSRI may be suitable, but be very careful
What is general maintenance therapy for bipolar disorder?
First line – Lithium (mood stabiliser)
Consider mood diary at bedtime.
Pyschological treatments less effective than in unipolar depression.
If someone has had a manic episode, what is their chance of another?
Unusual for a person to only ever have one manic episode. If a patient has experienced one, future ones are likely:
50% chance in the next year
80% chance in the next 4 years
