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Psychiatry > Bipolar Disorder > Flashcards

Bipolar Disorder Flashcards

1
Q

Discuss what is required for a dx of bipolar I.

how many sx required, duration, and what are sx

A

Abnormal mood: persistently elevated, expansive, or irritable

  • 1 week + (less if pt hospitalized)
  • At least 3 symptoms (at least 4 if irritable mood)

DIG FAST

  • Distractibility
  • Indiscretion: dangerous pleasurable activities
  • Grandiosity, ^ self esteem
  • FOI or racing thoughts
  • ^ Activity (goal-directed) or psychomotor agitation
  • v Sleep (decreased need)
  • Talkativeness, pressured speech
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2
Q

Discuss what is required for a dx of bipolar II.

A

Same features as mania, but not as severe

  • At least 3 symptoms (4 if mood is irritable)
  • > 4 days
  • At least 1 major depressive episode as well
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3
Q

Discuss what is required for a dx of cyclothymic disorder.

A
  • No mania, major depression, or mixed
  • 2 yr period mood sx (symptom free < 2
    months at a time)
  • Periods of depressive symptoms, not Major Depression. Periods of hypomanic sx, not manic.

(persistent depressive d/o is also 2 years and never symptom-free > 2 months, + 2 sx of CHESS-A)

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4
Q

What does it mean to have “mixed features”?

A

Simultaneously pt meets:

  • Manic criteria, w/ some MDD symptoms
  • MDD w/ some manic symptoms
  • At least 1 week (the same week)

DSM5 change
– Previously mixed episode was only DSM4 and was viewed as a more severe Bipolar I episode
– Now, any part of Bipolar spectrum can have mixed features

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5
Q

What does it mean to have BD with “rapid cycling”?

A
  • Bipolar I or II
  • At least 4 episodes/yr
    – Major Depression, Manic, or Hypomanic
    – Thyroid abnormality often associated
    – Can be caused by treating with only antidepressants
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6
Q

Is BD with rapid cycling more common in M or F?

What % of BD pts have rapid cycling?

A

F

5-15%

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7
Q

When should you consider mania “severe”?

A

(no criteria)

  • SI/HI or suicidal/homicidal/aggressive behavior
  • Poor judgment: puts pt or others at imminent risk of harm

Hypomania? Cyclothymia?
– Less impaired (socially, job); not severe
– Change is observable by others who know pt

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8
Q

Review some manic behavior clinical clues.

A
  • High # of marriages
  • Wearing clothes/jewelry of bright colors in outlandish combos
  • Disrobing in public places
  • Sudden trips, vacations, cross country travel
  • Many career changes
  • Business successes and failures
  • Idea preoccupation (religious, financial, sexual, persecutory)
  • Pathologic gambling
  • Over a lifetime, drastic changes in lifestyle
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9
Q

What medical conditions can mimic BD?

A 
 Neurological
– Epilepsy
– HIV, neurosyphilis
– Huntington’s disease
– Migraines
– Multiple sclerosis
– Brain tumor
– TBI, R-hemisphere lesion
– Wilson’s disease
 Endocrine
– Cushing’s disease
– Addison’s disease
– Postpartum
– Hyper or hypothyroid
 Other
– AIDS, SLE, Uremia
– Vitamin deficiencies
 B12, C, folate, niacin, thiamine
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10
Q

What medications can mimic BD?

A 
 Antidepressants
– TCA highest risk
 Amphetamines/stimulants
 Baclofen
 Bromocriptine
 Captopril
 Cocaine
 Corticosteroids
 Cyclosporine
 Disulfiram
 Hallucinogens
 Hydralazine
 Interferon
 Isoniazid
 Levodopa
 Opiates
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11
Q

What sx are more prominent in ADHD?

A
  • Inattention
  • Hyperactivity
  • Impulsivity
 Study
– kids referred with manic symptoms;
96% met ADHD criteria
– kids referred with ADHD symptoms;
16% met bipolar manic criteria
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12
Q

While giving a stimulant to kids with ADHD can treat ADHD, giving kids with BD a stimulant would do what?

A

Induce mania

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13
Q

What sx are more prominent in borderline personality d/o?

A
  • Affective instability due to marked mood reactivity
  • Impulsivity; potential to be self damaging
  • Recurrent suicidal behavior
  • Unstable and intense relationships
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14
Q

What is the lab w/u for mania?

A 
– Chem panel
– LFT’s
– Urine drug screen
– TSH
– CBC
– B12
– RPR/VDRL
– HIV
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15
Q

BD:

  • Peak age of onset?
  • Mean age of onset?
A
  • Peak: 15-19
  • Mean: 19-21

(if > 60 y/o, first consider medical illness)

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16
Q

Gender differences in BD 1?

2?

A

1: M = F
2: F > M

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17
Q

What marital status is least common in BD:

single, divorced, or married?

A

Married

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18
Q

Risk of BD 1 w/first-degree relative?
Concordance w/dizygotic twins?
Concordance w/monozygotic twins?

A

15%
20%
70%

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19
Q

BD 1 prevalence?

BD 2 prevalence?

Cyclothymia prevalence?

Bipolar spectrum prevalence?

A
  1. 8-1.6% (1st aid: 1-2%)
  2. 5-5.5% (1st aid: unclear)
  3. 4-1% (1st aid: < 1%)
  4. 6-6.5%
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20
Q

In BD, are maternal or paternal relatives more affected?

What is the x increased risk of the more affected side?

A

– Maternal relatives: 27.3% affected
– Paternal relatives: 14% affected

(2x risk of bipolar disorder if + history on mother’s side vs. father’s side)

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21
Q
  • Many genes in BD overlap w/what psych dz?
  • What are some c’somes implicated?
  • What ion’s cellular channel is implicated?
  • What type of homeostatic pattern may be seen?
A
  • Many gene sharing/overlap with schizophrenia
  • Not a single chromosome/single gene illness: 6q, 8q, 9p, 20p regions
  • Ca+ channel activity
  • Circadian patterns
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22
Q

What is the first manic episode usually triggered by?

A

Severe psychosocial stressor

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23
Q

Depression or mania first in:
M?
F?

A
  • Male: mania more likely

- Females: depression more likely

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24
Q

How long do mania episodes last in the average pt?

How frequently do they occur?

A

1.5-4 months!

1 episode every 2 years

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25
Q

W/o ppx, how many avg lifetime manic episodes will someone w/BD have?

A

9-10

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26
Q

What % of BD pts attempt suicide?

Complete suicide?

A
  • 25-50% attempt suicide
  • 20% complete suicide

(increased risk in mixed episodes and depressive phase)

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27
Q

In BD, how does the duration of manic episodes change over time?

How does the inter-interval change?

A
  • Duration increases over time

- Inter-interval duration decreases over time)

28
Q

What is the Kindling theory?

A

– Consequence of repeated sub-threshold stimuli that progressively leads to more episodes
– Subsequent application of single sub-threshold stimuli will evoke an episode

29
Q

Is monotherapy or polytherapy more common in BD?

A

Monotherapy is the exception; Polypharmacy common

30
Q

What are some drugs that can be used during mania?

A

All except lamotrigine and Symbyax

? see Jeopardy

31
Q

Which manic episode tx is best for rapid cyclers?

A

All equal (?)

32
Q

What is the DOC for BD?

A

Li+

33
Q

What is the short-term response rate of Li+?

A

70-80%

34
Q

When does Li+ start working significantly?

How long should a therapeutic trial last?

A

2-4 weeks

4-6 weeks

35
Q

How many pts taking Li+ will be completely sx-free?

A

1/3

36
Q

Li+ works better in which of the following?

  • Rapid vs nonrapid cycling
  • Dysphoric vs euphoric mania
  • Substance abuse vs no substance abuse
  • Family hx vs no fam hx
  • Few lifetime episodes vs > 3 lifetime episodes
A

Better in:

  • nonrapid cyclers
  • euphoric mania
  • no substance abuse
  • Family hx
  • Few lifetime episodes
37
Q

If pt is manic and highly active w/Li+ tx in the first few weeks, what should you do?

A

– Decrease the motor overactivity with other agents:

  • Typical and atypical antipsychotics (FGA and SGA)
  • Divalproex (Depakote)
  • Carbamazepine (Tegretol)
  • Benzodiazepines
38
Q

If pt is nonresponsive to Li+, what medication change is best?

A

Better to ADD Depakote or Tegretol rather than switch to monotherapy with something else.
- After 4-6 weeks, over next 1-3 months may slowly d/c adjuvant meds

39
Q

If Li+ is effective, how long should it be continued?

A

At least 9-24 months
– After1 manic episode-sometimes maintenance tx, sometimes d/c
– After 2 manic episodes, always maintenance tx

40
Q

Li+

Adverse effects?

A

rare = *
Derm: acne, psoriasis, rashes, alopecia
Endocrine: v thyroid, ^parathyroid*
GI: Nausea, diarrhea
Heme: ^ WBCs
Neuro: fine tremor, v conciousness, sedation
Other: Edema, weight gain
Nephrogenic diabetes insipidus (long-term risk), mild renal insufficiency
CV (rare): Arrhythmia, bradycardia, sick sinus syndrome (seizure/syncopal episodes)
- Narrow therapeutic window

41
Q

Which phases of BD is Li+ DOC for?

A

1st-line for all phases of BAD: acute mania, depression, maintenance tx

42
Q

Which phases of BD is Depakote used for?

A

1st-line for bipolar mania; bipolar maintenance tx (not depression)

(also for epilepsy, migraine ppx)

43
Q

Depakote: adverse effects?

A

rare = *
Derm: alopecia*
GI: nausea (avoid by giving food or use enteric coated Depakote®), vomiting, diarrhea, mild ^ LFTs, hepatotoxicity (< 2 y/o treated w/other drugs), pancreatitis*
Heme: v platelets*
Neuro: ataxia, HA, dizziness, tremor, sedation
Other: ^ ammonia level (encephalopathy if severe), weight gain, polycystic ovarian syndrome (PCOS), ^ suicide risk*
Birth defects (serious)

44
Q

Which phases of BD is carbamezapine used for?

A

Used to be 2nd-line, now 3rd-line behind SGA for tx of bipolar mania; bipolar maintenance tx. (not FDA-approved)

(also for trigeminal neuralgia)

45
Q

Carbamezapine (Tegretol): adverse effects?

A

rare = *
Derm: rash (vs. SJS. SJS is more common in asian ancestry who have HLA-B1502)
GI: nausea, vomiting, mild ^ LFTs, hepatotoxic*
Heme: v WBCs, aplastic anemia, agranulocytosis
Neuro: ataxia, diplopia, dizziness, tremor, sedation
Other: v Na+, weight gain, ^ suicide risk,
[Drug-induced lupus]
Birth defect: spina bifida

46
Q

Which phases of BD is lamotrigine used for?

A

NOT useful in treating acute manic episode. Approved for BAD maintenance tx and bipolar depression.

47
Q

Lamotrigine: adverse effects?

A

rare = *
Alcohol may increase SE severity
Derm: rash (benign vs. SJS). Diffuse, itchy.
GI: nausea, vomiting
Neuro: ataxia, HA, dizziness, double vision, blurred vision, fatigue
Other: insomnia, blood dyscrasias (agranulocytosis, aplastic anemia)

48
Q

Which phases of BD are FGAs and SGAs used for?

A

Pretty much all 2nd-gen antipsychotics have been used in the tx of 1 or more phases of BAD.

  • FGAs approved for tx of acute mania (3rd-line option).
  • SGAs w/mood stabilizers are commonly used for treating severe acute mania (mania w/psychosis and/or suicidal/homicidal/dangerous behavior).
49
Q

What drugs can increase Li+ levels via interactions?

A 
NSAIDs
Celecoxib
ACEIs (lisinopril)
ANG II inhibitors (losartan)
K+ sparing diuretics
Dehydration
Na+ depletion
Renal impairment
Advanced age
50
Q

What is the main advantage of using Depakote?

A

Can rapidly load

– Responders: most improvement in first 3 days

51
Q

While 1/3 BD patients taking Li+ will be sx-free, what number of pts taking Depakote will be sx-free?

A

1/3

52
Q

How long does it take for Tegretol to response to an acute manic episode?

A

1-2 weeks

53
Q

What is the MoA that Divalproex (Depakote) and Carbamazepine (Tegretol) use to treat seizures?

A
  • Blocks voltage-dependent Na + channels
  • Effects GABA system; unclear if that enhances anticonvulsant activity

(unknown MoA for BD)

54
Q

*Why are SGAs preferred over FGA in treating acute mania?

A

– v EPS side effects; v Tardive Dyskinesia
– All SGA’s apparently effective
– Depression generally does not worsen (unlike FGA’s)
– Antidepressant effects: quetiapine (Seroquel), olanzapine + fluoxetine (Symbyax)

55
Q

What is a downside of SGAs over FGAs?

A

Metabolic syndrome risk

56
Q

Review some SGAs FDA-approved for acute mania tx.

A

Olanzapine (Zyprexa), Risperidone (Risperdal), Quetiapine (Seroquel), Ziprasidone (Geodon), Aripiprazole (Abilify), Asenapine (Saphris)

57
Q

After how many manic episodes should you do long-term ppx in BD 1 d/o tx?

A

2 (1 if severe or strong fam hx; sometimes if 1 nl manic episode)

58
Q

What are first-lime meds for bipolar depression?

A
  • Lithium
  • Quetiapine
  • Lamotrigine
  • Olanzapine/fluoxetine combo (Symbyax)
59
Q

Why not give antidepressant monotherapy for bipolar depression?

A

Induces mania

60
Q

What are possible alternative, non-pharmacological options for treating bipolar depression?

A
  • ECT
  • maybe TMS

(don’t do either as mono-tx)

61
Q

What are some triggers for affective switch in BD?

A 
 Sleep loss
 Alcohol/substance use
 EEG abnormality
 Rapidly stopping Lithium
 Anti-depressant use or discontinuation
 Seasonality
 East-west travel
 Conflict/trauma
 Loss of support systems
 Grief
 Success
62
Q

Should you gradually or rapidly stop Li+?

A

Gradually

63
Q

*Mood stablizers are the first-line tx for BD. Strongest evidence supports the use of Li+ or ______________.

A

Lamotrigine

64
Q

*Which antidepressant class has the greatest risk of inducing mania?

A

TCAs

65
Q

When treating bipolar depression using an antidepressant (along w/a mood stablizer), should you use the antidepressant continually or only during the depressive episode?

A

Only during depressive episode (d/c s/p remission)

66
Q

*_____________ is one of the antidepressants that is LEAST likely to induce a switch to mania.

A

Buproprion (Wellbutrin)

67
Q

*Which 2 antipsychotics have the strongeset evidence for efficacy in treating bipolar depression?

A
  • Quetiapine (Seroquel) monotherapy

- Olanzapine + fluoxetine combo (Symbyax)

Psychiatry (16 decks)

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