Bipolar Disorder - F31 Flashcards
What is the epidemiology of bipolar?
Lifetime UK prevalence - 1-2%
Risk factors - most common in the 16-24yrs age bracket
i) Women being the most commonly affect during this time
ii) 25-64yrs men are more commonly affected
Living alone, unemployed or receiving unemployment support allowances are also more likely affected
Diagnosis: average of 10.5yrs to receive a correct diagnosis for bipolar in the UK, misdiagnosis occurs on average 3.5 times, if presents after 45 for the first time then suspect organic cause
What is the genetic relationship with bipolar?
5-10% increased risk for those with 1st degree relatives with bipolar disorder
i) Also links to cyclothymia (like a hypo-bipolar) and hyperthymia (like cyclothymia but without low moods)
ii) Also increased risks of suicidality, lithium responsiveness, comorbid alcohol use and panic disorders – aggregate in families with bipolar
What are some environmental risk factors for bipolar?
Recent life events and interpersonal relationships can have an effect on the onset and recurrence of bipolar episodes
i) 30-50% of adults diagnosed report traumatic/abusive experiences in childhood -
associated with earlier onset, higher suicide attempt rates and psychiatric co-morbidity i.e. PTSD
What is the pathophysiology of bipolar?
Various neuroanatomical and fMRI changes i.e. in the amygdala and ventral prefrontal cortex
Dopamine hypothesis
i) Dopamine has been shown to be increased during the manic phase – homeostatic down regulation of dopamine systems i.e. increase in dopamine GPCRs – resulting in decreased dopamine transmission characteristic of depressive phase then repeating of the cycle due to homeostatic (over) correction of dopamine
Other neurotransmitters involved are serotonin and noradrenaline (i.e. too high NAd = mania and vice versa)
What is the presentation of a manic episode?
Elated mood - carefree joviality to almost uncontrollable excitement Increased self-esteem or grandiosity
Decreased need for sleep Increase in goal-direct activity, energy level or irritability
Racing thoughts
Poor attention
Pressure of speech Increased risk taking i.e. spending money, risky sexual behaviours etc
A manic episode must fulfil at least 3 of the above symptoms and last 1-2 weeks, some/significant loss of function must be noted
For depressive symptoms see depression
What are some triggers of a manic episode?
Lack of sleep/early morning waking i.e. due to shift work
Positive life events – may trigger mania
Negative life events – may trigger depressive episode
What are some organic causes of mania?
Endocrine – thyroid, pituitary or adrenal dysfunction
Neurological – MS, CVA, epilepsy, intracranial mass
Drugs – steroids, stimulants, anti-depressives
What are the various diagnoses related to bipolar?
Bipolar affective disorder – F31 - 2x more episodes where patient’s mood and activity levels are significantly disturbed –both hypo/mania and depression
Cyclothymia - hypomanic episodes with periods of depression that do not meet the criteria for major depressive episodes
Rapid cycling (DSM5) - 4 or more episodes of depression and mania in any one year period; can be precipitated by drugs i.e. antidepressants, cannabis
Mania can occur with psychotic symptoms
What is the difference between bipolar I and II?
Is an American classification with DSM5 but shows some merits in some circumstances
I
i) Underlying depression, interspersed with episodes of mania
ii) Requires 1x manic episode and 1x major depressive episode for diagnosis
II
i) Patient has had at least 1x hypomanic episode with mania symptoms (but less severe, i.e. hospitalisation unlikely) but only lasting a number of days and 1x major depressive episode lasting at least 2 weeks - easy to miss but important not to as treatments different
What is the pharmacological management of bipolar?
Acute manic episode
i) Atypical antipsychotic – olanzapine, quetiapine; offer an alternative if intolerable; if this ineffective - can add lithium or valproate
ii) Stop antidepressant
Depressive episode
i) Avoid antidepressants as can cause rapid cycling mood (why correct diagnosis so important)
ii) Atypical antipsychotics e.g. quitiapine
Maintenance
i) Titrate atypical antipsychotics until desired mood level achieved then add lithium – mood stabiliser
ii) Can try adding valproate as 2nd line
Mood diaries are good to keep in order to assess symptom severity etc
What else is relevant to the management of bipolar?
Correct diagnosis is important as treatments for unipolar depression (bipolar 2 often mistaken for if hypomania not obvious) and bipolar are different
Risk management - look for: reckless behaviours, aggression, sexual promiscuity, lack of self care; some patients need admitting during manic phase, even if they feel well
Can assign power of attorney for when you become manic to minimise the effects of the manic episode (e.g. excessive spending)
Recognising early warning signs of mania or depression is useful
i) Patient and family education
Psychological therapies -
less effective than in unipolar depression but can still try high intensity CBT/IPT/behavioural therapy
What is the prognosis of bipolar?
One off manic episode is rare:
50% likelihood within the next year
80% likelihood within the next 4yrs
What is the difference between hypomania and mania?
Hypomania - 4+ days
- elevated mood, euphoric ,angry even
- increased energy
- increased talkativeness
- poor concentration
- mild reckless behaviour ie overspending
- increased libido/sexual dis-inhibition
- increased confidence
- decreased need for sleep
- change in appetite
- if found in community - managed with routine referral to CMHT
Mania - >1wk
- extreme elation - uncontrollable
- over-activity
- pressure of speech
- impaired judgement
- extreme risk taking
- social dis-inhibition
- grandiosity
- psychotic symptoms that are usually mood congruent e.g. auditory hallucinations
What is the mnemonic for manic symptoms?
I DIG FAST Irritability/elevated mood Distractibility Grandiosity Flight of ideas Activity increased Sleep not needed Talkative
