Bipolar affective disorder Flashcards
(33 cards)
What is hypomania
Symptoms need to be present for at least 4 days Mild elevation of mood Increased energy Mild risk-taking, overspending Overfamiliarity Distractibility Increased sexual energy Decreased need for sleep
What is mania
Symptoms present for at least 1 week or severe enough for hospital admission
Mood is elevated, expansive, irritable Increased activity Reckless behavior Disinhibition Marked distractibility Markedly increased sexual energy Sleep severely impaired or absent Grandiosity Flight of ideas
What is mania with psychosis
Mania plus:
Delusions that are often mood congruent (eg. grandios vs. persecutory when irritated)
Mood congruent, 2nd person auditory hallucinations (less frequent)
Classify different mood changes
1 episode of mania = Acute mania
2 episodes of mania = bipolar affective disorder
1 episode of mania + 1 episode of depression = bipolar affective disorder
2 episodes of depression = recurrent depressive disorder
What is dysthymia?
Chronically low mood, but not low enough to justify a diagnosis of depression
What is cyclothymia?
Changes in mood that do not meet criteria for mania or depression
What are the organic differentials for bipolar affective disorder?
Substance misuse (eg. steroids) Hyperthyroidism (very severe) Space occupying lesion (frontal lobe) Metabolic disorders Epilepsy
Aetiology of bipolar affective disorder
Genetics (predispose) - if relative with bipolar, higher chance of bipolar, schizoaffective or unipolar depression
Life events (precipitate) - prolonged stress, vulnerability
Prognosis of bipolar affective disorder
Average length of manic episode is 6 months
At least 90% will have a further mood disturbance
Typically, 10 mood disturbances over 25 years
Recovery from acute episodes is good, but long term prognosis poor:
<20% achieve 5 years of clinical stability with good social/occupational performance
20-30times more likely to die of suicide
Biological treatment of mania
Offer anti-psychotic (haloperidol, olanzapine, risperidone, quetiapine)
Consider lithium or valproate
Consider benzodiazepines like lorazepam or diazepam for mood disturbances
Stop any anti-depressants
Psychological management of mania
Psychoeducation
Social management of mania
Consider Mental Health Act Consider inpatient admission Calm, low-stimulus environment Advise not to make any decisions Advise to maintain relationships with carers
What organic cause of depression should be remembered in long-term lithium use
hypo-thyroidism
Treatment of bipolar depression
Consider mood stabiliser (lithium, valproate, lamotrigine)
SSRI can be used, but only with an anti-manic agent
Consider 2nd generation antipsychotics (eg. olanzapine, quetiapine)
CBT
Psychoeducation
Carer support
Inpatient admission if risk
Work around social inclusion
Support with regard to education, training, employment
What to do if lithium ineffective?
Add sodium valproate
If lithium is intolerable?
Consider valproate or olanzapine instead
In a women with child-bearing age, what should be considered?
Lithium and valproate are teratogenic
Consider antipsychotic as first-line mood-stabilisier
What physical health monitoring is important in bipolar affective disorder?
Offer a healthy eating/physical activity programme
Weight and other cardiovascular and metabolic indicators of morbidity should be monitored, at least annually
Some medications have their own monitoring requirements (e.g. lithium - levels weekly whilst initiating and after any dose change and every 3 months thereafter; also need to check U&E and TFT every 6 months)
Provide advice with regard to contraception and folic acid if lithium, valproate, carbamazepine are prescribed to women of childbearing age.
List the “mood stabilisers”
Lithium
Valproate
Carbamazepine
Lamotrigine
A number of antipsychotics can now also be used: quetiapine, olanzapine, aripiprazole
Indications for mood stabilisers
Prophylaxis in bipolar:
Single manic episode associated with significant risk
Illness with significant impact on functioning
Two or more acute episodes
Treatment of bipolar depression
Augmentation for antidepressants in treatment-resistant depression
NOT first line in acute mania/hypomania
When is lithium indicated?
Acute mania/hypomania (good evidence)
Prophylaxis in bipolar disorder
Bipolar depression
Treatment-resistant depression
Therapeutic window of lithium
Narrow (0.4-1.2mmol/L)
Monitor after a minimum of 5 days
Side effects of Lithium
GI upset Fine tremor Polyuria Polydipsia Metallic taste in mouth Weight gain Oedema
Toxic effects of lithium
Diarrhoea Course tremor Ataxia Dysarthria Nystagmus Confusion Convulsions
Toxicity is associated with low sodium diets, dehydration, drug interactions (NSAIDS, ACE inhibitors, thiazide and loop diuretics) and some physical illnesses such as Addison’s disease
