Bipolar Disorder Flashcards
Describe the different Thought Processes Patterns for getting from A to B?
Goal Directed - direct and normal
Tangential and Circumstantial are within the normal range but takes a long time to get back to the question or only sort of answers it
Flight of Ideas - Abnormal topic to topic and never comes back to main point but can tell connections between each topic
Loose Associations - most severe pathology of thought process and can NOT make connections (typically manic or psychotic)
What are the typical thought processsing patterns seen in Bipolar disorder/mania?
see Flight of Ideas
Circumstantial or loose associations at other times
What is the definition/symptoms of a Manic Episode?
At LEAST 1 week (7 days) duration of elevated mood + 3 other symptoms [or irritability + 4other symptoms bc irritability is non-specific] PLUS Persistently increased activity/energy
Additional symptoms: decreased NEED for sleep, grandiosity, increased self esteem, pressured speech, increased goal-directed actiity, Flight of Ideas/Racing thoughts, distractibility, Risk behavior
Can have psychotic symptoms
How is a Hypomanic episode different than a Manic episode?
Lesser extent and shorter period of time than a manic episode
NO PSYCHOTIC symptoms
What is an episode with Mixed Features?
Pt has symptoms of both a manic or hypomanic episode with concurrent depressive symptoms at the same week
For at least 1 week
What is the definition of rapid cycling? Who is more likely to be a rapid cycler? What are some triggers?
BPAD 1 or 2 in which 4 or more mood episodes occur in a year (frequently depressive or manic) and has a worse prognosis overall
70-90% are rapid cyclers are WOMEN!!!
More common in BPAD 2 vs BPAD 1
can be triggered by l_ithium-induced hypothyroidsim_ or antidepressants
HYPOTHYROIDISM
Bipolar 1 vs Bipolar 2 vs Mixed Episodes - compare simply
Bipolar 1 - manic - euthymic - MDE alternating
Bipolar 2 - MDE - hypomania - Euthymia (get full depressive eposides but never up to mania)
Mixed - Euthymic then to either Mania or MDE and then _both at the same time _
What are underlyng causes of BPAD that must be ruled out prior to diagnosis?
Substance Abuse
Co-morbid medical conditions
Medication side effects
Personality Disorder
Secondary gain
What are substance abuse problems that could cause similar symptoms to BPAD?
Acute Cocaine intoxication can look like mania/psychosis or an anxiety disorder and then like depression after the drug wears off
Heroin intoxication looks like depression with cognitive deficits and withdrawal can look like anxiety disorder or hypomania
Alcohol withdrawal can look like anxity, mania, hypomania or psychosis
What are co-morbid medical conditions that can cuase similar symptoms to BPAD?
Hyperthyroidism
Complex Partial Seizure
MS, SLE, Syphilis, Cushing’s
Delirium
Head trauma
Acute HIV encephalitis, hypoglycemia, hypoxia….
BPAD 1 in men vs women
Average Age Onset
Women = Men but affects them differently
Women are more likely to be rapid cyclers, have mixed states, and have more depressive episodes
Average Age of Onset is 18 yo (very rare after 50 so make sure you haven’t missed another medical diagnosis)
What is the clinical course of BPAD 1?
Untreated mania lasts 3 months, untreated depression lasts 6-12 months, untreated mixed episodes last 6 months
Patients will have on average 9 episodes
Most are Manic into Depression - which is when there is significant Suicide Risk!!!!!
Many develop substance problems
What are the co-morbidities with BPAD type 1?
60% substance use disorders
75% anxiety disorders
>50% Alcohol use disorder
all increase risk for suicide (esp alcohol)
What are the genetics of BPAD 1? What chromosmoes are implicated?
_STRONG genetic component: _
10fold increased risk in first degree relatives
50% have at least one parent w/ a mood disorder
- 1 PArent has Bipolar, then 25% risk in kid *
- If both parents have, then 50-75% risk *
Concordance for twins: HIGH
Chromosomes 5, 11, 18, and X
How is the Epidemiological picture different for BPAD Type 2 vs type 1?
How are the Co-Morbidities different from Type 2 vs Type 1?
How does Suicide rate compare for type 2 vs Type1?
Prevalence is a little higher and age of onset is a little higher (20 vs 18)
_Co-Morbidities: _
Anxiety 75%!!!! HIGH
Substance Abuse is less common
Increased incidence of at least one lifetime eating disorder
Suicidality:
1/3 pts attempt (same as 1) but LETHALITY is HIGHER
What is the clinical course for BPAD 2?
Many patients originally diagnosed with MDD then later get BPAD 2
Some patients go on to develop full blown manic episodes
*MORE lifetime mood episodes than type 1
****Depressive episodes are more frequent than hypomanic episodes and get more disabling over time **
What is Cyclothymia? Who gets it? What are symptoms?
Cyclothymia - like one step down on level of intensity of symptoms
Pts have hypomanic periods and dysthymic periods but never have symptoms severe enought to meet criteria for mania/hypomania/MD
Symptoms last for > 2 years without going for more than 2 months symptoms free
Male = Female from adolescence to early adult years
*Increased chance will evolve into BPAD Type 1/2
How do you treat BPaD?
BPADtreatment is based upon the stage that the patient is in but likely involves lithium
Stages: Acute Mania, Bipolar Depression, Maintenance
What are the treatment goals for Acute Mania? How can you achieve those goals? What meds?
Goals: SLEEP!, decrease though disorganization, address psychotic symptoms, prevent dangerous behavior
**MOOD STABILIZER - Lithium!!! (or Valproate or Carbamazepine)
can add antipsychotic (also helps with sedation for sleep symptoms)
Can add Benzodiazepine (lorazepam) for continued agitation
***Eliminate Mood De-stabilizing agents like Anti-depressants!!!! **
What is the treatment in Bipolar depression? What is the order of agents to use?
Mood Stabilizer: Maximize lithium Dose!!! >.8 mEq and takes 3-4 days to work (also acts as anti-depressant)
Then try Valproate or Carbamazepine as mood stabilizer but don’t act as anti-depressants
Then consider Lamotrigine
Then can try Quetiapine, Lurasidone Monotherapy or Olanzapine/Fluoxetine
THEN consider Mood Stabilizer + Antidepressant but NEVER treat with just anti-depressant alone!!
Lastly - ECt is an option for bipolar depression, elderly, and pregnant women
What is the Maintenance treatment to maintain euthymia?
Mood stabilizer like Lithium valproate or carbamazepine
Lamotrigine is helpful only for biplar depression but does not control mania so should not be given alone
Pts may be able to come off the anti-depressant or anti-psychotic during this phase if they are doing well
Ex. Lithium + Risperidone and eventually can slowly wean off the Risperidone and maintain just the Lithium
What is Lithium? What is its MOA?
Li is a naturally occuring cation
Don’t really know MOA but acts via second messenger to enhance serotonergic treansmission
Treatment of choice for BPAD!!!!! 1/3 Pts dont respond to it
What are the Side effects of Lithium?
Pregnancy Class D - causes Ebstein’s Anomaly malformation of tricuspid valve
N/D/Metallic Taste
EKG changes and prolongation of ST interval
Thyroid Abnormalities - Goiter, Hyperglycemia, Hypothyroidism
Tremor/sedation
Kidney - Polydypsia, polyuria, nephrogenic Diabetes Insipidus
Mild Leukocytosis
Weight gain, edema, dry mouth,
Cognitive Dulling
What is the toxic level of lithium and what are the signs and symptoms of Lithium Toxicity?
Levels > 1.2
Levels 1.2-1.5 see Ataxia, dysarthria, incoordination; Increased GI and Renal Symptoms; increased tremor
Levels 1.5-2: see confusion, N/V/D, slurred speech, tremor and ataxia
Levels 2-2.5: see Delirium, EKC changes and cardiac arrhythmia, ataxia
Levels >2.5: see change in consciousness, acute renal failure, seizure, coma death
