Psych - Bipolar Affective Disorder

Question 1

What is bipolar affective disorder? Distinguish between the ICD10 and DSM classifications

Answer 1

-Recurrent episodes of altered mood and activity, involving both upswings and downswings with individual episodes and/or patterns of recurrence (depending on classification used)

ICD 10: need at least 2 episodes, including at least one hypomanic or manic

DSM:

• Bipolar I disorder: one or more manic or mixed episodes, and usually one or more major depressive episode
• Bipolar II: recurrent major depressive and hypomanic but not manic episodes
• Cyclothymic disorder: chronic mood fluctuation over at least 2 years, with episodes of depression and hypomania (but not mania) of insufficient severity to meet diagnostic criteria

Question 2

What types of individual episodes are there?

Answer 2

• Depressive
• Manic
• Hypomanic (less severe than manic and absence of psychotic sx)
• Mixed: features of both mania and major are present or alternate rapidly

Question 3

What is the difference between mani and hypomania?

Answer 3

• Both terms relate to abnormally elevated mood or irritability
• Mania: severe functional impairment or presence of psychotic sx (delusions of grandeur, auditory hallucinations), lasts for >7 days
• Hypomania: describes increased or decreased function for 4 days or more

Question 5

Name some cardinal and associated features of bipolar affective disorder

Answer 5

-Cardinal features: alteration in mood - usually elated/expansive but can be characterised by intense irritability

Associated features

• Increased psychomotor activity (distractibility, decreased sleep)
• Exaggerated optimism
• Inflated self esteem
• Decreased social inhibition: sexual over-activity, reckless spending, dangerous driving, inappropriate business/religious/political initiatives
• Heightened sensory awareness
• Rapid thinking/speech
• in manic patients: mood congruent delusions and hallucinations - eg of grandeur or of very depressive themes
• Absence insight (but less so in hypomania, where people can still function relatively normally for a period of time)

Question 6

What is the differential diagnosis for bipolar affective disorder?

Answer 6

• Substance abuse: amphetamines or cocaine
• Mood abnormalities: 2nd to endocrine disturbance (idiopathic cushing’d or steroid induced psychoses/epilepsy)
• Schizophrenia: will present with more paranoid/reference delusions but both can have increased psychomotor activity
• Schizoaffective disorder: when affective and schizophrenic sx are equally resent
• Personality disorders (emotionally unstable or histrionic)
• ADHD (younger pts)

Question 7

What are the treatment principles for B.A.D?

Answer 7

• Coordinated care program based on early detection of deterioration
• Tx is mainly based on psychotropic medication in order to reduce the severity of sx, stabilise mood and prevent relapse.
• Address co-morbidities: significantly increased risk of DM, CVS disease and COPD

Question 8

How would you treat depressive episodes in a patient with B.A.D.?

Answer 8

• Treated in same way as unipolar depression but have to remember that anti-depressants precipitate mania (or ‘rapid cycling’) - t/f should always be co-prescribed with an anti-manic/mood stabilising agent
• Fluoxetine is 1st line
• Stop antidepressant if patient has onset of acute or manic episode

Question 9

How would you manage the mania/maintenance aspect of B.A.D?

Answer 9

Mood stabilisers:

• Lithium: mood stabiliser of choice (decreases deaths by suicide in these patients),
• Others: Na Valproate, carbamazepine and lamotrigine (never in women of reproductive age)

Management of mania:

• stop anti-depressant and initiate/continue antipsychotic (usually an atypical)
• Olanzapine, risperidone, zuclopenthixol, quetiapine, aripiprazole