Bipolar Affective Disorder (BPAD) Flashcards
ICD10 criteria for a diagnosis of BPAD
ICD 10 requires that the patient must experience “at least two episodes one of which must be hypomanic/manic or mixed, with recovery usually complete between the episodes”.
- Type 1: One or more episodes of full mania +/- an episode of depression
- Type 2: One or more episodes of hypomania with at least one episode of depression (mainly depressive picture)
Point prevalence of BPAD
1.5% in the general population
Prevalence of BPAD on the ward is 2%
Mean age of onset of BPAD and relationship to sex and ethnicity
- Mean age of onset is around 18-21
- No difference in prevalence between sexes or ethnicities
Chance of developing BPAD if a first degree relatie has the same condition?
- 7x more likely to develop condition than in the general population
What is mania. What are its core symptoms? When can a manic episode be diagnosed
Mood must be predominantly elevated, expansive or irritable, and abnormal for the individual concerned. The mood change will be prominent and sustained for at least 1 week (unless they require hospital admission in which case it is automatic)
The core symptoms of mania include elevated mood, energy and enjoyment.
At least three of the following must be seen for diagnosis of a manic episode (must severely interfere with personal functioning):
- Increased talkativeness/ pressured speech
- Flight of ideas
- Increased self-esteem and grandiosity
- Decreased need for sleep
- Distractibility
- Impulsive, reckless behaviour
- Increased sexual drive, sociability or goal-directed activity
What are some cognitive symptoms of mania
- Inflated self-esteem and confidence
- Believe they are gifted, attractive, creative, intelligent and extremely special
- Optimism- ignoring potential pitfalls of their ideas
- Their thoughts and concentration may feel clearer than ever, however, they are objectively distractable with pressure of speech and flight of ideas
What are some biological symptoms of mania
- Reduced sleep
- Increased appetite and libido (often sexually disinhibited) though may be ‘too busy to eat’
What are some psychotic features of mania
are associated with severe mania and are usually mood congruent:
- Hallucinations: typically mood-congruent (e.g celebrities congratulating them)
- Delusions: can be grandiose or persecutory
- Self-neglectct: preoccupation with their own thoughts and extravagant themes and their distractibility may lead to self-neglect, so patients may not eat or drink which results in poor living conditions.
- Catatonic behaviour- manic stupor
- Total loss of insight
How are patients at risk during a manic episode
Patients may disinhibited, at risk of impulsive decision making e.g overspending, gambling, reckless driving, drug and alcohol misuse. May be at risk of exploitation or assault. Irritability can lead to verbal or physical aggression, inciting assault. Self-harm and suicide attempts can occur in moments of sudden despair.
What is hypomania and when can it be classified
Decreased degree of functional impairment compared to mania, all the same symptoms just to a lesser extent. Must last for longer than 4 days
What are some physical causes of mania (‘secondary mania’)
- Organic brain damage (especially right hemisphere) is more common in the elderly.
- Medication: Levo-Dopa and corticosteroids are the most common culprits.
- Illicit drugs: stimulant or other street drugs induced mania if the mood state significantly outlasts the drugged state then a diagnosis of bipolar disorder can be made.
- Hypothyroidism creates a picture akin to depression; in hyperthyroid state one may present as hypomanic or agitated depressed.
Mania differentials
- Organic causes: delirium, intoxication (amphetamines, cocaine), dementia, frontal lobe damage, cerebral infarction, ‘myxoedema madness.’
- Schizoaffective disorder: psychotic and affective symptoms evolve simultaneously
- Emotionally unstable personality disorder: labile mood and impulsivity can mimic mania, but will be persistent traits, not episodic
- ADHD- but ADHD is more persistent and develop earlier (by the age of 6)
Investigations to consider when you suspect mania
- Collateral Hx
- Physical Examination
- Blood tests
- FBC
- TFTs
- CRP + ESR (infection)
- Urine drug screen (UDS)
- CT/MRI brain to exclude intracerebral causes (if indicated by abrupt symptoms, change in consciousness, focal neurological signs)
How can an acute manic or hypomanic episode be treated?
- Stop all medications that may induce symptoms (e.g. anti-depressants, recreational drugs, steroids and dopamine agonists)
- Monitor food and fluid intake to prevent dehydration
- If not currently on treatment: Give an antipsychotic and a short course of benzodiazepines
- If already on treatment: Optimise the medication, check compliance, Adjust doses, Consider adding another medication (e.g. antipsychotic added to mood stabiliser) Short-term benzodiazepines may help
- ECT may be used if patients are unresponsive to medication
How is BPAD managed in the long-term
- Mood stabilisers are the mainstay
- Other medications may be added when new symptoms arise or when facing stress that could precipitate relapse (e.g. antipsychotics or benzodiazepines)
- Depression in BPAD is difficult because antidepressants can cause a switch to mania, to reduce this risk
- Antidepressants should only be given with a mood stabiliser or antipsychotic
- 1st line: fluoxetine + olanzapine/quetiapine
- 2nd line: lamotrigine
- MUST monitor closely for signs of mania and immediately stop antidepressants if signs are present Medication can be
- Medication can be cautiously and slowly withdrawn if someone has been symptom free for a sustained period, otherwise must remain on therapy to avoid risk of relapse
- Psychological treatments: CBTà important for identifying indicators of relapse and developing relapse prevention strategies (e.g routine, avoiding stimulants, drug compliance etc.), Psychodynamic psychotherapy
- Social interventions: Family support and therapy, aiding return to work, interpersonal and social rhythm therapy (works on circadian rhythm, stabilising sleep etc.)
- Support groups: Bipolar UK
What are complications of lithium use
arrhythmia, CKD, Hypothyroidism, also teratogenic so should be avoided in pregnancy unless the mother is at significant risk
