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Bipolar Disorder

Bipolar disorder is characterised by recurrent episodes of depression and mania/hypomania:

  • Depressive episode - Period lasting >2 weeks of either low mood or anhedonia (or irritability in children and adolescents), accompanied by other additional symptoms e.g. lethargy, poor concentration.

  • Hypomanic episode - Similar to a manic episode but symptoms last for 4+ days, is not severe enough to cause marked impairment in social or occupational functioning or necessitate admission, and there are no psychotic features.

  • Manic episode - Period of persistently elevated, expansive, or irritable mood lasting > 1 week, accompanied by 3+ additional symptoms, and is severe enough to cause marked impairment in social or occupational functioning

    • Additional features of mania include psychomotor agitation (increased talkativeness, rapid speech, restlessness, distractibility), psychosis (delusions, and hallucinations), reduced need for sleep, and grandiosity.

    • If the patient requires hospitalisation, then it’s automatically classed as true mania even if the symptoms last less than 1 week.


N.B. The main difference to remember between mania and hypomania is that hypomania doesn’t cause any major social or functional deficit, and is typically shorter in duration.


Differentials:

  • Unipolar depression – more likely with onset after 25 yrs, and w/o family hx of bipolar

  • Cyclothymia – Chronic mood disturbance with depression and hypomania, where depressive symptoms don’t meet the criteria for a depressive episode

  • Schizophrenia – more likely in absence of prominent mood symptoms

  • Substance misuse, Iatrogenic, Metabolic disorders

ree

Mental State Examination Findings

  • A - Dressed inappropriately, privately, or outlandishly

  • B – Irritability, Restlessness, Distractable, Flirtatious, Increased psychomotor activity, Increased libido, Disinhibition, Extreme spending

  • S – Loud, Fast rate, Uninterruptible, Flight of ideas, Pressure of speech

  • MA – Euphoric (Elevated mood), which can quickly turn to irritability and anger

  • T

    • Form – Pressured, Tangentiality, Circumstantiality

    • Content – Grandiose delusions

  • P - Auditory hallucinations, which is often mood congruent

  • C - Attention and concentration often impaired

  • I - Poor


Management

Acute

  • Antipsychotics – Olanzapine, Risperidone, Haloperidol, Quetiapine

    • If 2 antipsychotics don’t work, Lithium or Sodium Valproate may be added (avoid in pre-menopausal women)

  • Exclude other causes, like substance misuse

  • Stop any antidepressants as it can exacerbate a manic episode



Preventation - Mood stabilisers, like Lithium or Sodium Valproate – Help prevent both mania and depression, and are quite effective

  • Lithium has a narrow therapeutic range, therefore its levels have to be carefully monitored to avoid toxicity - Before starting, check renal and thyroid function, and advise contraception in women


N.B. Lithium therapeutic dose → fine tremor. Toxic dose → coarse tremor.



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