Bipolar

Question 1

What is the minimum duration of a manic episode according to ICD-10?

Answer 1

At least 1 week, or any duration if hospitalization is required.

Question 2

What is the core mood feature required for a manic episode in ICD-10?

Answer 2

Abnormally elevated, expansive, or irritable mood clearly abnormal for the individual.

Question 3

How many symptoms are required to diagnose a manic episode in ICD-10?

Answer 3

At least 3, or 4 if the mood is only irritable

Question 4

associated symptoms of mania in ICD-10.

Answer 4

D - Distractibility or constant changes in activity or plans
I - inpulsivity such as overspending, reckless driving, or foolish business investments
G - Grandiosity - Inflated self-esteem or grandiosity

F - Flight of ideas or subjective experience of racing thoughts
A - activity increase
S - sleep deficit
T - talkativeness

Loss of normal social inhibitions, resulting in inappropriate behavior
Marked sexual energy or sexual indiscretions

Question 5

What is required in terms of functional impact in ICD-10 mania?

Answer 5

Significant disruption to work/social life, hospitalization, or psychotic features.

Question 6

What are the exclusion criteria for ICD-10 mania?

Answer 6

Not due to substance use, medications, or a general medical condition.

Question 7

Icd 11 differences of mania

Answer 7

Duration - several days, typically at least one week

Question 8

What is the minimum duration for hypomania in ICD-10?

Answer 8

At least 4 consecutive days.

Question 9

How many symptoms are required for ICD-10 hypomania?

Answer 9

At least 4 consecutive days.

Question 10

How many symptoms are required for ICD-10 hypomania?

Answer 10

3 or more (4 if mood is only irritable).

Question 11

Can psychotic symptoms occur in hypomania per ICD-10?

Answer 11

No, psychotic symptoms exclude the diagnosis.

Question 12

Functional impact of hypomania

Answer 12

No severe impairment in social or occupational functioning,

No psychotic symptoms,

Hospitalization not required.

Question 13

Risk assessment of BPAD

Answer 13

🔴 1. Risk of Suicide

High during depressive episodes and mixed states

Increased risk if:

History of suicide attempts or self-harm

Feelings of hopelessness or worthlessness

Comorbid substance misuse

Poor insight into illness

Recent discharge from psychiatric care

🔴 2. Risk of Harm to Others

More likely in manic or psychotic states

Can result from:

Irritability or aggression

Grandiose or persecutory delusions

Poor impulse control

🔴 3. Risk to Physical Health

Poor self-care during episodes

Side effects of medications (e.g., lithium toxicity)

Comorbid conditions (e.g., obesity, diabetes, cardiovascular disease)

Substance misuse (common in BPAD)

🔴 4. Risk of Non-Adherence to Treatment

Often due to:

Poor insight during manic episodes

Side effects of medications

Distrust of services or denial of illness

🔴 5. Risk to Social and Occupational Functioning

Relationship breakdowns

Job loss or financial problems

Legal issues (e.g., during manic episodes)

Question 14

Admission criteria

Answer 14

1. High risk of suicide of homicide
2. Endangering relationships, reputation, assets
3. Poor adherence
   Lack of psychosocial support
   Severe psychotic symptoms
   Severe depressive symptoms
   Severe mixed state or rapid cycling
   Catatonic
   Comorbidities

Question 15

Acute manic episode management

Answer 15

🔹 First-line options:

Atypical antipsychotic (monotherapy):

e.g. Olanzapine, Risperidone, Quetiapine, or Haloperidol

🔹 If symptoms are severe or response is inadequate:

Add lithium to the antipsychotic

Alternatively, valproate may be used if lithium is unsuitable

Question 16

Acute depression

Answer 16

🔹 First-line:

Fluoxetine + Olanzapine combination
OR

Quetiapine monotherapy
OR

Olanzapine monotherapy

🔹 Alternatives:

Lamotrigine (especially for bipolar II depression)

Valproate (less preferred, especially in women of childbearing age)

> ⚠️ Do NOT prescribe antidepressant monotherapy due to risk of switching to mania

Question 17

What is the mechanism of action of lithium in mood disorders?

Answer 17

Lithium modulates neurotransmission via effects on second messenger systems (e.g., inhibits inositol monophosphatase and GSK-3), leading to neuroprotective and mood-stabilising effects.

Question 18

Which drugs commonly interact with lithium and increase its toxicity risk?

Answer 18

NSAIDs (e.g., ibuprofen)

ACE inhibitors

Thiazide diuretics

Some antibiotics (e.g., tetracyclines, metronidazole)

Ssri

Methyldopa

Haloperidol

CCBs

Question 19

What are the common side effects of lithium?

Answer 19

Tremor

Polyuria/polydipsia (nephrogenic diabetes insipidus)

Weight gain

Hypothyroidism

GI upset

Metallic taste

Question 20

What teratogenic effects are associated with lithium use in pregnancy?

Answer 20

Lithium is associated with Ebstein’s anomaly (a rare congenital heart defect) when used in the first trimester.
NICE recommends avoiding lithium during early pregnancy unless essential

Question 21

What are the signs of lithium toxicity?

Answer 21

GI: nausea, vomiting, diarrhoea

CNS: coarse tremor, confusion, ataxia, dysarthria

Severe: seizures, coma, death

Question 22

How is lithium toxicity managed?

Answer 22

Stop lithium immediately

Forced diuresis with NS

Check serum lithium level, renal function, ECG

Supportive care

Dialysis if severe (e.g., level >2.5 mmol/L or severe neurotoxicity)

Question 23

Ix prior to Li

Answer 23

Physical
FBC
UNE
TFT
baseline bmi
Ecg
Preg test

Question 24

Li dosing

Answer 24

400 - 600 starting
Max 2 g
Usual 800 - 1.2

Question 25

What monitoring is required for a patient on lithium therapy?

Answer 25

🔹 Before starting: Renal function (U&E, eGFR) Thyroid function (TSH, T4) Baseline weight and BMI ECG if >40 years or cardiac risk Pregnancy test in women of childbearing potential 🔹 Lithium level monitoring: Target level: 0.6–0.8 mmol/L (maintenance) 0.8–1.0 mmol/L (if relapse risk is high) Timing: 12 hours post-dose (“trough” level) Weekly until stable, then every 3 months Renal n thyroid function: Every 6 months 🔹 Weight/BMI: Every 6 months

Question 26

What key points should be included when counselling a patient starting lithium?

Answer 26

✅ Purpose: Explain that lithium is a mood stabiliser used to prevent mood episodes in bipolar disorder. ✅ Dosing: Take regularly at the same time each day. Avoid missing doses or sudden discontinuation. ✅ Monitoring: Regular blood tests to monitor lithium level, kidney, and thyroid function. Levels must be done 12 hours after the last dose. ✅ Signs of toxicity: Warn to report: Nausea, vomiting, diarrhoea Tremor Confusion, drowsiness Muscle weakness or unsteady gait ✅ Drug & diet interactions: Avoid NSAIDs, ACE inhibitors, and diuretics unless advised. Keep salt intake stable – sudden reduction increases lithium levels. Stay well hydrated, especially in hot weather or illness. ✅ Pregnancy and contraception: Lithium can cause birth defects; discuss contraception. Notify healthcare providers immediately if planning pregnancy.