Bipolar Disorder Flashcards

1
Q

What is bipolar disorder?

A

Bipolar disorder is a chronic episodic illness associated with behavioural disturbances. It used to be called manic depression. It is characterised by episodes of mania (or hypomania) and depression.

Either one can occur first and one may be more dominant than the other but all cases of mania eventually develop depression.

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2
Q

What is the classification of bipolar disorder?

A

Type 1

Type 2

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3
Q

What is type 1 bipolar disorder?

A

Bipolar I: this type presents with manic episodes (most commonly interspersed with major depressive episodes). The manic episodes are severe and result in impaired functioning and frequent hospital admissions.

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4
Q

What is type 2 bipolar disorder?

A

Bipolar II: patients do not meet the criteria for full mania and are described as hypomanic. Hypomania in comparison to mania has no psychotic symptoms and results in less associated dysfunction. This type is often interspersed with depressive episodes.

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5
Q

How does the manic phase present?

A

Mania is characterised by elevated mood and increase in quantity and speed of physical and mental activity.

Self-important views and ideas are greatly exaggerated. Some patients may be excessively happy, whilst others may be irritable and easily angered.

During the manic phase
The following may be present:
-Grandiose ideas.
-Pressure of speech.
-Excessive amounts of energy.
-Racing thoughts and flight of ideas.
-Overactivity.
-Needing little sleep, or an altered sleep pattern.
-Easily distracted - starting many activities and leaving them unfinished.
-Bright clothes or unkempt.
-Increased appetite.
-Sexual disinhibition.
-Recklessness with money.
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6
Q

How does mania present in severe cases of bipolar disorder?

A

In severe cases there may be grandiose delusions (eg, belief that they are world leaders or monarchs), auditory hallucinations, delusions of persecution and lack of insight. The lack of insight is very dangerous as patients are unable to see the need for them to change their behaviour.

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7
Q

What is hypomania?

A

Hypomania is a lesser degree of mania with persistent mild elevation of mood and increased activity and energy but without hallucinations or delusions. There is also no significant effect on functional ability.

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8
Q

How is a diagnosis of bipolar disorder made?

A

ICD-10 requires at least two episodes in which a person’s mood and activity levels are significantly disturbed (one of which must be mania or hypomania).

Three of the following symptoms confirm mania:
Grandiosity/inflated self-esteem.
Decreased need for sleep.
Pressured speech.
Flight of ideas (rapidly racing thoughts and frequent changing of their train of thought).
Distractibility.
Psychomotor agitation.
Excessive involvement in pleasurable activities without thought for consequences (e.g., spending spree resulting in excessive debts).

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9
Q

What is involved in the clinical assessment of bipolar disorder?

A

Detailed history of the episode - symptoms, presence of hallucinations or delusions, collateral history if the patient consents to this:
Any previous episodes of mania or depression.
Any suicidal or homicidal thoughts.
Any self-neglect.
Family history.
Substance misuse, smoking and alcohol intake.
General physical health.

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10
Q

What are the differentials for bipolar disorder?

A
Hyper/hypothyroidism
Anorexia nervosa
Cerebrovascular event 
Dementia 
Schizophrenia 
CKD 
Medications such as steroids, isoniazid, L-dopa
Acute drug withdrawal or illicit drug ingestion
Cerebral insults e.g. neoplasm, infarcts
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11
Q

What is the management of bipolar disorder?

A

For depressed patient, they may need referral to secondary care if:

  • Severe depression
  • Poor response/adherence/intolerance to treatment
  • Comorbid misuse of alcohol or drugs
  • Bipolar disorder in pregnancy

Non-pharmacological methods

  • Self-help and support groups
  • Education regarding diagnosis
  • Psychological therapy
  • Encouragement of engagement in calming activities
  • Self-monitoring of symptoms, side-effects and triggers

Once patients begin treatment they should be reviewed at least weekly and then annually once they are stable. Special attention should be paid to lipid levels, plasma glucose, weight, use of tobacco, alcohol and other illicit drugs and monitoring of blood pressure. Regular questioning about side-effects and suicidal ideation should occur.

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12
Q

What is the management of the first manic episode?

A

Urgent control and may need rapid tranquilisation

Rapid tranquilisation is achieved by antipsychotics, benzodiazepines or antihistamines given orally, IM or IV.

Always consider hospital admission

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13
Q

What is the treatment of subsequent manic episodes?

A

If patients are already on an antipsychotic and develop a further manic episode then either the dose of the antipsychotic should be increased to the maximum licensed dose or it should be increased to the maximum tolerated dose. Drugs commonly used are haloperidol, olanzapine, quetiapine and risperidone. If one antipsychotic is ineffective it is worth changing to a different one.

If the second antipsychotic is ineffective at maximum licensed or tolerated dose, consider adding lithium. If lithium is inappropriate (eg, the patient refuses regular monitoring) consider adding valproate.

Valproate should not be used routinely in females of child-bearing potential and if it is used then patients need to be counselled about alternative forms of contraception.

If a patient with hypomania or mania is taking an antipsychotic with an antidepressant, the antidepressant should be stopped.

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14
Q

What is the treatment of acute depressive episodes in a patient with bipolar disorder?

A

Mild depression may not require any specific therapy and patients should be reviewed initially on a 1- to 2-week basis.

If depression develops rapidly in a patient with a previous manic episode who is not on treatment then an anti-manic drug should be started.

Patients with moderate-to-severe depression should be offered fluoxetine combined with olanzapine or quetiapine on its own.

If there is no response, lamotrigine on its own can be tried.

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15
Q

What is the long term treatment of bipolar disorder?

A

Bipolar disorder requires life-long treatment and management

Lithium should be considered first-line, with the addition of valproate if ineffective.

Valproate or olanzapine should be considered for patients intolerant of lithium or who are not prepared to undergo regular monitoring.
Do not use valproate in women of child-bearing age without appropriate caution.

If symptoms still continue then the patient should be referred to a mental health specialist. Medications that might be used in this situation are lamotrigine (especially in bipolar II disorder) or carbamazepine.
Lithium will require monitoring of levels and monitoring of renal function and thyroid function. Patients need to be advised of adequate rehydration and the dangers of suddenly stopping treatment.

Long-term therapy usually continues for two years but may be needed for as long as five years.
If medication is stopped, patients should be made aware of early warning symptoms of recurrence. Medication should be tailed off gradually (unless acute toxicity develops). Mood should be monitored for two years after treatment is stopped.

CBT

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16
Q

Which treatment should be used for bipolar patients with rapid cycling?

A

Patients with rapid cycling should have their thyroid function tested. If they are on antidepressants these should be stopped. Anti-manic therapy should be optimised and compliance checked.

First-line therapy is a combination of lithium and valproate and, if this fails, lithium alone can be used. Lithium withdrawal or toxicity may also cause rapid cycling and levels should be checked.