Bipolar Disorder Flashcards
Definition
chronic episodic mood disorder characterised by at least one episode of mania and a further episode of mania or depression.
Who else can be diagnosed with bipolar?
Either one can occur first but bipolar also includes those who at time of diagnosis only suffer with manic episodes as inevitably these will lead to development of depression.
Epidemiology
Bipolar
- Lifetime risk is 1-3%
- Mean age of onset is 19
- Higher in black and other minority ethnic groups
- Male : Female = 1:1
Pathophysiology
- Monoamine hypothesis - as well as low mood it also includes elevated mood due to increase of central monoamines
- Dysfunction of HPA axis - abnormal secretion of cortisol.
- Strong heritability - 40-70% MZT and 5-10% in first degree relative
- Stressful or significant life events - trigger first manic episode.
Neurochemical elements of bipolar
inc dopamine and serotonin
Endocrine element of bipolar
Inc cortisol, aldosterone, and thyroid
Causes and RF
4A3S
Aggressive Spenders
Age in early 20s
Anxiety disorders
After depression
Strong Fhx
Substance misuse
Stressful life events
Symptoms
I DIG FASTER
Irritability
Distractibility and Disinhibited
Insight impaired / Increased libido
Grandiose delusions
Flight of ideas
Activity / Appetite increased
Sleep decreased
Talkative
Elevated mood / energy increased
Reduced concentration / reckless behaviour and spending.
ICD 10 classification mania
Mania requires 3/9 symptoms :
- Grandiosity / inflated self esteem
- Decreased sleep
- Pressure of speech
- Flight of ideas
- Distractibility
- Psychomotor agitations
- Reckless behaviour
- Loss of social inhibitions
- Marked sexual energy
ICD 10 requirement of bipolar
Bipolar requires at least two episodes in which a persons mood and activity levels are significantly disturbed - one of which must be main or hypomania
5 states of bipolar
- Currently hypomanic
- Currently manic
- Currently depressed
- Mixed disorder
- In remission
MSE findings of bipolar
- Appearance - Flamboyant and unusual combination of clothing or personal neglect.
- Behaviour - Overfamiliar, disinhibited, increased psychomotor activity and distractible and restless.
- Speech - Loud, inc rate and quantity. Pressure of speech, uninterruptible, puns and rhymes, neologisms
- Mood - Elated, euphoric and or irritable
- Thought - Optimistic, pressured thought, flight of ideas, loosening of association, delusions
- Perception - No hallucinations. Mood-congruent auditory hallucinations rarely occur
- Cognition - Attention and concentration often impaired. Fully oriented
- Insight - Very poor
What is hypomania state
Mildly elevated or irritable mood ≥ 4 days. Partial insight reserved
Mania without psychosis
Hypomania but treated extent present for >1 week and complete disruption of work and social activities. May have grandiose ideas and excessive spending leading to debts. Sexual disinhibition and reduced sleep - exhaustion
Mania with psychosis
Severely elevated or suspicious mood with the addition of psychotic features - grandiose or persecutory delusions and auditory hallucinations. Aggression.
Bipolar 1
Involves periods of severe moods episodes from mania to depression
Bipolar 2
Milder form of mood elevation involving milder episodes of hypomania that alternate with periods of severe depression
Rapid cycling
More than 4 mood swings in a 12 month period with no intervening asymptomatic periods. Poor prognosis.
Ix for bipolar
Self rating scales - mood disorder questionnaire
BT - FBC, U+E, LFT and glucose and calcium
Urine drug test - illicit drugs
CT head - space occupying lesions which can cause manic symptoms
Treatment
- Full risk assessment
- Driving - DVLA
- Lorazepam and or mood stabilisers - lithium.
- CBT
- ECT
- Follow up appt
CALMER :
Consider hospitalisation
Antipsychotics
Lorazepam
Mood stabilisers
ECT
Risk assessment
When would hospitalisation be required
- MHA - hospitalisation
- Reckless behaviour causing risk to pt or others
- Significant psychotic symptoms
- Impaired judgement
- Psychomotor agitation.
1st line biological treatment bipolar
Atypical antipsychotics - olanzapine alone, combined with fluoxetine or quetiapine alone
Mood stabiliser - Lamotrigine but lithium is also effective
Antidepressants - should be used in conjunction as does not help mania.
4 weeks after acute episode resolved lithium is first line treatment. If ineffective add valproate.
Acute manic episode medication
Antipsychotic - olanzapine, risperidone or quetiapine. Rapid onset of action compared to mood stabilisers.
Mood stabilisers - lithium. Valproate should be added 2nd line
Benzodiazepines - aid sleep and reduce agitation
Rapid tranquilisations - haloperidol or lorazepam.
Prognosis and complication
- Mood disorders - hypomania, mania, mixed episode and cyclothymia
- Psychotic disorders - schizophrenia and schizoaffective disorder
- Secondary to medical conditions - hyper / hypothyroidism. Cushings and cerebral tumours
- Drug related
- Personality disorders - histrionic and emotionally unstable