Bipolar Disorder

• What is bipolar disorder?

  A serious long-term mental illness, which is usually characterised by episodic depressed and elated moods and increased activity (hypomania or mania)
• What is a manic episode?

  Distinct period of abnormally & persistently elevated, expansive or irritable mood lasting 1 week

  • severe enough to cause marked impairment in functioning
  • includes psychotic features (delusions, hallucinations)
• What is a hypomanic episode?

  Similar to manic episode (less severe)

  • symptoms least for minimum 4 days
  • not severe enough to cause marked impairment of functioning
  • no psychotic features
• What is a depressive episode?

  Period of at least 2 weeks where there is EITHER depressed mood OR loss of interest/pleasure in activities
• What is a mixed episode?

  EITHER...A mixture/rapid alternation of manic & depressive symptoms

  • A mixture/rapid alternation of manic & depressive symptoms

  OR

  • At least 1 week where meet criteria for manic/hypomanic episode & at least 3 symptoms of depression present

  OR

  • At least 2 weeks where meet criteria for major depressive episode & at least 3 manic/hypomanic symptoms are present
• What is the difference between bipolar I & bipolar II?

  Bipolar I -> have had at least 1 manic episode (mania & depression - most common)

  Bipolar II -> have not had a manic episode (hypomania & depression)
• What are the symptoms of a manic episode in bipolar disorder?

  Grandiose ideas & delusions (feeling superior, invincible etc)

  Pressure of speech (rapid, urgent speech)

  Excessive energy

  Flight of ideas

  Abnormally elevated mood

  Altered sleep pattern (little sleep)

  Poor concentration

  Bright clothes

  Increased appetite

  Increased libido/sexual disinhibition

  Recklessness (esp with money)

  Hallucinations (often voices)
• What are the symptoms of a depressive episode?

  Low mood

  Anhedonia (loss of interest in activities)

  Hopelessness

  Fatigue

  Difficulty concentrating

  Feelings of worthlessness or guilt

  Recurrent thoughts of death/suicide

  Change in sleep (reduced/excessive)

  Changes in appetite

  Psychomotor agitation/retardation

  Severe cases -> delusions/hallucinations
• What are the symptoms of hypomania?

  Mild elevation of mood or irritability

  Increased energy & activity

  Feelings of well-being, or physical & mental efficiency

  Increased sociability, talkativeness, or over-familiarity
• When should you suspect bipolar disorder?

  Symptoms of...

  • Mania
  • Hypomania
  • Depression & a Hx of previous episodes of mania/hypomania
  • Mixture of both manic & depressive symptoms
• What are the DDx of bipolar disorder?

  Unipolar depression

  Cyclothymia

  Schizophrenia

  Mood disorder due to underlying medical condition (stroke, thyroid, MS)

  Substance misuse

  Organic brain disease

  Iatrogenic cause

  Metabolic disorders

  Personality disorders

  Anxiety disorders

  OCD

  ADHD
• Suicide is a significant risk factor for bipolar disease. Go from intense high to intense low. Risk is much higher in mixed episodes of bipolar disorder -> have thoughts & motivation of suicide.
• What are the investigations for bipolar disorder?

  Primary Care Evaluation of Mental Disorders (PRIME-MD)

  PHQ-9

  Rapid Mood Screener (RMS)

  Mood Disorder Questionnaire (MDQ)

  Bipolarity Index

  Young Mania Rating Scale

  FBC

  Thyroid function

  Serum vitamin D

  Toxicology screen
• What are the RFs of bipolar disorder?

  FH of bipolar/schizophrenia

  Onset of mood disorder before 20

  Adverse life events

  Childhood trauma

  Hx of depression

  Hx of substance misuse

  Co-morbid anxiety disorder
• What are the signs of lithium toxicity?

  Blurred vision

  Coarse tremor

  Nausea/diarrhoea

  Anorexia

  Increased urination/incontinence

  Ataxia

  Confusion

  Dysarthria (difficulty speaking)

  Coma

  ECG changes

  Muscle twitches

  Seizures

  Death
• Lithium toxicity is an emergency admission - need close monitoring & treatment.
• What is the management of bipolar disorder?

  Psychological interventions - CBT, psychoeducation

  Lithium (mood stabilizer) -> alternative can be sodium valproate

  Management of mania/hypomania -> consider stopping antidepressant if a pt takes one; consider antipsychotic therapy (olanzapine or haloperidol)

  Manage depression -> talking therapies, consider antidepressants (do not use alone - can increase the risk of manic episodes)

  Address co-morbidities (diabetes, CVD, COPD)

  ECT - used in prolonged, treatment-resistant, life-threatening mania
• What is the plasma therapeutic range for lithium?

  0.4 - 1 mmol/l

  have to take levels 12 hours from last dose (trough level)

  too low -> not taking meds

  too high -> lithium toxicity
• What does the pathophysiology bipolar disorder include?

  Genetic predisposition

  Neurotransmitter imbalances (serotonin, dopamine & norepinephrine)
• What are the possible complications of unmanaged bipolar disorder?

  Other psychiatric disorders (anxiety disorders, substance misuse disorders & ADHD)

  Increased risk of suicide

  Cognitive impairment

  Physical health issues (CVD, diabetes, obesity)

  Social & occupational dysfunction
• What factors affect the prognosis of bipolar disorder?

  Course (chronic & relapsing)

  Functional Impairment

  Suicide Risk

  Comorbidities (anxiety, substance misuse, CVD)

  Treatment response (non-adherence is associated with poor prognosis)
• What are clang associations?

  Ideas related only by rhyme or being similar sounding
• When changing dosage of lithium, when should levels be checked?

  1 week after dose change, then weekly until levels stabilise
• What is lithium?

  Mood stabiliser
• What are the adverse effects of lithium?

  Nausea & vomiting

  Diarrhoea

  Fine tremor

  Nephrotoxicity (polyuria, secondary to nephrogenic diabetes insipidus)

  Thyroid enlargement (may lead to hypothyroidism)

  ECG changes (T wave flattening/inversion)

  Weight gain

  Idiopathic intracranial HTN

  Leucocytosis

  Hyperparathyroidism & resultant hypercalcaemia
• What is the pathophysiology of bipolar disorder?

  Neurotransmitter dysregulation

  Alterations in monoamines (serotonin, dopamine & noradrenaline)

  Manic episodes -> increased dopaminergic activity -> heightened arousal & euphoria

  Depressive episodes -> reduced serotonergic & noradrenergic transmission -> low mood & anhedonia

  
  

  HPA activity is dysregulated in bipolar pts

  Hyperactivity → elevated cortisol levels → during depressive states

  Blunted response → during manic episodes
• What is important to monitor when a patient is taking lithium?

  Plasma lithium levels

  Weight

  eGFR

  TFTs
• What is important about taking a patient off lithium?

  Don't just stop (unless lithium toxicity), can cause rebound mania
• What is circumstantiality?

  The inability to answer a question without giving excessive, unnecessary detail
• What is the management of acute mania?


  Risperidone