Bipolar dx Flashcards
Bipolar 1 is more common in…
men
Bipolar 2 is more common in…
women
When can bipolar dx onset?
Any age
rf for bipolar dx
- exact cause unknown
- genetics
- NT (dp, nor, sr), gaba
- PFC, hippo, amygdala
- HPtA axis (hypothyroid)
- enviro–fam stress and adverse events
cyclothymic dx
alternate with sx mild-mod dep for 2Y
- rapid cycle possible
Anticonvulsant mood stabilizers
- sodium valproate/divalproex sodium valproic acid
- carbamazapine
- lamotrigine
- gabapentin
When does cyclothymia begin?
In adolescence or early adulthood
Bipolar 1 vs 2
- 1 more severe, highest mort, at least 1 manic episode
- 2 at least 1 hypomanic, at least 1 major dep dx
Bipolar 1 manic ep dx (DSM)
- abnorm or pers elevated irritable mood and goal directed energy for at least 1 wk
- 3+ infl SE, dec need for sleep, more chatty, flight of ideas, distractibility, inc goal-directed activity or psycho agit, excess involve in pleasurable activities with high potential for painful consequences
- marked impairment in social or occup fxn OR psychotic ft
- not caused by sub use, meds, w/d, med condx
BP comorb
anx, SUD
The manic highs mirror the depressive lows in…
depth and intensity
The more manic episodes one has the more…
intense they are
Bipolar 1 dx general
- at least 1 manic ep
- usually recog sx of alt manic w/ major dep episodes (MDE) and/or hypomanic ep
- psychotic ep (delus/halluc) or MDE may be absent over lifetime of the person (unusual)
Clinical features of mania
Distractibility
Indiscretion
Grandiosity
Flight of Ideas
Activity increase
Sleep deficit
Talkativeness
Bx of mania
- mood lability - rapid extreme mood swings, w/ irritability or sudden outburst of misplaced rage
- quick to anger/feels misunderstood/low frus trol
- pacing
- dramatic mannerisms
- uses jokes, puns
- flamboyant or sex suggestive dress
Bipolar 2 dx
- presence of hx of at least one major dep ep or at least one hypomanic ep
- never had a manic ep
- impairment in fxn in at least 1 area
- no psychosis with hypomania but may have with dep
- v impulsive - suicide
Difference in mania btwn 1 or 2
hypomania in 2 is not strong enough to cause marked impairment in social or occup fxn or causes hospitalization
DSM 5 for hypomanic episode
- distinct pd of abnormal and pers elevated, expansive or irritable mood and inc activity or energy lasting at least 4 consecutive days and lasting most of day
- 3+ sx during mood disturbance: infl SE, dec sleep, chatty, flight of ideas, distractible, inc goal directed activity, excess involve in activities with high potential for painful consequences
- chx in fxn
- observable mood and fxn chx by others
- not marked impairment or need hospital
- not from subs or med condx
mixed features
sx dep and mania occur at same time
Rapid cycling
4+ manic episodes for at least 2w in 12M
- partial of full remission for 2M at a time or switch to opp episode
- high risk reccur
- greater severity of illness
Which sx dominate for rapid cycling?
Depressive
Do drugs work on rapid cycling?
Often resistant
hypomanic episode (general)
- episode assoc with definited noticeable chx in fxn unchar for ind
- NOT severe enuf to cause marked impair in social or occup fxn or hospital
- no psychotic ft
- elevated, expansive, or irritable mood for at least 4d
cyclothymic dx
- present for at least 2y in adults (1y kids/adol)
- multiple hypomanic sx but not ep
- dep sx but not dep dx
- sx present over half the time (and not w/o sx for more than 2M at a time)
- fluc hypomanic sx and dep sx
- alt with sx of mild to mod dep for at least 2y (adults)
- rapid cycling possible
Atypical antipsychotics
- risperidone
- quetiapine
- ariprprazole
- olanzapine
Mood stabilizers for acute mania
- lithium plus antipsychotic
- divalproex plus antipsychotic
Why do we avoid just giving antideps for bp?
Can send you into mania
Which med is often given for bp ppl more on the dep side?
Olanzapine and fluoxetine
Possible thought process for bipolar
loose, tangential, flight of ideas, circumstantial
Possible thought content for bp dx
grandiose, paranoid, persecutory delusions
Possible speech for bp dx
pressured, clang, loud, rapid
bp assessments
- danger to self/others
- medical status
- need protection
- coexist med condx
- need hospital
- fam understand
What to teach fam friends of bp person?
s/s relapse
nc for bp dx
- med manage
- dec PA
- inc food/fluids
- 4-6h sleep at night
- meet self-care
- who to call for s/s relapse
- coping and group/ind
What to avoid if bp?
lots caff, alc, drugs, some OTC meds like ephedrine bc they can cause relapse
Meds for full mania
Mood stabilizers, atypical antipsychotics, some BDZs
tx for acute hypomania
lithium
Why is sleep important in bp?
Can prevent a manic episode
atatypical antipsychotics
olanzapine, risperidone, ariprprazole, lurasidone, quetiapine, ziprasidone
Lithium therapeutic range
0.6-1.4
Lithium CI
CVD, renal, brain damage, thy disease, preg/bf mom
Dosing of lithium
- Usually start low and titrate
- onset 5-7d, 2w
- often dose 1200-3000
- often start on Li and antipsych and d/c antipsych after mania is done
Expected SE of lithium
N/V/D, tremor, renal tox, goiter, hypo
- assess levels
- seen <1.5
lithium early tox SE
GI, hand tremor (coarse), confuse, hyperirritable, EEG chx, sedate, incoor
- 1.5-2
What to do if suspect early Li tox
w/h med and get blood level
- reevaluate dose
- start again the next day
Advanced signs of Li tox
ataxia, EEG chx, clonic mvt, lots diluted urine, sz, stupor, severe hypo, coma
- 2-2.5
Risk of death with adv Li tox
death from pulm condx
Tx for adv Li tox
- hospital
- drug stop
- may need bowel irrigation
Severe tox of Li SE
- convuls, oliguira, death
- over 2.5
Tx for severe Li tox
hemodialysis
Lithium NC
- can see inc SI when d/c Li
- don’t restrict Na in diet (maintain normal levels)
- hydrate (esp if sweat)
- if ill and losing fluids, call dr
- intermittent blood tests
Lab monitoring for Li
- 1-2x/w at first
- then monitor creatinine conc, thy hor, CBC q6m
- risk of kidney damage
- thy can dec after 6-18M, watch for dry skin, hair dec, brady, cold intol, constipate
Action of Li
Action unknown
- cross cell membrane, alter Na transport, not protein-bonding
NC for valproate
- check serum levels
- broad spec efficacy
- longer mood stable
Carbamazapine NC
- when Li not work well or 2nd choice
- check serum levels
- risk of low WBCs
- check hepatic/renal fxn
Dangerous sx of carbamazpine
RASH
Topiramate
anticonvulsant mood stabilizer
Gabapentin use
May be effective for acute mania and rapid cycling
Lamotrigine
- used for rapid cycle and dep bp phase or add in refrac mood dx
- can get rash that can lead to SJS
What to do if see rash with lamotrigine
STOP med
Sx of SJS
- flu-like and blister, burn eyes
- toxic epidermal necrosis (top layer of skin separates)
Other tx for bp dx
ECT, team safety, seclusion protocol, support group, health teach
- CBT, interpersonal and social, fam focused (APRN)
ECT for bp dx
- subdues severe manic bx esp in pt with tx-resist mania and pt with rapid cycle
- more effective than drug-based therapy for tx-resist bp dp
- for dep episodes
