On this page
Study tools
Write your answer
Saved on this device. No marking — you are the marker.
Q1: Presentation (2 min)
A 30-year-old man is brought in by police after 9 days of not sleeping, grandiose beliefs, overspending and pressured speech.
- Define a manic episode (DSM-5: elevated/irritable mood plus increased energy for over 1 week, 3+ of DIGFAST, marked impairment/psychosis).
- Recite the DIGFAST mnemonic and identify the features in the vignette.
- List the atypical features that demand an organic work-up (abnormal vitals, clouding of consciousness, visual hallucinations, age over 50, focal neurology).
- State the investigations to exclude an organic cause (drug screen, TSH, glucose, calcium, U&E, MRI brain if indicated).
Q2: Management (3 min)
- State the first pharmacological step in acute mania (STOP antidepressants) and why.
- Give the drug hierarchy: antipsychotic (haloperidol/olanzapine) for rapid control plus a mood stabiliser (lithium/valproate); combination/ECT for refractory.
- Give lithium dosing, target level (0.8 to 1.2 mmol/L in acute mania, 0.6 to 0.8 maintenance), the 12-hour trough sampling rule and baseline tests.
- Describe rapid tranquillisation options and the legal framework for admission (Mental Health Act).
Q3: Complications (2 min)
- Describe lithium toxicity (level over 1.5 mmol/L; coarse tremor, ataxia, dysarthria, nystagmus, seizures) and its precipitants (NSAIDs, thiazides, ACE inhibitors, dehydration).
- Give the management of toxicity (stop drug, IV normal saline, haemodialysis if severe).
- List the long-term adverse effects of lithium: nephrogenic diabetes insipidus, hypothyroidism, hyperparathyroidism, weight gain, psoriasis.
- State the teratogenicity pairing: valproate = neural tube defects; lithium = Ebstein anomaly.
Q4: Prognosis & special situations (2 min)
- State that bipolar has the highest suicide rate of any mental disorder (6 to 15% lifetime) and that lithium is the only drug proven to reduce suicide (Cipriani 2013).
- Describe rapid cycling (at least 4 episodes/year; avoid antidepressants; favour valproate).
- Outline management in a woman planning pregnancy: avoid valproate; use lamotrigine or lithium at lowest effective dose with folate 5 mg and a fetal echocardiogram at 18 to 20 weeks; Pregnancy Prevention Programme if valproate is unavoidable; ECT for severe perinatal illness.
- Explain the kindling/sensitisation model and why it justifies early, continuous prophylaxis.