Depressive D/os, Bipolar and related d/os Flashcards
Etiology of bipolar disorder
Cause unknown
Significant genetic component- multifactorial
Possibility of multiple biochemical pathways:
-Increase in epi and NE causes mania and decrease in the two causes depression
-Increase in monoamines (dopamine, serotonin, NE)
-Glutamate
Neuro causes:
Decreased activation and diminution of areas that regulate emotions
Increased activation in ventral limbic brain regions that mediate the experience of emotions and generation of emotion
White matter hyperintensities
Dx of bipolar I d/o
Requires the presence of a manic episode of at least 1 wk’s duration or that leads to hospitalization or other significant impairment in occupational or social functioning (episode cannot be caused by another medical illness or by substance abuse)
More details of manic episode
Characterized by elation, irritability, or expansiveness
At least 3 of the following must be present:
-Grandiosity
-Diminished need for sleep
-Excessive talking or pressured speech
-Racing thoughts or flight of ideas
-Clear evidence of distractibility
-Increased level of goal-focused activity at home, at work, or sexually
-Excessive pleasurable activities, often with painful consequences
Hypomanic episode (bipolar II)
Elevated, expansive, or irritable mood of at least 4 consecutive days’ duration
3 of the sx of manic episode must be present
The difference between that and a manic episode is that the episode is not severe enough to cause social or occupational impairment
What is often present in bipolar disorder?
Depression
Major depressive episode
For the same 2 wks, the person experiences 5 or more of the following sx, with at least one of the sx being either a depressed mood or characterized by a loss of pleasure or interest:
-Depressed mood
-Markedly diminished pleasure or interest in nearly all activities
-Significant wt loss or gain or significant loss or increase in appetite
-Hypersomnia or insomnia
-Psychomotor retardation or agitation
-Loss of energy or fatigue
-Feelings of worthlessness or excessive guilt
-Decreased concentration ability or marked indecisiveness
-Preoccupation with death or suicide; pt has a plan or has attempted suicide
Sx cause significant impairment and distress and are not the result of substance abuse or a medical condition
Labwork for bipolar disorders
CBC with diff ESR Fasting glucose level CMP Proteins Thyroid panel Liver and lipid panel ANA Urine copper level VDRL
Other workup for bipolar disorders
EKG
Reasons for inpt management for bipolar d/o
Danger to self Danger to others Delirium Marked psychotic sx Total inability to function Total loss of control Medical conditions that warrant medication monitoring
Considerations for partial hospitalization or day tx for bipolar d/os
Pt experiences severe sx but has some level of control and a stable living environment
4 major goals of outpt tx for bipolar disorders
Look at areas of stress and find ways to handle them
Monitor and support the medication
Develop and maintain the therapeutic alliance
Provide education
Pharmacologic tx for bipolar depression who is not currently being treated with a mood-stabilizing agent
Quetiapine, olanzapine (caution), or lamotrigine, with carbamazepine and lamotrigine as alternatives
Pharmacologic tx for bipolar depression who is already optimally treated with a mood-stabilizing agent
Lamotrigine
Pharm tx for bipolar d/o with severe mania or mixed episodes
Combined therapy with an antipsychotic agent and another antimanic medication
Consider combo of lithium with lamotrigine
Consider adding clozapine for augmentation
Pharm tx for mania/hypomania or mixed episodes
Initiate lithium, valproate, carbamazepine, aripiprazole, olanzapine, quetiapine, risperidone, or ziprasidone
Consider clozapine, haloperidol, or oxcarbazepine in pts with mania or mixed episodes
Consider lithium or quetiapine in those with mixed episodes
When is ECT useful for bipolar d/o?
When rapid, definitive medical/psychiatric tx is needed
When the risks of ECT are less than that of other tx
When d/o is refractory to an adequate trial with appropriate strategies
When pt prefers this tx modality
Diet considerations in bipolar d/o
If on lithium, increased salt intake may lead to reduced serum lithium levels and reduced efficacy
Reduced salt intake may lead to increased levels and toxicity
Pts should be advised not to make significant changes in salt intake
Bipolar with psychotic features
Categorized as mood congruent (in harmony with the mood disorder) or mood incongruent (not in harmony with the mood d/o)
With mood incongruent category, consider schizoaffective d/o or schizophrenia
Bipolar with melancholic features
Characterized by severe anhedonia, early morning awakening, wt loss, and profound feelings of guilt
Common to have suicidal ideation
Bipolar with atypical features
Categorized mainly by two specific, predictable characteristics: overeating and oversleeping
Tend to have younger age of onset, more severe psychomotor slowing, and more frequent coexisting diagnoses of panic d/o, substance abuse or dependence, and somatization d/o
Bipolar with catatonic features
Hallmark sx: Stuporousness Blunted affect Extreme withdrawal Negativism Marked psychomotor retardation
Postpartum onset
Within 4 wks postpartum
