Bipolar affective disorder

Question 1

What is the scale of mood disorders?

Answer 1

Question 2

What is the ICD-10 criteria for bipolar affective disorder?

Answer 2

At least 2 episodes one of which must be manic/hypomanic or mixed, with recovery complete between the two episodes.

NB (?): Criteria for the depressive episode is the same as for unipolar depresson, and criteria for mania/hypomania episode if the same as for unipolar hypomania/mania.

Question 3

What is a mixed episode in bipolar affective disorder (BPAD)?

Answer 3

Mixed affective episode = occurrence of BOTH hypomanic/manic AND depressive symptoms in a single episode present everyday for at least 2 weeks.

Question 4

What are the types of BPAD?

Answer 4

Type 1 - one episode of mania +/- depression

Type 2 - one episode of hypomania +/- depression

Question 5

How common is BPAD? When is the mean age of onset?

Answer 5

1.5% point prevalence

Lifetime prevalence for type 1 is 1% and for type 2 is 1.1%

Mean age of onset for:

• type 1 is 18.2years
• type 2 is ~20 years

Question 6

What is a major risk with BPAD for the individual?

Answer 6

Suicide rate in BPAD is ~15-18 times greater than in the general population

Question 7

How common is mania after having an episode of depression?

Answer 7

10% of those with a depressive episode will go on to develop an episode of mania within 10 years

Question 8

What are some risk factors for BPAD?

Answer 8

• Upper social classes have higher incidence
• Genetics - first degree relative increases risk 7-fold and MZ twins show 33-90% concordance
• No sex differences
• No ethnic differences

Question 9

What is the peak age of onset of BPAD?

Answer 9

Peaks at 15-19 and 20-24

Mean age of onset is 21 years

Question 10

How is a manic episode diagnosed?

Answer 10

A…:

1. Elevated, expansive, irritable mood + abnormal for the individual
2. Prominent change in mood
3. Sustained for at least 1 week (unless hospitalised)

B: …AND at least 3 (4 if only irritable mood) of the following, leading to interference in daily living:

1. Activity/physical restlessness
2. Talkativeness
3. Flight of ideas or ‘thoughts racing’
4. Distractibility or constant changes in activity/plans
5. Grandiosity or inflated self-esteem
6. Marked sexual energy/sexual indiscretions
7. Loss of social inhibitions (leading to inappropriate behaviour)
8. Reckless behaviour not recognised as such by patient
9. Decreased need for sleep

Question 11

When do psychotic features appear in mania? Are they mood congruent?

Answer 11

They are associated with severe mania

Yes, usually mood congruent

Question 12

Give 4 psychotic features of mania.

Answer 12

Delusions

Incomprehensible speech - due to pressured speech

Self neglect - usually due to preoccupation with thoughts and extravagant themes so they may not eat or drink

Catatonic behaviour - manic stupor

Total loss of insight

Question 13

Give two types of delusions which are common in mania with psychosis.

Answer 13

Grandiose Delusions: grandiose ideas become delusions and are usually related to some form of identity or role e.g. special powers or religious content.

Persecutory delusions: suspicion may develop into well formed persecutory delusions

Question 14

How do you diagnose a hypomanic episode?

Answer 14

A:…

1. Elevated or irritable mood
2. To a degree that is abnormal for the individual concerned
3. Sustained for at least 4 ocnsecutive days

B: …AND at least 3 of the following present leading to some interference with impaired functioning in daily living:

1. Activity/physical restlessness
2. Talkativeness
3. Overfamiliarity/increased sociability
4. Recklessness, mild overspending or irresponsible behaviour
5. Sexual energy increased
6. Distractibility/difficulty concentrating
7. Decreased need for sleep

Question 15

What is the difference between mania and hypomania?

Answer 15

1. Degree of functional impairement - hospitalisation may be required in mania due to risk to self or others; unlikely in hypomania
2. Duration - 4 days for hypomania and 7 days for mania but this is arbitrary as most studies have shown that most hypomanic episodes in bipolar type 2 last for <4 days.
3. Psychosis - may occur in mania but does not occur in hypomania

Question 16

What are some secondary causes of mania?

Answer 16

Organic brain damage - especially right hemisphere (more common in elderly)

Medication - Levo-Dopa, corticosteroids

Illicit drugs - stimlants, street drugs cause this if the mood state significantly outlasts the drugged state (then BPAD can be diagnosed)

Endocrine - Hyperthyroidism sometimes presents as hypomanic or agitated (hypothyroidism usually presents like depression)

Question 17

What is the bio-psycho-social management of BPAD?

Answer 17

Bio - mood stabiliser (see lecture)

Psycho - psychoeducation, family therapy and individual/group psychotherapy

Social - supported employmen programmes, adapting in education systems, regular engagement

Question 18

A 34 year old South Asian woman presents with a two month history of elated mood, increased energy and increased productivity in her marketing business. Her mother has a history of anxiety and her father has a history of bipolar affective disorder. Which of the following is the most influential factor in her presentation.

• A. Her family history
• B. Her gender
• C. Her ethnicity
• D. Her age
• E. Her occupation

Answer 18

FH

Question 19

What is cyclothymia?

Answer 19

Cycling of subthreshold symptoms of elevated and depressed mood over a period of at least 2 years