Overview Bipolar disorder, previously termed manic depression, is a psychiatric diagnosis characterised by abnormally elevated or irritable mood episode(s) accompanied by disruptive symptoms of distractibility, indiscretions, grandiosity, flight of ideas, hyperactivity, decreased need for sleep, and talkativeness. It is well known that bipolar disorder carries with it high mortality and morbidity rates. The lifetime risk for suicide for people with bipolar disorder is 15%. Early recognition and treatment of bipolar disorders improve outcomes
| Definition Bipolar disorder type I: A syndrome with complete manic symptoms occurring during the course of the disorder. Bipolar disorder type II: Hypomania, characterized by depression and episodes of mania that do not meet the full criteria for manic syndrome. Hypomonia: Symptoms are similar to those of mania, although they do not reach the same level of severity or cause the same degree of social impairment. Rapid-cycling bipolar disorder: Occurrence of at least four episodes— both retarded depression and hypomania/mania—in a year. Labile: A mood and/or affect that switches rapidly from one extreme to another. For example, a patient can be laughing and euphoric one minute, followed by a display of intense anger and then extreme sadness in the following minutes of an interview. |
Interview
History
| Mini State Examination (MSE) | Findings in Bipolar (Mania episode) |
| Appearence and Behaviour | Brightly coloured clothes, overactive, restless, overfriedly, increased appetitie, increased sexual desire, may be dishevelled |
| Speech | Pressure of speech, rapid and copious |
| Mood and affect | Elated mood, cheerful and optimistic, euhphoria, may be iritable/hostile |
| Thought form and though content | Flight of ideas, imparied judgement, expansive ideas, extravaganat, grandiose delusions, persecutory delusions |
| Cognition | ↓concentration and attention, easily distractable |
| Insight | Invariably impaired, sees no reason why their grandiosity should be restrained |
| Perception | Hallucinations (auditory), consistent with mood (eg. people talking about his special power) |
| Mini State Examination (MSE) | Findings in Bipolar (Depressive episode) |
| Appearence and Behaviour | Desheveled, furrowing of brows, ↓rate of blinking, shoulder bent, head down, ↓gesture, ↓eye contant |
| Speech | Slow, long pauses, little spontaneous speech, low volume |
| Mood and affect | Low mood/misery (worse in morning), pessimistic about the present, hopelessness about future, guilt about the past, suicidal, dysphoric, blunt affect |
| Thought form and though content | Delusions common (especially persecutory) |
| Cognition | ↓attention, concentration and memory |
| Insight | variable |
| Perception | reduced intensity of normal perceptions. Occasionally auditory hallucinations |
Mental State Examination (ABCDEFGHIJ)
Type I Bipolar
Type II Bipolar
| Remember Bipolar disorder is characterised by recurrent episodes of elevated mood and depression, together with changes in activity levels. Elevated mood is severe and sustained (mania) in bipolar I disorder and less severe (hypomania) in bipolar II disorder |
| Side note Children of parents with bipolar disorders have a 4 to 15 percent risk of also being affected, compared with a 0 to 2 percent risk in children of parents without bipolar disorders |
Bipolar disorders often are first diagnosed in adolescence or early adulthood after several years of symptoms. Patients with bipolar disorders often present for treatment with depression or in a mixed state. The clinical course of bipolar disorders varies. Patients rarely experience a single episode, with relapse rates reported at more than 70 percent over five years.
Signs of Mania
Mood
Cognition
Behaviour
Psychotic symptoms (Not common)
DIGFAST
|
| Think Patients in the midst of an episode of mania are often quite irritable and have very little insight into their own disease, making compliance with treatment difficult. |
Signs of Depression
Depressed mood
Anhedonia
Other minor symptoms
| Think Patients in the midst of an episode of mania are often quite irritable and have very little insight into their own disease, making compliance with treatment difficult. |
| Remember Depression is usually more common and longer lasting than elevated mood, and—together with inter-episode milder symptoms—contributes most to overall morbidity |
DSM V criteria for a manic episodes (DIGFAST)
Factors that support Diagnosis
Early diagnosis and treatment of acute mood episodes improve prognosis by reducing the risk of relapse and doubling the rate of response to medications. Treatment should continue indefinitely because of the risk of relapse. In the maintenance phase, patients with bipolar disorders should receive regular clinical examinations that focus on depressive, manic, and sleep symptoms; suicide risk; comorbid conditions and general medical health; and substance abuse
Maintenance Non- pharmacological methods
Maintenance Pharmacological (Prophylaxis) - Mood stabilizers
| Pharmacology Lithium is a mood stabilizer. Side effects (LITHIUM CV): Leukocytes Increased Tremors Increased Urine Mother-teratogenic Coma Vision problems. |
| Remember During the course of an episode of acute mania, patients almost always require an antipsychotic in addition to a mood stabilizer, at least for the short term. |
Emergency Acute Mania Patients with acute mania need to be hospitalized because they could harm themselves or others.
Emergency Acute Depresion Patients with acute depression should be assessed for suicidal or homicidal ideation and the need for inpatient treatment
| Scheduling (must assess patient within 24hrs of admission) |
| Mentally ill or disorder |
| Facility and treatment available |
| Risk to themselves or others |
| Least restrictive method |
| They wont admit voluntarily |
Complication
Mental disorder
Medication
| Remember Other psychiatric disorders, such as anxiety disorder and alcohol and drug misuse, are common |
Prognosis
DSM V categorise these as seperate disorders
