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Bipolar affective disorder Flashcards

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1
Q

What is bipolar I disorder?

A

Episodic mood disorders characterised by episodes of mania, hypomania or mixed
Charaterised by one or more episodes of above

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2
Q

What does a patient experience in a manic episode

A

Euphoria, irritability, expansiveness
Increased activity/increase energy
Increase self-esteem/grandiosity
Rapid/pressure of speech
Flight of ideas
Decrease need for sleep
Distractibility
Impulsive/Reckless behaviour
Rapid changes between mood states (labile mood)

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3
Q

What is the difference between type I and II bipolar?

A

type I - manic episode
II - hypomanic episode

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4
Q

How long do manic symptoms have to last to be classed as an episode?

A

1 week

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5
Q

How long does a mixed episode have to last to be official?

A

2 weeks

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6
Q

What does a patient experience in a mixed episode presentation?

A

Several prominent manic symptoms and several prominenet depressive symptoms occuring for most of the day nearly every day

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7
Q

lifetime prevalence of bipolar

A

1% general pop

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8
Q

How does bipolar I presnetation differ with gender?

A

Males earlier onset and more diabling manic symptoms
Females - more depressive symptoms
Equal occurence

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9
Q

When is risk of suicide in bipolar I esp high?

A

Fallout after manic episode eg spending, relationship breakdwon realisation
Type II - depressive episodes

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10
Q

What often cooccurs with bipolar I disorder?

A

Substance use disroder
Panic disorder

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11
Q

What does co-occurence of panic disorder with bipolar I suggest?

A

More severe illness, poorer response to treatment and higher risk of suicide

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12
Q

How long do depressive symptoms need to alst to be an episode in bipolar?

A

2 weeks

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13
Q

How liong does hypomania have to last to be an epsiode?

A

Severeal days

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14
Q

How is Bipolar II charactereised?

A

1 or more hypomanic episode AND ar least one depressive episode
No prev hisotry of manic or mixed episodes

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15
Q

Hypomanic episode symptoms

A

persistent elevated mood
persistent irritability
increase activity/energy
increase talkativeness
rapid/racing thoughts
increase self-esteem
decrease need for sleep
distractibility
impulsive/reckless behaviour

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15
Q

Hypomanic episode symptoms

A

persistent elevated mood
persistent irritability
increase activity/energy
increase talkativeness
rapid/racing thoughts
increase self-esteem
decrease need for sleep
distractibility
impulsive/reckless behaviour

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16
Q

How does a patient present in a hypomainic episode?

A

Significant change from usual mood, energy and behaviour but no impairment in funcitoning

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17
Q

Depressive episode symptoms

A

period of low mood
diminished interest in activities
changes in appetite
changes in sleep
psychomotor agitation/retardation
fatigue
feelings of worthlessness/inappropriate guilt
hopelessness
difficulty in concentrating
suicidality

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18
Q

Onset of bipolar II disorder

A

Late adolescent to mid 20s
Often with one or more depressive episodes - unrecognised before symptmos hypomania emerge

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19
Q

Why review diagnosis of type II bipolar at each patient contact

A

15% develop episodes of mania - change to typt I

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20
Q

Why do people with bipolar have a higher risk of developing medical conditions?

A

CVD diseases, metabolic syndrome due to effect of medicaitons

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21
Q

Risks in bipolar affective disorder

A

Overspending, debts
Disinhibition (incl. promiscuity, pregnancy)
Exploitation – financial, relationship,
Driving
Family/Children
Violence – self & others
Self-neglect – personal care, physical health
Suicide
Alcohol and Recreational substances

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22
Q

How much higher are rates of suicide in bipolar than normal pop?

A

15 x

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23
Q

Why do antidepressants often not help in bipolar?

A

Can cause manic switch - from depression to mania

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24
What is bipoilar often misdiagnosed as?
Depression - depressive episodes have same criteria, esp type II
25
Why can it be difficult to diagnose manic episodes?
Patients reporting bias - prefer to be in manic/hypomanic state, get more done Mixed mood episodes are quite common, obscure mania
26
Why is hypomania often difficult to diagnose?
Subthreshold symptoms common in depressive illness 30-55% patients have hypomanic symtpoms in depressive episode and common in dperessive disorder
27
What group of patients should be treated as sus bipolar?
Treatment resistant depression
28
Self reported scales for bipolar
Mood Disorder Questionnaire (MDQ) – brief screen – 12 or 3 item Young Mania Rating Scale (Patient Health Questionnaire (PHQ) YMRS) Beck Depression Inventory – BDI Quick Inventory Depressive Symptomatology-Self Report (QIDS-SR)
29
Interview rating scales in mood disorders
Interview with physician: Hamilton Depression Rating Scale (HAMD) Montgomery and Asberg Depression Rating Scale (MADRS) Quick Inventory Depressive Symptomatology – Clinician (QIDS-C)
30
What syndrome does lamotrigine increase the risk of
Steven Johnson
31
Why do you titrate lamotrigine slowly?
Risk of steven johnson syndrome - severe skin condition (erythema multiforme)
32
Factors when deciding treatment
Prev experience of meds Comorbid physical illness Patients preference Adverse effects of meds
33
Acute management first episode of manic or hypomanic episode
1-Consider stop antidepressants 2-Start antipsycjotics, titrated carefully and monitor side effects 3-Potential benzodiazapine if needed 4-Lithium, valproate, arpiprazole
34
first line antipsychotics
risperidone, olanzapine, haloperidol, quetiapine
35
Side effects of antipsychotics to monitor for?
Acute dystonia, akathasia, extrapyramidal symptoms
36
How often review benzodiazapine when acute use manic episode?
Daily
37
Relapse of bipolar disorder management
Optimise current treatment Check complaince Antipsychotic - start with what worked before Mood stabilisers - choice of lithium, valproate, carbamazapine (NOT LAMOTRIGINE) use of alcohol/recreational substances
37
Relapse of bipolar disorder management
Optimise current treatment Check complaince Antipsychotic - start with what worked before Mood stabilisers - choice of lithium, valproate, carbamazapine (NOT LAMOTRIGINE) use of alcohol/recreational substances
38
What drug do you not offer in relapse of manic episodes in bipolar
lmaotrigine
39
Acute depressive episode management if not being treated for bipolar
Fluoxetine + olanzipine Quetiapine on own Can offer olanzapine or lamotrigine on own patient preference If no repsonse -> fluoxetine + olanzapine or quetiapine, lamotrigine on own
40
First line treatment for long term management of bipolar
lithium
41
2nd line for long term management bipolar
Valproate alternatives - olanzapine, quetiapine
42
Psychological management of bipolar
Educate patients and carers (with patients’ consent) about nature & severity of illness. The aim is to empower patients to manage their illness – self-monitoring, recognition of early warning signs eg decrease need for sleep may trigger a manic relapse. Discuss about future management according to patients’ preferences inc advance directive Offer CBT/Interpersonal Therapy/Family Intervention according to patients’ needs & preferences
43
Social treatment of bipolar
The aim is to return to premorbid functioning level in terms of education & employment. Lifestyle advice on smoking/alcohol/recreational substances/exercise/diet Support group: Bipolar UK
44
Management of acute depressive episode if already on lithium for bipolar
Check Li level and adjust dose appropriately If lithium at amx offer in combination -Fluoxetine + olanzipine or quetiapine -olanzapine on own Stop if no repsonse to combination of fluoxetine + olanzapine or adding quetiapine Lamotrigine
45
Management of acute depressive episode if already on valproate for bipolar
Increase dose to max tolerated in therapeutic range Patient preference combine with -Fluoxetine + olanzapine or quetiapine -Olanzapine -Stop if no response to above Consider lamotrigine
46
Why monitor lithium weekly?
Narrow therapeutic index
47
How often do yuo monitor lithium levels
weekly until stable then 3 monthly
48
What are problems with lithium?
Narrow therapeutic index - toxicity Leukocytosis Nausea, vomitting, diarrhoea Renal and thyroid dysfunction CVS disease Muscle weakness and tremor Sudden discontinuation – 50% risk of mania Acne Dry motuh Pregnancy
49
What monitor on lithium
Renal function and TFTs (thryoid) 6 monthly
50
What is the risk with sudden discontinuation of lithium?
50% increase risk of mania
51
Risks ass with lithium in pregnancy
Teratogenicity Cardiac abnormalities Ebstein anomaly
52
What is required with lithium treatment in pregnancy?
Dose requirements increased during the second and third trimesters (but on delivery return abruptly to normal). Close monitoring of serum-lithium concentration advised in pregnancy (risk of toxicity in neonate
53
What can valproate cause in pregnancy?
Reduced IQ - 10-15 Teratogenicity (neural tube) Polycystic ovary
54
What symptoms constitutes mania?
Abnormally and persistent elevated or irritable mood Increased energy Inflated self esteem or grandiosity Decreased need for sleep Pressured speech Racing thoughts or flight of ideas Distractability Increased activity Excess pleasurabe or risky activity
55
How long must symptoms go on for to class as a manic episode?
Must have abnoramlly and persistent elevated or irritable mood and increased energy plus any other 3 symptoms forat least 1 week, with functional impairemtn
56
What is the minimum duration for hypomania?
4 days
57
What episodes normally predominate/come first in bipolar?
Depressive - why its often misdiagnosed
58
Bipolar I vs II
I - patient has had at least one manic episode II - patient has had hypomanic episodes byt never a manic one
58
Bipolar I vs II
I - patient has had at least one manic episode II - patient has had hypomanic episodes byt never a manic one
58
Bipolar I vs II
I - patient has had at least one manic episode II - patient has had hypomanic episodes byt never a manic one
59
What is the most dangerous episode in bipolar? (Highest risk of suicide)
Mixed episodes - symptoms of opposite pole present
60
What is rapid cycling in bipolar?
4+ episodes of any type per year
61
What is cyclothymia?
Sub syndromal ups and downs CF dysthmia = just downs

Mental Health (57 decks)

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