Fatima (Bipolar disorder) Flashcards
What is bipolar disorder?
Bipolar disorder is a serious, potentially lifelong and sibling mental health condition, characterised by periods of mani/hypomania and periods of depressed mood.
It has significant impact on individuals function and wellbeing and has a high risk of suicide.
Mania- a period of abnormally elevated, extreme changes in mood or emotions, energy level or activity level. This change is recognised by other as beyond the person’s usual self.
Each extreme episode can last for several weeks or longer.
Manic vs hypomanic episode
Manic episode:
At least one week of elevated, or irritable mood which causes marked impairment in social or occupational functioning or psychic features, which may involve delusions or hallucinations.
Hypomanic episode:
At least 4 days of elevated mood or irritability which are uncharacteristic, observable by other people, but not severe enough to cause marked social impairment or require hospital admission. No psychotic features
Epidemiology
It is fairly common.
Around 1 in 100 people
BPD can occur at any age but it often develops between the ages of 15 and 19.
Men and women are equally likely to develop BPD.
Causes
Exact cause is unknown. Several factors are likely to be involved in the development of bipolar disorder including
- genetic factors- family history is a strong individual risk factor, with first degree relatives having an 8-fold higher risk compared with the baseline population
- environmental factors- these may act as triggers e.g. traumatic and stressful life events in early childhood and adulthood
- neurochemical factors- chemical imbalances in the brain
Types of bipolar disorder
Two types:
- Bipolar I disorder: at leats one manic episode. This may be preceded by or followed by episodes of hypomania or major depression, but there is no requirement for these to make the diagnosis
- Bipolar II disorder: at least one hypomanic episode and at least one episode of major depression. Episodes may occur at any point over the course of the individual’s life
Other conditions associated with BPD
Can be co-morbid with other mental health disorders such as anxiety, personality disorders, and ADHD.
Individuals with co-morbidities tend to have greater symptoms burden and lower response to treatment. (Treatment is usually very challenging, reduces QoL and reduces functionality, need extra support from family and healthcare providers)
BPD and suicide
Risk of suicide attempt and completed suicide is high in BPD.
Up to hale of all people with BPD report at leats one suicide attempt.
Around 10-15% will die by completed suicide.
Risk of suicide may be higher during depressive episodes.
Other risk factors for suicide include environmental stressors, loneliness, and lack of support.
Recognition and assessment of BPD
Diagnosis is not easy. In primary care the diagnosis should be kept in mind and referral for specialist assessment should be considered especially in
- individuals with a family history of BPD
- history of adolescent depression
- treatment-resistant depression
- sudden onset of symptoms
complex cases with co-morbitidy e.g. ADHD
Assessment of BPD in primary care
NICE recommends that questionnaire should not be used in primary care to identify BPD in adults.
History in patient with low mood could be taken and involves asking about symptoms
- have you every had an episode of excited or irritable mood lasting 4 days or more?
- have you had periods of increased energy when you are more active or don’t need as much sleep?
- have there been times where you were more prone to taking risks, gambling, or using alcohol or drugs to calm your mood?
Risk assessment
1- Assesses risk
- Risk assessment for suicide and self-harm should be conducted.
- In some people other risks such as confrontational behaviour, excessive spending, or risky sexual behaviour should be considered
2- Safeguarding
- Vulnerable dependants should be asked about and appropriate safeguarding steps taken if needed
3- Assess insight
- Reduce insight can affect willingness to accept treatment. Questions may be asked and there should be concerns if the patient expresses delusional ideation or hallucinations
Symptoms of BPD
Individuals with BPD have episode of mania (feeling very high and overactive) and depression (feeling low and lethargic).
Symptoms of manic episodes include:
- elevated mood
- accelerated though and speech
- irritability
- decreased sleep
- increased sleep or decreased appetite
- distractibility
- grandiose ideas
- flamboyant or inappropriate dress
- behaviours of excess
- delusions and hallucinations
Symptoms of depressive episodes:
- may be clinically identical to depression in absence of previous manic episodes
- individual may experience several episodes of depression in sequence
Management of BPD
According to NICE;
- All patients with suspected BPD should be referred to a specialist mental health service to make the diagnosis, treat the acute episode and establish a long term management plan
- There should be urgent referral if mania or severe depression is suspected, or there are concerns about the risk to the patient or to others
Diagnosis and initial management of BPD is carried out in specialist care. Once stable the patient may be referred back to primary care for ongoing treatment.
Lithium, valproate or antipsychotics should not be started in primary care without secondary care support.
Patient should be advised to stop driving until the acute illness, and to inform the DVLA of their diagnosis
Psychological therapy
NICE recommends that:
- People with BPD should be offered a psychological therapy designed specifically for BPD or be offered a choice of talking therapy (CBT, IPT) in line with treatment options for more severe depression
- Therapists should have experience of working with people with BPD
- Talking therapy can be offered in the primary care setting with referral made to local psychological therapy service is needed
Lifestyle modification
Exercise
Diet
Sleep
Drug therapy
Decisions about drug treatment for people with bipolar disorder should always be made in secondary care. NICE recommends that:
- Choices for moderate or severe bipolar depression in someone who is not already taking a drug to treat their BPD include
- Fluoxetine combined with olanzapine
- Quetapine on its own
- Either olanzapine or lamotrigine on their own
-If the person is already taking lithium and becomes depressed they lithium levels should be checked, and the treatment dose optimised. If lithium is at a maximum dose treatment options include adding fluoxetine and olanzapine, quetiapine, or lamotrigine.
