Bipolar Disorder

Question 1

What is bipolar disorder?

Answer 1

A disorder characterized by two or more episodes in which the patient’s mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of hypomania or mania, and on others, depression

Question 2

What is the aetiology of bipolar disorder?

Answer 2

80% of causes thought to have genetic component
Stressful life events
Sleep deprivation
Physical illness

Question 3

What are the types of bipolar disorder?

Answer 3

Bipolar type 1
Bipolar type 2
Cyclothymia
Rapid cycing

Question 4

What is bipolar type 1?

Answer 4

At least one episode of mania

May or may not have depression

Question 5

What is bipolar type 2?

Answer 5

At least one episode of hypomania

At least one episode of depression

Question 6

Which is more common, bipolar type 1 or 2?

Answer 6

Type 2

Question 7

What is cyclothymia?

Answer 7

Chronic mood disturbance associated with numerous episodes of mild hypomania and depression
Episodes are either not long enough or severe enough to meet criteria for bipolar diagnosis

Question 8

What is rapid cycling?

Answer 8

Four or more episodes of mood disturbance within a year

Question 9

What is hypomania?

Answer 9

Less severe than mania
Mood is elevated or irritable to an abnormal degree for at least 4 days, causing some interference with interpersonal function
Persistent and non-reactive

Question 10

What are the symptoms of hypomania?

Answer 10

At least 3 of:

• Increased activity or physical restlessness
• Increased talkativeness
• Difficulty in concentration or distractibility
• Decreased need for sleep
• Increased sexual energy
• Mild spending sprees or other types of reckless or irresponsible behaviour

Question 11

What is mania?

Answer 11

Mood is predominately elevated, expansive or irritable to an abnormal degree for at least 1 week or to the extent that hospitalisation is required, causing severe interference with personal functioning

Question 12

What are the symptoms of mania?

Answer 12

At least 3 of the following:

• Increased activity, restlessness
• Increased talkativeness
• Flights of ideas or thoughts racing
• Loss of normal social inhibitions
• Decreased need for sleep
• Inflated self esteem or grandiosity
• Distractibility or constant changes in activity or plans
• Reckless or risky behaviour in which the patient doesn’t see the risk
• Marked sexual energy or sexual indiscretion
• Psychosis

Question 13

Describe appearance and behaviour in mania

Answer 13

Bright clothes
Distractibility
Loss of normal social inhibitions/overfamiliarity

Question 14

Describe speech in mania

Answer 14

Increased talkativeness

Punning and clang associations

Question 15

Describe thoughts in mania

Answer 15

Increased flow
Flight of ideas and loosening of associations
Grandiosity

Question 16

What is mania with psychosis?

Answer 16

Mania when delusions or hallucinations are present
Hallucinations are completely impossible or culturally inappropriate
Different from schizophrenic hallucinations (not 3rd person, no running commentary)
Most common are grandiose, self-referential, erotic or persecutory

Question 17

What is the management for an acute episode of mania?

Answer 17

First line: Olanzapine
Second line: Lamotrigine, valproate, lithium
Third line: ECT

Question 18

What is the management for an acute episode of depression?

Answer 18

First line: Quetiapine
Second line: Lamotrigine, valproate, antidepressants
Third line: ECT

Question 19

Why are antidepressants not first line for depression in bipolar disorder?

Answer 19

They have the potential to destabilise mood and cause mania

Question 20

What is the pathway for maintenance therapy in bipolar disorder?

Answer 20

First line: lithium
Second line: anticonvulsants (lamotrigine, valproate) or antipsychotics (quetiapine)
Psychoeducation and other psychotherapy

Question 21

When is lithium avoided?

Answer 21

First trimester of pregnancy

If compliance is an issue

Question 22

What are the therapeutic and toxic levels of lithium?

Answer 22

Therapeutic: 0.4-1mmol/l
Toxic: >1.5mmol/l

Question 23

What is required of patient on lithium?

Answer 23

Regular blood tests: lithium levels, U&Es, thyroid function tests

Question 24

What are the side effects of lithium?

Answer 24

Fine tremor
Dry mouth
Metallic taste
Weight gain
Hypothyroidism
QT prolongation
Decline in renal function

Question 25

What fetal disorder can lithium in the first trimester cause?

Answer 25

Epstein’s cardiac anomaly

Question 26

What symptoms can lithium toxicity cause?

Answer 26

D&V
Course tremor, myoclonus
Restlessness, confusion and drowsiness, seizures
Electrolyte disturbances
Severe: Renal failure, arrhythmia , Coma, Death§

Question 27

Which other drug for bipolar disorder should be avoided in pregnancy?

Answer 27

Valproate