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 high mood, less sleep, grandiose ideas and overspending, with a past episode of depression, is bipolar affective disorder, currently in a manic episode.
2. Schizoaffective disorder A mix of mood and psychotic symptoms, where the psychosis runs independently of the mood. Here, a week of high mood, less sleep, grandiose ideas and overspending, with a past episode of depression points elsewhere.
3. Drug-induced mood change High mood or swinging mood, brought on by a drug or substance. That does not match a week of high mood, less sleep, grandiose ideas and overspending, with a past episode of depression.
4. Organic or endocrine cause A physical or hormonal cause, such as thyroid disease or steroid medicines. It does not fit a week of high mood, less sleep, grandiose ideas and overspending, with a past episode of depression.
5. Unipolar depression Depression with no history of any high mood episodes. But a week of high mood, less sleep, grandiose ideas and overspending, with a past episode of depression does not point to it.

The point: Bipolar affective disorder is a mood disorder with repeated episodes of both low mood (depression) and high mood (mania or hypomania). A manic episode is a clear period, lasting at least a week, of unusually high, expansive or irritable mood, with features such as an inflated sense of self-worth or grandiose ideas, needing less sleep, talking fast (pressure of speech), thoughts jumping quickly from one to another (flight of ideas), being easily distracted, doing more goal-directed activity, and taking risks such as overspending or acting without normal restraint (disinhibition). Psychotic features, such as false beliefs or hearing things that are not there, can also occur. A manic episode is severe enough to cause marked difficulty coping, or to need admission to hospital. Hypomania is a milder form, without psychosis and without severe difficulty coping. Bipolar I disorder is defined by at least one manic episode, and bipolar II disorder by hypomania together with depression, with no full manic episode. Other conditions to consider include depression on its own with no highs (unipolar depression), so a patient with depression should always be asked about past highs before starting an antidepressant, because an antidepressant given on its own can bring on mania or rapid mood swings (rapid cycling); schizoaffective disorder, a mix of mood and psychotic illness that runs independently of mood; mood changes brought on by a drug; and physical causes such as thyroid disease. Treatment combines drug and talking therapies under specialist mental health services: an acute manic episode is treated with an antipsychotic drug, and any antidepressant is stopped; long-term prevention of relapse uses a mood stabiliser, with lithium being the most effective, though it needs regular blood tests of lithium levels, kidney function and thyroid function. Depression in bipolar disorder is treated carefully, to avoid tipping the patient into mania (switching). Checking for risk of harm is central to care, because of the dangers during both high and low phases of the illness.

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 Checking kidney and thyroid function before starting lithium. It does not fit a week of high mood, less sleep, grandiose ideas and overspending, with a past episode of depression.
2. Mental state examination A structured check of the patient's current mental state, to describe the episode they are in now. But a week of high mood, less sleep, grandiose ideas and overspending, with a past episode of depression does not point to it.
3. Risk assessment Checking for the risk of harm, which can occur during either a high or a low phase. Here, a week of high mood, less sleep, grandiose ideas and overspending, with a past episode of depression points elsewhere.
4. Rule out organic and drug causes Ruling out physical causes and drug causes, such as thyroid disease or stimulant drugs. That does not match a week of high mood, less sleep, grandiose ideas and overspending, with a past episode of depression.
5. Full psychiatric history including past manic or hypomanic episodes correct Correct. A full history uncovering past mood episodes shows this is bipolar disorder rather than depression alone.

The point: Bipolar affective disorder is a mood disorder with repeated episodes of both low mood (depression) and high mood (mania or hypomania). A manic episode is a clear period, lasting at least a week, of unusually high, expansive or irritable mood, with features such as an inflated sense of self-worth or grandiose ideas, needing less sleep, talking fast (pressure of speech), thoughts jumping quickly from one to another (flight of ideas), being easily distracted, doing more goal-directed activity, and taking risks such as overspending or acting without normal restraint (disinhibition). Psychotic features, such as false beliefs or hearing things that are not there, can also occur. A manic episode is severe enough to cause marked difficulty coping, or to need admission to hospital. Hypomania is a milder form, without psychosis and without severe difficulty coping. Bipolar I disorder is defined by at least one manic episode, and bipolar II disorder by hypomania together with depression, with no full manic episode. Other conditions to consider include depression on its own with no highs (unipolar depression), so a patient with depression should always be asked about past highs before starting an antidepressant, because an antidepressant given on its own can bring on mania or rapid mood swings (rapid cycling); schizoaffective disorder, a mix of mood and psychotic illness that runs independently of mood; mood changes brought on by a drug; and physical causes such as thyroid disease. Treatment combines drug and talking therapies under specialist mental health services: an acute manic episode is treated with an antipsychotic drug, and any antidepressant is stopped; long-term prevention of relapse uses a mood stabiliser, with lithium being the most effective, though it needs regular blood tests of lithium levels, kidney function and thyroid function. Depression in bipolar disorder is treated carefully, to avoid tipping the patient into mania (switching). Checking for risk of harm is central to care, because of the dangers during both high and low phases of the illness.

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 Stopping any antidepressant during a manic episode, because it can make the mania worse. That does not match a week of high mood, less sleep, grandiose ideas and overspending, with a past episode of depression.
2. Cautious treatment of bipolar depression Treating the depressive phase carefully, to avoid tipping the patient into mania. But a week of high mood, less sleep, grandiose ideas and overspending, with a past episode of depression does not point to it.
3. Antipsychotic for an acute manic episode correct Correct. An antipsychotic drug is the first choice for treating an acute manic episode.
4. Specialist mental health referral and psychological therapy Referral to specialist mental health services, plus talking therapy, for rounded care. It does not fit a week of high mood, less sleep, grandiose ideas and overspending, with a past episode of depression.
5. Lithium level and organ monitoring Regular blood tests of lithium levels and organ function, to keep treatment safe. Here, a week of high mood, less sleep, grandiose ideas and overspending, with a past episode of depression points elsewhere.

The point: Bipolar affective disorder is a mood disorder with repeated episodes of both low mood (depression) and high mood (mania or hypomania). A manic episode is a clear period, lasting at least a week, of unusually high, expansive or irritable mood, with features such as an inflated sense of self-worth or grandiose ideas, needing less sleep, talking fast (pressure of speech), thoughts jumping quickly from one to another (flight of ideas), being easily distracted, doing more goal-directed activity, and taking risks such as overspending or acting without normal restraint (disinhibition). Psychotic features, such as false beliefs or hearing things that are not there, can also occur. A manic episode is severe enough to cause marked difficulty coping, or to need admission to hospital. Hypomania is a milder form, without psychosis and without severe difficulty coping. Bipolar I disorder is defined by at least one manic episode, and bipolar II disorder by hypomania together with depression, with no full manic episode. Other conditions to consider include depression on its own with no highs (unipolar depression), so a patient with depression should always be asked about past highs before starting an antidepressant, because an antidepressant given on its own can bring on mania or rapid mood swings (rapid cycling); schizoaffective disorder, a mix of mood and psychotic illness that runs independently of mood; mood changes brought on by a drug; and physical causes such as thyroid disease. Treatment combines drug and talking therapies under specialist mental health services: an acute manic episode is treated with an antipsychotic drug, and any antidepressant is stopped; long-term prevention of relapse uses a mood stabiliser, with lithium being the most effective, though it needs regular blood tests of lithium levels, kidney function and thyroid function. Depression in bipolar disorder is treated carefully, to avoid tipping the patient into mania (switching). Checking for risk of harm is central to care, because of the dangers during both high and low phases of the illness.

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