Bipolar Disorder Flashcards by Ellie Kendall

What are the 2 key elements of bipolar?

Depression
Mania/hypomania

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What are the 2 main subtypes of bipolar disorder and how do they differ?

Bipolar I (mania and depression alternate)
Bipolar II (hypomania and depression, at least 1 episode of each)

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What are hypomania episodes?

milder form of mania
don’t usually cause impairment
often improve productivity

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What can Bipolar II often be mistaken for? Why?

MDD

usually patients present with depression and don’t see hypomania as severe/a problem
often depression becomes more predominant than hypomanic episodes over time

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Difference between Mania and Hypomania?

Mania = causes impairment in functioning, decreasing productivity

Hypomania = doesn’t cause impairment, can increase productivity

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How long is the time period of elevated/irritable mood necessary for a diagnosis of:
A) Mania ?
B) Hypomania ?

Mania = 1 week (most of the day, nearly everyday)

Hypomania = 4 consecutive days, at least (most of the day, nearly everyday)

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What is the DSM-5 criteria for diagnosing mania/hypomania?

Over a week (M) /4days (HM), 3 or more of:

inflated sense of self (grandiosity)
decreased need for sleep
more talkative than normal (pressure of speech)
racing thoughts (flight of ideas)
high distractibility
acts in goal-oriented manner
excessive involvement in high risk pleasurable activities

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What is the DSM-5 criteria for diagnosing mania?

1 week of excessively high/irritable mood
3 or more of the 7 symptoms
symptoms cause marked impairment or psychotic features
not attributable to substance misuse/other conditions

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What is the DSM-5 criteria for diagnosing hypomania?

at least 4 consecutive days of excessively high/irritable mood
3 or more of the 7 symptoms
the change is observable by others
doesn’t cause impairment, no psychosis features (that’s automatically mania)
not attributable to substance misuse/other conditions

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Which gender is BP slightly more prevalent in?

Males

(1 : 1.1 // F:M)

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What is the mean age of onset of:
A) BP I ?
B) BP II ?

Bipolar I = 18

Bipolar II = mid 20s

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What is a differential diagnosis of first manic episode diagnosed in later life ?

Frontotemporal dementia

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Is average life expectancy decreased in Bipolar patients?

Yes, by 9-20 years

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Why is life expectancy decreased in BP patients?

increased risk of disease (cardiovascular, metabolic etc)
medication adverse effects
smoking
suicide

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Can BP be cured?

It is a chronic, life-long condition for most
It can be treated not cured

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What is the risk of suicide in BP patients compared to general population?

At least 15x higher in BP

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What are some common co-morbidities of BP?

Anxiety
ADHD
Drug/substance misuse
Eating disorders
Migraine

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Which type of BP disorder is more closely linked to eating disorders?

Bipolar II

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What are the 2 aspects of the aetiology of bipolar disorder?

Environmental
Genetic

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What are the contributing environmental causes of BP?

childhood trauma
stress and loss
seasonal changes (mania = warmer months, depression = colder)
medications (antidepressants can exacerbate mania)
medical disorders (MS, Epilepsy, hypothyroidism, CVD)
substance misuse

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What are the contributing genetic causes of BP?

heritability >70%
30 risk loci found

Genetics play the largest role in BP

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Which factor is more causative in BP, environment or genetics ?

Genetics

Which other condition is most strongly correlated with:
A) BP I ?
B) BP II ?

BP I = schizophrenia
BP II = MDD

How many risk gene-loci have been found in relation to BP?

What % of BP patients will likely experience psychosis in their lifetime?

50% (usually in manic episodes of BP I)

What is the pathophysiology of bipolar disorder?

Not certain Dysregulation of dopamine and serotonin systems Mania with psychosis = increased dopamine in striatum (similar to schizophrenia)

What is rapid cycling?

4+ episodes of mania or depression within a year

What is the increase chance of having bipolar if a family member has it ?

10x more likely

What are the 3 phases of BP that require treatment?

Acute Mania Acute Depression Maintenance phase (prophylaxis)

What drugs are used to treat acute mania?

Lithium (mood stabiliser) Antipsychotics (D2 antagonists) Valproate (antiepileptic) Carbamazepine (antiepileptic)

Which of the mania-related drugs are least tolerable?

Lithium ! Antipsychotics are most tolerable followed by valproate and carbamazepine

Which drugs are used to treat acute depression in bipolar?

Lithium Low does quetiapine Lamotrigine (anti-epileptic) NOT ANTIDEPRESSANTS as increase rapid mood cycling/switching to mania

If antidepressants are used in BP, what must they be used along side?

Antipsychotics and lithium

Which drugs are useful as prophylactics in BP maintenance phase?

Lithium Quetiapine or valproate if lithium isn’t viable

Which of the antipsychotics are useful in BP phases other than manic episodes?

Quetiapine and olanzapine, the others are only effective in mania

How is lithium eliminated from the body?

Renal (kidney) function

Why do you need to do regular blood tests when prescribing lithium?

It has a narrow therapeutic window between being ineffective and toxic

What is the ideal plasma level of lithium?

0.6-0.8 mmol/L (12hrs post-dose)

What drugs are contraindicated when using lithium?

Any drugs that alter renal function, e.g - ACE inhibitors - NSAIDs - thiazide diuretics

What is lithium metabolism like?

Absorbs quickly Isn’t metabolised Is excreted unchanged, by kidney

Which drug is effective across all 3 phases of BP?

Lithium *Better in mania than depression though*

Is CBT effective treatment during acute episodes of mania/depression in BP?

No, but can be effective after an episode

What plasma level of lithium has a high risk of toxicity/side effects

Above 1.2 mmol/L

What is the first line treatment for all 3 stages of BP?

Lithium (mood stabiliser)

How much does lithium decrease risk of attempted/successful suicide in BP?

decreases risk by 80%

What are the intended MOA effects of lithium?

- INCREASES 5-HT and GABA transmission = inhibitory - DECREASES glutamate and dopamine = excitatory

What are some side effects of lithium at a NORMAL dose?

- fine hand tremors - mild GI upset - mild brain fog - weight gain - ankle oedema

What are some signs of lithium toxicity ?

- Anorexia - Nausea/vomiting - Diarrhoea - Muscle weakness - Course tremor - Drowsiness

What drugs fall under the term valproate?

- valproic acid - sodium valproate - valproate semisodium (Depakote = valproic acid + sodium valproate, 1:1)

Which phases of BP indicate potential use of valproate?

Acute mania (3rd line, resistant mania) Maintenance against mania (if lithium wasn’t successful)

What is the MOA of valproate?

Increases GABA Decreases neuronal excitability

What are the adverse effects of valproate?

Very commmon: - nausea - tremor - weight gain - pregnancy complications (NTDs)

What are some side effects in pregnancy associated with valproate?

- NTDs (Spina Bifida) - malformation - polydactyly - limb reduction - atrial septal defects

What effects can a mother taking valproate during pregnancy have on the development on the child?

Late walking Late talking Memory problems Difficulty with speech and language Lower IQ Increased risk of autism by 3-5x