Bipolar

Question 1

Why is it so hard to dx bipolar disorder?

Answer 1

• because it often gets misdx as depression - pt isn’t going to come in while in manic state b/c they feel great

Question 2

What are good labs to order if a person comes in with a suspected bipolar/depressive disorder to rule out other things?

Answer 2

• tox screen
• TFTs
• RPR
• CMP
• CBC

Question 3

What are key psychiatric terms to describe a possible hypomanic bipolar pt’s behavior?

Answer 3

comes in and says:

• I have been up all night working - she has had a decreased need for sleep
• talking about her superiority to others in her program (grandiosity or inflated self esteem)
• markedly more active in her grad school research - increase in goal directed activity
• thought processes jump from 1 idea to another - flight of ideas

Question 4

Key psychiatric terms to describe a possible manic bipolar pt’s behavior?

Answer 4

• Thinks he is greates thinker in the history of humanity - grandiosity or inflated self esteem
• speech is rapid and pressured, tangenital speech
• decreased need for sleep
• exceeded his limit after charging several thousand dollars - injudicious impulsive behavior
• police brought the person to the hospital

Question 5

Main characteristics of hypomania?

Answer 5

• briefer duration (at least 4 days) of manic sxs, and often used to refer to a less severe level of sxs
• psychosis doesn’t occur with hypomania**
• causes only mild fxnl impairment and can even improve fxning
• Doesn’t lead to hospitalization

Question 6

Main characteristics of mania?

Answer 6

• longer duration (at least 1 week) and more severe sxs
• psychosis can occur (doesn’t have to though)
• sig. impairment in fxning
• often leads to hospitalization

Question 7

2 subtypes of bipolar?

Answer 7

bipolar 1:

• hx of at least 1 manic episode, with or w/o past major depressive episodes
• although not reqd for dx, depression is present more commonly than mania for most pts

bipolar 2:

• hx of at least 1 episode of major depression
• hx of at least one hypomanic episode
• no hx of manic episode

Question 8

DSM-5 manic episode?

Answer 8

• distinct period of abnormally and persistently elev, expansive, or irritable mood, lasting at least 1 week
• during period of mood disturbances - 3 or more of following sxs persisted and have been present to a sig degree:
• grandiosity
• decreased need for sleep
• more talkative, pressured speaking
• flight of ideas
• distractibility
• increase in goal oriented activity
• excessive involvement in pleasurable activities - painful consequences - buying sprees, sex
• mood distrurbance is severe to caused marked impairment in occupational fxning, social activities
• hospitalization
• has psychotic features
• sxs not due to effects of substance or medical conditions (hyperthyroidism)

Question 9

hypomanic episode DSM-5?

Answer 9

• distinct period of abnorm and persistently elevated, expansive, or irritable mood and abnormally and persistently increased energy, lasting at least 4 consecutive days
• during this period - present with 3 or more of the following sxs:
  grandiosity
  decreased need for sleep
  more talking, pressured speech
  distractability
  increase in goal directed activity
  excessive involvement in pleasurable activities with high potential for painful consequences
• uncharacteristic of the pt
• sxs observed by others
• **not severe enough to cause marked impairment in social or occupational fxning to necessitate hospitalization

Question 10

epidemiology of bipolar?

Answer 10

• lifetime prevalence traditionally est as about 1%
• more recently, spectrum of bipolar conditions est to have higher prevalence (better screening?)
• WHO ID bipolar as 6th leading cause of disability adjusted life years worldwide among people 15-44
• bipolar 1 affects men and women equally
• II is more common in women
• age of onset - generally 15-30

Question 11

Is genetics a factor in bipolar disorder?

Answer 11

• monozygotic twin: 40-70%
• 1st degree relative: 5-10%
• unrelated person - 0.5-1.5%
• suspicion should increase when there is positive famiyl hx
• no single gene has been ID’d
• likely a complex interaction b/t genetic and enviro factors is involved
• some studies have suggested role for tryptophan hydroxylase 2, which is a rate limiting enzyme in synthetic pathway of serotonin

Question 12

Clinical course of bipolar I?

Answer 12

• marked by relapse and remissions
• often alternating pattern b/t manic and depressive episodes
• 90% who have 1 manic episode have another in 5 years
• 90% with bipolar have at least 1 psychiatric hospitalization and majority have 2 or more
• depressive sxs are more frequent than manic sxs - 3:1 ratio

Question 13

clinical course of bipolar 2?

Answer 13

• course less studied, and less understood
• depressive sxs much more frequent than hypomanic episodes ( suggested to be 37:1)
• onset earlier age
• greater risk at attempting and committing suicide

Question 14

Comorbidities of bipolar disorder?

Answer 14

• high rates of comorbid alcohol or substance abuse
• lifetime risk for addictive disorder - 65%
• comorbid anxiety disorder is common
• b/t 25-50% attempt suicide, and 15% are successful (sig higher than those with depression)

Question 15

What does a mixed state refer to?

Answer 15

• presence of both depressive and manic sxs simultaneously
• person may experience impulsiveness, insomnia, irritability, and flight of ideas that can present in manic episode as well as suicidal thoughts, guilt, feelings of hopelessness, and changes in appetite that are common during depressive episodes
• mixed episodes are incredibly distressing to the individual, it can lead to panic attacks, substance abuse, and suicide
• it’s really difficult to tx

Question 16

What is cyclothymia?

Answer 16

defined by presence of:
- numerous periods of hypomania and of depression, persisting for at least 2 years
this is distinctly diff from bipolar I and II where there is predominance of depressive sxs
- doesn’t meet DSM criteria for major depression
- considered to be 1 of the bipolar disoders and is tx with same kinds of meds

Question 17

Mania and MDE - dx?

Answer 17

• bipolar I

- at least 1 wk for mania and 2 weeks for MDE

Question 18

hypomania and MDE - dx?

Answer 18

• bipolar II

- has to be for at least 4 days for hypomania and 2 weeks for MDE

Question 19

Hypomanic and depression sxs, frequently switching - dx?

Answer 19

• cyclothymic disorder

- has to be for at least 2 years

Question 20

Key principles in tx?

Answer 20

• untx bipolar is assoc with substantial morbidity
  and mortality
• tx differs from that of unipolar depression
• common for bipolar to be missed

Question 21

Tx of bipolar?

Answer 21

• depends on how pt presents and includes number of meds:
• classic “mood stabilizers”:
  lithium, valproate, carbamazepine
• other drugs used:
  quetiapine (seroquel)
  risperidone
  olanzapine (zyprexa)
  ziprasidone (geodon)
  clozapine (clozaril)

Question 22

What are obstacles for bipolar management?

Answer 22

• many pts like mania
• when pts feel good, they don’t want to take meds
• education is key!!

Question 23

Good ?s to ask a pt that you suspect has bipolar?

Answer 23

• have you experienced sustained periods of feeling uncharacteristically energetic?
• have you had periods of not sleeping but not feeling tired?
• have you felt your thoughts were racing and couldn’t be slowed down?
• have you had periods where you were excessive in sexual interest, spending money, or taking unusual risks?

Question 24

Primary diff b/t hypomania and mania?

Answer 24

• lack of sig impairment in social or occupational fxning and absence of psychosis or sxs that necessitate psychiatric hospitalization

Question 25

What can mimic bipolar disorders?

Answer 25

- drugs such as cocaine and amphetamines can cause substance induced mood disorders - hyperthyroidism - mimic signs of mania as well - critical to check tox screen and TFTs

Question 26

How will you catch most people with bipolar disorder?

Answer 26

- asking about a hx of manic or hypomanic episode when they present with depressive sxs