Bipolar disorder Flashcards
You are on your emergency medicine rotation when Ben, a 22 yo M is brought into the ER by police. His OP psychiatry PA initiated the crisis response team due to concerns at his visit. He is talking rapidly and loudly about his plans for the country as he is the president. You attempt to interview him, but he is constantly changing subjects and is easily distracted. You learn he has slept less than 2 hours per night for the past 8 days. You ask what he’s been doing and he states “I’ve been planning my campaign for mayor!! I already ordered $10,000 in merchandise!.” He can be seen speaking out loud, as if to someone.
What is the diagnosis?
Bipolar Disorder!
(manic episode)
difference between major depressive and bipolar
mania
Bipolar 1
epidemiology
0.6% of population
M = F, but men are more likely to have mania while women are more depressive/rapid cycling
Average age of onset is 20 yo
Bipolar II
epidemiology
0.8% of population
F > M
Average onset is mid 20’s
bipolar
RF
Bipolar I
6-7% die from suicide
Highest risk immediately after hospital discharge
VERY heritable (73-93%)
Bipolar II
Hypomania causes less impairment but depressive episodes tend to be more severe
1 in 3 will attempt suicide, completion rates equal to bipolar I.
Will have several depressive episodes before a hypomanic one, hard to dx
5-15% will end of up having a manic episode → change to Bipolar I d/o
Lifetime suicide risk is 15x higher than general population
Bipolar disorder accounts for ¼ of suicide deaths
60% will have 3 or more comorbid disorders - anxiety and SUD are the highest
40% will develop an eating disorder
bipolar
subtypes
Bipolar I
Bipolar II
Cyclothymia
Substance/Medication induced
Due to another medical condition
Bipolar 1 Criteria A
Time frame
Criteria A
A distinct period of abnormally and persistently elevated, expansive, or irritable mood AND
Abnormally and persistently increased activity or energy, lasting at least 7 days and present most of the day, nearly every day (or any duration if hospitalization is necessary).
The episode requires hospitalization to prevent harm to self or others, or psychotic features.
The episode is not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication, other treatment) or to another medical condition.
Not better explained by schizophrenia, schizoaffective disorder, schizophreniform disorder, or delusional disorder
NOTE: Bipolar I does NOT require a MDD dx. However, this is rarely an occurrence.
Mania Criteria (DIGFAST)
B: During the period of mood disturbance and increased energy and activity, at least 3 of the following symptoms have persisted (4 symptoms if the mood is only irritable), represent a noticeable change from usual behaviour, and have been present to a significant degree:
Distractibility (i.e. - attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
Indiscretion/Impulsivity, characterized by excessive involvement in activities that have a high potential for painful consequences (e.g. - unrestrained buying sprees, sexual behaviours, or foolish business investments).
Grandiosity or inflated self-esteem.
Flight of ideas or subjective experience that thoughts are racing.
Activity (goal-directed) increasing (e.g. - either socially, at work or school, or sexually) or psychomotor agitation.
Sleep decreased (e.g. - feels rested after only 3 hours of sleep).
Talkative (more than usual or pressure to keep talking)
Bipolar I Disorder
specifiers
Specifiers:
○Current or most recent episode: manic, hypomanic, depressed, unspecified
○Severity: Mild, moderate, severe
○In partial remission
○In full remission (2+ months)
○With anxious distress
○With mixed features (3+ MDD, 3+ mania sxs)
○With rapid cycling (4 or more episodes per year, only 10 % experience this)
○With melancholic features
○With atypical features
○With mood-congruent psychotic features
○With mood-incongruent psychotic features
○With catatonic
○With peripartum onset
○With seasonal pattern
Bipolar II Disorder
Criteria
A: Criteria have been met for at least 1 hypomanic episode and at least 1 major depressive episode.
Major Depressive Episode
●5 or more of the following sxs have been present for the same 2 week period and represent a change from previous functioning, and at least 1 of the sxs is either depressed mood or loss of interest/pleasure
○Depressed mood
○Anhedonia
○Significant weight loss/gain
○Insomnia or hypersomnia
○Psychomotor agitation or retardation
○Loss of energy
○Feelings of worthlessness or guilt
○Diminished ability to concentrate
Recurrent thoughts of death or suicide
B: There has never been a manic episode.
C: The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
D: The disturbance in mood and the change in functioning are observable by others.
E: - No marked social or occupational impairment.
-There is never hospitalization.
-No psychotic features (if there are psychotic features, t the episode is, by definition, manic).
F: The episode is not attributable to the physiological effects of a substance or another medical condition.
Same Specifers as Bipolar I
Hypomania Criteria
Time frame
A distinct period of abnormally and persistently elevated, exansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.
3/7 (4/7 if irritable) DIGFAST Mania Criteria
Bipolar II
more
Depressive episodes are likely to cause more impairment than hypomanic episodes.
Bipolar II have more lifetime episodes and spend more time in depressive states.
First onset is likely a depressive episode.
Childbirth can trigger hypomania
⅓ of bipolar II report a suicide attempt
Cyclothymic Disorder
general
●For at least 2 years, (or 1 year in kids), there have been numerous periods with hypomanic symptoms that do not meet criteria for hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for major depressive episode
●During this 2 year period, the hypomanic and depressive symptoms have been present for at least half the time and the individual has not been without symptoms for more than 2 months at a time
●Not attributable to effects of a substance or medical condition
●Sxs cause clinically significant distress or impairment
●15-50% risk cyclothymia will go on to develop Bipolar 1 or 2 disorder
***Bipolar version of dysthymia (MDD)
Substance/Medication Induced Bipolar and Related Disorder
general
Possible drugs
●A prominent and persistent disturbance in mood that predominates in the clinical picture and is characterized by elevated, exansive, or irritable mood, with or without depressed mood or markedly diminished interest in all, or almost all, activites.
●There is evidence from the hx, PE, and lab findings of both:
○The sxs developed during or soon after substance intoxication or withdrawal or after exposure to a medication.
○The involved substance is capable of producing the sxs
●The disturbance does not occur exclusively during the course of a delirium
●The disturbance causes clinically sig distress or impairment
Stimulants (ADHD), SSRI’s/SNRIs, Steroids, thyroid medications, cocaine, MDMA, PCP
Mood Disorder
Questionnaire
(MDQ)
