Bipolar and Cyclothymia

Question 1

If a patient has bipolar with psychotic features. . .

Answer 1

. . . they need a mood stabilizer AND an antipsychotic

Question 2

Presentation of bipolar in children

Answer 2

Often presents with a mixed or dysphoric picture characterized by short periods of intense mood lability and irritability.

Alternatively, it is often misdiagnosed as depression, as a major depressive episode often precedes the onset of manic episodes in adolescents with bipolar I.

Question 3

Labile mood

Answer 3

A mood or affect that switches rapidly from one extreme to another

For example, laughing and euphoric one minute, intense anger followed by extreme sadness moments later, often over the course of minutes during an interview

Question 4

Rapid-cycling bipolar disorder

Answer 4

• Occurrence of at least 4 mood episodes (depression or mania/hypomania) within 1 year
  
  • Separated by either a full or partial remisson of at least 2 months duration
  • OR
  • Full switch from one pole to the other (full mania to major depression)

Question 5

Concordance rate of identical vs dizygotic twins for bipolar disorder

Answer 5

Identical: 69%

Dizygotic: 19%

In other words, there is a strong genetic component

Question 6

Diagnostic criteria for manic episode

Answer 6

• Period of abnormally and persistently elevated or irritable mood and increased energy
• Lasts at least 1 week OR any duration if hospitalization is required OR any duration if manic psychosis is present
• 3 or more of the manic symptoms (DIGFAST)
• Must cause impaired functioning
• Not better explained by another dx or substance/medical condition

Question 7

In adolescence, episodes of mania are often accompanied by. . .

Answer 7

. . . psychotic features

Hospitalization is often necessary for these patients

Question 8

When making a diagnosis of bipolar in children or adolescents. . .

Answer 8

. . . at least 1 week of mania and 2 weeks of major depression should be present in the history to ensure accurate diagnosis

Question 9

Major ddx for bipolar I and manic symptoms in children

Answer 9

ADHD in combination with ODD or CD

These patients can present with a pattern of distractability, motor agitation, and impulsive angry outbursts.

Note that bipolar is extremely uncommon in school age children while ADHD and ODD/CD are common at this time.

Question 10

First-line therapies for bipolar without psychotic features

Answer 10

• Mood stabilizers:
  
  • Lithium
  • Divalproex
  • Carbamazepine

OR

• Atypical antipsychotics:
  
  • Risperidone
  • Olanzapine
  • Quetiapine

Question 11

Divalproex and age

Answer 11

Divaporex has well established safety for children younger than age 12, and so it is first-line for bipolar disorder in these patients.

For age 12 or older, lithium is often the drug of choice.

Question 12

All mood stabilizers require. . .

Answer 12

. . . regular monitoring of blood levels

Just like many antiepileptics

Question 13

Monitoring for lithium

Answer 13

Regular blood level of lithium

Thyroid function tests

Kidney function tests

Question 14

Monitoring for carbamazepine

Answer 14

CBC for aplastic anemia or agranulocytosis

Question 15

Before prescribing any mood stabilizer, you should obtain. . .

Answer 15

. . . a pregnancy test (from female patients)

Since they are basically all teratogenic in some way/shape/form

In contrast, atypical antipsychotics for treating mania have no teratogenic effects.

Question 16

Monitoring for divalproex

Answer 16

Liver function tests

Platelet levels

Question 17

“Unmasking” of mania

Answer 17

Many antidepressants are believed to be able to trigger or “unmask” mania

As a consequence, they should be avoided or used carefully in patients with mania. If a patient does start one, they should be carefully observed for emergent manic symptoms.

Question 18

Criteria for a hypomanic episode

Answer 18

• Essentially the same criteria as a manic episode, but shorter duration and less intense
• Elevated, expansive, or irritable mood with increased energy/activity
• Lasts for 4 days or more with 3 or less associated symptoms (DIGFAST)

Question 19

Symptoms for manic episode (mnemonic)

Answer 19

Question 20

Symptoms for major depressive episode (mnemonic)

Answer 20

Question 21

Criteria for major depressive episode

Answer 21

• Depressed mood and/or anhedonia
• Lasts for 2 weeks or more
• With tour or more other associated symptoms (SIGECAPS)

Question 22

Diagnostic criteria for cyclothymia

Answer 22

• Fluctuating hypomanic and depressive symptoms
• Never meeting full criteria for hypomanic, manic, or depressive episodes
• History of at least 2 years for which symptoms are present at least half of the time without any aymptomatic periods > 2 months
• Symptoms lead to significant distress and/or impaired functioning

Question 23

Common medical therapies or drugs of abuse that mimic cyclothymia’s “mood swings”

Answer 23

Steroids

Stimulants

Question 24

“Mixed state” in bipolar disorder

Answer 24

Exhibiting elements of both depression and (hypo)mania

Question 25

The presence of ___ rules out cyclothymia

Answer 25

The presence of psychotic features rules out cyclothymia

Question 26

___ also often presents with mood lability and relationship difficulties and may co-occur with cyclothymic disorder

Answer 26

Borderline personality disorder also often presents with mood lability and relationship difficulties and may co-occur with cyclothymic disorder

Question 27

Medications for cyclothymia are. . .

Answer 27

. . . the same as for run of the mill bipolar

Lithium and valproate are first-line as mood stabilizers. Lamotrigine can be used to address depressive symptoms.

Similarly, anti-depressants should be avoided due to the possibility of inducing (hypo)mania.

Education is a very imporant component for these patients.

Question 28

What do you do if someone fails conventional mood stabilizer therapy for bipolar?

Answer 28

Combination therapy with mood stabilizer and atypical antipsychotic

ex, valproate and quetiapine