Bipolar Disorder

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Bipolar Disorder Vrajesh Patel:

Bipolar Disorder Vrajesh Patel

Case:

Case A 32 year old female comes to the clinic complaining of “restlessness and hyperactivity” since last 14 days. She has been talking more than usual, speaking quickly. Her family cannot understand her sometimes. She has also been distracted and has problems completing her work. When questioned about her job, she says she had been working harder than before to improve everyone’s productivity. She says that everything is fine and she has never felt better in her life. According to her spouse these symptoms are new. Vital signs are as below: BP: 110/80 mmHg; Pulse: 86/min; Temp: 98 o F WHICH OF THE FOLLOWING IS THE MOST LIKELY DIAGNOSIS?

Possible Answer Choices:

Possible Answer Choices Alcohol Withdrawal Bipolar Disorder Type I Bipolar Disorder Type II Brief Psychotic Disorder Thyrotoxicosis Schizophrenia Anxiety

Possible Answer Choices:

Possible Answer Choices Alcohol Withdrawal Bipolar Disorder Type I Bipolar Disorder Type II Brief Psychotic Disorder Thyrotoxicosis Schizophrenia Anxiety

BIPOLAR DISORDER:

BIPOLAR DISORDER Bipolar Disorder is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition and mood with or without one or more depressive episodes. The elevated moods are referred to as mania, or if milder, Hypomania. Individuals who experience manic episodes also commonly go to depressive episodes or symptoms, or a mixed state in which features of both mania and depression are present at the same time. Severe manic episodes can sometimes lead to such psychotic symptoms like delusions and/or hallucinations. This disorder has been sub-divided into Bipolar I, Bipolar II, Cyclothymia, and some other types which are often described as the Bipolar Spectrum.

This picture might help…:

This picture might help…

No? May be this one is better…:

No? May be this one is better…

Etiology & Epidemiology:

Etiology & Epidemiology The lifelong prevalence of bipolar disorder in the US has been noted to range from 1% to 1.6%. The cause like vary between individuals. It affects men and women equally and has a mean age of onset at 30 years in either sex. It is more prevalent among this in the high socioeconomic status. In most people with bipolar disorder, the clear cause for the manic or depressive stages is unknown.

Triggers:

Triggers Life changes such as childbirth Medications: Steroids, anti-depressants Alcohol dependence Periods of sleeplessness Illicit drug use

1st Innings: The MANIC phase:

1 st Innings: The MANIC phase Symptoms: DIGFAST D istractibility I rresponsibility G randiosity F light of Ideas A ctivity: Increased Goal-Oriented Activity S leep is decreased T alkativeness or pressured speech

Additional:

Additional These symptoms of mania occur with Bipolar Disorder I. In people with the Bipolar Disorder II, the symptoms of mania are similar but less intense, the term we describe as Hypomania. Additionally, Bipolar Type II Is characterized by one or more major depressive episodes.

Innings 2: The DEPRESSED phase:

Innings 2: The DEPRESSED phase Symptoms: SIG E CAPS S - Sleep disturbances I - Loss of Interest G - Guilty Feelings E - Loss of Energy C - Loss of Concentration A - Appetite/Weight Changes P - Psychomotor Agitation S - Suicidal Ideas

Diagnosis:

Diagnosis The diagnosis of BIPOLAR DISORDER I requires the presence of a manic episode of at least 1 week duration that leads to hospitalization or other significant impairment in occupational or social functioning. The episode of mania cannot be caused by another medical illness or by substance abuse. These criteria are based on the specifications of the Diagnostics and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Manic episodes are characterized by at least 1 week of profound mood disturbance, irritability or expansiveness. At least 3 of the manic symptoms must be present.

Diagnosis contd…:

Diagnosis contd … The diagnosis of BIPOLAR DISORDER II is made by the presence of hypomanic episode. Hypomanic episodes differ from the manic episodes in that they are less severe, do not require hospitalization and lasts for a minimum of 4 days.

Diagnosis contd…:

Diagnosis contd … CYCLOTHYMIC DISORDER is a mild form of Bipolar disorder (manic depressive illness) in which a person has mood swings over a period of at least 2 years that go from mild depression to euphoria and excitement.

Management:

Management Distinguish whether you are treating acute mania or bipolar depression. Acute Mania: Use Lithium, Valproic Acid, and atypical antipsychotics as 1 st line treatment. Bipolar Depression: Lithium or Lamotrigine is indicated. If acute mania with severe symptoms, consider the use of atypical antipsychotics due to the shorter onset of action. If kidneys are compromised, do not use Lithium.

Let’s Test You !!:

Let’s Test You !! A 33 year old man was taken to the ER by the police after neighbors complained about his behavior. His family informed the doctor that he has been diagnosed with Bipolar Disorder and was recently started on Lithium. While in the ER, he becomes combative and punched a nurse on the mouth. What is the next step in the management of this patient?

Choices:

Choices Obtain Lithium level Admit to psychiatric unit Refer to psychiatry Add Valproic Acid Olanzapine

Choices:

Choices Obtain Lithium level Admit to psychiatric unit Refer to psychiatry Add Valproic Acid Olanzapine

Explanation:

Explanation The patient is exhibiting mania and you do not need to verify the lithium level given that his symptoms are acute . He apparently has been noncompliant with medications and obtaining a level is not the best choice. He needs to be medicated and antipsychotics are considered 1 st line treatment for bipolar patients, especially if acutely and severely manic. Admitting an agitated patient to the psychiatric unit is not as important as administering treatment.

Notes for STEP 2 CK:

Notes for STEP 2 CK LITHIUM IS THE CORRECT ANSWER TO MOST BIPOLAR QUESTIONS. “REFER TO PSYCHIATRY OR ANY OTHER PHYSICIAN” IS NEVER THE CORRECT ANSWER ON THE STEP 2 CK THEY WANT TO TEST YOUR KNOWLWGE AS THE PHYSICIAN SO FOCUS ON WHAT YOU WILL DO?

PET Scan:

PET Scan

Sources:

Sources “Diagnostic and Statistical Manual of Mental Disorders, 4 th Edition Revised” (DSM IV-TR) Fischer MD, Conrad. “ Master the Boards” pg 509-510. i mages.google.com www.wikipedia.com