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AIP: Self-harm > Bipolar effective disorder > Flashcards

Bipolar effective disorder Flashcards

1
Q

What is bipolar affective disorder?

A

chronic episodic mood disorder, characterised by at least one episode of mania (or hypomania) and a further episode of mania or depression

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2
Q

Why does the term bipolar also include those who at the time of diagnosis have suffered only manic episodes?

A

all cases of mania will eventually develop depression

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3
Q

What 2 types of factors cause BAD?

A

biological + environmental factors

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4
Q

What are 4 types of factors (both biological and environmental) which may contribute to BAD?

A
  1. Monoamine hypothesis: elevated mood result of increased central monoamines (noradrenaline and serotonin)
  2. Dysfunction of the HPA axis
  3. Genetic: shows strong heritability, esp 1st degree relatives
  4. Stressful or significant life events
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5
Q

What are 3 types of biological factors which may contribute to the development of BAD?

A
  1. Genetic
  2. Neurochemical: increased dopamine and serotonin
  3. Endocrine: increased cortisol, aldosterone and thyroid hormone
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6
Q

How is dysfunction of the HPA axis thought to contribute to the development of BAD?

A

abnormal secretion of cortisol, as found in unipolar depression, and dysfunction of the hypothalamic pituitary thyroid axis may contribute to BPAD

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7
Q

What are 4 types of environmental factors which may contribute to the development of BPAD?

A
  1. Adverse life events
  2. Exams
  3. Post-partum period
  4. Loss of loved one
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8
Q

What is the lifetime risk of developing BPAD?

A

1-3%

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9
Q

What is the mean age of onset of BPAD?

A

19 years

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10
Q

In which ethnic groups is BPAD higher?

A

black and other minority ethnic groups

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11
Q

What is the male: female ratio affected by BPAD?

A

1:1

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12
Q

What are 6 risk factors for the development of BPAD?

A
  1. Age in early 20s
  2. Anxiety disorders
  3. After depression
  4. Strong family history
  5. Substance misuse
  6. Stressful life events
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13
Q

What are 3 levels of severity of mania?

A
  1. Hypomania
  2. Mania without psychosis
  3. Mani with psychosis
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14
Q

What is the mnemonic for remembering the symptoms of mania and what do they stand for?

A

I DIG FASTER

  • I: irritability
  • D: distractibility/ disinhibited (sexual, social, spending)
  • I: insight impaired/ increased libido
  • G: grandiose delusions
  • F: flight of ideas
  • A: activity/ appetite increased
  • T: talkative - pressure of speech
  • E: elevated mood/ energy increased
  • R: reduced concentration/Reckless behaviour and spending
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15
Q

What is the definition of hypomania? 4 aspects

A
  1. mildly elevated mood or irritable mood present for ≥4 days
  2. symptoms of mania are to lesser extent than true mania
  3. considerable interference with work and social life but not severe disruption
  4. partial insight may be preserved
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16
Q

What are 4 aspects of the definition of true mania, without psychosis?

A
  1. Symptoms present for >1 week
  2. Complete disruption of work and social activities
  3. May have grandiose ideas and excessive spending could lead to debts
  4. There may be sexual disinhibition and reduced sleep may lead to exhaustion
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17
Q

What are 4 aspects of the definition of mania with psychosis?

A
  1. Severely elevated or suspicious mood
  2. With the addition of psychotic features such as grandiose or persecutory delusions and auditory hallucinations that are mood congruent
  3. Patient may show signs of aggression
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18
Q

What are the 3 classifications of bipolar affective disorder?

A
  1. Bipolar I: involves periods of severe mood episodes from mania to depression
  2. Bipolar II: milder form of mood elevation, involving milder episodes of hypomania that alternate wtih periods of severe depression
  3. Rapid cycling: more than 4 mood swings in a 12-month period with no intervening asymptomatic periods. Poor prognosis
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19
Q

What is the ICD-10 criteria for mania?

A

requires 3/9 symptoms to be present:

  1. grandiosity/ inflated self-esteem
  2. Decreased sleep
  3. Pressure of speech
  4. Flight of ideas
  5. Distractibility
  6. Psychomotor agitation (restlessness)
  7. Reckless behaviour e.g. spending sprees, reckless driving
  8. Loss of social inhibitions (leading to inappropriate behaviour)
  9. Marked sexual energy
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20
Q

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

A

at least 2 episodes in which a person’s mood and activity levels are significantly disturbed - one of which MUST be mania or hypomania

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21
Q

What are the 5 states that the ICD-10 divides bipolar disorder into?

A
  1. Currently hypomani
  2. Currently manic
  3. Currently depressed
  4. Mixed disorder
  5. In remission
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22
Q

What are 10 questions to ask in the history of someone with suspected BAD?

A
  1. How would you describe your mood?
  2. Have you ever felt on top of the world?
  3. Do you feel that you have too much energy compared to those around you?
  4. Are you able to concentrate on routine activities?
  5. Do you find yourself needing less sleep but not getting tired?
  6. Has your interest in sex changed?
  7. Have you had any new interests or exciting ideas lately?
  8. Do you have any special abilities that are unique to you?
  9. Are you afraid that someone is trying to harm you?
  10. Family history and substance misuse
23
Q

What aspects of bipolar disorder may be gauged from the conversation when taking a history (rather than specific questions)? 2 key things

A
  1. pressure of speech
  2. flight of ideas
24
Q

What must you specifically ask in a history of depression to exclude possible BAD?

A

specifically ask about previous instances where mood has been signifcantly elevated, previous overactivity or disinhibition

25
Q

What are the 8 key aspects of a mental state examination and how may each of these be affected in mania in BAD?

A
  1. Appearance: flamboyant/ unusual combination of clothing, heavy makeup and jewellery. Personal neglect when condition severe
  2. Behaviour: overfamiliar, disinhibited (flirtatious, aggressive), increased psychomotor activity, distractible, restless
  3. Speech: loud, increased rate and quantity, pressure of speech, uninterruptible, puns and rhymes, neologisms
  4. Mood: elated, euphoric, and/or irritable
  5. Thoughts: optimistic, pressured thought, flight of ideas, loosening of association, circumstantiality, tangentiality, overvalued ideas, grandiose/persecutory delusions
  6. Perception: usually no hallucinations. mood-congruent auditory hallucination may occur
  7. Cognition: attention and concentration often impaired. fully oriented
  8. Insight: generally very poor
26
Q

What are 3 things that make eliciting a thorough history from a manic patient very difficult?

A
  1. irritability (80% of manic patients)
  2. distractibility
  3. disinhibition
27
Q

What are 4 investigations that can be considered in mood disorders?

A
  1. Self-rating scales e.g. Mood Disorder Questionnaire
  2. Blood tests: FBC, TFTs, U+Es, LFTs, glucose, calcium
  3. Urine drug test: illicit drugs can cause manic symptosm
  4. CT head: rule out SOL
28
Q

What are 6 types of blood tests to perform in BAD and why for each?

A
  1. FBC: routine
  2. TFTs: hper and hypothyroidism are differentials
  3. U+Es: baseline renal function with view to starting lithium
  4. LFTs: baseline hepatic function with view to starting mood stabilisers
  5. Glucose: routine
  6. Calcium: biochemical disturbances can cause mood symptoms
29
Q

What are 5 differentials for BAD?

A

Mood disorder: hypomania, mania, mixed episode, cyclothymia

Psychotic disorders: schizophrenia, schizoaffective disorder

Secondary to medical condition: thyroid, Cushing’s, cerebral tumour (e.g. frontal lobe), stroke

Drug related: amphetamines, cocaine, acute drug withdrawal, SE of steroids

Personality disorders: histrionic, emotionally unstable

30
Q

What are 4 medical conditions that could mimic BAD?

A
  1. Hyper/hypothyroidism
  2. Cushing’s disease
  3. Cerebral tumour (e.g. frontal lobe lesion with disinhibition)
  4. Stroke
31
Q

What are 4 ways that an episode appearing like a manic episode of BAD could be in fact related to drug use?

A
  1. Amphetamines
  2. Cocaine
  3. Acute drug withdrawal
  4. Side effect of corticosteroid use
32
Q

What are 7 aspects of the management of BAD?

A
  1. Full risk assessment
  2. Driving: DVLA has clear guidelines about driving when manic, hypomanic or severely depressed
  3. Mental Health Act: if patient violent or risk to self
  4. Pharmacological management
  5. High-intensity psychological intervention e.g. CBT
  6. ECT - not first line, if antipsychotic drugs ineffective
  7. Follow up initially once a week, then 2-4 weekly for first few months
33
Q

What are 4 situations when hospitalisation is required for bipolar disorder?

A
  1. Reckless behaviour causing risk to patient or others
  2. Significant psychotic symptoms
  3. Impaired judgement
  4. Psychomotor agitattion
34
Q

When is ECT used in BAD?

A

when antipsychotic drugs are ineffective and the patient is so severely disturbed that further medication or awaiting natural recovery is not feasible

35
Q

What is the follow up recommended in patients presenting with an acute episode of BAD?

A
  • once a week initially
  • 2-4 weekly for first few months
36
Q

What are the aspects of the biopsychosocial approach to managing BAD?

A
  • Biological: mood stabilisers, benzodiazepines, antipsychotics, ECT
  • Psychological: psychoeducation, CBT
  • Social: social support groups, self-help groups, encourage calming activities
37
Q

What are 4 aspects of the management of an acute manic episode/ mixed episode in BAD?

A
  1. First line: antipsychotic such as olazapine, risperidone or quetiapine
  2. Mood stabilisers: mainly lithium
  3. Benzodiazepines
  4. Rapid tranquilisation with haloperidol and/or lorazepam
38
Q

Why are antipsychotics used first line in severe mania?

A

rapid onset of action compared to mood stabilisers

39
Q

What mood stabiliser can be used second-line in addition to lithium?

A

sodium valproate

40
Q

What can benzodiazepines be used for when treating an acute manic episode/mixed episode?

A

to aid sleep and reduce agitation

41
Q

What are 3 aspects of the management of a bipolar depressive episode?

A
  1. Atypical antipsychotics e.g. olanzapine (±fluoxetine), olanzapine alone, quetiapine alone
  2. Mood stabiliser: lamotrigine or lithium
42
Q

What are 3 options for antipsychotics which can be used for a bipolar depressive episode?

A
  1. olanzapine + fluoxetine
  2. olanzapine alone
  3. quetiapine alone
43
Q

What is the key mood stabiliser of choice for a bipolar depressive episode?

A

lamotrigine (lithium also effective)

44
Q

What is the thinking regarding the use of antibiotics in bipolar depressive episodes?

A

should be avoided as can induce mania

45
Q

If anti-depressants are given in a bipolar manic episode what should they be prescribed with?

A

in conjunction with the cover of anti-manic medication

46
Q

What is the long-term medical management of bipolar affective disorder?

A

lithium should be offered first line to prevent relapses

47
Q

If lithium is ineffective as long-term management to prevent relapses of BAD what are 3 options for enhancing management?

A
  1. consider adding valproate
  2. olanzapine
  3. quietiapine
48
Q

What are 4 tests performed before lithium is started?

A
  1. U+Es
  2. TFTs
  3. Pregnancy test
  4. ECG
49
Q

What are 9 side effects of lithium?

A
  1. Polyuria
  2. Polydipsia
  3. Fine tremor
  4. Weight gain
  5. Oedema
  6. Hypothyroidism
  7. Impaired renal function
  8. Memory problems
  9. Teratogenicity in first trimester of pregnancy
50
Q

What are 5 signs of lithium toxicity at 1.5-2.0 mmol/L?

A
  1. Nausea and vomiting
  2. Coarse tremor
  3. Atxia
  4. Muscle weakness
  5. Apathy
51
Q

What is the normal therapeutic level for lithium?

A

0.5-1 mmol/L

52
Q

What are 7 signs of severe lithium toxicity (>2.0 mmol/L)?

A
  1. Nystagmus
  2. Dysarthria
  3. Hyperreflexia
  4. Oliguria
  5. Hypotension
  6. Convulsions
  7. Coma
53
Q

What monitoring is performed for a patient taking lithium?

A
  • lithium levels 12 hours after first dose
    • weekly until levels have been stable for 4 weeks
    • then every 3 months
  • TFTs, renal function + calcium: every 6 months
54
Q

What is the first-line treatment for rapid cycling BPAD?

A

lithium and sodium valproate (in combo)

AIP: Self-harm (15 decks)

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