Mania + BAD

Question 1

What is mania?

Answer 1

Essentially opposing symptoms of depression - at least 1 week (up to 4 months)

10% of patients w/ depression –> mania (bipolar)

Question 2

ICD-10 criteria for mania?

Answer 2

Elated, irritable (80%), labile mood
Hyper activity/increased energy levels
Poor concentration, distractibility
Reduced sleep
Increased self-esteem (grandiosity)
Disinhibition/overfamiliarity
Reckless/impulsive behaviour
Increased sex drive
Flight of ideas/ racing thoughts

Question 3

Other symptoms of mania?

Answer 3

rapid, pressured or rhyming speech

Stupor (unresponsive, akinetic/mute)

Question 4

What type of psychotic symptoms can manic patients experience?

Answer 4

Delusions (48%) - usually grandiose

Hallucinations (15%) - auditory

Question 5

Hypomania clinical presentation?

Answer 5

Persistent mild elevated mood for a few days
Feeling of wellbeing, increased energy, elation and efficiency
Nb. no impairment of social function

Question 6

What differentiates hypomania from mania?

Answer 6

Psychotic symptoms - present in mania, not in hypomania

Question 7

Acute management of mania?

Answer 7

1. Anti-psychotic (olanzapine PO)

2. Mood stabiliser (valproate PO)

Question 8

Prophylaxis for mania?

Answer 8

Lithium

Question 9

Prognosis of mania?

Answer 9

90% will have another manic/depressive episode

10% will commit suicide

Question 10

MSE appearance and behaviour for a manic patient?

Answer 10

Appearance - flamboyant clothing, sunglasses, hats, heavy make-up and jewellery

Behaviour - hyperactive, entertaining, flirtatious, hyper-vigilant, assertive, aggressive, impulsive, pleasure-seeking, disinhibited

Question 11

MSE Speech and mood for a manic patient?

Answer 11

Speech - pressure of speech, neologisms, clang-associations

Mood - elated, irritable/tearful, labile

Question 12

Thought form/content for a manic patient?

Answer 12

Optimistic, self-confident, grandiose

Pressure of thought/speech, flight of ideas, loosening of associations

Circumstantiality, tangentiality

Mood congruent (rarely incongruent) delusions

Question 13

Risk factors for BAD?

Answer 13

Drug abuse (cannabis), severe stress, disruption of daily routine, circadian rhythms, higher social class

genetics - first degree relative (=10% risk of BAD), depression, schizoaffective disorder

Monoamine theory - mania due to increased levels of NA, serotonin and dopamine

Question 14

Diagnosis of BAD?

Answer 14

> 2 episodes of depression +mania/hypomania or recurrent episode of mania

20% cases present with first rank psychotic symptoms

Question 15

Types of BAD?

Answer 15

Rapid cycling - >4 episodes of mania, hypomania +/- depression within 1 year

Cyclothymia - mild, chronic BAD

Question 16

Investigations for BAD?

Answer 16

FBC, LFTs, U+Es, TFTs, ESR\
Serum +/- Urine test for drugs
Pregnancy test

Question 17

Management of BAD?

Answer 17

1st line = Lithium
Psychotic symptoms - give A/P - olanzapine
For depressive episodes give A/P (e.g. citalopram) +/- lithium (to avoid manic switch)

Question 18

What management can be used it lithium is CI?

Answer 18

Olanzapine + fluoxetine
or
Lamotrigine (anti epileptic) + citalopram

Question 19

What drugs, other than lithium, can be used as mood stabilisers?

Answer 19

All have S.E of nausea

2nd line = Valproate (quicker onset than lithium and particularly useful in rapid cycling BAD) - CI in pregnancy

2nd line = lamotrigine (better tolerated than lithium) - relapses of depression or prophylaxis of BAD - fewer S.E. (N+V, and head symptoms - dizzy, headache etc.)

2nd or 3rd line = Carbamazepine

Question 20

S.E. of valproate?

Answer 20

Nausea, tremor, sedation, wt gain, alopecia