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Psychiatry > Bipolar Disorder > Flashcards

Bipolar Disorder Flashcards

1
Q

What characterises bipolar disorders?

A

Episodes of mania and depression

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2
Q

When do bipolar disorders usually begin?

A

Teens - 20s - 30s

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3
Q

Lifetime prevalence bipolar?

A

BPI: 0.3-1.5%
BPII: 4% (broader criteria)

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4
Q

Gender spread bipolar?

A

Equal (M=F)

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5
Q

How are bipolar disorders classified?

A
  • Bipolar I
  • Bipolar II
  • Bipolar III: depressed pt who develops hypomania during Rx
  • Bipolar IV: depressed pt with substance induced hypomania
  • Unspecified
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6
Q

What is Bipolar I Disorder?

A

Presence of at least one full fledged (disrupting normal social and occupational function) manic episode, and usually depressive episodes.

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7
Q

What is Bipolar II Disorder?

A

Presence of major depressive episodes with at least one hypomanic episode, but no full-fledged manic episodes.

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8
Q

What is unspecified bipolar disorder?

A

Disorders with clear bipolar features that do not meet the specific criteria for other bipolar disorders

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9
Q

What is cyclothymic disorder?

A

Prolonged (>2y) periods including both hypomanic and depressive episodes; however episodes do not meet criteria for bipolar disorder.

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10
Q

Aetiology BD?

A
  • Exact cause unknown
  • Heredity significant
  • Dysregulation of 5HT3 and NA
  • Stressful events of a/w onset and exacerbations
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11
Q

Which drugs can trigger exacerbations in patients with bipolar?

A
  • Sympathomimetics (e.g. cocaine, amphetamines)
  • EtOH
  • Certain antidepressants (e.g. TCAs, MAOIs)
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12
Q

Pattern of BpD?

A

Acute phase of symptoms followed by repeating course of remission and relapse.

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13
Q

What are BpD relapses?

A

Discrete episodes of more intense symptoms that are manic, depressive, hypomanic or a mixture. Last from weeks –> 3-6m

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14
Q

Lifetime suicide incidence?

A

15x that of general population

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15
Q

What is a manic episode?

A

> 1w of a persistently elevated expansive or irritable mood and persistently increased goal-directed activity or energy plus >3 additional symptoms

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16
Q

What are the additional symptoms characterising a manic episode?

A

Elevated / irritable mood

  1. Inflated self esteem or grandiosity
  2. Decreased need for sleep
  3. Greater talkativeness
  4. Flight of ideas
  5. Distractability
  6. Inc goal directed activity
  7. Inc risk taking behaviour (e.g. buying sprees, foolish investments)
  8. Inc sexual activities
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17
Q

Appearance and manner of manic patient?

A

May be:

  • Exuberant
  • Flamboyantly dressed
  • Authoritative manner
  • Rapid, unstoppable speech
  • Clang associations
  • Easily distracted (thoughts, projects)
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18
Q

What are clang associations?

A

New thoughts triggered by word sounds rather than meaning

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19
Q

What is manic psychosis?

A
  • Psychotic symptoms (diff to distinguish from schizophrenia)
  • Extreme grandiose or persecutory delusions (e.g. being Jesus)
  • Sometimes hallucinations
  • Marked activity increase
  • Mood very labile
  • May enter delirium (delirious mania)
  • labile
  • often very angry, intrusive, uncooperative
  • no sleep
  • very talkative, flight of ideas
20
Q

What is hypomania?

A

-Less extreme variant
-Episode last >2-4d
-Behaviour distinctly diff from patient’s usual non depressed self
-includes >3 or additional symptoms of mania
Mood brightens, decreased sleep requirement, psychomotor activity increases, pressured speech

21
Q

What is a depressive episode?

A

> 5 of the following in 2w period with one being depressed mood:

  • depressed mood most of day
  • markedly decreased interest/pleasure
  • significant weight gain/loss, change to appetite
  • insomnia or hypersomnia
  • fatigue
  • psychomotor agitation
  • feelings of worthlessness or guilt
  • dec concentration
  • thoughts of death or suicide, or specific attempt
22
Q

What is a mixed episode?

A

Episode of mania/hypomania with >3 depressive symptoms for most days. Particularly high suicide risk, prognosis worse than for pure states

23
Q

How is BpD diagnosed?

A
  • Clinical criteria (DSM) ==> identify Sx of mania/hypomania + Hx remission-relapse
  • T4 and TSH (r/o hyperthyroidism)
  • Exclude stimulant drug abuse clinically or urine test
24
Q

What must be asked of all patients with ?BpD??

A

Suicidal ideation, plans or activity.

25
Q

Why does positive drug screen not r/o BpD?

A

Drug use may have triggered an episode in a patient with bipolar disorder: seek evidence of symptoms (manic or depressive) not related to drug use

26
Q

Clinical evaluation to r/o phaeochromocytoma?

A

Marked HTN (if not hypertensive, no phaeo)

27
Q

What is bipolar disorder?

A

Cyclic condition involving bouts of mania +/- depression (bipolar I) OR hypomania + depression (bipolar II)

28
Q

Cycle frequency in BpD?

A

Variable: some pts only few eps over lifetime, others >4/year (rapid cycling forms)

29
Q

Is it more common for patients to alternate or remain constant between mania and depression cycles?

A

Only a few pts alternate back and forth, in most one or the other predominates

30
Q

How is BpD treated?

A
  • Mood stabilisers (lithium, anticonvulsants), an SGA or both
  • Support and psychotherapy: education, lifestyle, harm reduction
  • Severe mania/depression requires inpatient Mx
31
Q

What are the phases of BpD treatment?

A
  • Acute: stabilise and control initial, often severe manifestations
  • Continuation: attain full remission
  • Maintenance/prevention: keep patients in remission
32
Q

Which anticonvulsants may be used to treat BpD?

A
  • Valproate
  • Carbamazepine
  • Lamotrigine
33
Q

Urgent behavioural control (Rx) in severe manic psychosis with compromise pt safety and management?

A
  • Sedating SGA

- +/- benzo (lorazepam/ clonazepam 2-4MG IM or PO tid)

34
Q

Mx less severe acute episodes without contraindications?

A
  • Lithium good for mania and depressive episodes

- Slow onset so add anticonvulsant (lamotrigine good if depression) / SGA

35
Q

Best evidence for Mx bipolar depression?

A

-Quetiapine or lurasidone alone
OR
-Fluoxetine AND olanzapine

36
Q

How is lithium initiated in BpD?

A

300mg po bd/td

  • titrate based on steady state blood levels and tolerance to 0.8-1.2mEq/L
  • levels taken 5d after stable dose; 12h after last dose
37
Q

Acute lithium toxicity signs?

A
  • Gross tremor
  • Increased deep tendon reflexes
  • persistent HA
  • Vomiting
  • Confusion
  • May progress: stupor, seizures, arrhythmias
38
Q

Drugs which may precipitate hyperlithemia?

A
  • Thiazide diuretics
  • ACEi
  • NSAIDs (not aspirin)
39
Q

Important non pharm considerations in Mx?

A
  • Group therapy
  • Enlist support of close friends/ family
  • Discuss adherence
  • Avoid: stimulant drugs, EtOH, minimise sleep deprivation,
  • recognise early signs of relapse
  • $$$ counselling (i.e. enlist loved one to control $)
  • Refer to support groups
40
Q

Frequent psych comorbidities?

A
  • A & D

- ADD / childhood conduct d/os

41
Q

BPAD RFx?

A
  • Genetic
  • Head injury
  • Organic CNS disease
  • AIDS
  • Chidbirth
  • Season (spring, summer)
  • Circadian rhythm disruption
  • Life events (sleep disruption)
42
Q

Clinical pattern BPAD?

A

-usu presents in adolescence as depression (mania ~5y on)
-interval contracts then stabilises
-kindling
Overall 3x more depressed than manic; 2x depressive eps of unipolar pts

43
Q

Rx suicidal BPAD pt?

A

Consider lithium and clozapine

44
Q

DDx BPAD?

A
  • Schizophrenia
  • 1” organic state (e.g. orbitofrontal lesions)
  • Drug induced psychosis (cocaine, amphetamines, opiates, cannabinoids)
  • Creative “possessed by the muse”
45
Q

Psychological mx BPAD?

A
  • Education
  • Adjustment
  • Lifestyle
  • Harm reduction

Psychiatry (16 decks)

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