Bipolar disorder

Question 1

Which gender is bipolar more common in, and which ages for each?

Answer 1

Equal male: female. 15-19 for women and 20-24 for men

Question 2

Give 3 mood, 5 cognitive, 5 behavioural and 2 psychotic clinical features suggestive of mania.

Answer 2

Mood: Irritability, euphoria, labile mood.
Cognition: Grandiosity, distractibility, flight of ideas, confusion, lack of insight, impaired judgement, extreme risk taking.
Behavioural: Pressure, hyperactivity, decreased need for sleep, hypersexuality, extravagance, social disinhibition.
Psychosis: Delusions, hallucinations.

Question 3

What is needed with the symptoms to diagnose mania?

Answer 3

Symptoms lasting over a week (or shorter, but severe enough to warrant hospital admission) and a loss of function.

Question 4

What is bipolar? What is it characterised by?

Answer 4

Depression alternating with mania. Characterised by repeated (i.e. >2) mood disturbances.

Question 5

How quick do manic episodes normally onset and how long do they normally last?

Answer 5

Usually begin suddenly, lasting anywhere from 2 weeks to 4-5 months.

Question 6

What are types 1 and 2 bipolar affective disorder?

Answer 6

Type I: mania + depression. Type II: repeated depression with hypomanic episodes.

Question 7

What is hypomania and how does it differ from mania?

Answer 7

It is a less severe state of mania. There are no psychotic symptoms, decrease in functioning, or need for hospital admission. It has to last >4 days.

Question 8

What is cyclothymia?

Answer 8

Cyclical mood swings with subclinical features (‘bipolar lite’)

Question 9

Give 2 drug causes of mania, and 6 physical.

Answer 9

Drug: STEROIDS, amphetamines/cocaine.
Physical: Hyperthyroid, infection, stroke, tumour, epilepsy, multiple sclerosis. Also STRESS/GRIEF.

Question 10

Give 2 investigations you could do in a manic patient.

Answer 10

CT head, TFTs, etc etc depending on suspected cause

Question 11

How is acute mania treated?

Answer 11

Any SGA. Lithium can also be started in a manic episode. Remember that people like being manic so can be difficult to treat

Question 12

When should prophylaxis be considered for bipolar mania?

Answer 12

If, after treatment of an acute episode of mania, there is a relapse.

Question 13

What is first line medical treatment, and what evidence is there for it?

Answer 13

Lithium. Only drug in bipolar that has evidence for decreasing suicide.

Question 14

How often should dose be checked and what levels are optimum?

Answer 14

Check it weekly until consistent, then check monthly for 6 months, then 3 monthly.
0.4-1

Question 15

If lithium levels gradually increase, what could be happening?

Answer 15

Nephrotoxicity

Lithium toxicity

Question 16

What bloods need to be monitored and how often?

Answer 16

TFTs and U+Es 6 monthly

Question 17

What is second line if lithium isn’t working?

Answer 17

Semisodium valproate or carbamazepine

Question 18

Give 2 other mood stabilisers that can be used.

Answer 18

Lamotrigine (is as good as SSRIs for bipolar depression treatment), and olanzapine. Quetiapine can be used, good for mania and depression.

Question 19

When would combination treatment be considered?

Answer 19

After persistent, long term mania. Can combine lithium with any of the above.

Question 20

What can be used for depression in bipolar?

Answer 20

SSRIs, venlafaxine, ECT, and as mentioned above, lamotrigine

Question 21

What is the mainstay of psychological treatment and what does this target?

Answer 21

CBT. Support groups and psychoeducation are also very important. CBT targets topics such as stigma, fear of relapse, acute illness, reckless habits and hypersexuality