2 English reference biped affective disorder [National Guidelines for Clinical Application of Essential Drugs: 20 12 Edition]. Chemicals and biological products]
3 Overview Bipolar disorder, also known as bipolar disorder, generally refers to a mood disorder characterized by manic or hypomanic episodes and depressive episodes [1].
Leonhard( 1957), a German, first proposed that affective disorder can be divided into two categories: unipolar affective disorder and bipolar affective disorder. Bipolar disorder refers to manic episodes and depression. The data show that the risk rate of bipolar disorder is lower than that of unipolar disorder, and the genetic tendency of bipolar patients is higher than that of unipolar disorder. In addition, patients with bipolar disorder often get sick early, and the prognosis is not as good as that of patients with unipolar disorder, but the effect on lithium salt is good. According to CCMD-ⅱ-R Ⅱ-R, bipolar disorder can be divided into manic period, depressive period, mixed type, rapid circulation type and other subtypes.
When bipolar disorder is manic, it is characterized by high mood, increased speech and increased activity; However, during the onset of depression, there will be symptoms such as depression, mental retardation and decreased activity [1]. Severe patients may also have psychotic symptoms such as hallucinations, delusions or catatonic symptoms at the peak of the attack [1]. Bipolar disorder usually has a paroxysmal course. Mania and depression often appear repeatedly or alternately, but they can also exist together. The symptoms of each episode often last for a long time (manic episode lasts more than 65,438+0 weeks, and depressive episode lasts more than 2 weeks), which has adverse effects on patients' daily life and social function [65,438+0].
4 The etiology of bipolar disorder is unclear [1]. A large number of research data suggest that genetic factors, neurobiochemical factors and psychosocial factors have obvious effects on the occurrence of this disease [1].
5 Diagnosis of Bipolar Disorder Bipolar disorder is characterized by recurrent (at least twice) obvious emotional and activity level disorders. Sometimes, the disorder is characterized by high mood, increased energy and activity (mania or hypomania), and sometimes depression, decreased energy and activity (depression). Intermittent periods usually show complete remission. Compared with other mood disorders, the incidence of this disease is closer in both sexes. Because manic patients are relatively rare, and are similar to patients with at least occasional depressive episodes (in family history, pre-illness personality, onset age, long-term prognosis, etc. ), such patients also belong to bipolar disorder. [ 1]
Manic attacks usually start suddenly and last for two weeks to four or five months (the median is about four months); Depression often lasts longer (the median is about six months); But except in old age, it rarely exceeds 1 year. These two types of seizures are usually secondary to stressful life events or other mental trauma, but the existence of stress is not a necessary condition for diagnosis. The first onset can be seen at any age from childhood to old age. The frequency of attack, recurrence and remission form vary greatly, but with the passage of time, the remission period tends to shorten. After middle age, depression becomes more common and lasts longer. [ 1]
Bipolar disorder, which is the main point of hypomania diagnosis at present [1]:
Diagnosis needs: (a) The current episode meets the criteria of hypomania; And (b) there must be at least one other emotional episode (hypomania, mania, depression or mixed) in the past;
Bipolar disorder is currently the main diagnosis point of manic episode without psychotic symptoms [1];
Diagnostic needs: (a) The current episode must meet the criteria of manic episode without psychotic symptoms; And (b) there must be at least one other emotional episode (hypomania, mania, depression or mixed) in the past;
Bipolar disorder is currently the key point of diagnosis of manic episode with psychotic symptoms [1];
Diagnostic needs: (a) The current episode must meet the criteria of manic episode with psychotic symptoms; And (b) there must be at least one other emotional episode (hypomania, mania, depression or mixed) in the past;
Bipolar disorder, which is the main diagnostic point of mild to moderate depression at present [1];
Diagnostic requirements: (a) The current episode must meet the criteria of mild depressive episode or moderate depressive episode; And (b) there must be at least one episode of hypomania, mania or mixed emotions in the past;
Bipolar disorder is currently the main diagnosis point of major depressive episode without psychotic symptoms [1];
Diagnostic requirements: (a) The current episode must meet the criteria of severe depressive episode without psychotic symptoms; And (b) there must be at least one episode of mania, hypomania or mixed emotions in the past;
Bipolar disorder, at present, is the main diagnostic point of major depressive episode with psychotic symptoms [1];
Diagnostic needs: (a) The current episode must meet the criteria of severe depressive episode with psychotic symptoms; And (b) there must be at least one episode of mania, hypomania or mixed emotions in the past;
Bipolar disorder, which is the focus of mixed state diagnosis at present [1];
The patient had at least one episode of mania, hypomania or mixed emotions in the past, and now he is either in a mixed state or shows a rapid change in symptoms of mania, hypomania and depression.
5. 1 diagnostic points Although the most typical form of bipolar disorder is manic and depressive episodes, which are separated by normal emotions; However, depression is accompanied by hyperactivity and verbal compulsion for days to weeks, and it is not uncommon for mania and exaggeration to be accompanied by agitation, decreased energy and instinctive drive. Depression symptoms and hypomania or manic symptoms can also be quickly converted, different from day to day, and even sometimes different. If the symptoms of the two groups are prominent most of the time and the attack lasts for at least two weeks, the diagnosis of mixed bipolar disorder should be made [1].
The treatment of bipolar disorder is based on the comprehensive treatment of emotional stabilizers [1]. Bipolar disorder recurs in a circulatory way almost all his life, and its frequency is much higher than that of depression, especially in patients with fast circulatory course [1]. Therefore, bipolar disorder is often a chronic process disorder, and its treatment goal should not only relieve acute symptoms, but also adhere to the principle of long-term treatment to prevent recurrent attacks [1].
6. 1 The hospitalization of bipolar disorder must first ensure the safety of patients, and clinicians need to judge whether patients should be hospitalized. The indications of hospitalization are: the danger of self-injury, suicide and injury; The patient's overall ability declines, and he can't eat and avoid the environment; Symptoms deteriorate rapidly, such as high excitement, impulsiveness, self-injury and other behaviors that seriously hurt themselves and endanger others; Lack or loss of support from family and social support system. [ 1]
6.2 Drug treatment of manic episode 6.2. 1 Lithium carbonate The main indication of lithium carbonate is mania, which is the first choice for treating mania at present, and can also prevent manic or depressive episode of mania and bipolar disorder [1].
Schizophrenia and affective psychosis can also be treated with lithium salt [1]. It can be used as a synergistic drug to treat schizophrenia with emotional disorder and agitation symptoms [1].
Acute and chronic nephritis, renal insufficiency, severe cardiovascular disease, myasthenia gravis, the first three months of pregnancy and patients with sodium deficiency or low-salt diet are prohibited [1].
Use with caution in patients with Parkinson's disease, epilepsy, diabetes, hypothyroidism, neurodermatitis and senile cataract [1].
The effective dose range of lithium carbonate is 750 ~ 1500mg/d, and occasionally it can reach 2000mg/d. Generally, 250mg is given first, 2 ~ 3 times a day, and the dose is gradually increased after meals, and gradually increased to the therapeutic dose within 3 ~ 5 days. Generally, it takes at least 1 week to take effect. The dose of maintenance therapy is 500 mg ~ 1500 mg/d, which should be reduced appropriately for the elderly and infirm, and also when combined with antidepressants or antipsychotics. Because the therapeutic dose of lithium salt is close to the toxic dose, we should not only closely observe the changes of the condition and treatment response, but also dynamically monitor the blood lithium concentration and adjust the dose according to the condition, treatment response and blood lithium concentration. The blood lithium concentration should be maintained at 0.8 ~ 1.2 mmol/L during acute treatment and 0.4 ~ 0.8 mmol/L during maintenance treatment, and the upper limit of blood lithium concentration should not exceed 1.4mmol/L to prevent lithium salt poisoning. [ 1]
The side effects of lithium carbonate are related to the blood lithium concentration [1]. It usually appears 1 ~ 2 weeks after taking the medicine, but it also appears later [1]. According to the occurrence time of side effects, they can be divided into early side effects, late side effects and poisoning precursors [1]:
① Early side effects: weakness, fatigue, drowsiness, finger tremor, anorexia, epigastric discomfort, nausea, vomiting, loose stool, diarrhea, polyuria, dry mouth, etc. [ 1].
② Late side effects: The patient suffered from persistent polyuria, polydipsia, weight gain, goiter, myxedema and finger tremor. Rough tremor suggests that the blood drug concentration is close to the poisoning level [1].
③ Precursors of lithium poisoning: vomiting, diarrhea, general tremor, convulsion, slow movement, drowsiness, dizziness, slurred speech and disturbance of consciousness. The blood lithium concentration should be detected immediately. If the blood lithium exceeds 1.4mmol/L, it should be reduced. If the clinical symptoms are serious, lithium salt treatment should be stopped immediately [1].
6.2.2 Antiepileptic drug therapy 1) Sodium valproate: Sodium valproate has the same effect on mania as lithium salt, and may have a better effect on mixed mania, rapid circulation bipolar disorder and those who are ineffective in lithium salt treatment. Sodium valproate starts with a small dose, 200mg each time, 2 ~ 3 times a day. 200mg。 Add it every 2 ~ 3 days. The dosage range is 800 ~1800 mg/d. The therapeutic concentration should reach 50 ~100 mg/L. The common side effects are gastrointestinal symptoms, sedation, ataxia and tremor. Elevated transaminase is common, and adverse reactions of hematopoietic system are rare. Very few patients have rare toxic hepatitis and pancreatitis, which is a rare heterogeneous reaction. Liver function and white blood cell count should be checked regularly during treatment. At present, sodium valproate has no indication to treat bipolar disorder in China, which should be paid attention to. [ 1]
2) Carbamazepine: It is effective in treating acute mania and preventing manic attacks, especially suitable for manic patients who have no response to lithium salt treatment, can not tolerate the side effects of lithium salt and have rapid cycle attacks. It should be gradually increased from a small dose to 600 ~ 1200mg/d, and taken orally for 2 ~ 3 times. Too fast dose increase will lead to dizziness or ataxia. Carbamazepine has anticholinergic effect, and side effects such as blurred vision, dry mouth and constipation may occur during the treatment. Rash is more common, and exfoliative dermatitis can occur in severe cases. Occasionally, it can cause leukopenia, thrombocytopenia and liver damage. The changes of hemogram should be monitored. Carbamazepine has been rarely used in clinic because of its serious adverse reactions. [ 1]
6.2.3 Antipsychotics with indications, stable mood and high safety can be selected [1].
Haloperidol is a traditional antipsychotic drug, which can quickly control acute manic episode. In severe attack, haloperidol was injected intramuscularly 2 ~ 3 times a day, 5 ~ 10 mg each time. Among the new antipsychotics, olanzapine, risperidone combined with quetiapine and lithium carbonate can treat manic episode, while clozapine combined with lithium carbonate can treat refractory mania. The dosage of antipsychotic drugs depends on the severity of the disease and adverse drug reactions. [ 1]
6.3 Drug treatment of depressive episode
Summary of School 2023 Community Work 1
Moderate community activities are also the "seasoning" and "lubricant" of our college students' s