Psychiatry for MRCP Part 1

A 26-year-old man is brought in by family after a week of barely sleeping, talking rapidly, spending large sums he cannot afford and claiming he will transform the city. He is elated and irritable, with grandiose plans and no insight. He had an episode of severe depression two years ago. What is the most likely diagnosis?

1. Bipolar affective disorder correct Correct. A week of elevated mood, reduced sleep, grandiosity and overspending with a prior depressive episode is bipolar affective disorder in a manic episode.
2. Schizoaffective disorder Mood and psychotic symptoms with independent psychosis. A week of elevated mood, reduced sleep, grandiosity and overspending with prior depression raises it.
3. Drug-induced mood change Mania or lability from a substance. A week of elevated mood, reduced sleep, grandiosity and overspending with prior depression points elsewhere.
4. Organic or endocrine cause Such as thyroid disease or steroids. A week of elevated mood, reduced sleep, grandiosity and overspending with prior depression redirects it.
5. Unipolar depression Depression without any history of highs. A week of elevated mood, reduced sleep, grandiosity and overspending with prior depression separates it.

The point: Bipolar affective disorder is a mood disorder characterised by recurrent episodes of both depression and mania or hypomania. A manic episode is a distinct period of abnormally elevated, expansive or irritable mood lasting at least a week, with features such as inflated self-esteem or grandiosity, reduced need for sleep, pressure of speech, flight of ideas, distractibility, increased goal-directed activity and risk-taking (overspending, disinhibition), and psychotic features can occur; it causes marked impairment or needs admission. Hypomania is a milder form without psychosis or severe impairment. Bipolar I is defined by at least one manic episode, and bipolar II by hypomania with depression. The differential includes unipolar depression (so a depressed patient should be asked about past highs before an antidepressant is started, because antidepressants alone can precipitate mania or rapid cycling), schizoaffective disorder, drug-induced states and organic causes. Management combines pharmacological and psychological care under specialist services: acute mania is treated with an antipsychotic (and any antidepressant is stopped), while long-term relapse prevention uses a mood stabiliser, with lithium being the most effective, requiring monitoring of levels, renal and thyroid function. Depression in bipolar disorder is treated cautiously to avoid switching. Risk assessment is central because of the risks of harm during both manic and depressive phases.

Source: NICE CG185 — bipolar disorder: assessment and management NICE · tier 1, national regulator or guidance

A 26-year-old man is brought in by family after a week of barely sleeping, talking rapidly, spending large sums he cannot afford and claiming he will transform the city. He is elated and irritable, with grandiose plans and no insight. He had an episode of severe depression two years ago. What is the most appropriate investigation?

1. Baseline tests before lithium Renal and thyroid function. A week of elevated mood, reduced sleep, grandiosity and overspending with prior depression makes them preparatory.
2. Mental state examination To characterise the current episode. A week of elevated mood, reduced sleep, grandiosity and overspending with prior depression makes it routine.
3. Risk assessment For harm during either phase. A week of elevated mood, reduced sleep, grandiosity and overspending with prior depression makes it essential.
4. Rule out organic and drug causes Such as thyroid disease or stimulants. A week of elevated mood, reduced sleep, grandiosity and overspending with prior depression makes it thorough.
5. Full psychiatric history including past manic or hypomanic episodes correct Correct. A full history revealing past mood episodes distinguishes bipolar disorder from unipolar depression.

The point: Bipolar affective disorder is a mood disorder characterised by recurrent episodes of both depression and mania or hypomania. A manic episode is a distinct period of abnormally elevated, expansive or irritable mood lasting at least a week, with features such as inflated self-esteem or grandiosity, reduced need for sleep, pressure of speech, flight of ideas, distractibility, increased goal-directed activity and risk-taking (overspending, disinhibition), and psychotic features can occur; it causes marked impairment or needs admission. Hypomania is a milder form without psychosis or severe impairment. Bipolar I is defined by at least one manic episode, and bipolar II by hypomania with depression. The differential includes unipolar depression (so a depressed patient should be asked about past highs before an antidepressant is started, because antidepressants alone can precipitate mania or rapid cycling), schizoaffective disorder, drug-induced states and organic causes. Management combines pharmacological and psychological care under specialist services: acute mania is treated with an antipsychotic (and any antidepressant is stopped), while long-term relapse prevention uses a mood stabiliser, with lithium being the most effective, requiring monitoring of levels, renal and thyroid function. Depression in bipolar disorder is treated cautiously to avoid switching. Risk assessment is central because of the risks of harm during both manic and depressive phases.

Source: NICE CG185 — bipolar disorder: assessment and management NICE · tier 1, national regulator or guidance

A 26-year-old man is brought in by family after a week of barely sleeping, talking rapidly, spending large sums he cannot afford and claiming he will transform the city. He is elated and irritable, with grandiose plans and no insight. He had an episode of severe depression two years ago. What is the most appropriate management?

1. Stop any antidepressant during mania It can worsen the episode. A week of elevated mood, reduced sleep, grandiosity and overspending with prior depression makes it a safety step.
2. Cautious treatment of bipolar depression To avoid switching to mania. A week of elevated mood, reduced sleep, grandiosity and overspending with prior depression makes it careful.
3. Antipsychotic for an acute manic episode correct Correct. An antipsychotic is first-line for an acute manic episode.
4. Specialist mental health referral and psychological therapy For comprehensive care. A week of elevated mood, reduced sleep, grandiosity and overspending with prior depression makes it appropriate.
5. Long-term mood stabiliser for relapse prevention A long-term mood stabiliser, most effectively lithium, prevents relapse, and a week of elevated mood, reduced sleep, grandiosity and overspending with prior depression here points elsewhere.

The point: Bipolar affective disorder is a mood disorder characterised by recurrent episodes of both depression and mania or hypomania. A manic episode is a distinct period of abnormally elevated, expansive or irritable mood lasting at least a week, with features such as inflated self-esteem or grandiosity, reduced need for sleep, pressure of speech, flight of ideas, distractibility, increased goal-directed activity and risk-taking (overspending, disinhibition), and psychotic features can occur; it causes marked impairment or needs admission. Hypomania is a milder form without psychosis or severe impairment. Bipolar I is defined by at least one manic episode, and bipolar II by hypomania with depression. The differential includes unipolar depression (so a depressed patient should be asked about past highs before an antidepressant is started, because antidepressants alone can precipitate mania or rapid cycling), schizoaffective disorder, drug-induced states and organic causes. Management combines pharmacological and psychological care under specialist services: acute mania is treated with an antipsychotic (and any antidepressant is stopped), while long-term relapse prevention uses a mood stabiliser, with lithium being the most effective, requiring monitoring of levels, renal and thyroid function. Depression in bipolar disorder is treated cautiously to avoid switching. Risk assessment is central because of the risks of harm during both manic and depressive phases.

Source: NICE CG185 — bipolar disorder: assessment and management NICE · tier 1, national regulator or guidance