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Psychiatry > Bipolar disorder > Flashcards

Bipolar disorder Flashcards

1
Q

Categories within DSM-V bipolar spectrum

A
  • Bipolar I
    • ​Mania: psychotic + non-psychotic
    • Mixed state
    • Major depression
  • Bipolar II
    • ​Hypomania + Major depression
  • Bipolar NOS
    • ​Hypomania w/o major depression, subsyndromal hypomania w/ major depression, rapid cycling
  • Cyclothymia
    • ​Subsyndromal mania/depression
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2
Q

Prevalence of bipolar disorder

A
  1. 8% Bipolar I
  2. 5% Bipolar II

(Approx 1.5% overall, higher if bipolar NOS included up to 4%)

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3
Q

Risk to first degree relatives of pts with BPD

A

First degree relatives of BPD

  • 10% bipolar (4-24%)
  • 15% depression
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4
Q

Precipitating factors for BPD

A
  • Bio: Shift work, stop/start of meds, street drugs
  • Psycho: Loss/gain events
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5
Q

DSM-5 definition of mania

A

Abnormally and persistently elevated, expansive, or irritable mood (often irritable rather than elevated)

lasting at least 1 week

accompanied by persistently increased energy or activity levels

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6
Q

DSM-5 criteria for manic episode

A

Mania (as per definition)

Marked impairment in functioning

3 or more symptoms of mania

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7
Q

Symptoms of mania/hypomania (DSM-5)

A
  1. Euphoria/irritability
  2. Excessive self-esteem, grandiosity
  3. Reduced need (not necessarily quantity) for sleep
  4. Increase in goal-directed activity
  5. Flight of ideas
  6. Distractibility
  7. Increased talkativeness, pressure of speech
  8. Overfamiliarity
  9. Disinhibition/poor judgement –> increased involvement to out-of-character activities that might have painful consequences
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8
Q

Implications of psychotic symptoms in BPD

A

Bipolar I by definition (i.e. not hypomania)

Marker of severity

May indicate schizoaffective disorder

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9
Q

DSM-5 definition of hypomania

A

Abnormally + persistently elevated/irritable mood

At least 4 days

Noticed by others + clearly different from nondepressed mood

Not causing marked impairment in f(x) (or would be mania)

Insight may be preserved (cf mania)

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10
Q

Clinical features of mixed states

A

Depressive and manic symptoms coexist within one day (all the energy + all the negativity)

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11
Q

M:F ratio of bipolar

A

1:1

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12
Q

Mean age of onset of BPD

A

Early 20s

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13
Q

Heritability of BPD

A

70-80%

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14
Q

Differential for bipolar

A
  • Medical: Esp thyroid, Cushing’s, iatrogenic
  • Physical: Substance misuse
  • Psychosis: schizophrenia, schizoaffective
  • Neurodevelopmental: ADHD
  • Neurodegenerative: Esp FTD
  • Neurotic: Anxiety, PTSD
  • Personality: Esp borderline personality disorder
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15
Q

Predominant symptom load in BPD

A

Depressive, therfore always ask about mania in depressive presentations

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16
Q

Mortality in BPD

A

Attempted suicide 25-50%

Completed suicide approx 10% (esp during mixed episode)

Life expectancy 5-10years less than general population

17
Q

DSM-5 criteria for bipolar I

A

1 or more manic episodes with or without 1+ hypomanic/depressive episodes

18
Q

DSM-5 criteria for bipolar II

A

1+ depressive episodes AND 1+ hypomanic episode

19
Q

Definition of rapid cycling of mood

A

>=4 mood episodes of any pole in one calendar year

Poor prognosis, associated with increased suicide risk

More common in females

20
Q

Clinical features of bipolar II

A

More chronic

More depressive

More rapid cycling

Shorter inter-episode periods

21
Q

Common psychiatric comorbidities with bipolar

A

Anxiety (93% comorbidity for any anxiety disorder, esp social)

Substance misuse (71%)

22
Q

Natural history of untreated BD

A

10 episodes in lifetime with inter-episode duration stabilising around 4th/5th episode

23
Q

BPD relapse rate

A

40-50% within 1 year

>70% within 5 years

24
Q

Prognosis of BPD on Lithium

A

7-10% no recurrence

45-50% some recurrence

40% persistent recurrence

25
Q

Poor prognostic factors for BPD

A
  • Poor employment Hx
  • Male sex
  • Treatment noncompliance
  • Psychotic symptoms
  • Alcohol abuse
26
Q

Good prognostic factors for BPD

A
  • Late onset
  • Low physical comorbidity
  • Low suicidal thoughts
27
Q

Annual physical health checks for BPD

A

Every 3 months initially!

Weight: BMI, nutritional status, physical activity

Cardiovascular: Pulse, BP

Metabolic: HbA1c, fasting blood glucose, lipid profile

LFTs

If on Lithium: U+Es: incl Ca, and TFTs

28
Q

Management of acute manic episode or mixed affective state

A
  1. Admission + assessment
  2. Stop antidepressant, if present
  3. Optimise antimanic or antipsychotic levels (e.g. Li, valproate), if taking
  4. Administer antipsychotic if manic
  5. Administer mood stabiliser if euthymic
  6. Administer short-term benzo if agitated
  7. Consider physical health interventions (e.g. pregnancy test, urine drug screens)
29
Q

Antipsychotic treatment algorithm for manic episodes

A
  1. First line: Haloperidol, olanzapine, quetiapine, risperidone
  2. Second line: Alternative antipsychotic
  3. Third line: Add Lithium
  4. Fourth line: Add/switch lithium with valproate
  5. Drug-resistant: Consider ECT
30
Q

Licensed treatments for bipolar prophylaxis

A
  1. First-line: Lithium, gold-standard, but must be continued for >2 years
  2. Valproate, olanzapine, quetiapine
  3. Li/valproate PLUS antipsychotic
  4. Carbamezapine, lamotrigine (carbamazepine better for manic relapse, lamotrigine mainly for depressive)

Most pts require antipsychotic + mood stabiliser

31
Q

Treatment of depressive episode of bipolar

A
  • Mild:?treat ?watchful waiting
  • Moderate-severe: Olanzapine + SSRI (usually fluoxetine, caution for ppt mania), OR quetiapine (best evidence) as first-line
  • Recent unstable mood/resistance to treatment: Lamotrigine as 2nd line
32
Q

Length of maintenance treatment in bipolar depressive episode

A

8-12 weeks

33
Q

Long-term management of bipolar, psychoeducation

A
  1. Illness: Nature, treatment, etc
  2. Medication: Efficacy + SEs
  3. Crisis plan: Noting early warning signs + effective responses
  4. Follow-up: Physical + psychological, incl. mobile monitoring
34
Q

Long-term management of BPD, psychological

A
  • Family-focused therapy: Psychoeducation of family + acceptance of illness/treatment + identification of warning signs/ppting stressors
  • True colours: Mood monitoring via QIDS-SR and Altman SRM (depression and mania respectively)
  • CBT for residual symptoms (not relapse rate)
  • Social rhythm therapy: Aimed at reducing relapse rate + improving recovery by providing regular pattern of daily activities, improving sleep hygiene. e.g. day hospital)
35
Q

Long-term management of BPD, social

A

Employment support groups, pre-vocational training

36
Q

Maintaining factors for bipolar disorder

A

More/less sleep

Poor compliance

Chosen environment

Ethanol + street drugs

37
Q

Biological aetiology of bipolar disorder

A

Genetics (Heritability 70%)

Paternal age >45

Psychiatry (20 decks)

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