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SIU5 Neurology > Bipolar Disorder and schiz > Flashcards

Bipolar Disorder and schiz Flashcards

1
Q

is bipolar easy to diagnose?

A

Diagnosis is difficult, may take years

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2
Q

what are the symptoms?

A 
It is defined by changing mood cycles 
three elements of this condition are
depressive symptoms 
psychotic symptoms
manic symptoms
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3
Q

what are manic symptoms?

A

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

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4
Q

what are psychotic symptoms?

A

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

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5
Q

classification of bipolar using DSM V

A

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

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6
Q

what is the goal in mgt of bipolar

A

Effective long-term treatment is the goal

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7
Q

what are the challenges in mgt of bipolar

A

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

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8
Q

medications needed for bipolar

A

Mood stabilisers taken long-term e.g. lithium, anti-epileptics: carbamazepine, Lamotrigine, valproate
Antipsychotics: Olanzapine, aripiprazole, quetiapine
Hypnotics
Antidepressants SSSRI

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9
Q

through meta-analysis, describe the compliance of lithium

A

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

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10
Q

Side effects of lithium are?

A 
Polyuria (and polydipsia- thirsty) 
Weight increase
Hyperthyroidism 
Tremor 
Memory and concentration disturbance.
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11
Q

what are the s/e of antipsychotics

A

increased risk CVD and diabetes; weight gain (10kg+ per year)

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12
Q

can you rx lithium and valproate in primary care

A

no

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13
Q

non- pharmacological treatments for bipolar

A 
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)
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14
Q

what are the ICD 10 criteria for bipolar

A
  • 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
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15
Q

criteria for rapid cycling bipolar disorder

A

having 4 OR MORE ep EACH YEAR

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16
Q

criteria for psycosis

A

bipolar I plus psychotic symptoms

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17
Q

impacts of bipolar on daily life

A
  • drving
  • decision making
  • med compliance
  • capacity
  • relationships
  • stigma (perception of collegues)
18
Q

NICE clinical mgn of bipolar

A
  • 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
19
Q

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!

A
  1. parkinson like s/e - body rigidity, tremour, unsteady gait –> antimuscarinic: Procyclidine
    Benzhexol, Benztropine, Biperidin, Orphenadrine
  2. 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)
  3. akathisia - motor and mental reslessness -> propanolol
  4. tardive dsykinesia - late onset, sm irreversible movement disorder, rhythmic contraction. orofacial and choreiform dsykinesia.
  5. neuroleptic malignant syndrome NMS
20
Q

what are the causes of neuroleptic malignant symdrome

A

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.

21
Q

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

A

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

22
Q

what are the trt for NMS

A

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)
23
Q

baseline measurements for initiation of long term antipsychotics

A
  • Wt, height, BMI, waist cir.
  • BGL, Blood lipid level
  • pulse and BP
  • ECG
  • prolactin with risperidone
  • gradual titration of quietiapine
24
Q

Monitoring for antipsychotic trt every 6 w

A
  • 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
25
Q

NICE CG schizophrenia trt option

A
  • oral antipsychotics

- in conjunction with psychological intervention

26
Q

Poly Pharmacy of antipsychotics

A

Using > 2 agents is NOT recommended
Using typical AND atypical together is NOT recommended ==> single agent only!! Exc when switching/ acute ep of phycosis/ partial responder
bc of QT prolongation and sudden
cardiac death

27
Q

Why never use 2 antipsychotics together

A 
High dose gives additive S/e 
EPSE
Elderly will fall due to sedation 
NMS, sudden death 
Wt gain -> CVR/ Diabetes
28
Q

S/ e of clonzapine
Why can’t be used unless
reserved for treatment resistant schiz as it is the only superior antipsychotic

A

agranulocytosis, neutropenia- leukaemia or blood disorder- monitor WBC weekely for 4 m, then 2 wly for the rest of yr, then mly
Wt gain+ Hypertension +metabolic syndrome–> diabetes
Sedation
raised temp. feverish
constipation- can kill!
Hypersalivation
seizure
NO EPSE
Should NOT be used unless failed at least TWO antipsychotics

29
Q

What are the typical antipsychotic

A

Chlorpromazine
Haloperidol
promazine
sulpiride

30
Q

Atypical antipsychotics

A
  • amisupiride (D2 rec antag)
  • olanzepine / clonzepine/ quietiapine/ respiridone (5HT2A:D2 rec antag)
  • aripriprazole (partial agnosit can switch base on DA level
31
Q

ICD10 classification of schizophrenia

A

at least one of : (postive sym)
thought boardcasting (formal thought disorder)
running commentary, or hallucinated voice
delusion
persistent delusion

or at least two of:( -ve sym)
presistent hallucination for 1m
neologism, thought disoder
catatonic behaviour - posturing
apathy, blunting

symptoms present during episode lasting at least 1m

32
Q

which AT cause weight gain/ metabolic syndrome eg diabetes?

A

olanzepine
quetiapine
clonzapine

33
Q

what are the s/e for amisulpride and risperidone?

A

increase prolactin

EPSE- tremor, rigidity, muscle stiffness

34
Q

NICE CG178 states that xxx is an option when ‘avoiding covert (hidden) non-adherence… is a clinical priority.’

A

depot

35
Q

how to improve patinet adherence

A

cqc – Outcome 1: pt understand trt, involved in decision about trt
– Outcome 2: clients should “ know how to change any decision”
– Outcome 9: clients should “have information about the medication

36
Q

S/e of atypical antipsychotics
olanzapine
quetiapine
clozapine (used in TRS)

A 
weight gain +++ but less EPSE
(CVR/T2DM
dry mouth etc
sedation +++
sexual prob +)
37
Q

s/e of clozapine

A 
1 sedation +++
2 sexual prob +
3 seizure
4 hypersalivation 
5 constipation 
6 agranulocytosis
7 hypertension , CVR
8 metabolic syn
9 diabetes
10 WEIGHT GAIN +++
38
Q

which antipsychotic med has the least s/e

what are those s/e

A

aripriprazole 2nd gen
sedation +
EPSE (tremor, muscle stiffness) +

39
Q

generation of risperidone and amisulpride what are the s/e

A 
risperidone is 2nd gen but boarderline 
amisulpride is 1st gen 
s/e: prolactin +++
EPSE, muscle stiffness ++
(Weight gain +
CVR/T2DM
dry mouth +
sexual prob +++
sedation +)
40
Q

what if schzi pt has poor med compliance?

A

use depot (deep IM inj), long acting injection

41
Q

first line for schiz?

A

the response and tolerability differs
between patients.
This individual response means that there is no clear first-line antipsychotic
suitable for all.

42
Q

If prescribing chlorpromazine, warn of its potential to cause skin photosensitivity.

A

Advise using sunscreen if necessary

SIU5 Neurology (13 decks)

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