History

Fact Explanation
Elevated mood According to the glutamate hypothesis of mood disorders; excessive glutamate release causes excitotoxicity. In Bipolar disorder, elevated glutamate is found in the cingulate gyrus. Elevated mood is the hallmark of manic symptoms in Bipolar disorder.[1,2]
Euphoria Another symptom of mania that is present in Bipolar disorder, it is often manifest as perpetual happiness or happiness in excess of situational realities. [1]
Overactivity Patient's are extremely active in their occupational and social activities. They may take on new responsibilities at work, enter new social circles or consider new business ventures. However they quickly become bored as they are unable to maintain focus and concentration. [1]
Reduced need for sleep Patient's feel energetic, and feel no need to rest or sleep. Sometimes it is due to the new commitments and activities they have initiated. Extreme cases may be at risk of death due to exhaustion. [1]
Increased optimism Patient's are increasingly optimistic about life, believing that everything will turn out for the best. They believe firmly that their business ventures, social activities will be successful despite evidence to the contrary. [1]
Increased libido Patient's show increased indulgence in pleasurable activity including sex. They are increasingly attracted towards new sexual partners and may have risky sexual exposure. They are also disinhibited in speaking of sex and may be viewed as being inappropriate or indecent. [1]
Irritiability Reduced focus and concentration leads to increased irritability. They may also feel that others are jealous or sabotaging their activities. [1]
Impairment of social or occupational activity There is impairment of judgement and they make risky investments, become irritable and uncooperative in office and at home. This leads to impaired social and occupational function. Identification of this is important as a severe impairment indicates a manic episodes which requires hospitalisation; whereas a hypomanic episode with little or no impact on social function can be managed on an outpatient basis. [1]
May alternate with periods of depression Features of depression may alternate with features of mania. Symptoms such as low mood, reduced appetite, apathy, poor sleep, feeling of worthlessness, fatigue, suicidal ideation may be present during depressive episodes. The distribution of manic and depressive episodes may vary between patients. Some may have frequent manic and depressive episodes, whereas other may have a predominantly manic episodes with only a few or no depressive episodes. [1]
Rapid cycling of symptoms Up To a third of patients will experience rapid cycling of symptoms, with alternating manic and depressive episodes. By definition patients with four or more episodes per year are known as rapid cyclers. [1,3]
References
  1. BELMAKER R.H.. Bipolar Disorder. N Engl J Med [online] 2004 July, 351(5):476-486 [viewed 14 June 2014] Available from: doi:10.1056/NEJMra035354
  2. JUN C, CHOI Y, LIM SM, BAE S, HONG YS, KIM JE, LYOO IK. Disturbance of the Glutamatergic System in Mood Disorders Exp Neurobiol [online] 2014 Mar, 23(1):28-35 [viewed 14 June 2014] Available from: doi:10.5607/en.2014.23.1.28
  3. FARINDE A. Bipolar disorder: A brief examination of lithium therapy J Basic Clin Pharm [online] 2013 Sep, 4(4):93-94 [viewed 14 June 2014] Available from: doi:10.4103/0976-0105.121656

Examination

Fact Explanation
Mental State Examination: Appearence The patient will appear excited, may have a wide eyed stare. Will be dressed in inappropriate clothes that may be overly provocative, consisting of bright oddly matched colors. May wear excessive makeup, hair extensions, other accessories etc. Patient may find it difficult to be seated during the interview and may walk around the room, change seating position often, sit where it is inappropriate such as on tables, desks etc. [1,2]
Mental State Examination: Speech Patients exhibit increased speech, and speak rapidly. They may have pressure of speech and speak in puns or with clang associations. There is a flight of ideas, as the patient's mind frequently changes topic. Manner of speaking may be incoherent as it may be too rapid to be intelligible, be focussed on topics such as sexuality and is generally grandiose in nature.[3]
Mental State Examination: Affect Mood is elevated. Though some patients may exhibit a certain degree of irritability. Rapid cyclers may change from euphoria to a low mood between interviews. [1,3]
Mental State Examination: Perception Patient's may have auditory hallucinations of a grandiose theme. Usually second person auditory hallucinations that centre on themes of praise, special ability or secret knowledge. [1,4]
Mental State Examination: Thoughts Typically grandiose delusions are present. These may be of varying themes depending on the patient's socio-economic background. Common themes include having super powers, being heir to great wealth, being related to royalty, having power to control others or being a famous historical figure. Amorous delusions of a another person being madly in love with them or persecutory delusions, where the patient believes he is being persecuted for his special abilities. [1,3,5]
Mental State Examination: Depersonalisation/Derealisation Usually not present.
Mental State Examination: Cognitive functions Cognitive function is impaired. Attention and concentration which is assessed by the 'serial sevens' test is markedly impaired in a manic episode. In addition recall is also impaired due to the poor concentration and distractibility. Long term memory may be preserved. [1,3,5,6]
Mental State Examination: Insight Insight may be preserved in a hypomanic episode or Bipolar I disorder. However in a manic episode or Bipolar II disorder, insight is lost. [1]
References
  1. BELMAKER R.H.. Bipolar Disorder. N Engl J Med [online] 2004 July, 351(5):476-486 [viewed 14 June 2014] Available from: doi:10.1056/NEJMra035354
  2. BONGARDS EN, ZAMAN R, AGIUS M. Can we prevent under-diagnosis and misdiagnosis of bipolar affective disorder? Repeat audits to assess the epidemiological change in the caseload of a community mental health team when bipolar disorder is accurately assessed and diagnosed. Psychiatr Danub [online] 2013 Sep:S129-34 [viewed 14 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23995161
  3. HANWELLA R, DE SILVA VA. Signs and symptoms of acute mania: a factor analysis BMC Psychiatry [online] :137 [viewed 14 June 2014] Available from: doi:10.1186/1471-244X-11-137
  4. SHINN AK, PFAFF D, YOUNG S, LEWANDOWSKI KE, COHEN BM, ÖNGüR D. Auditory hallucinations in a cross-diagnostic sample of psychotic disorder patients: a descriptive, cross-sectional study. Compr Psychiatry [online] 2012 Aug, 53(6):718-26 [viewed 14 June 2014] Available from: doi:10.1016/j.comppsych.2011.11.003
  5. MITCHELL PB. Bipolar disorder. Aust Fam Physician [online] 2013 Sep, 42(9):616-9 [viewed 14 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24024220
  6. PåLSSON E, FIGUERAS C, JOHANSSON AG, EKMAN CJ, HULTMAN B, ÖSTLIND J, LANDéN M. Neurocognitive function in bipolar disorder: a comparison between bipolar I and II disorder and matched controls BMC Psychiatry [online] :165 [viewed 14 June 2014] Available from: doi:10.1186/1471-244X-13-165

Differential Diagnoses

Fact Explanation
Use of psychoactive substances Patients with psychiatric disorders may have co-morbid substance abuse. However a thorough search should be made for a history of drug abuse especially for psychoactive substances such as alcohol, amphetamines,heroin and cocaine. [1,2]
Personality disorder Patient's with a personality disorder may have, symptoms that are similar to bipolar disorder. However duration of symptoms dating back to childhood and other personality traits differentiate it from Bipolar disorder. [3]
Epilepsy Temporal lobe epilepsy can cause hallucinations that may mimic psychotic features of bipolar disorder. It can be detected by performing an EEG if clinical suspicion exists. [4]
Space occupying lesion of the brain May present with behavioral change, particularly frontal lobe tumors. Will have associated upper motor neurological symptoms and epilepsy. Maybe associated with early morning headache and vomiting. [5]
Fahr Disease Fahr Disease occurs due to idiopathic basal ganglia calcification. Initial symptoms are changes in speech and motor coordination. Can be diagnosed by neuroimaging. [6]
Wilson's Disease Wilson's Disease is an autosomal recessive condition that results in a deficiency of ceruloplasmin. This causes deposition of copper in the body tissues. If this occurs in cerebral tissue, neuropsychiatric symptoms such as depression, personality change, mood disorders and even psychosis can occur. [7]
References
  1. WARDLE MC, GARNER MJ, MUNAFò MR, DE WIT H. Amphetamine as a social drug: effects of d-amphetamine on social processing and behavior. Psychopharmacology (Berl) [online] 2012 Sep, 223(2):199-210 [viewed 16 June 2014] Available from: doi:10.1007/s00213-012-2708-y
  2. ROCHA THIAGO BOTTER MAIO, ZENI CRISTIAN PATRICK, CAETANO SHEILA CAVALCANTE, KIELING CHRISTIAN. Mood disorders in childhood and adolescence. Rev. Bras. Psiquiatr. [online] 2013 December, 35:S22-S31 [viewed 16 June 2014] Available from: doi:10.1590/1516-4446-2013-S106
  3. PääREN A, BOHMAN H, VON KNORRING AL, VON KNORRING L, OLSSON G, JONSSON U. Hypomania spectrum disorder in adolescence: a 15-year follow-up of non-mood morbidity in adulthood. BMC Psychiatry [online] 2014 Jan 15:9 [viewed 16 June 2014] Available from: doi:10.1186/1471-244X-14-9
  4. STRETTON J, POPE RA, WINSTON GP, SIDHU MK, SYMMS M, DUNCAN JS, KOEPP M, THOMPSON PJ, FOONG J. Temporal lobe epilepsy and affective disorders: the role of the subgenual anterior cingulate cortex. J Neurol Neurosurg Psychiatry [online] 2014 May 29 [viewed 16 June 2014] Available from: doi:10.1136/jnnp-2013-306966
  5. PACKER RJ. Childhood brain tumors: accomplishments and ongoing challenges. J Child Neurol [online] 2008 Oct, 23(10):1122-7 [viewed 16 June 2014] Available from: doi:10.1177/0883073808320758
  6. SANTOS KW, FRAGA BF, CARDOSO MC. Dysfunctions of the stomatognathic system and vocal aspects in Fahr disease: case report. Codas [online] 2014 Apr, 26(2):164-7 [viewed 16 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24918511
  7. BIDAKI R, ZAREI M, MIRHOSSEINI SM, MOGHADAMI S, HEJRATI M, KOHNAVARD M, SHARIATI B. Mismanagement of Wilson's disease as psychotic disorder. Adv Biomed Res [online] 2012:61 [viewed 16 June 2014] Available from: doi:10.4103/2277-9175.100182

Investigations - Fitness for Management

Fact Explanation
Serum electrolytes Lithium which is used in both the treatment of acute mania and prophylaxis, is excreted by the kidneys. Therefore serum electrolytes should assessed as Lithium is excreted using the same mechanism as Sodium. [1,2]
Serum creatinine Lithium is excretion occurs by the renal system, therefore serum creatinine should be assessed as a an indicator of baseline renal functions. [1,2]
Thyroid Function Tests Lithium can cause hypothyroidism, therefore prior to initiation of prophylaxis, baseline thyroid functions should be assessed. [1,2]
Full Blood Count This is performed to rule out any coexistent hematological disorder such as anemia that can mimic depression. In addition prophylaxis with anti convulsants can cause bone marrow depression, therefore a baseline FBC is essential. [2]
Fasting venous plasma glucose Patients may require treatment with atypical antipsychotics, which as have metabolic side effects and are diabetogenic. [2]
Electrocardiogram LIthium may precipitate cardiac arrhythmias, therefore pre-treatment ECG is necessary. [2]
Liver Enzymes Sodium valproate is used in the prophylaxis of rapidly cycling bipolar disorder. It can cause an elevation of liver enzymes, therefore a baseline assessment is necessary. [2,3,4]
References
  1. MIR SA, WANI AI, MASOODI SR, BASHIR MI, AHMAD N. Lithium toxicity and myxedema crisis in an elderly patient. Indian J Endocrinol Metab [online] 2013 Dec, 17(Suppl 3):S654-6 [viewed 16 June 2014] Available from: doi:10.4103/2230-8210.123558
  2. ROCHA THIAGO BOTTER MAIO, ZENI CRISTIAN PATRICK, CAETANO SHEILA CAVALCANTE, KIELING CHRISTIAN. Mood disorders in childhood and adolescence. Rev. Bras. Psiquiatr. [online] 2013 December, 35:S22-S31 [viewed 16 June 2014] Available from: doi:10.1590/1516-4446-2013-S106
  3. MIRSEPASSI Z, MAZINANI R, FADAI F, ALIBEIGI N, NAZERI ASTANEH A. Topiramate Add-on Lithium Carbonate for Treatment of Acute Mania. Iran J Psychiatry Behav Sci [online] 2013 Fall, 7(2):11-5 [viewed 16 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24644505
  4. MEHTA S. Unipolar Mania: Recent Updates and Review of the Literature. Psychiatry J [online] 2014:261943 [viewed 16 June 2014] Available from: doi:10.1155/2014/261943

Investigations - Followup

Fact Explanation
Serum Lithium levels For prophylaxis of bipolar disorder, Serum Lithium level should be tightly controlled, as it is a drug with a narrow therapeutic index. Should be performed every 3-6 months. Therapeutic range 0.4-0.8 mmol/L. Assessment of lithium level should be performed 8-12 hours after administration of the last dose. [1,2]
Serum creatinine Regular assessment of renal function is necessary for patients on Lithium, as a reduction of renal function can lead to Lithium toxicity. Should be done annually. [1,2]
Serum electrolytes A component that in the assessment of renal functions. Should be performed annually.[1,2]
Thyroid Function Tests Long term use of Lithium can cause hypothyroidism, therefore regular assessment of thyroid function must be performed. Should be performed annually.[1,2]
Fasting venous plasma glucose Atypical antipsychotics are diabetogenic, there regular testing of patients receiving this medication is necessary. [3]
Liver Enzymes Sodium Valproate which is used in the prophylaxis of rapidly cycling bipolar disorder is a hepatotoxic drug, therefor regular assessment of liver enzymes is needed. [4]
References
  1. MIR SA, WANI AI, MASOODI SR, BASHIR MI, AHMAD N. Lithium toxicity and myxedema crisis in an elderly patient. Indian J Endocrinol Metab [online] 2013 Dec, 17(Suppl 3):S654-6 [viewed 16 June 2014] Available from: doi:10.4103/2230-8210.123558
  2. KIRKHAM E, BAZIRE S, ANDERSON T, WOOD J, GRASSBY P, DESBOROUGH JA. Impact of active monitoring on lithium management in Norfolk. Ther Adv Psychopharmacol [online] 2013 Oct, 3(5):260-5 [viewed 16 June 2014] Available from: doi:10.1177/2045125313486510
  3. SALVIATO BALBãO M, CECíLIO HALLAK JE, ARCOVERDE NUNES E, HOMEM DE MELLO M, TRIFFONI-MELO ADE T, FERREIRA FI, CHAVES C, DURãO AM, RAMOS AP, DE SOUZA CRIPPA JA, QUEIROZ RH. Olanzapine, weight change and metabolic effects: a naturalistic 12-month follow up. Ther Adv Psychopharmacol [online] 2014 Feb, 4(1):30-6 [viewed 16 June 2014] Available from: doi:10.1177/2045125313507738
  4. MEHTA S. Unipolar Mania: Recent Updates and Review of the Literature. Psychiatry J [online] 2014:261943 [viewed 16 June 2014] Available from: doi:10.1155/2014/261943

Investigations - Screening/Staging

Fact Explanation
Screening for psychoactive substances Psychoactive substances such as alcohol, cannabis, cocaine and amphetamines can cause symptoms similar to Bipolar Disorder. [1]
References
  1. ROCHA THIAGO BOTTER MAIO, ZENI CRISTIAN PATRICK, CAETANO SHEILA CAVALCANTE, KIELING CHRISTIAN. Mood disorders in childhood and adolescence. Rev. Bras. Psiquiatr. [online] 2013 December, 35:S22-S31 [viewed 16 June 2014] Available from: doi:10.1590/1516-4446-2013-S106

Management - General Measures

Fact Explanation
Patient education Psychoeducation has shown to reduce the rate of relapses in bipolar disorder and improve the patient's quality of life. The patient should be educated about identifying manic symptoms such as over talkativeness, elation and to seek medical advice. Also to refrain from risky activities such as financial investments during this period. [1,2]
Family education Educate the family on early identification of mood symptoms, and to bring the patient to medical attention. This can reduce risk to the patient. [1,2]
Education on side effects of drugs Patients who are prescribed Lithium for prophylaxis should be educated on side effects (such as metallic taste of the mouth) and the need for regular monitoring of serum Lithium levels, renal functions and thyroid functions. They should also be advised to avoid diuretics and NSAIDS as this can precipitate Lithium toxicity. Features of toxicity such as a coarse tremor, ataxia, excessive thirst should be identifiable by the patient. [1,2,3]
Risk assesment A risk assessment should be performed. This has three components. Risk to self due to exhaustion, engaging in risky activity, risk of contracting STI due to unprotected sexual activity, financial risks due to excessive spending and damage to reputation should be considered under risks to the patient. Risks to others include physical violence, being unfaithful to partners and risk to co-workers due to disregard for occupational safety. [4]
Treatment setting Decision on providing out patient treatment or in ward care should be made after consideration of several facts. It should include risk assessment of the patient, social and occupational function, impairment of socio-economic functions. Usually hypomania/ Bipolar II can be treated on an outpatient basis whereas mania/ Bipolar I needs inward care. [1,5]
References
  1. MAIERA E. Bipolar disorder and stress. Psychiatr Danub [online] 2012 Sep:S59-60 [viewed 16 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22945189
  2. nformation from your family doctor. Bipolar disorders. Am Fam Physician [online] 2012 Mar 1, 85(5):499-500 [viewed 16 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22534228
  3. HASSAN S, KHALID F, ALIRHAYIM Z, AMER S. Lithium Toxicity in the Setting of Nonsteroidal Anti-Inflammatory Medications Case Rep Nephrol [online] 2013:839796 [viewed 16 June 2014] Available from: doi:10.1155/2013/839796
  4. HENRY C, LUQUIENS A, LANçON C, SAPIN H, ZINS-RITTER M, GERARD S, PERRIN E, FALISSARD B, LUKASIEWICZ M. Inhibition/activation in bipolar disorder: validation of the Multidimensional Assessment of Thymic States scale (MAThyS). BMC Psychiatry [online] 2013 Mar 13:79 [viewed 16 June 2014] Available from: doi:10.1186/1471-244X-13-79
  5. RENES JW, REGEER EJ, VAN DER VOORT TY, NOLEN WA, KUPKA RW. Treatment of bipolar disorder in the Netherlands and concordance with treatment guidelines: study protocol of an observational, longitudinal study on naturalistic treatment of bipolar disorder in everyday clinical practice BMC Psychiatry [online] :58 [viewed 16 June 2014] Available from: doi:10.1186/1471-244X-14-58

Management - Specific Treatments

Fact Explanation
Management of Acute Mania The most efficacious acute treatments for mania are the antipsychotics rather than the traditional ‘mood stabilisers’ lithium, valproate and carbamazepine. Specifically, that report found that the preferred options – after taking into account both efficacy and tolerability – were risperidone, olanzapine and haloperidol. [1] However Lithium has been traditionally used in the management of acute mania. [2]
Management of Bipolar depression Using antidepressents in the management of bipolar depression may induce a manic/ hypomanic episode. Therefore it may be prudent to use atypical antipsychotics which have intrinsic mood stabilizing properties, such as Quetiapine. New antidepressants such as the selective serotonin-reuptake inhibitors are less likely than older agents to induce mania in persons with bipolar depression. Alternatively a combination of olanzapine with fluoxetine can be used. [1,3,4]
Prophylaxis of Bipolar Disorder Prophylaxis of bipolar disorder has traditionally been with Lithium, which has been used, for decades. It reduces the risk of suicide, depression and relapse in patients with bipolar disorder. A plasma level between 0.4 to 0.8 mEq/L should be maintained for effective prophylaxis.[2,3] Sodium Valproate is used in patients who suffer from rapid cycling bipolar disorder. Alternative anticonvulsants that can be used are carbamazepine, lamotrigine and topiramate, though their usage remains limited. [3] In recent times the use of atypical anticonvulsants for bipolar disorder has increased, due to their efficacy in combating psychotic features of the disease and their mood stabilising properties. However their use is limited by the risk of tardive dyskinesia and metabolic side effects. [3] Combination therapy with Lithium and an atypical antipsychotic or an anticonvulsant has been successful in some studies. [3]
References
  1. MITCHELL PB. Bipolar disorder. Aust Fam Physician [online] 2013 Sep, 42(9):616-9 [viewed 14 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24024220
  2. FARINDE A. Bipolar disorder: A brief examination of lithium therapy J Basic Clin Pharm [online] 2013 Sep, 4(4):93-94 [viewed 14 June 2014] Available from: doi:10.4103/0976-0105.121656
  3. BELMAKER R.H.. Bipolar Disorder. N Engl J Med [online] 2004 July, 351(5):476-486 [viewed 14 June 2014] Available from: doi:10.1056/NEJMra035354
  4. MIRSEPASSI Z, MAZINANI R, FADAI F, ALIBEIGI N, NAZERI ASTANEH A. Topiramate Add-on Lithium Carbonate for Treatment of Acute Mania. Iran J Psychiatry Behav Sci [online] 2013 Fall, 7(2):11-5 [viewed 16 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24644505