Theme: Bipolar Disorder

Reminder to:
1) Leave original text in black
2) Mochi’s notes in blue
3) Lecturer's input in purple

Past Year Questions:

1) 2014

Other Questions:
1) OSCE Sem 8 2015/2016
2) Dr Shu

OSCE Sem 8 2015/2016

Patient with drug induced mania (happy, climb mosque, religious grandiosity, urine stimulant
positive.
1. History taking
2. Differential diagnosis

Final Pro Part 2 2014

Patient emotionally irritable. Assess the mood (bipolar)

Answer Script: Marks

Communication skills
● Greet/ intro (open qn: how are you today?) ½
● Explain ½
● Non-verbal communication ½
● Clarity of language ½

Assalamualaikum Cik Ina. Im ____, houseman in charge today. Do you mind if I

ask you a few questions? How are you feeling today?
Salam Cik Ina. Saya ____, ho in charge harini. Boleh ke saya tanya soalan sikit?
Puan okay harini?

Manic assessment (FAILED

A. Elevated mood & full of energy (> 1 week) if not
elicited)
How do you feel in your mood?
Do you feel overly happy/cheerful for no apparent reason?
Do you get more irritable?
How long have you been feeling that way?
Mood puan macam mana harini? Ada rasa terlalu happy tanpa sebab?
Puan ada perasan puan cepat marah?
Dah berapa lama puan rasa macam ni?

B. - Distractibility
Do you get distracted easily?
Puan ada tak susah fokus atau cepat terganggu bila bersembang?
- Insomnia
How is your sleep? Do you feel a decreased need for sleep? Do you feel
tired the next day ?
Tidur macam mana puan? Ada rasa macam tak perlu tidur sbb terlampau
aktif? Esok nya penat tak?
- Grandiosity
Do you feel like you are above everyone, having superpowers or feeling
mighty?
Puan ada ke rasa hebat atau rasa ada kuasa luar biasa?
- Flight of ideas
Are you able to think clearly? Do you have any racing thoughts?
Puan boleh berfikir dengan jelas? Ada tak rasa idea melimpah ruah dalam
satu masa?
- Activity (goal-directed)
Do you feel more creative these days? Have you taken on any new projects
or developed new interests?
Puan ada ambik project baru? Tak boleh tidur selalu buat apa?
- Speech (pressured)
Have you become more talkative than before?
Ada orang cakap puan makin banyak bercakap sampai susah berhenti?
- Thoughtlessness (spending spree, gambling, drinking, sex, investment)
Are you spending as much as before/Have you been on any spending
sprees?
Can you afford to spend this much?
Any reckless or dangerous behaviour? Did it lead to problems with police?
Has your sexual desire or activity changed in any way?
Ada shopping melebihi keperluan dan bajet? Pernah ada masalah sampai
Melibatkan polis? Hubungan intim puan dengan suami?
 >3 if mood disturbance & increase activity
>4 if irritable only

C. Does it affect your daily lives, relationship with friends and family?

Depression Assessment
A Are there periods when you feel low in yourself?

>5, > 2 weeks

Damia Lost Weight In Psychiatry Fatin Worry Damia Recur
● Depressed mood
● Loss of interest
● Weight loss/gain
● Insomnia
● Psychomotor agitation
● Fatigue
● Worthlessness
● Recurrent suicidal thoughts

Previous history: past PSY, previous depression, family, premorbid personality

Drug/ Substance History

Do you take any drugs?
Are you on any medications?
Do you drink alcohol?

Rule out Schizoaffective: psychosis symptoms

Proper termination

What is your diagnosis?

Bipolar disorder in manic phase

What is your differential diagnosis?

Substance induced bipolar disorder
Mood disorder due to GMC
Cyclothymic disorder
Schizoaffective disorder
MDD
How do you treat this patient?

Pharmacology Non-pharmacology

Mood stabilisers 1. ECT

1. Lithium 2. Cognitive behavioural therapy
2. Sodium valproate 3. Interpersonal social rhythm
3. Carbamazepine therapy (train patient tido bila
Atypical antipsychotic makan bila)
1. Risperidone 4. Group therapy
2. Olanzapine 5. Family oriented intervention
3. Ziprasidone
4. Aripiprazole
5. Quetiapine
Typical antipsychotic
1. Haloperidol
 Dr Shu

Instruction to candidate:
Madam Rosie, 35 years old married woman was diagnosed with bipolar disorder and she will
be started on Lithium.
You as a house officer are in-charge in counselling this patient regarding the medication.

Instruction to patient:
You are just diagnosed with Bipolar Disorder and was advised by a specialist to start on Lithium.
You are very anxious and worried about starting on this medication. Here are some questions
that you can ask to the house officer who was in-charge to counsel you regarding the Lithium.
1. “Yes, I know that I have Bipolar, but I don’t know what Lithium is.”
2. “What are the side effects?”
3. “Can I stop taking it once I feel healthy?”
4. “Is it really totally okay to take long term?” – to prompt the candidate regarding long term
effects and teratogenic effect since the patient is married
Answer Script:

Communication Skills 2
Greet/ intro (open qn: how are you today?);
Explain; non-verbal communication; clarity of language; proper termination

Assalamualaikum Cik. Saya ____, houseman in charge.Puan rasa macam mana

harini? Puan dah di diagnosed dengan Bipolar disorder oleh pakar kita. Kita akan
start treatment puan dengan Lithium. Puan ada soalan sebelum saya mulakan?
You have been diagnosed with bipolar disorder by our specialist. We are going to
start your treatment with Lithium. Before I proceed, do you have any questions?

Lithium counseling
● Lithium is effective in controlling your mood symptoms
● The MOA is still unknown, however, it appears to act by modulating the
neurotransmitter.
● You will remain on this medication for a long term. If you desire to stop, you
need to discuss with a specialist.
● Usual dose: 300mg tab tds. Lower dose in elderly (especially if renal impaired)
Lithium ni berkesan untuk kawal mood puan. Secara teori, Lithium ini akan
mengawal neurotransmitter dalam otak kita.
Ubat ini perlu diambil untuk jangka masa yang lama. Jadi jika puan nak
berhenti, puan kena berbincang dulu dengan pakar.

Premedication
Before we start this medication, we need to take your blood (renal function, TFT) and
do ECG as a baseline .
If female, ask LMP +/- UPT to confirm not pregnant (risk of cardiac defect eg
Ebstein’s anomaly)
Do you plan for pregnancy?
Sebelum kita start ubat, kita akan ambik darah puan dan buat ECG sebagai baseline.
Puan last period bila? Ada plan untuk pregnant ke?

Side Effects
However it has various side effects such as :
○ Nausea, vomit, diarrhoea (first 2 weeks)
○ Metallic taste (rasa besi?)
○ Thirst, polyuria, dehydration, lethargy (diabetes insipidus)
○ Fine tremor
○ Weight gain
○ Peripheral edema
○ Acne
Puan mungkin akan alami kesan sampingan ubat ni contohnya dalam 2 minggu
pertama, puan mungkin ada loya, muntah atau cirit birit. Selain itu, ada rasa besi di
mulut, dahaga, banyak kencing, letih, menggigil, penambahan berat badan, bengkak
kaki dan juga jerawat.
Management of Side Effects

If you notice those symptoms, please come to the clinic. We will:

● Lower/ alter dose schedule
● Change to other mood stabiliser or adding other medication
● We will give you medications to treat the side effects
ie:
GI upset → take with meal, antiemetics or PPI
Fine tremor → beta blocker
Peripheral edema → diuretic
Acne → topical/ oral antibiotics
Jika puan ada alami simptom yang saya sebut tadi, datang ke klinik. Kita akan
kurangkan dose, tukar dose atau tukar kepada ubat yang lain. Dan kita akan berikan
ubat untuk hilangkan simptom puan tu.

Long term side effects

1. Leukocytosis (increase WBC)
2. Movement (tremor)
3. Nephrotoxicity (renal failure)
4. hypOthyroid
5. Pregnancy- Ebstein Anomaly (affect your fetal heart)
Kesan sampingan pada jangka panjang pula adalah peningkatan sel darah putih,
menggigil, masalah buah pinggang, masalah thyroid dan juga effect jantung bayi jika
puan mengandung.

Monitoring
● We will monitor lithium level in your blood weekly until it stabilizes then we
monitor 3 monthly.
● If symptoms of intoxication appears like I mentioned before, you will need to
stop the medication and consult doctor immediately.
Tapi puan jangan risau, kita akan pantau paras lithum dalam darah puan setiap
minggu sehingga stabil. Bila dah stabil kita akan pantau 3 bulan sekali. Kalau ada
symptoms peningkatan lithium dalam darah yang saya bagitau tadi, puan kena
berhenti ambil ubat dan datang ke hospital segera.

Drug interaction, lifestyle and diet

● While taking this medication, you need to be careful with total body water and
sodium levels.
● Low sodium diet, excessive sweating/ dehydration and concurrent use of
diuretics esp. Thiazide are dangerous as they are predisposed to intoxication.
● If go for ECT, need to stop at least 3 days :- can prolong seizure & cause
post-ictal delirium
Sepanjang puan ambil ubat ni, saya nasihatkan puan banyak kan minum air dan
ambik garam dalam makanan secara sederhana. Jangan kurang ye. Kerana jika
puan dehydrated dan kurang garam dalam badan akan meningkatkan risiko
keracunan lithium. Jika puan perlu jalani ECT, puan perlu stop ambik ubat sekurang
kurangnya 3 hari sebelum kerana boleh menyebabkan sawan berpanjangan.
Closure
Please inform any doctor that you are in Lithium to avoid drug reaction
Don't forget to take your medication daily
Do you have any questions?
Thank you
Jika puan jumpa mana mana doktor, puan perlu maklumkan yang puan sedang ambil
lithium dan jangan lupa ambil ubat setiap hari ya. Puan faham apa yang saya
terangkan? Ada soalan tak? Thank you Puan.

Notes:

Drugs Dose Side Effects Long Term Side Effects

Lithium 600-1800mg/d GI upset (first 2w) LMNOP

Polyuria Leukocytosis
Polydipsia Movement (tremor)
Metallic taste Nephrotoxicity
hypOthyroid
Pregnancy (Ebstien anomaly)

Na Valproate 600-2500 mg/d GI upset HIS

Sedation Hepatotoxicity
Weight gain Male Infertility
Tremor Spina bifida
Thrombocytopenia
Raised liver enzyme

Carbamazepine 200-1600mg/d Hypotension Steven Johnson syndrome

GI upset (fever, rash, blisters, drooling)
Dizziness Agranulocytosis
Drowsiness
Fatigue