Bipolar - Yr 4

Question 1

define bipolar 1

Answer 1

bipolar 1 disorder is defined as one or more manic or mixed (signs of mania and depression) episodes.

Question 2

Bipolar 2

Answer 2

bipolar 2 is defined as a depressive episode with at least one episode of hypomania (this is shorter lived than mania and is not accompanied by psychotic symptoms). Hypomania is noticeably abnormal but does not result in functional impairment or hospitalisation.

Question 3

Bipolar III

Answer 3

Bipolar III disorder describes depressive episodes with hypomania occurring only when taking an antidepressant

Question 4

What is the main characteristic of manic episodes

Answer 4

manic episodes:

• elated mood (persistent, out of context, can be extreme, ecstatic or euphoric.
• increased energy / activity
• increased speech
• expansive ideas ( start new projects, grandiose ideas acted upon, disinhibition, impulsive and risky behaviour, spending money)
• Psychotic symptoms (delusions, hallucinations, grandiose delusions - may believe they have superhuman powers, important, wealthy etc., auditory hallucinations unusual - but in 2nd person.)
• cognitive state (impaired attention and concentration)

Question 5

What is the lifetime risk of bipolar?

Answer 5

lifetime risk of bipolar is less than 1%

Question 6

what is the male to female ratio of bipolar?

Answer 6

female 1.5 : male 1

Question 7

A patient undergoing a manic episode of Bipolar may show symptoms of increased speech - describe how this may present

Answer 7

• pressure of speech
• increased rate
• increased volume
• associated flight of ideas
• puns and rhymes may be used to connect thoughts.

Question 8

A patient undergoing a manic episode of bipolar may show signs of expansive ideas - describe how this may present.

Answer 8

• patients feel energetic, optimistic with good ideas.
• many projects may be started but unfinished
• poor judgement
• grandiose ideas acted upon with disastrous consequences.
• impulsive/risky behaviour e.g. increased/irresponsible money spending.
• disinhibited behaviour e.g. stripping in public.

Question 9

What psychotic symptoms may be present in a patient who is having a manic episode of bipolar disorder?

Answer 9

• delusions (mood congruent so if irritable then may have persecutory delusions, if elated then grandiose delusions)
• hallucinations
• grandiose delusions (believe they have superhuman powers, are very important etc.)
• Auditory hallucinations are uncommon but are usually in 2nd person and reflect the mood and grandiosity.

Question 10

What cognitive state may a patient with manic bipolar disorder have?

Answer 10

attention and concentration are impaired

Question 11

What are the physical symptoms of a manic episode of bipolar?

Answer 11

• reduced sleep
• high activity day and night
• increased appetite (however do not gain weight due to high activity)
• *some patients may experience weightloss because they are too active to prepare food,
• increased sex drive (sexual disinhibition and promiscuity)

Question 12

What are the predisposing and precitipating factors for bipolar disorder?

Answer 12

Predisposing:
- family history

Precipitating:

• severe stresses or significant life events.
• (increased risk of manic events in postpartum period)

Question 13

what is the average age of onset for bipolar disorder?

Answer 13

20 yrs

Question 14

What are some biological causes of mania?

Answer 14

Biological:

• cerebral neoplasms, infarcts, tumour, infection .
• cushing’s disease
• huntington’s disease
• hyperthyroidism
• multiple sclerosis
• renal failure
• SLE
• temporal lobe epilepsy
• B12 and niacin deficiency

Question 15

What substances can be the cause of a manic episode?

Answer 15

• amfetamines
• anticholinergics
• antidepressants
• antiviral drug
• antimalarials
• captopril (ACE inhibitor)
• cimetidine (H2 receptor antagonist)
  -Cocaine
• Corticosteroids
• Hallucinogens
• ## Levodopa

Question 16

list some differential diagnosis for a patient presenting with elevated or irritable mood.

Answer 16

Mood disorders:

• hypomania, mania, mixed affective disorder
• bipolar affective disorder
• cyclothymia
• depression (may present with irritable mood)

Secondary to physical condition
Secondary to psychoactive substance abuse

Psychotic disorders:

• schizophrenia
• Schizoaffective disorder

Personality disorders
Delirium / dementia

Question 17

What is the criteria for bipolar affective disorder?

Answer 17

1 episode of mania AND 1 or more episodes of either mania or depression

Question 18

What is the acute management of mania?

Answer 18

• it can be difficult to treat mania in the community due to the patient’s lack of insight, chaotic lifestyle & overactivity.
• hospital admission may be necessary under MHA.
• stop antidepressants
• Antipsychotics e.g. haloperidol, olanzapine, quetiapine or risperidone (oral or IM ) useful as they have a calming effect (given even when no psychotic symptoms present)
• benzodiazepine: a short course could help for extreme agitation.
• Lithium can also be added but it takes longer than antipsychotics to work (usually introduced in long term management)
• try valproate if lithium not tolerated
• ECT for severe or catatonic cases

Question 19

describe how a patient with bipolar depression may be managed in secondary care?

Answer 19

1) psychological intervention e.g CBT, IPT, BCT
2) Try fluoxetine combined with olanzipine or add quetiapine. or try lamotrigine on its own.
3) if this patient is already on Lithium. Try increasing dose. Or adding fluoxetine combined with olanzapine; quetiapine or lamotrigine to lithium.
4) If patient is already on valproate. Try increasing does. Or adding meds listed above.

Question 20

Describe how to manage a patient with bipolar affective disorder in the longer term in secondary care.

Answer 20

1) Explain and discuss what bipolar is and the long term treatment.
2) Psychological interventions. Offer family, as well as individual and group structured interventions.
3) Pharmacological interventions. Lithium (1st line) and/or valproate, or olanzapine.

Question 21

• OSCE * Practice describing / explaining the nature and variable course of bipolar disorder to a patient.

Answer 21

1) What is bipolar?
- Bipolar disorder is a condition that affects your moods, which can swing from one extreme to another.
- People with bipolar disorder have periods or episodes of depression (feeling very low and lethargic) and mania (feeling very high and overactive).

2) How long does it last?
- Unlike simple mood swings, each extreme episode of bipolar disorder can last for several weeks (or even longer).
- Between episodes of depression and mania, you may sometimes have periods where you have a “normal” mood.

3) depressed symptoms:
- feeling low and irritable
- loss of interest
- no energy

4) Mania symptoms:
- feeling very elated
- lots of energy, not sleeping as much.
- having lots of new ideas and making big plans
- spending money

5) Psychosis:
- During episodes of mania and depression, someone with bipolar disorder may experience strange sensations, such as seeing, hearing or smelling things that aren’t there (hallucinations).

• They may also believe things that seem irrational to other people (delusions).

Question 22

what is the course and prognosis of bipolar?

Answer 22

• most patients who have a manic episode will have recurrent BPAD.
• recovery from episodes is good with treatment
• relapse is high without prophylaxis
• suicide rate = 10%