Bipolar Disorder and schiz Flashcards
is bipolar easy to diagnose?
Diagnosis is difficult, may take years
what are the symptoms?
It is defined by changing mood cycles three elements of this condition are depressive symptoms psychotic symptoms manic symptoms
what are manic symptoms?
mood elevation plus
agitation and insomnia or irritation
easily distracted
Over/under eating
high self esteem, loss of identity
ex involvement in pleasurable activity - Over spending
increase in sexual desire (NB difficult in mixed wards)
flight thoughts and new ideas
excessive talking and increased speed of speech
increased chance of drinking, smokimg
what are psychotic symptoms?
Hallucinations (hearing, seeing or sensing things not there) Hearing voices Andre
Delusions which may be persecutory, religious, grandiose or bizarre (strongly held beliefs not influenced by logical reasoning)
formal thought disorder- putting word tgt that doesnt make sense= unorganised speech
classification of bipolar using DSM V
bipolar I - 1 manic ep longer than 1 w, with/out 1 depressive ep
bipolar II - 1 depressive ep, 1 hypomania
biopolar III - antidepressant induced mania
bipolar IV - depression when previously hyperthymic
what is the goal in mgt of bipolar
Effective long-term treatment is the goal
what are the challenges in mgt of bipolar
Long-term treatment is challenging
high rate of noncompliance within psychiatric disorders
patients receive polypharmacy
“One directional” treatments for bipolar depression may accelerate mania
“One directional” treatments for bipolar mania may cause depression or dysthymia
Many patients experience chronic low-level dysphoria and/or cognitive dulling sometimes ascribed (blame on) to treatments
medications needed for bipolar
Mood stabilisers taken long-term e.g. lithium, anti-epileptics: carbamazepine, Lamotrigine, valproate
Antipsychotics: Olanzapine, aripiprazole, quetiapine
Hypnotics
Antidepressants SSSRI
through meta-analysis, describe the compliance of lithium
evidence shows effectiveness in preventing new ep of mood disturbance and mania for pt who takes Li for 2 years. not effective in preventing depressive ep.
patient compliance is very low- av. 2 m = not long enough to be effective
Side effects of lithium are?
Polyuria (and polydipsia- thirsty) Weight increase Hyperthyroidism Tremor Memory and concentration disturbance.
what are the s/e of antipsychotics
increased risk CVD and diabetes; weight gain (10kg+ per year)
can you rx lithium and valproate in primary care
no
non- pharmacological treatments for bipolar
Exercise -wt mgt, healthy eating Enough sleep Diary (for mood) Avoid alcohol Smoking cessation Stress mgt Meditation High intensity psychological therapy including: Psycho-education, CBT, interpersonal psychotherapy, Behavioural couples therapy, Family therapy Advanced directives (Mental Capacity Act)
what are the ICD 10 criteria for bipolar
- a minimum of 2 mood episodes, one of which must be manic or hypomanic
- Does not recognize a difference between bipolar I and bipolar II
criteria for rapid cycling bipolar disorder
having 4 OR MORE ep EACH YEAR
criteria for psycosis
bipolar I plus psychotic symptoms
impacts of bipolar on daily life
- drving
- decision making
- med compliance
- capacity
- relationships
- stigma (perception of collegues)
NICE clinical mgn of bipolar
- Stop antidepressant (if manic)
- Offer antipsychotics : haloperidol, -
olanzapine, quetiapine, risperidone - if poorly tolerated or ineffective at max dose, offer alternative antipsychotic
- If still ineffective, offer lithium, check plasma lithium level to optimise trt
- If ineffective, offer valproate (not for women at child-bearing age) instead
- Consider adding haloperidol, olanzapine, quetiapine, risperidone
- Increase the dose of valproate or other mood stabiliser
motor s/e of first generation of antipsychotics
what is rare but fatal s/e?
promazine
chlorpromazine
(phenothiazine class)
haloperidol
D2 antagonist also has anti-emetic effect!
- parkinson like s/e - body rigidity, tremour, unsteady gait –> antimuscarinic: Procyclidine
Benzhexol, Benztropine, Biperidin, Orphenadrine - acute dsytonia - concious but involuntary movement of body, arms. prolong contaction cause increase in muscle tone cause spasm -> antimuscarnic: reserpine (not used in depressed pt)
- akathisia - motor and mental reslessness -> propanolol
- tardive dsykinesia - late onset, sm irreversible movement disorder, rhythmic contraction. orofacial and choreiform dsykinesia.
- neuroleptic malignant syndrome NMS
what are the causes of neuroleptic malignant symdrome
Use of high-potency antipsychotics,
rapid increase in dose
long-acting forms of antipsychotic
Incidence NMS is between 0.2%–3.23%.(use of atypical APs reduced the prevalence)
Young males particularly susceptible male:female ratio estimated at 2:1.
what are the symptoms of neuroleptic malignant syndrome (similar to Serotnin symdrome, how to distinguish?)
sertonin syndrome is cuased by SSRI overdose BUT NMS is caused by antipsychotics
physical: muscle rigidity, cramps, tremors, rhabdomylosis,
Autonomic: instability, fever, unstable BP (hypertensive crisis), metabolic acidosis,
Cognitive: agitation, delirium, coma
Laboratory: incrased plasma creatine phosphokinase (CPK- release when muscle is damaged)
Features which distinguish NMS from serotonin syndrome
bradykinesia,
muscle rigidity (dopamine),
raised WBC
what are the trt for NMS
Medical emergency
- treat fever (iv para)
- treat muscle ridigity e.g. dantrolene: postsynaptic muscle relaxant that lessens excitation-contraction coupling in muscle cells. It achieves this by inhibiting Ca2+ ions release from sarcoplasmic reticulum stores by antagonizing ryanodine receptors.
- renal support (rhabdomylosis cuase renal failure)
baseline measurements for initiation of long term antipsychotics
- Wt, height, BMI, waist cir.
- BGL, Blood lipid level
- pulse and BP
- ECG
- prolactin with risperidone
- gradual titration of quietiapine
Monitoring for antipsychotic trt every 6 w
- response to trt
- S/e
- movement disorder
- wt weekly for 6 w then at 12 w then 1 y
- waist circumference
- pulse And BP
- BGL, BLL
- ADHERENCE
- physical health : CVR diabetes risk
- LFT
- CPK Creatinine phosphokinase if NMS suspected
