Bipolar AI Quiz PDF

Bipolar AI Quiz MOOD DISORDERS A. Definitions: 1\. The mood or affective disorders are characterized by a primary disturbance in internal emotional state which is pervasive and sustained feeling ,causing subjective distress and problems in social and occupational functioning. 2\. Given the patie...

Bipolar AI Quiz MOOD DISORDERS A. Definitions: 1\. The mood or affective disorders are characterized by a primary disturbance in internal emotional state which is pervasive and sustained feeling ,causing subjective distress and problems in social and occupational functioning. 2\. Given the patient's current social and occupational situation he or she emotionally feels a\. somewhat worse than would be expected (dysthymia) b. very much worse than would be expected (depression) c\. somewhat better than would be expected (hypomania) d. very much better than would be expected (mania) 3.The Diagnostic and Statistical Manual of Mental Disorders, Fourth edition, Text Revision (DSM-IV-TR) categories of primary mood disorders are: a\. Major depressive disorder: Recurrent episodes of depression, each continuing for at least 2 weeks. b\. Bipolar disorder: Episodes of both mania and depression (continuing for at least 1 week) bipolar I disorder or both hypomania (continuing for at least 4 days) and depression (bipolar II disorder). c\. Dysthymic disorder: Dysthymia continuing over a 2-year period (1 year in children). d\. Cyclothymic disorder: Hypomania and dysthymia occurring over a 2-year period (1 year in children) e\. Mood disorder due to a general medical condition and substance-induced mood disorder are secondary mood disorders. B. Epidemiology The lifetime prevalence of mood disorders is a\. Major depressive disorder: 5 -12% for men; 10- 20% for women. b\. Bipolar disorder: 1% overall; no sex difference. Bipolar disorder q There are episodes of both mania and depression (bipolar I disorder) or both hypomania and depression (bipolar II disorder). q Patients with both manic and depressive episodes or with manic episodes alone are diagnosed with bipolar disorder. q The signs and symptoms tend to recur, often in periodic or cyclical fashion. q In contrast to schizophrenia, in mood disorders the patients mood and functioning usually Return To Normal Between episodes. Bipolar Disorders (I and II) u Bipolar I disorder is distinguished from major depressive disorder by the presence of mania. u A mixed episode is characterized by symptoms of both full- blown manic and major depressive episodes for at least 1 week, whether the symptoms are intermixed or alternate rapidly every few days. u An average of 28% of bipolar patients at least occasionally experience mixed states. Moreover, many patients in a manic episode have some symptoms of depressed mood, anxiety, guilt, and suicidal thoughts, even if these are not severe enough to qualify as a mixed episode. u Bipolar II disorder, in which the person does not experience full-blown manic (or mixed) episodes but has experienced clear-cut hypomanic episodes as well as major depressive episodes Bipolar disorder Epidemiology: u Life time risk of manic episode is in the range of 0.8 -- 1% u Prevalence in males and females is the same u Mean age of onset is about 17- 25 years u Age range from childhood (5 or 6 years) to 50 years or even older. u It is highly comorbid with anxiety disorders and substance misuse. 1\. Genetics: u Approximately 90% of people with bipolar illness have a first-degree relative with a mood disorder. u Estimates of concordance range between 33% and 90% for monozygotic twins and between 5% and 25% for other siblings. 1\. Genetics: u Studies have suggested that bipolar disorder is inherited in some families in an X-linked pattern. u Other linkage sites may be on chromosomes 4, 11 (the site of the gene for tyrosine hydroxylase), 18, and 21. u As of yet, no single chromosomal site seems to play a dominant role in the development of bipolar disorder, but several genes may interact to confer risk. u Genes related to ion channels are implicated in the etiology of bipolar disorder (e.g. calcium channels on chromosome 12). 2\. Psychosocial factors: u The first manic episodes are often precipitated by life events such as bereavement, personal separation, work-related problems or loss of role. u sleep deprivation is important precipitating factor. 3\. Monoamine theory u states that increased levels of noradrenaline, serotonin and dopamine have been linked with manic symptoms. Excitatory neurotransmitter glutamate is also implicated. D. Kindling hypothesis: u Kindling is a phenomenon observed when repeated, subthreshold stimulation of the brain eventually results in seizure activity. u It has been postulated that bipolar illness follows a similar paradigm, some patients have a first episode of illness in response to stress (e.g., a loss). u The persistence of neuronal damage leads to recurrence of mania without precipitating factors, and subsequent manic episodes become more frequent. Clinical symptoms of bipolar disorder Depressive episode u People with a major depression feel sad and helpless most of the day every day for weeks at a time. They don't enjoy anything. They lack energy, feel worthless, have trouble sleeping, and cannot concentrate and may become suicide. Manic episode u People with bipolar disorder, alternate between two poles--- depression and its opposite, mania. u Mania is characterized by restless activity, excitement, laughter, excessive self- confidence, rambling speech, and loss of inhibitions. Manic Episodes Definitions: u Is a distinct period of an abnormally and persistently elevated, expansive or irritable mood lasting for at least 1 week. Hypomanic episode: u lasts at least 4 days and is similar to a manic episode except for absence of psychotic features and lesser degree of social and occupation impairment. Clinical features of Manic Episode: 1\. Appearance Increased sociability or over- familiarity-Wearing bright colors and excessive cosmetics Loss of social inhibition, resulting inappropriate behavior 2\. Mood Elevated, expansive or irritable. Elevated mood is often euphoric and often infectious. 3\. Speech Increased talkativeness \"pressure of speech\", rapid and loud voice A. B. C. D. 4\. Thoughts: Difficulty in concentration with distractibility Flight of ideas or racing thoughts Inflated self- esteem and grandiosity Constant change in plans 5\. Behavior: § Increased activity and physical restlessness yet non productive. Decreased need for sleep overspending or other types of reckless or irresponsible behavior Increased appetite and sexual activity 6\. May be associated with psychotic symptoms: delusions and hallucinations. criteria for Manic Episode DSM5 A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary). B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior: 1\. Inflated self-esteem or grandiosity. 2\. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). 3\. More talkative than usual or pressure to keep talking. 4\. Flight of ideas or subjective experience that thoughts are racing. 5\. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. 6\. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity). 7\. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition. Note: Criteria A--D constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder. Differential diagnosis: 1\. Mood disorder caused by a general medical condition: A. CNS disorders: Mania is associated with right sided cerebral vascular lesions and it is commonly associated with lesions in the frontal and temporal lobes. Neurological disorders as stroke, head trauma, brain tumor, dementia, epilepsy, infections, and multiple sclerosis. B. Endocrine causes: thyrotoxicosis, Cushing\'s syndrome. DD: 2\. Substance induced mood disorder: A. Medications: Antidepressants, anticholinergic drugs, corticosteroids, dopamine agonist , bronchodilators , decongestants B. Drugs of abuse: Amphetamine, cannabis, cocaine, hallucinogens, alcohol. DD: 3\. Other psychiatric disorders: u Schizophrenia u Schizoaffective disorders u Agitated depression u ADHD Assessment and questionnaire: History: u Diagnosis and severity of the current episode u Number of previous episodes u Average length of episodes u Level of psychosocial functioning in between episodes u Previous response to treatment u Family history of psychiatric problems u Current and past use of alcohol and other drugs. The Young mania rating scale (YMRS) u The YMRS is an 11-item questionnaire which helps clinicians to measure the severity of manic episodes in children, adolescents and adults. u mania (YMRS = 12), depression (YMRS = 3), or euthymia (YMRS = 2). Investigations for organic/ treatable cause: u Hormonal assays e.g., for hyperthyroidism. u Electrolytes e.g., for confusional states presenting similar to manic excitement u Urine drug screen u CT/MRI to rule out space occupying lesion, infarction, hemorrhage. Course and prognosis: u The average length of manic episode (treated or not) is about 3- 6 months. 90% of patients with mania are likely to have another. u The interval between episodes becomes progressively shorter with both age and number of episodes. u Lithium can bring 60-70% remission rate. u Good prognostic factors: female gender, short duration of manic episode, later age of onset, no suicidal thoughts, less psychotic symptoms, few comorbid physical conditions and good compliance. Management: Short term management: q To control of the acute episode Long term management: q To prevent relapse and recurrence q For patients who have 2 or more episodes within 5 years, or 1 severe manic episode especially with positive family history. Short term management: A. Hospitalization B. ECT C. D. Pharmacotherapy Psychotherapy A. Hospitalization: u Especially if; severe symptoms, high risk of harm to self or others, serious side effects. B. ECT: u For excitement or if there is poor response to treatment. u 8- 12 settings (3 times weekly) C. Pharmacotherapy : Mood stabilizing agents a\. Lithium b\. Valproate c\. Carbamazepine Antipsychotics: They have antimanic and mood-stabilizing effects. Along with mood stabilizers for rapid control of agitated or psychotic patients Conventional antipsychotics (e.g. haloperidol, chloropromazine). Atypical antipsychotics are preferred as; olanzapine (10- 20 mg/day), risperidone (4-6 mg/ day), quetiapine (300- 600mg/day), ziprazidone, aripiprazole (15-30mg/day). Benzodiazepine: § Clonazepam and Lorazepam Used as adjunctive treatment of acute manic agitation, aggression and insomnia. Mood stabilizing agents Lithium § The first-line treatment for bipolar disorder, approximately 80% of patients respond to lithium, although such response may take 1 to 2 weeks. Antipsychotic drugs are often co-administered during this initial period to control behavior and psychosis. § Given as tablets of 400 mg , test serum level after 7-10 days and adjust to maintain serum level of 0.8-1.2 meq/dl (for treatment of acute episode). § Before its use some investigations must be done as; renal functions tests, thyroid function, ECG, blood picture, and pregnancy test in females. § Side effects of lithium include tremor, sedation, nausea, polyuria, polydipsia, memory problems, weight gain, hypothyroidism, and teratogenic. Valproate Easier to use and has faster onset of action Dose: 15- 30 mg/kg Carbamazepine Dose: 10- 20 mg/kg For treatment of patients who do not respond to lithium. D. Psychotherapy: Usually after symptoms resolution. u Cognitive therapy to challenge grandiose thoughts u Psychoeducation: \- \- \- \- \- on etiology, signs and symptoms, importance of compliance learn to recognize the early warning signs of an approaching episode of mania. drugs (dose, duration, side effects, and toxicity) limit caffeine and alcohol intake regularity in rhythms of activity and wakefulness, sleep hygiene, eating and exercising. u Family therapy: To work on impact of manic symptoms on family and resolve interpersonal problems. Long term management: 1\. Pharmacotherapy: u Always maintain successful acute treatment regimens (e.g. mood stabilizer+ antipsychotic) for prophylaxis. u First line: Lithium or olanzapine, Valproate, quetipine, aripiprazole. u Second line:, carbamazepine, lamotrigine, risperidone. u Lithium: adjust serum level at 0.6- 1.0 meq/dl. u Continue treatment for at least 2 years, and up to 5 years if there is a significant risk of relapse. 2\. Psychoeducation: u Helping patients to identify precipitants or early manifestations of illness, so that treatment can be initiated early. u Emphasis on the need to stay on medications even when well. u Education about the "S" that may precipitate episodes should be given---Sleep (sleep deprivation may precipitate mania), Season (mania occur seasonally in summers/spring), and Stress.