Bipolar Disorder - General Flashcards
What do patients with bipolar disorder suffer from?
Bouts of both depression and mania
Can mania occur without depressive swings?
Yes, though it is far more commonly associated with them (even if sometimes it takes several years for the first depressive episode to occur)
Briefly describe the 4 main differences between hypomania and mania?
Hypomania is shorter lived than mania, involves no psychotic symptoms, has little functional impairment or need for hospitalisation
How can hypomania be differentiated from normal happiness?
Persistence, non-reactivity and social disability
How long should a person’s mood be elevated or irritable to a degree that is definitely abnormal for the individual to be diagnosed with hypomania?
4 consecutive days
How long should a person’s mood be elevated or irritable to a degree that is definitely abnormal for the individual to be diagnosed with mania?
1 week (unless severe enough to require hospitalisation)
How many of the 9 signs of mania must be present for a diagnosis?
3 if the mood is elevated, 4 if the mood is irritable
What 4 signs of mania are different to those seen in hypomania?
Flight of ideas or racing thoughts, loss of normal social inhibitions resulting in inappropriate behaviour, increased self-esteem/grandiosity, reckless behaviour where the individual does not recognise the risks
What 5 signs of mania are similar to those seen in hypomania?
Increased activity, increased talkativeness (pressed speech), decreased need for sleep, distractibility (constant changes in plans) and marked sexual energy
Mania can be further divided based on the presence or absence of what?
Psychosis
What features are common in mania with psychosis?
Delusions and hallucinations (usually grandiose, self-referential, erotic or persecutory)
What are two useful tips to help differentiate mania with psychosis from schizophrenia?
Delusions are not completely impossible or culturally inappropriate, and hallucinations are not third person or giving a running commentary
What is the ICD-10 definition of bipolar disorder?
A disorder characterised by two or more episodes in which the patient’s mood and activity levels are significantly disturbed. This can be mania, hypomania or depression.
Can a single episode of mania or hypomania be diagnosed as bipolar disorder?
Yes (even if the person has never been depressed)
The first episode of mania or hypomania on a background of recurrent depression means what?
The diagnosis has been changed from depression to bipolar disorder and a change in management is needed
Describe bipolar I?
Has to have met the criteria for mania, although previous episodes may have been hypomanic/depressive. Essentially mania + depression.
Describe bipolar II?
Current or past hypomanic episode AND current or past depressive episode, never having met the criteria for a manic episode. Essentially hypomania + depression.
Which is the more common form of bipolar disorder?
Bipolar II
What is rapid cycling?
Frequent mood swings from one state to the other, usually 4 or more episodes in a year
What defines ultra-rapid cycling?
4 or more episodes in a month
What happens in a mixed affective state?
Features of mania and depression are seen within the same episode
What is cyclothymia?
A personality trait with spontaneous mood swings that are not sufficiently severe or persistent to warrant another diagnosis (they are never manic and never depressed but often cycle around milder ends of the spectrum)
Who is cyclothymia often seen in?
The families of those with bipolar disorder
What can the mood be like in mania?
Elevated or irritable
How may cognition be affected in mania?
Disturbance of registration of memories
What are some physical symptoms of mania?
Insomnia, mild-moderate weight loss, increased libido
What are some behavioural changes seen in mania?
Disinhibition, increased sexual energy, excessive drinking or spending
What type of hallucinations are often seen in mania?
Fleeting auditory (internal, stop when the person notices them)
What are some social impacts of mania?
Debts, lost relationships, social exclusion, lost employment
What is the lifetime prevalence of bipolar? What is the sex distribution?
1%, equal male to female ratio
When is the onset of bipolar disorder usually? How does this compare to unipolar depression?
Late teens/early 20s - around 10 years earlier than unipolar depression
Having a family history of bipolar disorder may be of significance how?
Can cause earlier onset, and episodes are precipitated by over levels of stress
Bipolar disorder with onset over the age of 60 is often associated with what 3 things?
Treatment resistance, progressive decline and an underlying organic cause
What are some common co-morbid conditions with bipolar disorder?
Anxiety, substance misuse, personality disorders, eating disorders and schizophrenia
What is the most common mood disturbance in bipolar?
Depression
What is the concordance rate in monozygotic twins of bipolar disorder?
60-80%
What are some differential diagnoses of bipolar disorder?
Acute intoxication, Cushing’s syndrome, use of steroids and dopamine agonists
What factors are important in the choice of medication used to treat acute mania/hypomania?
Clinical judgement, contraindications and prior response
What is the first thing you should always do when treating a manic or hypomanic patient (if necessary)?
Stop anti-depressant medication
What is the first line treatment for acute mania/hypomania? Give examples.
Atypical antipsychotic e.g. olanzapine, risperidone or quetiapine
What are the main options which can be used to treat acute mania/hypomania?
Atypical anti-psychotic, sodium valproate, lithium or carbamazepine
When is sodium valproate a useful treatment for acute mania/hypomania?
When there is hypomania or rapid cycling
Why is lithium use often prohibited as an acute treatment for mania/hypomania when the patient is not already on a mood stabiliser?
Lots of screening is necessary before starting it
If the response to an atypical anti-psychotic in acute mania/hypomania is insufficient, what should you do?
Combine with sodium valproate or lithium
If a patient presents with acute mania/hypomania and is already on an anti-psychotic drug, what is the management?
Check dose and compliance, increase if possible or add valproate or lithium
If a patient presents with acute mania/hypomania and is already on valproate or lithium, what is the management?
Check plasma levels and increase dose if possible, can add an anti-psychotic
All medication in acute mania/hypomania should be given how if possible?
Orally (if not then IM)
In all patients with acute mania/hypomania, what can be given to assist with agitation?
A short acting benzodiazepine
What treatment can be considered for acute mania/hypomania or depression which is life threatening in bipolar disorder?
ECT
In acute bipolar depression, anti-depressants should not be prescribed without what?
An anti-manic drug
In acute bipolar depression, who should anti-depressants be avoided in?
Those with a recent hypomanic episode or history of rapid cycling
What anti-depressant drug class (and specific drug) is the best choice for acute depression in bipolar disorder?
SSRI (particular fluoxetine)
For both acute and chronic bipolar depression, what is the first line treatment?
An atypical anti-psychotic, usually olanzapine or quetiapine
Anti-depressants can be used alongside what other drugs to prevent mania?
Anti-psychotics, lithium or valproate
What is the gold standard maintenance therapy for bipolar disorder?
Lithium
Aside from lithium, what other medications can be used as maintenance therapy for bipolar disorder?
Atypical anti-psychotics (usually olanzapine), sodium valproate or lamotrigine
When is sodium valproate especially useful as a maintenance therapy?
If the patient is primarily manic/hypomanic
When is lamotrigine especially useful as a maintenance therapy?
If the patient is primarily depressed rather than manic
As well as drugs, what other interventions are important in the treatment of bipolar disorder?
Psychoeducation and other psychological therapies
What is the mean duration of a manic episode?
2 months
How many people who have a manic episode will relapse within 10 years?
90%
What are some predictors of a poor outcome in bipolar disorder?
Early onset, low socioeconomic status, long duration, rapid fluctuation, mixed presentation, psychosis, co-morbidities
What is the relationship between bipolar disorder and suicide?
Bipolar carries an increased risk of suicide
