Bipolar disorder

Question 1

Definition

Answer 1

Bipolar disorder is characterised by periods of mania/hypomania alongside depression with complex genetic factors interacting with environmental stressors to precipitate the disease.

Question 2

Pathophysiology

Answer 2

• Patients struggle to regulate emotions due to an impairment in prefrontal cortical processing.
• The dopamine hypothesis states mania is characterised by hyperdopaminergia and increased signalling in reward pathways = underpins the use of antipsychotic medication in bipolar disease.

Question 3

Epidemiology and risk factors

Answer 3

• Family history:
• Environmental stressors
• Substance misuse
• Past history of depression

Question 4

Manic symptoms

Answer 4

• Elevated or irritable mood
• Risky behaviours e.g. sexual indiscretions, gambling
• Increased energy levels
• Functional impairment
• Pressure of speech
• Decreased need for sleep
• Psychomotor agitation
• Inflated self-esteem or grandiose delusions
• Flight of ideas: rapid thought processes that leap from topic to topic
• Distractibilty

Question 5

Depressive symptoms

Answer 5

• Low mood
• Anhedonia
• Low energy
• Functional impairment
• Weight loss or gain
• Sleep disturbance: insomnia or hypersomnia
• Feelings of worthlessness
• Suicidal ideation
• Poor concentration

Question 6

Hypomania and Mania definition

Answer 6

Abnormally elevated mood or irritability

Question 7

Duration of Hypomania

Answer 7

≥ 4 days

Question 8

Duration of Mania

Answer 8

> 7 days

Question 9

Function of hypomania

Answer 9

No significant functional impairment

Question 10

Function mania

Answer 10

Severe functional impairment

Question 11

Psychotic features of hypomania

Answer 11

None

Question 12

Psychotic features of Mania

Answer 12

Psychotic symptoms, e.g. delusions or hallucinations

Question 13

Diagnostic Criteria

Answer 13

ICD-10 and DSM-5 criteria.
Bipolar type I (MC):
- One or more manic or mixed episodes, with or without a history of depressive episodes

Bipolar type II :
- Less common
- At least one hypomanic episode and at least one depressive episode
- No previous manic episode

Question 14

Investigations

Answer 14

• Clinical diagnosis and does not require specific investigations. Questionnaires may be considered, such as the PHQ-9 for depression .

Further investigations for organic causes
- Toxicology screen and thyroid function tests.

Question 15

Management general

Answer 15

• Urgent referral to specialist mental health assessment if mania or severe depression sus or are in danger to themselves or others
• Mood stabilising drug to prevent mood fluctuations:
  = anti-psychotic
  = lithium
  = valporate
  = lamotrigine

Question 16

BD: Mania Acute Tx

Answer 16

• Antidepressants should be tapered and discontinued
• Admission = If patient is a risk to themselves or others
  Acute management:
• FIRST LINE: haloperidol, olanzapine, quetiapine, or risperidone
• Second line: one FL med doesn’t work try alternative
• Third line: If antipsychotics fail try lithium or valporate

Question 17

BD Mania Long term Tx

Answer 17

• Commenced four weeks after resolution with the following options available
  = Continue current therapy for mania or
  = Lithium
  = Add valproate if lithium is ineffective

Question 18

BD Depression

Answer 18

• Medication = offer one of the following:
  = Antipsychotic: quetiapine or olanzapine
  = Fluoxetine combined with olanzapine
  = Lamotrigine

Psychological intervention: specific bipolar tailored therapies, or patients can have high-intensity CBT

Question 19

Complications

Answer 19

Suicide
Antipsychotics side-effects
Lithium side-effects
Physical illness
- CVD
- Metabolic syndrome
- CKD