Bipolar Disorder - Signs and symptoms of the initial prodrome

Following are the common signs and symptoms of Bipolar Disorder (prodrome)

• Irritability and aggressiveness
• sleep disturbances
• depression and mania symptoms/signs
• hyperactivity
• anxiety
• mood swings 

Ref: Skjelstad DV, Malt UF, Holte A. Symptoms and signs of the initial prodrome of bipolar disorder: a systematic review. J Affect Disord. 2010 Oct;126(1-2):1-13. doi: 10.1016/j.jad.2009.10.003. Epub 2009 Nov 1. PMID: 19883943.

Bipolar Disorder - Differential Diagnoses

 Following organic and functional disorders might mimic symptoms of Bipolar Disorder

• Anxiety disorders (ex. generalized anxiety disorder, panic disorder etc.)
• Hyperthyroidism
• Cushing's disease/ syndrome
• Multiple sclerosis
• Post Traumatic Stress Disorder
• Schizo-affective disorder
• Schizophrenia
• Attention Deficit Hyperactivity Disorder

Ref: 

1. World Health Organization(WHO). (1993). The ICD-10 classification of mental and behavioural disorders. World Health Organization.
2. Price AL, Marzani-Nissen GR. Bipolar disorders: a review. Am Fam Physician. 2012 Mar 1. 85(5):483-93

Bipolar Disorder - Types (DSM-5)

 Bipolar Disorder, as per the Diagnostic and statistical manual of mental disorders (5th ed.), includes the following types

1. Bipolar 1 : this is diagnosed when symptoms of mania last 7 days or more. Also, can be diagnosed when an individual has severe mania which requires hospitalization. 
2. Bipolar 2 : diagnosed when an individual has symptoms of hypomania, preceded or followed by a major depressive episode
3. Cyclothymic disorder : Includes symptoms of hypomania and depression that last for 2 years or more in adults, not severe enough to warrant a diagnosis of the above 2 conditions. 

Ref:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Bipolar Disorder - Introduction

 It is a psychological disorder, coded as F31 in ICD 10 [1], characterized by unusual and pervasive changes in their mood. A person suffering from biploar disorder can go from feeling extremely sad to feeling extremely happy within a few days or in some case, in a few hours. 

Symptoms of this disorder are spread over a spectrum. Someone with severe symptoms, is easy to diagnose while diagnosing someone who is on the lower side of this spectrum is challenging. 

Ref:

1. World Health Organization(WHO). (1993). The ICD-10 classification of mental and behavioural disorders. World Health Organization.

Treatment of Malaria In India - Update part 2

Treatment of Severe Plasmodium Falciparum Malaria 

Should not be treated on out patient basis, as it requires parenteral administration of antimalarials and has a risk of mortality. 

1. Artesunate: It is the drug of choice. It should be given in a dose of 2.4 mg/kg IV on admission (0 hour), then at 12 hours and 24 hours and then once daily till the patient takes orally or for 7 days. Then, they should get full course of ACT for 3 days (Table 1). However, ACT containing MQ should be avoided in cerebral malaria due to possibility of development of neuropsychiatric complication

2. Quinine: It is an acceptable alternative to AS. It should be given at a dose of 20 mg quinine salt/kg of body weight in 5% dextrose/dextrose saline, over 4 hours, on admission. It is followed by 10 mg/kg of body weight 8 hourly infusions which should be started 8 hours after the 1st loading dose. The infusion rate should not exceed 5 mg/kg of body weight/hour. Initial loading dose should not be given if patient has already taken quinine. If quinine therapy is used beyond 48 hours, the dose should be reduced to 7 mg/kg of body weight 8 hourly till patient takes orally. Then, he should be given oral quinine in a dose of 10 mg/kg of body weight 8 hourly to complete 7 days of therapy. Quinine injection must not be given as bolus injection. It is always given in IV infusion. Doxycycline in a dose of 3 mg/kg of body weight per day for 7 days is to be added when the patient starts taking orally. Doxycycline is contraindicated in pregnancy and children below 8 years of age. In those cases, instead of doxycycline, clindamycin is to be given in a dose of 10 mg/kg of body weight 12 hourly for 7 days

3. Artemether: It should be given in the dose of 3.2 mg/kg of body weight intramuscularly on admission and 1.6 mg/kg of body weight intramuscularly once per day for 4 more days. Then, ACT is to be given for 3 days

4. Alpha-beta artemether: It should be given in a dose of 150 mg/day for 3 days intramuscularly. It is not recommended for children. It should be followed by ACT for 3 days. 

References

1. Guidelines for the Treatment of Malaria 2010 (2nd edition). World Health Organization, 20, Avenue Appia-CH-1211 Geneva 27.

2. Guidelines for Diagnosis and Treatment of Malaria in India 2011 (2nd edition). Government of India, National Institute of Malaria Research, New Delhi.