Bipolar disorder Flashcards
Definition
Bipolar disorder is characterised by periods of mania/hypomania alongside depression with complex genetic factors interacting with environmental stressors to precipitate the disease.
Pathophysiology
- 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.
Epidemiology and risk factors
- Family history:
- Environmental stressors
- Substance misuse
- Past history of depression
Manic symptoms
- 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
Depressive symptoms
- Low mood
- Anhedonia
- Low energy
- Functional impairment
- Weight loss or gain
- Sleep disturbance: insomnia or hypersomnia
- Feelings of worthlessness
- Suicidal ideation
- Poor concentration
Hypomania and Mania definition
Abnormally elevated mood or irritability
Duration of Hypomania
≥ 4 days
Duration of Mania
> 7 days
Function of hypomania
No significant functional impairment
Function mania
Severe functional impairment
Psychotic features of hypomania
None
Psychotic features of Mania
Psychotic symptoms, e.g. delusions or hallucinations
Diagnostic Criteria
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
Investigations
- 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.
Management general
- 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
BD: Mania Acute Tx
- 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
BD Mania Long term Tx
- Commenced four weeks after resolution with the following options available
= Continue current therapy for mania or
= Lithium
= Add valproate if lithium is ineffective
BD Depression
- 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
Complications
Suicide
Antipsychotics side-effects
Lithium side-effects
Physical illness
- CVD
- Metabolic syndrome
- CKD
