Lecture 29 - Mood D/o: Bipolar D/o

Question 1

5 categories of thought processes: which are normal, which are abn?
describe them

Answer 1

Goal Directed
tangential
Circumstantial

Abn:
Flight of ideas – patient doesn’t answer the directed question, jumps from topic to topic, but topics are connected

Loose associations – patient doesn’t answer question and no connections between topics. Manic or psychotic patients

Question 2

DSM Criteria for Manic Episode

duration
symptoms

Answer 2

at least 1 week

Elevated mood + 3 symptoms
Irritable mood + 4 symptoms
w/ increased activity or energy

Symptoms: DIG FAST
Distractable
Irresponsbility – risky behavior; hedonistic
Grandiosity –
Flight of ideas
Activity – incresaed goal directed activity; agitation
Sleep – decreased need for; only sleeps 2 hours/night
Talkative – pressured speech

MAY BE PSYCHOTIC

Question 3

DSM criteria for hypomanic episode

duration
Symptoms

Answer 3

at least 4 days of symptoms
mood disturbance does not cause marked impairemnt in social/occupational function.
NO PSYCHOTIC FEATURES

DIG FAST

Question 4

BP with…Mixed features of mania/hypomania – duration?

Answer 4

at least 1 week

Question 5

what classisfies a rapid cycler?

EPI
prognosis

Answer 5

Bipolar I or II disorder in which 4 or more mood episodes occur in a year

usually BP2
70-90% females
worse prognosis overall

Question 6

Things to rule out before making BP diagnosis?

Answer 6

Substance use – cocaine in the past month;
Heroin – can look like depression
Heroin withdrawal – anxiety, hypoamania
ETOH withdrawl – anxiety, mania, hypomania, psychosis

co morbid conditions – hyperthyroid, partial sz, MS, SLE, delirium, head trauma, cushing’s

Medication side effects – antidepresants (trigger mania), prednisone, stimulants, dopaminergic agents

personality do

Secondary gain

Question 7

BP 1 –

general EPI

Answer 7

.6% of the population
Men=Women
18 yo = median age of onset (rare after 50 yo)

Question 8

BP1
Clinical course

depression or mania first?
mean mood episodes per lifetime?

Answer 8

depression before mania for most patients

Untreated mania – 3 months
Untreated depression - 6 to 12 months

9 mood episodes per lifetime

Question 9

BP1
suicide attempts %?
Suicde completion %?

when is the highest risk for suicide?

co- morbidities

Genetics

Answer 9

36% of patients attempt suicide
10-19% suicide completion rate
Highest risk is transmission to dep

Substance use, anxiety, alcohol use

10-fold increased risk of BPAD in relatives of patients with BPAD I or II
50% of all Bipolar patients have at least one parent with a mood d/o

Question 10

Main difference between BP 1 and BP 2 ?

Answer 10

BP1 – manic episodes, euthymia +/- dysthemia

BP2 – hypomanic episodes +/- dysthemia; no psychosis

Question 11

BP2 –
EPI – % of pop; age of onset compared to BP1
what’s more common: hypomanic or depressive episodes?
co-morbidities

Answer 11

8% of the US;
○ Age of onset 20 yo (slightly later than BP1)
• Clinical Course —12% of patients initially dx with MDD; some may become BP1
○ Depressive episodes more common than hypomanics
• Co morbidities – anxiety, substance use, eating d/o

Question 12

Suicide in BP2:
% attempt?
lethality higher or lower than BP1

Answer 12

1/3 of patients attempt; lethality is HIGHER than BP1

Question 13

Cyclothymic Disorder –
describe it
duration

Answer 13

Patients with cyclothymia have hypomanic periods and dysthymic periods, but never have symptoms severe enough to meet criteria for either mania, hypomania, or major depression (cycling between the abn mood phases)

Sxs last for >2 yrs, without going for more than 2 months sx-free

Question 14

Cyclothymic Disorder –
EPI – gen pop?
Co-morbidities

Answer 14

.4-1% of the gen pop; males = females;

○ Co morbidities – BPD, substance use;

Question 15

Treatment of Acute mania –

methods of treatment:

Go to drug

Goals of treatment:

Answer 15

hospitalization

methods: Mood stabilizers (lithium, valproate)

Antipsyhcotics –

Benzos

Sleep, decrease disorganization, prevent dangerous behavior, education family and patient

Question 16

Treatment of bp depression –
– what must be considered in terms of drugs use to treat?

go to drug

other therapies?

Answer 16

If you treat the patient with only an antidepressant and no mood stabilizer, you may precipitate a manic episode

Lithium
Lamotrigine

ECT

Question 17

what is the treatment of choice for BP?

what % of patients repsond?

Answer 17

Lithium

60-70% respond to this

Question 18

Name 3 mood stabilizers?

Answer 18

Lithium
Valproate
Carbamazepine

Question 19

Lithium–
pregnancy considerations?
other side effects
interaction with…

Answer 19

Pregnancy D – can lead to Ebsteins anomaly (tricuspid valve malformation); However this may be over-reported and therefore still given to females

SE: Nausea, diarrhea, EKG Changes, Thyroid abn, Tremor, Poyldipsia/polyuria, Diabetes Insipidus,

Ibuprogen – can increase the lithium level by interfering with renal clearance

Question 20

Valproic Acid
== more effective for which type of BP?
-- birth considerations
--side effects
--interactions

Answer 20

more effective for rapid cyclers and mixed states

		§ Teratogen: High risk for birth defects -- women need to be on documented birth control 
		§ Side effects -- Nausea, diarrhea, tremor, sedation, weight gain, 
			□ Rare -Thrombocytopenia, hepatotoxicity 
		§ Interactions/Metabolism -- p450s

Question 21

Carbamazepine

– birth considerations –
interactions –
Not good for…

Answer 21

– teratogen: patient must be on birth control

But also interactions with OCP and decreases this serum level
Interactions with other P450s

Not good for bp depression

Question 22

Carbamazepine

mechanism

side effects:

Answer 22

Inhibits voltage-dependent sodium channels
Inhibits presynaptic sodium channels

SE: nausea, atxia, sedation,
SIADH