BPAD

Question 1

What is ICD-10 of BPAF

Answer 1

2 + episodes of mood disturbances (depression, mania)
At least 1 episode has to have been mania/hypomania

Question 2

what is DSM-5 of BPAD

Answer 2

Bipolar 1 – 1 episode of mania
(may be followed by episode of
depression/hypomania)
Bipolar 2 - at least one hypomanic episode and at least one major depressive episode

Question 3

Mood in general

Answer 3

Normal to have changes in mood, sometimes in response to things.

When someone has a mood disorder its not the natural variation of mood, much more stark and prolonged changes.

Question 4

What are the signs and symptoms of mania?

Answer 4

• Symptoms must be present for at least 7 days
• Marked disruption of functioning - RISKS
• Mood
• Elevated, irritable, or labile
• Disinhibition with their money- spending alot in short time e.g., gamble, huge debts quickly
• Engaging or insensitive
• Energy and goal directed activity
• Impulsive
• Poor judgement
• Disregard for risks
• Grandiosity
• Exaggerated
• Talents
• Sleep
• Decreased need cf insomnia
• Cognition
• Racing thoughts, Distractibility
• Flight of ideas, Poor memory- Flight of ideas is when peoples thought processes go so fast but they miss things out of speech so difficult to understand.
• Speech
• Loud, Rapid, Clanging- Clanging - when the links between thoughts become more about the sounds
• Jokes, Gestures
• Perceptions
• Delusions, hallucinations, first rank- First rank symptoms that are very typical of schizophrenia - third person voice, running commentary, interference with thoughts.

Mood is amazing. This must be present for more than 7 days, not just a short blip in their mood.

This impinges on all manners of your life - employment, relationships, safety

Large percentage of people also have psychosis with mania. Delusions often not in keeping with the mood - look and sound happy but talking about something scary or traumatic.

Question 5

What are some psychotic symptoms of mania

Answer 5

• Usually in severe mania
• Grandiose delusions – related to identity or role
• Suspiciousness – can turn into persecutory delusions
• Pressured speech so severe unable to understand
• Irritable behaviour -> violent behaviour
• Preoccupation with thoughts/schemes lead to * severe self neglect
• Catatonic behaviour
• Complete loss of insight

Question 6

What are the signs and symptoms of hypomania?

Answer 6

• Symptoms must be present for at least 4 days
• Similar to mania symptoms
  
  • But milder
  • No psychotic symptoms
  • Functioning not markedly impaired
• If requires hospital admission = Mania
• If only hypomania: Bipolar Type II
• Is distinction between hypomania/mania arbitrary?

Milder than mania, no psychotic symptoms and function not as impaired.

Question 7

What might be the differential diagnosis leading to bipolar disorder?

Answer 7

• Schizoaffective/Schizophrenia
• Substance misuse (stimulants)
• Organic disease (dementia, thyroid etc)
• Personality disorder (esp BPAD2 vs BPD)

Can be difficult to disentangle symptoms to see what it might be.

Bipolar patients tend to recover more fully between episodes.

Question 8

What is the epidemiology of bipolar disorder?

Answer 8

• Lifetime prevalence 2.8% (≈Hyperthyroid)
• WHO 46th / 291 greatest cause of disability
  
  • Greater than breast cancer and Alzheimer’s
• Male to Female 1:1
• Mean age of onset is 18-20 but presentation delayed for up to 10 years
• Substance misuse/anxiety disorders commonly comorbid

Can be difficult to diagnose someone quickly with bipolar as around the age where it’s common to move around different people etc might go unnoticed. Also often because people have a first depressive episode which they are treated for, and then don’t have their first manic episode for many years. Also wouldn’t really go to the doctor to complain about feeling really happy.

Question 9

What is the course of action of bipolar disorder?

Answer 9

• Most people first present with depressive episode
• Manic episode usually within 5 years
• Manic episodes shorter (6 vs. 11 weeks)
• Rapid cycling (>4/yr)
• Gap between episodes shortens
• Pregnancy (>50% chance of relapse)

Generally as get older, episodes become more frequentPregnancy one of the biggest risk factors for the mental health of women generally. Can be very difficult to treat with concerns of wellbeing for the baby.

Question 10

What is the prognosis of bipolar disorder?

Answer 10

• Chronic illness
  
  • (40 year follow up – 16% remission)
• Hard to treat
• Mortality increased
  
  • SMR = 1.6 (60% higher risk of death)
  • Suicide rates much higher (SMR 15M and 22F)

Part of reason mortality increased due to lifestyle (smoking, risk taking) also partly due to the medications

Question 11

What is the biological aetiology of bipolar disorder?

Answer 11

• Genetics
	• MZ: DZ 40:5
	• 5 to 10% chance in first degree relatives
	• Overlap with Schizophrenia(!)
• Neuroanatomy
	• Early development
		○ White matter connections
		○ Pruning prefrontal cortex
		○ Leads to decreased connections between prefrontal networks and amygdala
	• Neurodegeneration
		○ Control for confounders
		○ Smaller total grey matter
• Neurotransmitters

When thousands of genes across whole genome infer an increased risk for a condition.

Question 12

What si the psycho-social aetiology of bipolar disorder?

Answer 12

• US study – link with childhood physical abuse
• New Zealand – involvement with child protection agency not linked
• Patients with BPAD
  
  • Emotional and sexual abuse lower age of onset and increase risk of suicide
• No link with obstetric complications
• ACEs

Question 13

What are the three phases of bipolar disorder to consider in treatment?

Answer 13

BPAD depression
Acute mania
Mood stabilisation

Question 14

About bipolar depression

Answer 14

• Difficult
• Often unopposed antidepressant = MANIA
• Medication Naïve
  
  • Fluoxetine + Olanzapine or Quetiapine (antipsychotic with mood stabilising properties)
  • Consider Lamotrigine
• Already on mood stabiliser (lithium or valproate)
  
  • Check level and increase dose as required
  • Add Fluoxetine + Olanzapine
  • Consider Lamotrigine + Lithium/Valproate
• Discontinue anti-depressant when depressive symptoms stop

Lamotrigine is an antiepileptic drug which can also be used as a mood stabiliser

Question 15

Maintenance of health in bipolar disorder treatment

Answer 15

• Lithium – most effective long term pharmacological Rx
• Other mood stabilisers: Valproate, Lamotrigine, Carbamazepine
• Antipsychotics: Olanzapine, Quetiapine

Valporate has terrible implications for unborn children eg spina bifida

Question 16

About lithium as a treatment for bipolar disorder

Answer 16

• Narrow therapeutic index
• Exclusive renal excretion
• Toxicity
  □ Coarse tremor, marked GI upset, dehydration, lethargy, agitation, myoclonus, hypertonicity, confusion, drowsiness, arrhythmia

Need to have blood tests a lot for thyroid and renal function

Question 17

What are other considerations for bipolar disorder treatment?

Answer 17

HTT: home treatment techniques - struggle, manic patients often difficult and often get admitted to hospital

ECT - electroconvulsive therapy is actually one of the most effective therapies. Can be miraculous. Nowadays have general anaesthetic, muscle relaxant so don’t shake. Indicated for treatment resistant or life threatening depression and for refractory mania. Biggest risk of the treatment is the general anaesthetic and can have autobiographical memory loss.

Question 18

Triggers for a relapse

Answer 18

Non concordance-
Illicit drug use
Lack of sleep
Increased stress – bereavement, exams, divorce, moving house

Question 19

Risks caused by BPAD

Answer 19

Suicide
Unintentional self injury
Financial risk
Sexual risk – to others, to self
Violent risk
Arson

Question 20

Poor prognostic factors of BPAD

Answer 20

Poor prognostic factors
Poor employment
Alcohol abuse
Psychotic features
Depression
Male
Non-compliance

Question 21

Good prognostic factors

Answer 21

Short episodes of mania
Later age of onset
Few suicidal thoughts
Few psychotic symptoms
Good treatment response
Good compliance

Question 22

Side effects of Lithium as a treatment

Answer 22

• Side Effects:
  □ Polyuria, polydipsia, weight gain, fine tremor, lethargy, GI upset, skin problems
  □ Hypothyroidism, renal failure, teratogenicity (Ebstein’s anomaly), cardiac conduction problems

Question 23

signs of toxicity in lithium treatments

Answer 23

low level can be treated with fluids in A&E

severe- dialysis and ITU admission, can be caused when taking other drugs alongside Li which is bad such as, Nsaides- cause Li increase

Coarse tremor, marked GI upset, dehydration, lethargy, agitation, myoclonus, hypertonia, confusion, drowsiness, arrhythmia

Question 24

psychological treatments of BPAD

Answer 24

CBT
Family therapy
Psychoeducation- teaching families to watch for potential signs for relapse
Support Groups

Question 25

Treatments for acute mania

Answer 25

Lithium – response rate of around 80% but takes up to 2 weeks to take effect. Valproate-has to be used with a lot of care with women in childbearing age due to the causal effects it has on foetus development, malformations so not prescribed anymore for that age group. Antipsychotic – good in acute behavioural disturbance eg olanzapine, quetiapine, risperidone, haloperidol BDZ – used to help with sedation whilst waiting for above to work ECT (catatonia/prolonged or severe manic episode) – good evidence, seldom used. Pregnancy and breastfeeding - The risks associated with ECT in pregnancy and breastfeeding is the same to those in the general population which makes it good.

Question 26

Treatments for bipolar depression

Answer 26

Medication that is designed to treat depression such as SSRI certraline which will do more harm than good in BPAD patients if taken alone If severely depressed/suicidal/urgent can use: ECT Lithium Valproate Anti-psychotic eg quetiapine Anti-convulsant eg lamotrigine SSRIs (trust recommend combining fluoxetine and olanzapine) If on prophylactic medication – optimize, check compliance

Question 27

What are the 3 social factors affected by BPAD

Answer 27

social isolation, employment and family

Question 28

what is the impact of employment if you have BPAD

Answer 28

21% of people with a long-term mental health condition are in employment (ONS) 90% of people with bipolar had told their employer about their condition but 24% of them regretted making that decision (Bipolar UK) Rates of positive screening for bipolar disorder are higher in unemployed people, in those receiving particular benefits, and in people living alone. 4% of women on Employment Support Allowance screen positive for bipolar (Adult Psychiatric Morbidity Survey) Financial impact of job loss plus excessive spending can be devastating  

Question 29

what is the impact of social isolation of you have BPAD

Answer 29

Patients may become socially withdrawn during depressive episodes Reckless behavior may impact on relationships leading to reduced social support Long periods in hospital may lead to breakdown of friendships 72% of people with bipolar knew no one else with the condition when they were first diagnosed (Bipolar UK)

Question 30

what is the impact of family if you have BPAD

Answer 30

Disturbed routine Coping with the recklessness of the patient during manic episodes Financial distress Strained relationships, increased divorce rates Role reversal Social isolation Development of mental health difficulties in other members of the family