Bipolar disorder Flashcards
What is bipolar disorder?
A mental illness characterised by depressive episodes and (hypo)manic episodes
Patients may be euthymic between these episodes.
What are the different types of bipolar disorder
- Bipolar I: ≥1 manic episode ± history of major depression
-
Bipolar II: ≥1 hypomania (no mania) ± ≥1 major depression
- Typically less severe; does not inhibit function
- Cyclothymic: cyclic brief hypomania + depression
Outline the DSM-5 diagnostic criteria for bipolar disorder
- At least two episodes
- One of which must be either:
- Mania
- Hypomania
- Mixed affective.
What is a manic episode?
- Abnormal persistently elevated, expansive, or irritable mood
- ≥7d (unless hospitalised)
- Additional 3+ symptoms:
- Increased energy/activity; restlessness
- Pressure of speech; incomprehensible speech
- Flight of ideas; racing thoughts
- Distractibility; poor concentration
- Increased libido; disinhibition; sexual indiscretions
- Extravagant/impractical plans
- Psychosis
What is a hypomanic episode?
- 3+ symptoms of mania: less severe
- No marked social/functional impairment
- No psychosis
- ≥4 days
- May present with
- Mild elevation of mood; irritability
- Increased energy/activity; improved performance
- Feelings of well-being; physical and mental efficiency
- Increased sociability; talkativeness; over-familiarity
Outline the DSM-5 criteria for depression
- 5+ symptoms (must have one of bold), for ≥2/52
- Depressed mood
- Anhedonia
- Significant weight change or appetite disturbance
- Sleep disturbance
- Psychomotor agitation/retardation
- Fatigue; lethargy
- Feelings of worthlessness
- Diminished ability to think/concentrate; indecisiveness
- Recurrent thoughts of death; suicidal ideation/attempt
- Causing significant distress/impairment
- Not attributable to substance use; another medical condition
- Not better explained by psychotic disorders
- No PMH of (hypo)mania
Outline the severity of depression
- Subthreshold: Persistent if >2yrs
- <5 symptoms of depression
- Mild:
- Few, if any, symptoms in excess of 5 required
- Minor functional impairment
- Moderate:
- Symptoms or impairment between mild/severe
- Severe:
- Most symptoms
- Marked functional impairment ± psychosis
What is a mixed episode?
- Either
- (Hypo)mania and depression in a single episode
- Rapid alteration between (hypo)mania and depression
- Every day for 2/52
What is rapid-cycling bipolar disorder?
≥4 episodes within 12-months
Episodes can be depressive; (hypo)manic; or mixed
What is the difference between bipolar disorder with psychotic symptoms, and schizoaffective disorder?
- Bipolar with psychotic symptoms: mood congruent delusions
- Schizoaffective: no mood congruent delusions
State three distinguishing features between bipolar disorder and unipolar depression
Favouring bipolar disorder over unipolar depression:
- Hypersomnia; lability; weight instability
- 90% of bipolar disorder; 50% of unipolar depression
- Earlier age of onset; abrupt onset
- More frequent brief episodes
- Comorbid substance misuse
- Psychosis; psychomotor retardation; catatonia
- Lower likelihood of somatic symptoms
How can bipolar disorder episodes be described?
- Current
- Hypomanic
- Manic ± psychosis
- Mild or moderate depression
- Severe depression ± psychosis
- Mixed
- In remission
What is the median age of onset for bipolar disorder?
25 years
How does bipolar disorder vary between sexes?
- Equal incidence between sexes
- Bipolar II and rapid cycling is commoner in females
- Males tend to first experience manic episodes
- Females first experience depressive episodes
How does bipolar disorder impact suicide risk?
Bipolar disorder has 20x rate of attempted suicide
Name two significant co-morbidities seen with bipolar disorder
- Drug/alcohol misuse
- Anxiety disorders
Both increase risk of suicide
State three predisposing factors for bipolar disorder
- Bio: Genetic factors
- Psycho: Childhood experiences
- Social:
State two precipitating factors of bipolar disorder
- Bio: Substance misuse, iatrogenic eg. steroids
- Psycho: Self role
- Social: Life events, change in routine
Outline the perpetuating factors of bipolar disorder
- Bio: Substance misuse, physical illness
- Psycho: Personality traits
- Social: Work, relationships, support
List five complications of bipolar disorder
- Suicide; deliberate self harm
- Disinhibition and impaired social functioning
- Alcohol and substance misuse
- Financial difficulties due to overspending
- Traumatic accidents
- STIs; unplanned pregnancy
- Self-neglect
- Exploitation
- Anxiety disorders; personality disorders; ADHD
- HTN; cardiovascular disease
- T2DM; metabolic syndrome; CKD
What is the likelihood of relapse in bipolar disorder?
80% relapse after 1st episode within 5-7 years
Outline the management of bipolar disorder
- Risk management plan: developed with service user
- Psychotherapy
- Evidence-base manual specific for bipolar disorder
- High-intensity CBT; IPT; behavioural couples therapy
- Treatment of (hypo)manic episodes
- Treatment of depressive episodes
- Relapse prevention:
- Family intervention; psychotherapy
- Lithium
- Consider valproate; olanzapine; quetiapine
- Social: Targeted interventions towards family, housing, finance, employment
Which subtypes of bipolar disorder respond less well to lithium?
- Mixed bipolar disorder
- Rapid cycling mania
What medication should be avoided in bipolar?
Why?
Antidepressants
Poor evidence of efficacy, and risk of switching to mania
Which bipolar medications should be avoid in woman of child bearing age?
- Lithium: Epstein’s anomaly
- Sodium valproate: neural tube defects
- Carbamazepine: neural tube defects
Outline the pharmalogical management of a (hypo)manic episode of bipolar disorder
Consider stopping antidepressants
- Haloperidol; olanzapine; quetiapine; or risperidone
- Switch to an alternative SGA listed above
- Add lithium if uncontrolled after trying two SGAs
- Sodium valproate if ineffective/not suitable
- ECT in severe refractory mania
Outline the management of a depressive episode of bipolar disorder
- Fluoxetine + olanzapine; or quetiapine monotherapy
- Lamotrigine monotherapy
How do psychotic symptoms tend to present in a manic episode of bipolar?
- Mood congruent delusions: grandiose or persecutory
- Hallucinations
What are the indications for ECT?
- Severe depressive illness that is resistant to other treatment
- Life threatening mental illness
- Prolonged and severe mania
- Catatonia
- High suicide risk
- Stupor
- Severe psychomotor retardation
