Bipolar disorder Flashcards
Define bipolar disorder [1]
Bipolar disorder is characterised by recurrent episodes of depression and mania or hypomania. The symptoms often start at a younger age (under 25 years). It has a particularly high rate of suicide.
What are the two types of bipolar disorder? [2]
Two types of bipolar disorder are recognised:
* type I disorder: mania and depression (most common)
* type II disorder: hypomania and depression
NB:
- Hypomanic episodes involve milder symptoms of mania without having a significant impact on their function.
- Manic episodes involve excessively elevated mood and energy, significantly impacting their normal functions (e.g., caring and work responsibilities)
- Depressive episodes feature low mood, anhedonia and low energy and can be severe.
What is cyclothymia? [1]
Cyclothymia involves milder symptoms of hypomania and low mood. The symptoms are not severe enough to significantly impair their function.
Describe what mania/hypomania is [4]
- What’s the key difference between them? [1]
What is mania/hypomania?
* both terms relate to abnormally elevated mood or irritability
* with mania there is severe functional impairment or psychotic symptoms for 7 days or more
* hypomania describes decreased or increased function for 4 days or more
From an exam point of view the key differentiation is psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) which suggest mania
What are the clinical features of BD? [+]
Bipolar disorder can be classified according to different discrete episodes of elated, depressed or mixed disturbances in mood.
Describe the different types of episodes that might exist [4]
Manic episode:
- abnormal and persistently elevated, expansive, or irritable mood. Symptoms last ≥ 1 week. Three additional symptoms are supportive of mania. The presence of impairment in social and/or occupational function, necessitates hospitalisation or psychotic features present.
Hypomanic episode:
- abnormal and persistently elevated, expansive, or irritable mood. Symptoms last ≥ 4 days. Three additional symptoms are supportive of mania. No impairment in social and/or occupational functioning, requirement for hospitalisation or psychotic features.
Depressive episode:
- depressed mood or loss of interest/pleasure in nearly all activities. Symptoms last ≥2 weeks. Four additional symptoms are supportive of depression. Causes distress and impairs function.
Mixed episode:
- rapid alternating between manic and depressive symptoms, or criteria for mania/hypomania and at least three symptoms of depression for ≥1 week, or criteria for a depressive episode and at least three mania/hypomania symptoms for ≥ 2 weeks.
How do you differentiate bipolar disorder to borderline personality disorder? [2]
Differences: While both conditions involve mood swings, the duration, frequency and triggers differ significantly. In BPD, mood swings are often reactive to environmental factors and resolve quickly whereas in bipolar disorder they occur independently of environmental stimuli and persist for longer durations.
How do you differentiate bipolar disorder to schizophrenia? [2]
Differences: The presence of persistent psychotic symptoms in the absence of mood symptoms may suggest a diagnosis of schizophrenia.
In bipolar disorder, psychotic features are typically mood-congruent and occur during episodes of mania or depression.
Describe the natural course of bipolar disorder [2]
Usually starts in early/mid twenties with episode of mania followed by depression
Depression is more the common manifestation
Describe how manage bipolar disorder in the long term [+]
- Pharmacotherapy
- Pyschological therapy
- Social support
Pharmacotherapy
- Lithium works to stabilise mood
- Valproate or lamotrigine
- Atypical antipsychotics like olanzapine or aripiprazole can be used adjunctively for maintenance therapy, especially in patients with frequent relapses.
Psychological Interventions:
* Cognitive Behavioural Therapy (CBT) can help individuals understand their condition better and develop coping strategies for mood swings.
* Family-focused therapy can provide education about the disorder and improve communication within the family unit.
* Interpersonal and Social Rhythm Therapy (IPSRT) aims to stabilise daily routines and sleep patterns which can help manage symptoms.
Describe how you would manage an acute episode of bipolar disorder:
- acute manic episode [3]
- acute depressive episode [3]
Treatment options for an acute manic episode (as per the NICE guidelines updated 2023) include:
Antipsychotic medications (e.g., olanzapine, quetiapine, risperidone or haloperidol) are first-line
* Other options are lithium and sodium valproate
* Existing antidepressants are tapered and stopped
Treatment options for an acute depressive episode (as per the NICE guidelines updated 2023) include:
* Olanzapine plus fluoxetine
* Lamotrigine
How do you monitor lithium treatment? [1]
What is the aim for target range of lithium levels? [1]
Serum lithium levels (taken 12 hours after the most recent dose) are closely monitored to ensure the dose is correct.
- The usual initial target range is 0.6–0.8 mmol/L. Lithium toxicity can occur if the dose and levels are too high.
TOM TIP: Sodium valproate is teratogenic.
It can cause [2] if used in pregnancy.
TOM TIP: Sodium valproate is teratogenic. It can cause neural tube defects and developmental delay if used in pregnancy.
There are strict rules for avoiding sodium valproate in females with childbearing potential unless there are no suitable alternatives and strict criteria are met. The Valproate Pregnancy Prevention Programme is in place to ensure this happens, which involves ensuring effective contraception and an annual risk acknowledgement form. This has been given much attention over recent years and may be tested in exams.
Notable potential adverse effects of lithium include? [6]
- Fine tremor
- Weight gain
- Chronic kidney disease
- Hypothyroidism and goitre (it inhibits the production of thyroid hormones)
- Hyperparathyroidism and hypercalcaemia
- Nephrogenic diabetes insipidus
A patient is exhibiting features of severe lithium toxicity, which is generally seen if serum levels are above [] mmol/l
patient is exhibiting features of severe lithium toxicity, which is generally seen if serum levels are above 3.5 mmol/l
NB: Generally speaking, raised lithium levels above 4 regardless of whether any symptoms are present or not, would prompt dialysis.
A patient has lithium toxicity, with levels above 3.5 mmol/.
How would you tx? [1]
This patient is exhibiting features of severe lithium toxicity, which is generally seen if serum levels are above 3.5 mmol/l. Haemodialysis is appropriate for patients experiencing severe lithium toxicity because left untreated they will develop sustained seizure activity
The antipsychotics most commonly used in the treatment of manic episodes or mixed episodes in bipolar affective disorder are [4]
The antipsychotics most commonly used in the treatment of manic episodes or mixed episodes in bipolar affective disorder are quetiapine, olanzapine, risperidone and haloperidol.
A 49-year-old female with a history of manic-depressive psychosis, diagnosed at 22, presents to her General Practitioner with polydipsia and polyuria. Current medication includes lithium and a steroid inhaler for bronchial asthma. Examination reveals a blood pressure (BP) of 105/70 mmHg, with a pulse of 82 bpm and regular. There are normal fasting sugar levels and no postural drop on standing.
What are the investigation findings most likely to help diagnose this condition?
Elevated serum calcium levels
Elevated serum creatinine levels
High urine osmolality and low serum osmolality
Low urine osmolality and high serum osmolality
Low urine osmolality and low serum osmolality
Low urine osmolality and high serum osmolality
- Lithium is the most common cause of acquired nephrogenic diabetes insipidus. Low urine osmolality and high serum osmolality are seen in diabetes insipidus (DI). It is due to a deficiency in antidiuretic hormone secretion or poor response of kidneys to ADH. DI is associated with low urine osmolality in the face of elevated plasma osmolality. There are often other signs of dehydration, including a postural drop in BP and sodium at the upper limit of the normal range. Differentiating cranial and nephrogenic DI occurs with vasopressin in the water deprivation test, with nephrogenic DI failing to respond to vasopressin.
