Bipolar Disorders Flashcards
Bipolar disorder 1
At least 1 manic episode with either a hypomanic or depressive episode
Mood is destabilized throughout bipolar episodes and requires hospitalization often
Bipolar 2 disorder
At least 1 hypomanic and 1 current or past depressive episode only.
- there is NO history of manic episodes and NO psychosis
Mood is normally stable throughout the episode
- have suicide risk though and use of antidepressants can send them into a manic episode
Manic episode
At least 1 week of abnormally and persistently elevated/irritable mood
At least 3 of the following are present during this as well as a noticeable change from baseline by others:
- grandiose ideology
- decreased need for sleep (usually only needs 3 hrs)
- excessive talking and interrupting
- flight of disease/racing thoughts
- easily distracted
- clang associations (uses words that rhyme together that doesn’t make sense combined)
- increased goal-directed activity (“throws caution to the wind”)
- engages in risky behaviors (pleasure driven)
requires hospitalization due to seriousness of repercussions and is also not attributable to another illness or substances abuse (stimulants)
**also patients tend to not be able to make social connections or hold jobs since there is severe functional impairments **
Cyclothymic disorder
Mild form of bipolar 2 disorder that lasts greater than 2 years and symptoms being present at least half of the time
- has many or few symptoms of hypomanic episodes, but doesn’t long enough to be called bipolar 2
Remission also must last no more than 2 months (if it occurs)
Epidemiology of bipolar 1
2% lifetime prevalence
Age of onset = usually 20-30s (average = 25)
Increased risk of suicide patients (6-7%)
Possess a comorbidity of some sort
Often possess other functional impairments
Often have a comorbid substance abuse issue
Treatment of bipolar 1 mania
First line medication:
- lithium
- quetiapine
- divalproex
Treatment of bipolar 1 depression
First line therapies:
- quetiapine
Bipolar maintenance (euthymic) treatments
First line therapies
- lithium
- quetiapine
- lamotrigine
Difference between manic and hypomanic episodes
Hypomanic is essentially a mild manic episode where the mood disturbance does NOT cause impairment to social or occupational functioning or need to hospitalization
Also hypomanic = no psychotic features and lasts at least 4 consecutive days and needs at least 3 of DIG FAST
What is the most important symptom of a manic episode (most sensitive)?
Decreased need for sleep
- usually sleeps for less than 3-4 hours
Presentation of inital Bipolar 1 episode that gets diagnosed
Usually presents with depression first (54%)
Then mixed or manic episodes (24% and 22%)
dont assume that someone who doesn’t have mania doesnt have bipolar 1 necessarily
** because of this, it is often that bipolar patients tend to get initially diagnosed with MDD first, then later bipolar 1**
How do you ask for bipolar symptoms
Have you ever had a period of days at a time when you:
- haven’t needed to sleep more than an hour or two a night?
- have you done things recently that are really risky?
- have you started a lot of projects recently?
Mnemonic for bipolar symptoms
“DIG FAST”
- Distractability
- Impulsivity
- Grandiosity
- Flight of ideas
- Activity that is goal driven/Agitation
- Sleeplessness (3ish hrs a night max usually)
- Talkativeness or pressured speech (keeps rambling fast and hard to interject)
Why cant you use just an SSRI in depressive episodes for patients with bipolar 1 or family history of bipolar 1 ?
1) it often wont work
2) it often sends them into a manic episode
Lithium
Is the gold standard mood stabilizer for bipolar disorders
Also treats acute manic episodes and prevents relapse
MOA: unknown but believed to be related to inhibition of phosphoinostol cascade
has very narrow therapeutic index and high toxic risk
ADRs:
- tremors
- thyroid abnormalities (hypothyroidism most often)
- polyuria
- nephrogenic diabetes insipiudes
- teratogenic (ebstein anomaly)
Contraindicated = pregnancy and renal failure/disease
difficult to use with thiazides, NSAIDs due to the entire metabolism of lithium being done through the kidneys and PCTs in the kidneys
Treatment selection
Personal and family history
- if family history has the disease and they are successfully treated, start with the same treatment unless you cant
Medical comorbidities
Patient preference and cost
Route needed to be used
Bipolar 1 clinical pearls
Usually need at least 2 medications for mood stability
Often need to be on for life and need to be managed by a psychiatrist until several years of stability
Need to get collateral and records of past manic events (patients often don’t recall them easily)
Treatment for bipolar 2
First line:
- quetiapine
- lithium
- lamotrigine
Second line:
- venlafaxine
Other causes of hypomania or mania
Substances or medications
- steroids
- cocaine
- methamphetamine
Medical illnesses
- CNS malignancy
- hyperthyroidism
Psychiatric illnesses:
- PMDD
- PTSD
- borderline personality disorder
- generalized anxiety
- intermittent explosive disorder
Bipolar in pregnancy
In pregnancy mood episodes are common (before and after)
CANT use lithium and Depakote in pregnancy or patients who are childbearing age (birth defects)
First-line= quetiapine (in all mood phases with bipolar)
Catatonia
Abnormalities of movement and behavior arising from mental states
- looks Immobile, unable to relax and stupor like
- will not converse with anyone
- retains grasp when you try to shake hand
- doesnt listen to tasks
- also waxy flexibility (sustains abnormal positions if you put them in a position)
Seen in schizophrenia, bipolar and MDD
Best way to test is lorazepam challenge
- give 2 mg of lorazepam and see what happens
- (+) = starts acting normal and/or tries to converse with patient
Treatment = high dose benzos and ECT if needed
