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Flashcards in Bipolar Deck (23):
1

Bipolar 1 disorder criteria

1. One manic episode->May have been preceded or followed by hypomanic or major depressive episode
2. The occurrence of mania/depression is not better explained by schizoA, schizophrenia, schizophreniform, delusional or other unspecified schizophrenia spectrum/psychosis

2

Bipolar 2 criteria

1. Current or past hypomanic and current/past major depressive episode
2. There has never been a manic episode
3. Episodes not better explained by another schizo/psychosis

3

Criteria for manic episode (A, B7, C, D)

A. Distinct period of abnormally ++mood/expansile or irritable with ++goal oriented activity, present for at least a week, for most of the day nearly every day
B. 3 + of the following during change present to a significant degree
1. Inflated self esteem, grandiosity
2. Decreased need for sleep
3. More talkative, pressured speech
4. Flight of ideas, subjective experience thoughts racing
5. Distractability
6. +Goal oriented activity
7. Excess involvement in activities with potential for painful consequences
C. Mood disturbance significant enough to cause marked impairment in function
D. Not attributable to anything else

4

Criteria for hypomanic episode

A. Distinct period of abnormally ++mood/expansile or irritable with ++goal oriented activity, present for 4 consequetive days, for most of the day nearly every day
B. 3 + of the following during change present to a significant degree
1. Inflated self esteem, grandiosity
2. Decreased need for sleep
3. More talkative, pressured speech
4. Flight of ideas, subjective experience thoughts racing
5. Distractability
6. +Goal oriented activity
7. Excess involvement in activities with potential for painful consequences
C. Unequivocal change in function that is uncharacteristic
D. Change in functioning observable by others
E. Episode not severe enough to cause marked impairment to necessitate hospitalisation, if there is psychosis= mania
F. Not due to psychological effects of a substance

5

Criteria for major depressive episode

A. 5+ symptoms in same 2 week period, change from previous, at least one depressed mood or loss of pleasure/interest
1. Depressed mood nearly all day every day
2. Loss of interest pleasure
3. Insomnia/hypersomnia
4. Appetite/weight loss
5. Concentration
6. Loss of energy
7. Feelings of worthlessness/++inappropriate guilt
8. Psychomotor agitation/retardation
9. Recurrent thoughts of deatj/suicide
B Significant distress/impairment
C. Not attributable to psychological effects of medication/other medical consition

6

Sub-categories of bipolar

classified as without psychotic features, with
psychotic features, with catatonic features, with postpartum onset, with seasonal pattern, with
rapid cycling (at least 4 episodes of a mood disturbance in the previous 12 months)

7

Treatment overview

1. Pharmalogical:lithium, anticonvulsants, antipsychotics, antidepressants, ECT
2. Psychological: supportive psychodynamic psychotherapy, CBT, ITP
3. Social: vocational rehabilitation, leave of abscence, substitute decision maker for finances, alcohol and drug cessation, social skills training, education for family

8

Course and prognosis

High suicide 15%
Relapsing and remitting->depressive episodes seem to last longer
90% recurrence of mania within 5 years

9

Highest risk of suicide

When switching from mani episode to depression, especially when realisae consequences of actions while manic

10

Etiology

1. Genetic->69% concordance in monozygotic twins
2. Neurotransmitters->+Serotonin, NE, dopamine in mania, reduction in depression
3. PsychoD->mania serves as defense for depression
4. Neuroanatomical: +activation of cortical-cognition, +ventral limbic
5. Environmental->stressors

11

Common causes of manic relapse

1. Treatment non-adherence
2. Life stressors
3. Substance misuse
4. Anti-depressant use
5. Medication below therapeutic levels

12

Management of acute mania

1. Admission
2. Risperidone or olanzapine (second line= second generation, carbamazepine, valproate)

13

Management when treatment resistant acute mania

1. Admission
2. ensure that maximum tolerable drug concentration has been achieved.
3. switch to a different drug (eg from a second-generation antipsychotic to lithium)
4. combine drugs (eg a second-generation antipsychotic plus lithium)
5. electroconvulsive therapy (ECT)—this is a proven treatment for mania and may be extremely effective even when patients fail to respond to one or more antimanic drugs

14

Overview of prophylaxis for bipolar

1. Following acute mania, treatment for at least 12 months. May be required long term
2. Broad treatment approach->psychological, social, employment
3. Manage comorbidities->including substance
4. Maintain physical health
5. Work with families and carers

15

Pharmacological options for prophylaxis

1. Lithium
1. Second-generation antipsychotic
1. Lamotrogine

16

Differential diagnoses for elevated or irritable mood

1. Mood disorders
Mania, mixed, bipolar
Depression with irritable mood
2. General medical condition
3. Substance
4. SchizoA/Schizophrenia
5. Personality/developmental
6. Delirium/dementia

17

Medical conditions causes of mania

Cerebral neoplasms, infarcts, trauma
Cushing's
Huntington's
Hyperthyroid
MS
Renal failure
SLE
Temporal lobe epilepsy
Vitain B 12 deficiency

18

Substance causes of mani

Amphetamine
Cocaine
Hallucinogens
Legal high

Anabolic steroids
Antidepressant
Corticosterois
Dopaminergic->L dope, bromocriptine

19

Comparison b/w mania and schizoP->thought form, delusions, speech, biological, psychomotor

1. Mania
Circumstantial, tangential, FOI
Mood congruent delusions
Pressured speech
-ve need for sleep, +energy
Agitation

2. SchizoP
LOA, neologisms, thought bloking
Unrelated to mood, passivity, insertion, withdrawal
Hesitant, halting
Sleep less disturbed, less hyperactive
Agitation, catatonic, negative symptoms

20

History when presenting with ++mood

Particularly happy
Too much energy
Exciting ideas
Thoughts racing
Special powers
Sleep
Delusions, hallucinations
Past depressive/mani episodes
Substances
Medical history
Impairment

21

Examination of irritable++mood

General
Endocrinological
Neurological

22

Investigations when elevated mood

Social: collateral, home, work, children
Psychological->mood diary?

1. Exclude medical/substance causes
UDS
Vitamin B12, folate
CT, EEG if indicated
2. Establish baseline before administering medication
FBC, UEC, Cr/BUN, LFTs, TSH, pregnancy test, ECG

23

Prevalence of bipolar affective disorder

0.5-1%, men and women affected equally