Term
A patient presents with decreased sleep need and euphoric mood. Her thoughts are racing and she exhibits pressure speech and impulsive behavior in your office.
What is going on? |
|
Definition
This is classic mania as seen in Bipolar I Disorder (rare compared to Bipolar depression)
1) Irritable, expansive or euphoric mood
2) Decreased sleep need
3) Racing thoughts
4) Pressured speech
5) Impulsive behavior. |
|
|
Term
| Why does treatment of bipolar disorder require specialty psychiatric care? |
|
Definition
1) Comorbidity is the rule (shorten lifespan by 20 years)
-Increased CVD, Metabolic, Thyroid and Migraines
- Increased Anxiety, Personality and Substance use Disorders
2) 10-25% suicide risk
3) Common misdiagnosis (takes 10 years on average!)
4) Treatment regimens have many side effects |
|
|
Term
A patient suffers from a period of persistently and abnormally elevated mood that has lasted 2 weeks. She exhibits inflated self-esteem, is quit talkative and goal-directed, taking part in an excessive number of pleasurable activities with high potential for painful consequences. She has only been sleeping 4 hours per night.
Whats going on? |
|
Definition
Fits DSM IV criteria for diagnosis of Manic Episode (if it were only 4-7 days, it would be Hypomanic)
1) Mood disturbance lasting >1 week (elevated, expanded or irritable)
2) 3 or more
- Inflated self-esteem
- Decreased need for sleep
- More talkative with pressure to keep talking
- Flight of ideas or subjective, racing thoughts
- Distractible
- Increase in goal-directe activity or psychomotor agitation
- Excessive involvement in pleasurable activities with possible dangerous consequences. |
|
|
Term
| How can you distinguish between Manic and Hypomanic Episodes? |
|
Definition
1) Manic episodes last >1 week with at least 3 or 7 symptoms
2) Hypomanic last >4 days with at least 3 of 7.
- NOT EVERE ENOUGH TO CAUSE MARKED IMPAIRMENT |
|
|
Term
Distinguish between Major Depressive Episodes, Manic Episodes and Hypomanic Episodes based upon
1) duration of symptoms
2) Minimum # of symptoms
3) Marked impairment
4) Psychosis
5) Hospitalization
6) May be caused by general medical condition/drugs |
|
Definition
1) MDE is 2 weeks, with 5 symptoms, impairment and psychosis. It may include hospitalization
2) Manic episode is >1 week with at least 3 symptoms (4 if mood is only irritable), impairment and possibility of psychosis. Hospitalization may occur
3) Hypomanic Episodes last 4 days with at least 3 symptoms (4 if mood is only irritable), NO impairment, NO Psychosis and NO hospitalization
** None involve general medical condition/drugs** |
|
|
Term
A patient has had 4 manic episodes in the last 12 months, each of which have preceded major depressive episodes. She has also experienced a number of hypomanic episodes in the past.
How should you treat this condition? |
|
Definition
Rapid Cycling Bipolar 1
RC means at least 4 mood episodes (MDE, mania, hypomania or mixed) in last 12 months |
|
|
Term
| What pharmacological options are available to treat bipolar disorder? |
|
Definition
Mood stabilizers and Anti-psychotics are main-stay
*Cause metabolic morbidity!
1) Lithium is best for classic mania and works in 50% of patients
2) Anticonvulsants are good for rapid cycling (CBZ, Valproate), but have side effects
- Lamitrigine for bipolar depression
3) Antipsychotics such as Respiredone or Clozapine are good for acute mania w/ or w/o psychosis
- Use Atypical or look out for Tardive dyskinesia!
4) Benzodiazepines for sleep and agitation in manic patients
5) Antidepressants for bipolar depression ONLY WITH MOOD STABILIZERS (otherwise iatrogenic mania is induced) |
|
|
Term
| Why should you be careful when giving Antidepressants for bipolar depression? |
|
Definition
ONLY give with mood stabilizer (Lithium), otherwise you can cause iatrogenic mania.
Avoid and use therapy if possible. |
|
|
Term
| What are the 3 phases of bipolar disorder treatments? |
|
Definition
1) Acute (floridly manic and psychotic and hospitalized)
- Control abnormal mood state with mood stabilizers and other medications
2) Continuation (1-6 months of improvement without complete abolishment)
3) Maintenance
- after 6 months and continues indefinitely (hopefully with psychotherapy rather than heavy medication). |
|
|
Term
A patient comes in to your office worried because they have been experiencing sleepless nights, depressed mood, lack of appetite, guilt and loss of interest in his daily activities for the past 2 weeks.
Additionally, he says that his mood has been fluctuating and a month ago he had a 4 day period where he has felt "on top of the world," with an excessive sex drive, but that he had never felt this way before and it went away after 4 days.
What is going on and what should you do? |
|
Definition
This sounds like Non-cycling Bipolar 2
- Hypomanic episode rules out MDD
- Absence of mania rules out Bipolar 1
DSM IV
- One or more MDE
- More or more hypomanic episode
- No history of manic episodes |
|
|
Term
| What is a good way to elicit from a patient whether they have been having hypomanic symptoms? |
|
Definition
"Please try to remember a period when you were in a high state"
"How did you feel then?
- Answer 32 items. |
|
|
Term
| What conditions other than Bipolar disorder can present as Mania? |
|
Definition
1) Stroke
2) Head trauma
3) Dementia
4) Brain tumor
5) Infection
6) MS
7) Hyperthyroidism
8) Post-partum states |
|
|
Term
| How does the epidemiology of Bipolar disorder differ from that of depression? |
|
Definition
1) Bipolar I and II have a lifetime prevalence of 3.9% with an earlier onset.
- Bipolar I is 1:1 male to female
- Bipolar 2 is 1:2 male to female
- No face basis, but strong genetic basis
2) Depression onset is later in life with a stronger female bias |
|
|
Term
| What is the most common disorder in family members of an individual with bipolar disorder? |
|
Definition
Major Depressive Disorder
- This is a trick, because even though bipolar will be more common than age-matched controls, MDD is even more common co-morbidity. |
|
|
Term
| What etiological features of Bipolar disorder have been identified? |
|
Definition
Disorder of
- Brain (mood, sleep, cognition)
- CV system (hyperglycemia, insulin resistance, obesity)
- Immune system (pro-inflammataory, elevated cortisol)
1) Abnormalities in intracellular signaling cascades related to limbic system
2) Circadian regulation (lithium studies with SCN) |
|
|
Term
| What medication should you prescribe for rapid cycling sufferers of Bipolar disorder? |
|
Definition
Anticonvulsants (CBZ, Lamotrigine, Valproate)
* Lithium will not work as well** |
|
|
Term
| What are the 6 major signs of poor prognosis with bipolar disorder? |
|
Definition
1) Loaded FH (1st degree especially)
2) Early age of onset
3) Severity of manic episode
4) History of past suicide attempts
5) Chronic course
6) Rapid cycling (use anti-convulsants) |
|
|
Term
| What forms of Psychotherapy are effective in treating Bipolar disorder? |
|
Definition
Helps get out of mania in 2-4 weeks rather than 4-6 months!
1) Psycho-education for patient and family
2) CBT to identify negative or distorted thoughts about illness
3) Interpersonal and Social Rhythms Therapy (IPSRT)
- disorder specific therapy to address social rhythm abnormalities to stabilize daily schedule
4) Family Focused Therapy (FFT)
- in combination with one or more significant another teach family members to communicate with one another successfully
5) ECT as last result |
|
|
Term
A patient has one episode of mania but multiple, severe episodes of major depression. What diagnosis best describes this condition?
a. Cyclothymia
b. Dysthymia
c. Bipolar I Disorder
d. Bipolar II Disorder |
|
Definition
|
|
Term
All of the following are symptoms of mania EXCEPT:
a. Racing thoughts
b. Grandiosity
c. Pressured speech
d. Decreased interest in pleasurable activities |
|
Definition
|
|
Term
Bipolar Disorder can be treated with all of the following categories of medications EXCEPT:
a. Mood stabilizer
b. Anticonvulsants
c. Benzodiazepines
d. Antiparkinsonians |
|
Definition
| D- DA agonists are NO GOOD for mania |
|
|
Term
Antidepressants should only be prescribed:
a. When a patient has a clearly defined episode of major depression
b. After inquiring about prior history of mania/hypomania
c. Checking liver function tests
d. All of the above |
|
Definition
|
|
Term
Risk factors for the development of bipolar disorder include all of the following EXCEPT:
a. Postpartum depression
b. Major Depression with psychotic features
c. Having a parent with bipolar disorder
d. Caucasian race |
|
Definition
|
|
Term
Which statement is generally TRUE regarding the length of time between mood episodes in bipolar disorder:
a. Decreases over time
b. Increases over time
c. Stays almost exactly the same over time
d. Longer in rapid cyclers compared to non-rapid cyclers |
|
Definition
|
|
Term
Which medication would be the BEST choice for monotherapy of a patient with rapid cycling bipolar disorder?
a. Lithium
b. Clonazepam
c. Valproate
d. Fluoxetine |
|
Definition
C- Anti-seizure meds are best for rapid-cycling bipolar (Lithium is usually mainstay, but not for rapid-cycling)
Clonazepam is a Benzo (for sleep disturbances)
Fluoxetine is an SSRI (NEVER monotherapy in bipolar) |
|
|
Term
The most common psychiatric diagnosis in family members of individuals with bipolar disorder is
a. Bipolar disorder
b. Unipolar disorder
c. Anxiety disorder
d. Substance abuse |
|
Definition
|
|
Term
Which of the following statements best characterizes the relationship between circadian rhythms and bipolar disorder?
a. There is growing evidence to suggest that abnormalities in circadian biology may be tied to the pathophysiology of bipolar disorder
b. Light therapy is used routinely to treat bipolar disorder
c. Disruptions in regularity of routines may perturb the underlying circadian rhythm integrity of and lead to mood episodes in individuals at risk for bipolar disorder
d. a and c |
|
Definition
|
|
Term
All of the following conditions are commonly seen comorbid with bipolar disorder, EXCEPT:
a. Anxiety
b. Migraines
c. Multiple Sclerosis
d. Obesity |
|
Definition
| C- MS is autoimmune and is not associated |
|
|
