Bipolar disorder

Question 1

Definition

Answer 1

Recurrent alternating periods of abnormal mood elevation and depression, causing an impairment in function.
- Depressive and manic episodes

Question 2

Epidemiology

• Sex
• Peak onset
• Lifetime prevalence
• Suicide rates

Answer 2

M=F

Peak onset

• Younger than schizophrenia
• 15-24

Lifetime prevalence
- 1%

Suicide rates
- >20x risk of normal population.

Question 3

Risk factors

Answer 3

Family history
- 10x risk if first degree is affected

Early onset of mood disorder

Poor/ limited response to traditional antidepressants.

Question 4

Manic episode

Answer 4

Elevated/ agitated/ expansive mood

• For 7+ days
• Impairing function

Other features

• Grandiosity (psychotic if severe)
• Decreased need for sleep
• Flight of ideas
• Fast, pressured speech
• Racing thoughts
• Distractibility
• Psychomotor agitation
• Disinhibited behaviour

Question 5

Hypomania

Answer 5

Same mood as mania, lasting at least 4 days, present almost all the time.
- Not severe enough to impair function

Includes 3 or more of manic symptoms

Question 6

Drugs that can cause manic symptoms

Answer 6

Cimetidine

Corticosteroids

Cyclosporins

Levodopa

Antidepressants

Question 7

Management of acute mania/ hypomania

Answer 7

Pharmacological:

Discontinue antidepressants

Hypomania
- Mood stabiliser monotherapy (lithium, valproate, carbamazepine)

Mainia
- Atypical antipsychotic
Risperidone, quetiapine, aripriprazole, olanzapine.

Add benzo if monotherapy not tolerated.

If combination therapy fails
- Clozapine/ ECT

Supportive

• Calming environment
• Encouraging relationships

Question 8

Long term management for bipolar depression

Answer 8

Psychological

• High intensity CBT
• Interpersonal social rhythm

Pharmacological (moderate-severe depression)
1. Fluoxetine + olanzapine
OR Quetiapine/ olanzapine, aripriprazole

2. Increase lithium dose if already on and possible.
   - If not, add step 1/2.

If on valproate

• Consider increasing dose
• If not, step 1/2.

Question 9

Monitoring of antipsychotics

Answer 9

Monitor metabolic syndrome especially for atypical antipsychotics

• Pulse, BP after dose change
• Weight, BMI (6/52, then 12/52)
• Blood glucose, lipids (12/52)
• ## Side effects

Question 10

Neurophysiology

Answer 10

Stress-diathesis model
- genetic vulnerability with environmental influences

Limbic system dysregulation

• Decreased PFC and progressive hypoactivity in PFC
• Irregular connections of PFC to subcortical areas, leading to abnormal emotional processing.
• Amygdala: increased volume shows overactivity.