Bipolar Disorder

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  • Created by: LBCW0502
  • Created on: 19-10-18 11:46
What is bipolar disorder?
Disorder of mood with distinct periods of jubilation/elation with episodes of depression. Possible for complete recovery between mood episodes. Distinguished from mania/hypomania
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Outline the spectrum of mood
Subjective description of mood (happy/sad). Mania - hypomania - hyperthymic temperament - euthymia - depressive temperament - dysthymia - depression
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Describe features of presentation mania
Varies. Can present irritability (bipolar more than just mania). Symptoms - overactivity, reduced sleep, irritability, rapid speech, flight of ideas, disinhibition, grandiose delusions, reduced insight
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Describe features of hypomania
Lower mania, no psychotic features/shorter duration/reduced disability. Persistence, non-reactive. May be viewed as positive experience (productive). Overestimate capabilities
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What is the difference between bipolar 1 and bipolar 2?
Bipolar 1 - symptoms mania predominate. Bipolar 2 - depressive episodes predominant - interspersed with hypomania
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What is cyclothymia?
Mood fluctuates between sub-clinical depression and hypomania (other proposed - recurrent depressive episode with hyperthymic temperament)
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Describe features of the diagnosis of bipolar disorder - Diagnostic Criteria for manic Episode
Distinct period of abnormality, persistently elevated, expansive/irritable mood, lasts 1 week. During mood disturbance, 3 symptoms show - low self-esteem, less sleep, more talkative, flight of ideas, distracted, increased goal, more activities
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What is the difference between Schizophrenia and Schizoaffective disorder
Schizophrenia - hear voice from outside. Schizoaffective disorder - combination of Schizophrenic symptoms in bipolar disorder (hear voice but not from outside) - also symptoms from substance misuse
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Describe features of organic brain syndromes
Disinhibited, manic-like behaviour present with frontal lobe dementia, CVA, encephalitis, epilepsy. Present in elderly patients.
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Describe features of metabolic disorders
Hyperthyoidism, Cushing's disease, Addison's disease, Vitamin B12 deficiency, dialysis (cause manic symptoms). Symptoms usually resolve within 1 week of treatment
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Describe features of course and prognosis bipolar disorder
Chronic/recurrent illness. Average of 10 episodes in lifetime. Depression/mania may cluster together. Length of euthymia may shorten. Risk of suicide. High burden of physical illness for diabetes and heart disease
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Describe features of genetics involved in bipolar disorder
Family members with bipolar disorder have 5-10 times increased risk of illness, 2x increased risk of developing unipolar disorder. Complex genetics involving multiple gene paths
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Describe features of psychological influences on bipolar disorder
Biological factors are the main precipitants for bipolar disorder. Social support/self-esteem potentially act as precipitants or exacerbants. Traumatic experiences influenced by altering HPA axis response
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Describe features of neurohormonal abnormalities - HPA axis dysfunction
CRH secreted during stress - ACH released by anterior pituitary, cortisol release by adrenal glands. Cortisol has negative feedback on hypothalamus (stop further release of CRH). Psychotic depression - high levels of cortisol, abnormalities
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Describe features of neurotransmitter abnormalities
Dysregulation in monoamine neurotransmitters (mania). Abnormal dopamine/5HT/NA pathways. Irritable mood - hyperactivity in amygdala/ventromedial prefrontal cortex/orbital frontal cortex.
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Describe features of neurotransmitter abnormalities - other manic symptoms (1)
Flight of ideas (neurotransmitter hyperactivity in nucleus accumbens). Risk taking/pressured speech (poor impulse control regulated by orbital frontal cortex)
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Describe features of neurotransmitter abnormalities - other manic symptoms (2)
Impulse control may be regulated by dorsolateral prefrontal cortex and centromedial prefrontal cortex. Brain regions innervated by serotongergic noradrenergic and dopaminergic projections. Nucleus accumbens is only innervated by 5HT/dopamine
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What are the four different phases of bipolar disorder?
Acute mania, prophylaxis mania, acute depression, prophylaxis depression
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Describe the treatment options for acute mania (1)
Antipsychotic, valproate or lithium. Other psychotic considered if manic symptoms are severe (stronger sedative effect). Lithium takes long time to show effect (limits usefulness). Consider side effect profile
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Describe the treatment options for acute mania (2)
Benodiazepine for severe behavioural symptoms. Carbamazepine and lamotrigine - not recommended for treatment of acute mania
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Describe treatment options for prophylaxis mania (1)
Long term treatment for manic episode with risk/adverse consequences or patient with bipolar 1 who has had 2+ acute episodes. Lithium, valproate, antipsychotics olanzepine/quetiapine (long term).
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Describe treatment options for prophylaxis mania (2)
Specific agent choice depends on: previous response, co-morbidity, patient preference, patient's gender (valproate poses risks for younger females, risk of polycystic ovary disease, risk of teratogenicity if individual becomes pregnant).
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Describe treatment options for prophylaxis mania (3)
Recommended treatment continues for at least 2 years. Can continue up to 5 years: history of frequent episodes, severe psychosis, co-morbid substance misuse, on-going stressful life events, poor social support
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Describe the mechanism of action for antipsychotics (1)
Precise mechanism/pathology not clear. Hyperactive neuronal circuits (dysfunctional). Medicines retune dysfunctional neuronal circuits. Antipsychotics antagonist dopamine (D2) receptors (reduce symptoms in mania)
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Describe the mechanism of action for antipsychotics (2)
Antagonist 5HT2A receptors - reduce reduction non-psychotic symptoms, as a result of inhibition of glutamate hyperactivity
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Describe the mechanism of action for lithium (1)
Unclear mechanism (despite use for >50 years). Promote neuroprotection and long term plasticity of dysfunctional neuronal circuits. Potential mechanisms - inhibit secondary messenger enzymes (im), impact signal transduction beyond neurotransmitter
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Describe the mechanism of action for lithium (2)
Modulation of key proteins (protein G), affects signal transduction. Inhibition of signal transduction cascades e.g. glycogen synthetase kinase 3 (GSK) and protein kinase C
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Describe the mechanism of action for valproate (1)
Unclear mechanism (antimanic/anticonvulsant). 3 possibilities - inhibit Na channels (reduce influx, glutamate excitatory neurotransmission). Boost actions of GABA by inhibiting uptake, enhancing GABA release, inhibit GABA metabolism (transaminase)
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Describe the mechanism of action for valproate (2)
Regulation of downstream signal transduction cascades. Leads to promotion of neuroprotection and long term plasticity. Not clear if all mechanisms account for antimanic/anticonvulsant effects
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Describe the issues with lithium
Effective in all four phases of bipolar. Also used as adjunct in unipolar depression. Toxic (narrow therapeutic range). Requires regular blood monitoring. Poor compliance, Li long t1/2
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What are the side effects of lithium?
Thirst, polyuria, fine tremor, weight gain, hypothyroidism
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What are the signs of lithium toxicity?
Blurred vision, increasing vomiting, confusion, ataxia, coarse tremor, lack of co-ordination, impaired consciousness.
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Describe features of lithium toxicity and interactions
Li clearance (renal). Handles Li in the same way as Na. If patient is dehydrated/prescribed diuretic (Li level increases as Na retained). NSAIDs/ACE inhibitors (I/II) - increase Li level by reducing renal clearance- blood tests required
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Describe the issues with valproate
Licensed for acute mania, used both acute/maintenance, oral administration
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What are the side effects of valproate?
Gastric, weight gain, hair loss, polycystic ovary disease, hepatic toxicity
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Describe features of valproate use in women
Most teratogenic mood stabiliser (linked to polycystic ovary disease). Avoid in woman of child bearing potential. Ensure women understand: risks associated with pregnancy, use effective contraception, regular treatment review, consult for pregnancy
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Describe features of carbamazepine
Benefit acute mania and prophylaxis. Used with/without lithium. Used in rapid cycling disorder.
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Describe features of other anticonvulsants in mania (1)
Gabapentin (little evidence to support use in maintenance of bipolar/rapid cycling). Levetiracetam, felbamate, tiagabine, vigatarin, phenytoin (should be avoided)
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Describe features of other anticonvulsants in mania (2)
Topiramate and zonisamide - potential use but has association with weight loss - unlicensed medications
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Describe the treatment options for acute depression
Mild (re-assess in 2 weeks). Moderate-severe (SSRI - less likely to cause switching to mania). Patient with history bipolar disorder - antimanic agent if prescribed antidepressant. Stop antidepressant after 8 weeks in minimise risk of switch to mania
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Describe the treatment options for prophylaxis depression
Don't consider antidepressants. Lithium shows benefit. Less evidence to support use of valproate. Antipsychotics have some evidence e.g. olanzapine/quetiapine. Lamotrigine might be a further option
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Describe features of Lamotrigine
No licensed in the UK - used in management bipolar disorder. Limited evidence for prophylaxis of manic episodes. Evidence to prevent depressive episodes. Can avoid need of antidepressant, reduced risk of switching to mania
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Why is care needed with the initiation of Lamotrigine?
Slow dose titration minimise risk of Steven Johnson Syndrome. Particular care needed if patient concurrently receiving valproate
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Describe the challenges in long term compliance with medication?
Long term compliance for chronic conditions, apparent stability between episodes, patient's enjoy 'normal' mental state of jubilation/mild mania. Some patients see their manic symptoms as a problem for others
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What are the issues with management of bipolar depression?
Bipolar depression poorly studied, most evidence from unipolar studies. Risk of antidepressant drugs switching patients into mania. Risk greater with noradrenergic antidepressants
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What are the challenges in managing bipolar illness in women of child-bearing age?
Increased risk of relapse in key reproductive stages. Valproate, lithium and carbamazepine all pose teratogenic/developmental risks. Valproate associated with increased risk of polycystic ovary disease - link with weight gain cannot be separated
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Other cards in this set

Card 2

Front

Outline the spectrum of mood

Back

Subjective description of mood (happy/sad). Mania - hypomania - hyperthymic temperament - euthymia - depressive temperament - dysthymia - depression

Card 3

Front

Describe features of presentation mania

Back

Preview of the front of card 3

Card 4

Front

Describe features of hypomania

Back

Preview of the front of card 4

Card 5

Front

What is the difference between bipolar 1 and bipolar 2?

Back

Preview of the front of card 5
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