Bipolar disorder (affective disorders)

Question 1

Who does bipolar disorder affect?

Answer 1

-Lifelong prevalence of 2.4%
-Anxiety and substance misuse are commonly associated

Question 2

What causes bipolar disorder?

Answer 2

-Chronic illness associated with behavioural disturbances
-Characterised by episodes of mania / hypomania and depression
-2 types:
–Bipolar I = presents with severe manic episodes resulting in impaired functioning / hospital admissions, interspersed with major depressive episodes
–Bipolar II = patients experience hypomania (no psychotic symptoms and less dysfunction), interspersed with depressive episodes

Question 3

What risk factors are there for bipolar disorder?

Answer 3

-Family history

Question 4

How does bipolar disorder present?

Answer 4

Manic phase, LASTING 7+ DAYS:
-Grandiose ideas
-Pressure of speech
-Excessive energy
-Racing thoughts, flight of ideas
-Overactivity, needing little sleep / altered sleep pattern
-Easily distracted
-Bright clothes / unkempt
-Increased appetite
-Reckless with money
Hypomanic phase LASTING 3-4 DAYS:
-Lesser degree of mania, mild elevation of mood, increased activity but no psychosis
-Irritability, conceit and boorish behaviour
Depressive phase:
-Low mood, anergia, anhedonia
-Poor eye contact, limited facial expression
-Despair, guilt

Question 5

What are the ICD-10 diagnostic criteria for bipolar disorder?

Answer 5

-At least 2 episodes in which a person’s mood and activity levels are disturbed (one of which must be mania/hypomania)

Question 6

What are the differential diagnoses for bipolar disorder?

Answer 6

-Dementia
-Other psychotic disorders
-CBV event
-Thyroid disease
-Medications eg steroids, L-dopa
-Acute withdrawal / illicit drug ingestion

Question 7

How would you investigate someone with bipolar disorder?

Answer 7

-Full H+E and MSE
-Rule out organic cause eg drug history, TFTs, CT head

Question 8

What treatments would you consider in someone with bipolar disorder?

Answer 8

Biological:
-Antipsychotics to treat mania eg olanzapine, haloperidol, quetiapine, risperidone
-Lithium if 1st and 2nd line a/ps are ineffective (+valproate if necessary)
-Antidepressants must be stopped if pt already taking
-A/ds are less effective in depressive phase and can induce mania - should only be prescribed with anti-manics / if severe
Psychosocial:
-Self-help / support groups
-CBT

Question 9

What is lithium used for?

Answer 9

-Used as a mood stabiliser in bipolar affective disorder
-Can be used actively to treat mania or prophylactically to prevent episodes

Question 10

What are some side effects of lithium?

Answer 10

-Abdo discomfort, GI upset
-Arrhythmias, cardiomyopathy
-Dizziness
-Dry mouth / hyper salivation
-Electrolyte imbalance ESPECIALLY hyperCa2+ –> back / bone pain, constipation, low mood
-Goitre
-Hypotension
-Hypothyroidism
-Tremor

Question 11

What is the monitoring process for lithium?

Answer 11

-Blood levels range between 0.4 and 1.0
-Weekly blood tests to check levels - once stable –> 3 months (takes a few weeks to work, don’t stop suddenly due to risk of relapse)
-Every 6 months, bloods must be done due to number of side effects (FBC, U+Es, eGFR, TFTs, Ca2+, ECG, BMI)
-Level taken 12h post dose

Question 12

What cautions are there when taking lithium?

Answer 12

-Severe water loss can lead to increased blood conc –> lithium toxicity and possible worsening of severe symptoms eg tremor, GI symptoms, dizziness
-Teratogenic - caution pregnancy
-Drink in moderation, can drive
-Caution with ACEis, NSAIDs, COX-2 inhibitors