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what is it called when manic and depressive symptoms COEXIST?
mixed affective episode
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what is the lifetime risk of BPAD?
1%
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what is average age of onset of BPAD?
20-30s
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what is sex ration of BPAD?
m=f
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which socioeconomic groups is BPAD assoc with and urban/rural?
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what 3 categories can you split symptoms of mania into and give eg
- 1. biological:
- less need for sleep (not assoc with fatigue)
- increased energy (spending, risky business)
- increased interest in sex (disinhibition)
- general: psychomotor excitation
- 2. cognitive:
- self esteem, grandiose
- poor concentration, easily distractible
- accelerated thinking: flight of ideas, pressured speech
- impaired judgement and insight
- 3. psychotic
- thought form disorder: circumstantiality (lots of detail eventually to the point), tangentiality (never to the point),
- thought content disorder: secondary delusions (grandiose and persecutory) - mood congruent,
- abnormal perceptions: auditory hallucinations (2nd person) and sensory distortions (hyperacusis or visual hyperaesthesia)
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what is the main difference between hypomania and mania?
- in mania there has to be 1 week duration of symptoms
- COMPLETE DISRUPTION OF WORK AND SOCIAL LIFE (whereas in hypomania it is not complete)
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what is the differential diagnosis of elevated or irritable mood?
- MOOD DISORDERS: hypomania, mania, depression (after AD or ECT) or agitated depression
- SECONDARY TO GENERAL MEDICAL CONDITIONS: brain tumour, infarct, infection, cushiness disease, huntington's disease, hyperthyroid, MS, temporal lobe epilepsy
- PSYCHOACTIVE SUBSTANCE USE: amphetamines, antidep, cocaine, steroids, hallucinogens
- PSYCHOTIC DISORDERS: schizoaffective disorder (may be similar to mania with psychosis, but delusions are mood INCONGRUENT), schizophrenia
- PERSONALITY DISORDERS
- DELIRIUM OR DEMENTIA
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what is the immediate biological treatment of bipolar / mania? (4marks)
- RISK ASSESSMENT: where what who treat (OP, CC, IP)
- 1. mood stabilisers: lithium, anti-convulsants (sodium valproate, carbamazapine, lamotrigine)
- 2. anti psychotic: olanzapine
- 3. prophylaxis: if had 2 episodes
- 4. depression: anti-depressants (but may cause secondary mania) use SSRI with mood stabiliser
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how is lithium administered?
as a chemical salt - carbonate or citrate, sulphate
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what is the distribution and MOA of lithium?
- small so cross BBB into CNS
- interacts with receptors to decrease noradrenaline release and increase serotonin synthesis
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what needs to be done before starting lithium?
- 1. establish diagnosis
- 2. discuss need for prolonged treatment
- 3. renal and thyroid function, weight
- 4. pregnancy test (Ebsteins heart defect)
- 5. tell patient must use contraception if on Lithium as don't want to accidentally have baby then its got defect
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what is the starting dose of lithium and at what time of day?
- 600-800mg nocte
- then can gradually increase dose
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when do levels of lithium need to be checked again?
after 5-7 days from first starting
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what is the level of lithium that is aimed for in the blood?
0.5-1.0 mmol/l
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what are the benefits of lithium in mania?
- 1. reduce the risk of manic episodes by 30-40%
- 2. reduce the length and severity of manic episodes
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how is lithium treatment monitored?
- 1. monitor mood - mood diary?
- 2. adherence or concordance with treatment?
- 3. any SE from lithium
- 4. Li level every 3 months (note every time change dose of Li, check after a week)
- 4. Renal function every 6 months
- 5. Thyroid function every 12 months
- 6. Discontinue Li slowly - otherwise risk of manic relapse
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what are the SE of lithium?
- thirst- polydipsia
- polyuria
- metallic taste
- GI disturbance
- sedation
- mild tremor
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at what levels of lithium do signs of Li toxicity appear?
above 1.3mmol/l
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what are the early signs of lithium toxicity?
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what are the late signs of lithium toxicity?
- disorientation
- dysarthria
- convulsions
- coma
- severe bloody diarrhoea
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what are the causes of death in Li toxicity?
- cardiac effect
- pulmonary complications
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who is susceptible to Li toxicity at therapeutic levels?
- elderly
- also as many on diuretics which dehydrates
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what is the MOA of anticonvulsant drugs?
- enhances the actions of GABA
- may have effects on membrane excitability
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give 4 indications of carbamazepine in psychiatry
- 1. treatment resistant mania or depression
- 2. treatment resistant schizophrenia
- 3. adjunct to lithium in prophylaxis of BPAD
- 4. rapid-cycling BPAD: multiple episodes >4/year
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what are the adverse effects of carbamazepine? think systems…
- CNS: headache, drowsiness, diplopia
- Liver: elevation of GGT, hepatitis, cholestatic jaundice
- Other GI: N&V
- Blood dyscrasias
- Skin rashes
- Teratogenic effects - folate deficiency (spina bifida, anencephalcy)
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how does carbamazepine affect other drugs?
- hepatic enzyme inducer
- so induces metabolism of:
- anticoagulants, AD, AP, OCCP, Steroids
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what are the 5 MOA of sodium valproate?
- inhibit GABA transaminase
- inhibit calcium channel current
- increase GABA binding in hippocampus
- reduce action of NA at alpha2 receptors
- inhibit formation of protein kinase C
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what are the indications of sodium valproate? (6)
- 1. refractory mania
- 2. rapid cycling BPAD
- 3. may have benefit in prophylaxis
- 4. epilepsy
- NB: most effective in non-psychotic patients
- may have benefit in prophylaxis
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what are the SE of sodium valproate?
- WHAT
- weight gain
- hepatotoxicity
- alopecia
- tremor, teratogenic
- N&V
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what is MOA of lamotrigine?
- stabilise sodium channels
- inhibits glutamate release
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what is the use of lamotrigine in bipolar?
- it is an anti-depressant in bipolar depression
- (mood stabiliser)
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what are the SE of lamotrigine?
- rash
- GI problems
- CNS problems
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what are the 2 major SE to be worried about in anti-psychotics?
- tardive dyskinesia
- neuroleptic malignant syndrome (medical emergency)
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what are extra-pyramidal SE?
- acute dystonia: torticollis
- spasm of any muscle group esp head and neck
- akathesia: inner disccomfort and restlessness
- signs of parkinsons disease
- tardive dyskinesia: repetitive, involuntary, purposeless actions eg lip smacking, grimacing, tongue protrusion. tardive=slow onset
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what are the psychosocial treatments of bipolar disorder?
- 1. bipolar prodromes: recognise early signs and symptoms
- 2. life events monitoring, diary
- 3. regulate social and sleep routines (disruption of circadian rhythms)
- 4. structured short term problem-focused therapies eg cognitive to develop new coping skills
- teach to reject negative thoughts
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what are the SE of risperidone?
sexual dysfunction especially in men
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what are the SE of olanzapine?
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whats the median duration of a manic episode?
4 months
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what is the median duration of a depressive episode?
6-12 months
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what % of pts get chronic mania with deteriorating course?
10-15%
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how does mania change with age?
- remissions are shorter
- episodes more severe
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which is more common mania or depression in middle aged?
depression more common and longer
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who experiences more mixed affective and depressive episodes?
women
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what is rapid cycling mania? who gets it more
- 4 or more episodes per year
- women more
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what are 5 poor prognostic factors of mania/bipolar?
- young age onset
- more severe symptoms
- co-morbid: Personality disorder
- Co-morbid substance misuse
- treatment avoidance
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what are the type of delusions found in depression with psychotic symptoms?
- worthlessness\
- guilt
- ill health
- poverty
- nihilistic delusions: pt believe something important has ceased to exist eg family no longer exists, bowel disintegrated
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what is depressive stupor?
- severe depression
- slowing of movement
- poverty of speech
- motionless
- mute
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