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Semester 3 > Case 8 - Bipolar > Flashcards

Case 8 - Bipolar Flashcards

1
Q

what is bipolar 1 disorder

A

manic episodes typically alternate with depressive episodes during the course of illness

there is a recurrent mania subtype which is rare

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2
Q

what is bipolar II disorder

A

lifetime experience of at least one major depressive and one hypomanic episode - not manic

often depressive episodes become predominant over time and are very functionally impairing

hypomanic episodes do not usually cause impairment, often improve productivity at home and work and sometime are not disclosed because they are not seen as a problem by the patient

usual cause of presentation is depression or unpredictability of mood

BPII can be mistaken for recurrent MDD if you don’t look for a past history of hypomania

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3
Q

what is a manic episode

A

A. a distinct period of abnormally and persistently elevated, expansive or irritable mode and abnormally and persistently increased activity or energy lasting at least one week and present most of the day nearly every day

B. during A, 3 or more of the following (4 if mood is only irritable) are present to a significant degree and represent a noticeable change from usual behaviour
- inflated self esteem
- decreased need for sleep
- pressure of speech
- flight of ideas or subjective experiences that thoughts are racing
- distractibility
- excessive involvement in pleasurable activity that have high potential for painful consequence

C. sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalisation or there are psychotic features

D. not attributable to the physiological effects of a substance or another medical. condition

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4
Q

what is hypomania

A

A. a distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 xonsectuve days and present most of the day, nearly every day

B. during A, 3 or more of the following (4 if mood only irritable) have persisted, represent a noticeable change from usual behaviour and have been present to a significant degree: same 7 features as mania

C. episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic

D. the disturbance in mood and the change in functioning are observable by others

E. the episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalisation. If there are psychotic features preset, the episode is, by definition, manic

F. not attributable to the physiological effects of a substance or medical condition

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5
Q

how is food fortified

A

add micronutrients

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6
Q

what is first onset age of first moof episode in bipolar I

A

18

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7
Q

when is first mode episode of bipolar II

A

mid 20’s

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8
Q

what is the average life expectancy reduced by

A

9-20 years

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9
Q

what is the lifetime suicide risk of bipolar

A

at least 15 times of the gen pop

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10
Q

which kind of environment makes you more prone to getting bipolar

A

more common in high income counties
adverse childhood experiences
stress and loss
seasonal effets
medical disorders

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11
Q

what medications make you more prone to developing bipolar

A

corticosteroids, Ldopa, thyroid hormones, antidepressants

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12
Q

what are the genetic risk loci now identified for bipolar

A

voltage gated Ca2+ and Na+ channels
GluN2 subunit of NMDA receptors
synaptic components
regulation of Insulin secretion
endocannabinoid signalling

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13
Q

what is BPI strongly correlated with

A

SCHZ

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14
Q

what Is BPII strongly correlated with

A

MDD

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15
Q

what is the genetic overlap with schizophrenia

A

27% of the 30 risk loci associated with schizophrenia
a detailed family history will often find familial co aggregation of bipolar disorder and schizophrenia in the same family tree

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16
Q

how many people will develop psychosis during their lifetime with bipolar

A

50%, predominantly in the manic phase and some in severe depressive episodes.

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17
Q

what do manic episodes in bipolar disorder respond to

A

antipsychotic drugs - D2 receptor antagonists

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18
Q

is dopamine synthesis altered in bipolar disorder without psychosis

A

no

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19
Q

which parts of the brain have elevated DA synthesis in bipolar

A

all striatum divisions

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20
Q

what dopamine dysfunction is associated with psychosis

A

presynaptic dopamine dysfunction

21
Q

what are the three phases of bipolar

A

acute manic
acute major depressive
maintenance phase

22
Q

what drug are given during the acute manic episodes

A

antipsychotics - D2 antagonists
lithium - mood stabiliser
valproate - an anti epileptic
carbamazepine - an antiepileptic

23
Q

what medicine I given in acute depressive episodes

A

quetiapine in relatively low doses
lamotrigine - an anti epileptic
lithium

24
Q

why are antidepressants not used

A

increased risk of switch to mania or rapid cyclone

may sometimes be helpful but used as 2nd or 3rd line and must be used with an effective anti manic drug

25
Q

what are combinations of anti manic and anti depressive drugs q

A

fluoxetine and olazapine
SSRI and Li combination

26
Q

what is maintenance treatment directed towards

A

prophylaxis against future acute episodes

27
Q

what is the gold standard maintenance treatment

A

lithium
efficacy in reducing the risk of suicide

28
Q

what other drugs are used prophylacticly

A

quetiapine - better against depression
valproate - against mania

29
Q

features of lithium

A

an alkali metal usually administered as a salt
not bound to plasma proteins, is not metabolised and is excreted unchanged almost soloed by the kidney

30
Q

what kind of salt is lithium administered as

A

carbonate or citrate

31
Q

why is there caution around lithium

A

renal impairment

32
Q

what is the therapeutic window

A

0.6-0.8mmol/L (12 hours post dose)
Below 0.6 - decreased or absent effectiveness
Above 0.8 - decreased tolerability
Above 1.2 - high risk of toxicity

33
Q

what test is done regularity with lithium

A

regular blood tests for Li level

34
Q

what is first line treatment for all phases of bipolar disorder

A

lithium

35
Q

what are the mechanisms of action of lithium

A

increase 5HT and GABA (inhibitory) neurotransmission

decreased glutamate and DA neurotransmission

possibly via effects on adenylate cyclase, inositol metabolism an protein kinase C activity

decreased oxidative stress

increased trophic and protectivee factors

36
Q

what are protective factors of lithium

A

BDNF and the anti-apoptotic factor B cell lymphoma-2

37
Q

side effects of lithium

A

fine tremor
Mild GI upset
Clinically evident nephrogenic diabetes insipidus (NDI) (reversible)
Increased thirst, polyuria, and reduced urinary concentrating ability
Renal tubule mechanism: Li probably inhibits a G-protein coupled pathway that is activated by ADH to increase aquaporin channels in the collecting ducts
mild cognitive effects
Metallic taste
Ankle oedema
Weight gain
Increased risk of hypothyroidism and hyperparathyroidism
Very small risk of decreased renal function with chronic use particularly which levels >0.8mmol/

38
Q

signs of toxicity

A

increasing anorexia, nausea, diarrhoea
Muscle weakness, drowsiness, ataxia, course tremor, muscle twitching
At 2.0 mmol/L increased disorientation, seizures coma and death

39
Q

what is valproate a general term to describe

A

valproic acid
Sodium valproate
Valproate semisodium (a coordination complex of valproic acid and sodium valproate in a 1:1 molar relationship. AKA depakote

40
Q

what are the indications for valproate in bipolar disorder

A
  • actue manic episodes (third line in resistant mania and added to lithium when lithium and antipsychotics have not been adequately effective

-

41
Q

when would valproate be used as maintenance in bipolar

A

indicated when lithium has not been effective or is poorly tolerated

moderate protection against manic relapse
less protective against depressive release

42
Q

what is the mechanism of action of valproate

A

wide range of immediate and long term biochemical and genomic effects

43
Q

what are the acute effects of valrpoate

A

increased GAB
decreased neuronal excitability via the blockade of voltage gated Na+ channels

44
Q

what are the long term effects of valproate in changes in systems in the body

A

changes in:
- glucocorticoid, 5HT, and DA neurotransmitter systems
- inositol metabolism and protein kinase C activity
- Want/beta-catenin cell signalling pathway
- brain lipids and their metabolism

45
Q

what are the other long term effects of valproate

A

increased trophic and protective factors e.g BDNF and the anti-apoptotic factor B cell lymphoma 2

class I histone deacetylases (HDAC) inhibition leads to altered gene expression

46
Q

what are the other long term effects of valproate

A

increased trophic and protective factors e.g BDNF and the anti-apoptotic factor B cell lymphoma 2

class I histone deacetylases (HDAC) inhibition leads to altered gene expression

47
Q

what are the side effects in pregnancy

A

teratogenic and developmental effect in a range of foetal organ systems

rates of major malformations around 7-14%

exposure in first trimester leads to increase risk of SB, atrial septal defect and cleft palate

postnatal neurodevelopment problems in up to 30-40% of exposed children

risk of autism increased3-5 times

48
Q

what is the pregnancy prevention programme

A

an assessment of their potential for becoming pregnant
Pregnancy tests before starting and during treatment
Counselling about the risks of valproate and the need for effective contraception throughout treatment
A review of ongoing treatment by a specialist at least annually
A new risk acknowledgement form that patients and prescribers will go through every year

valproate packing also now carries a visual warning, patients are given a warning card with every prescription, and pharmacists are required to discuss the risks every time they dispense valproate to women of childbearing potential

Semester 3 (94 decks)

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