Bipolar Disorder

Question 1

Mental status exam: Reveals a markedly talkative woman whose thought processes quickly jump from one idea to another. She does state that her thoughts are moving fast. She does not display any bizarre behavior and denies any auditory or visual hallucinations
LABS: name two that would give us good information?

Answer 1

Labs:

1. Toxicology screen negative;
2. Thyroid function tests (TFTs) within normal limits

Question 2

What psychiatric terms are used to describe the following regarding our case?

1. “up all night working”
2. “talking about her superiority to others in her program”
3. “markedly more active in her graduate school research”
4. “thought processes jump from one idea to another”

Answer 2

1. (decreased need for sleep)
2. (grandiosity or inflated self esteem)
3. (increase in goal-directed activity)
4. (flight of ideas)

Question 3

What psychiatric terms are used to describe the following regarding our case?

1. “I am the greatest thinker in the history of humanity!”
2. “speech is rapid and pressured”
3. “stayed awake for several nights without fatigue”
4. “exceeded his credit limit after charging several thousand dollars”

Answer 3

1. (grandiosity or inflated self-esteem)
2. (pressured speech)
3. (decreased need for sleep)
4. (injudicious impulsive behavior)

Question 4

1. What does hypomania refer to?
2. What is absent in hypomania?
3. Functional impairment?
4. Hospitalization?

Answer 4

1. Refers to a briefer duration (at least 4 days) of manic symptoms, and is often used to refer to a less severe level of symptoms
2. Psychosis does not occur with hypomania.
3. Causes only mild functional impairment, and can even improve functioning
4. Does NOT lead to hospitalization

Question 5

1. What does Mania refer to?
2. What can be present or absent?
3. Functional impairment?
4. Leads to?

Answer 5

1. Longer duration (at least one week) and more severe symptoms
2. Psychosis can occur (doesn’t have to though)
3. Significant impairment in functioning
4. Often leads to hospitalization

Question 6

Bipolar is divided into two subtypes: Bipolar I
1. History of what for diagnosis?

2. Although not required for the diagnosis of bipolar I disorder, what is more present in Type 1?

Answer 6

1. ***History of at least one manic episode, with or without past major depressive episodes
2. depression is present more commonly than mania for most patients

Question 7

Bipolar is divided into two subtypes: Bipolar II

History of what for diagnosis? 3

Answer 7

1. History of at least one episode of major depression
2. History of at least one hypomanic episode
3. NO history of a manic episode

Question 8

Criteria for Manic episode:
1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at what period of time?

2. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree?
   7

Answer 8

1. least 1 week (or any duration if hospitalization is necessary).

2.
1) Inflated self-esteem or grandiosity

2) Decreased need for sleep (eg, feels rested after only 3 hours of sleep)
3) More talkative than usual or pressure to keep talking
4) Flight of ideas or subjective experience that thoughts are racing
5) Distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli)
6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
7) Excessive involvement in pleasurable activities that have a high potential for painful consequences (eg, engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

Question 9

Criteria for Manic episode:

The mood disturbance must meet what criteria? 3

Answer 9

1) is sufficiently severe to cause marked impairment in occupational functioning, usual social activities, or relationships with others,
2) necessitates hospitalization to prevent harm to self or others, or
3) has psychotic features.

Question 10

Criteria for Manic episode:
The symptoms are not due to what?
2

Answer 10

1. the direct physiological effects of a substance (eg, a drug of abuse, a medication, or other treatment) or
2. a general medical condition (eg, hyperthyroidism).

Question 11

Criteria for Hypomanic Episode:
1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least how long?

2. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
   7

Answer 11

1. 4 consecutive days and present most of the day, nearly every day.
2. 1) Inflated self-esteem or grandiosity

2) Decreased need for sleep (eg, feels rested after only 3 hours of sleep)
3) More talkative than usual or pressure to keep talking
4) Flight of ideas or subjective experience that thoughts are racing
5) Distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli)
6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
7) Excessive involvement in pleasurable activities that have a high potential for painful consequences (eg, engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

Question 12

Criteria for hypomanic episode:
1. The episode is associated with an unequivocal change in functioning that is different how?

2. The disturbance in mood and the change in functioning are what?
3. Describe the severity of the episode? 2

Answer 12

1. is uncharacteristic or the individual when not symptomatic.
2. observable by others.
3. • The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic

• The episode is not attributable to the physiological effects of a substance.

Question 13

Age of onset generally between _______ years?

Answer 13

15 and 30 years

Question 14

Genetics
Approximate lifetime risk:
1. Monozygotic twin? 
2. First degree relative?
3. Unrelated person? 

Your suspicion should
increase when there is
a positive family history!

Answer 14

1. 40-70%
2. 5-10%
3. 0.5-1.5%

Question 15

Clinical Course
Bipolar I
1. Marked by what?
2. Often a alternating pattern of what?
3. What are the more frequent symptoms?

Answer 15

1. Marked by relapses and remissions
2. Often alternating pattern between manic and depressive episodes
3. ***Depressive symptoms are more frequent than manic symptoms (3:1 ratio)(This is interesting because what DEFINES this disorder?!)

Question 16

Clinical Course
Bipolar II
Course is less well studied, and therefore, less well understood

1. We do know that what symtpoms are much more frequent than what?

Answer 16

1. depressive symptoms, hypomanic episodes

Question 17

Bipolar Disorder Comorbidities
1. High rates of comorbid abuse of what?

2. Lifetime risk for addictive disorder?
3. Comorbid _______ disorder is also common
4. Between _____% attempt suicide, and ___% are successful (significantly higher than those with depression)!

Answer 17

1. alcohol or substance abuse (Hmmm, makes things a little tricky when doing a toxicology screen, doesn’t it- might be on top of coke or meth.)
2. 65%
3. anxiety
4. 25-50, 15

Question 18

1. What does a mixed state refer to?
2. Signs and symptoms that the patient may have?
   8
3. Mixed episodes can be incredibly distressing to the individual. It can lead to what?

Answer 18

1. This refers to the presence of both depressive and manic symptoms simultaneously.
2. The person may experience the -impulsiveness,
   - insomnia,
   - irritability, and
   - flight of ideas that can be present in a manic episode as well as

• suicidal thoughts,
• guilt,
• feelings of hopelessness, and
• changes in appetite that are common during depressive episodes.

3. • panic attacks,
   • substance abuse
   • suicide.

Question 19

1. Cyclothymia is what?
2. How is this different from Bipolar?
3. Does not meet what criteria?
4. Treated with what?

Answer 19

1. Defined by the presence of:
   - Numerous periods of hypomania and of depression, persisting for at least two years
2. This is distinctly different from Bipolar I and Bipolar II, where there is a predominance of depressive symptoms
3. Does not meet DSM criteria for major depression
4. Considered to be one of the bipolar disorders and is treated with the same kinds of medications

Question 20

Describe the following for Bipolar I:

1. Mania and MDE
2. Hypomania and MDE
3. Hypomanic and depression symptoms, frequently switching
4. Duration

Answer 20

Bipolar I disorder

1. +
2. -
3. -
4. At least 1 week for mania, 2 weeks for MDE

Question 21

Describe the following for Bipolar II:

1. Mania and MDE
2. Hypomania and MDE
3. Hypomanic and depression symptoms, frequently switching
4. Duration

Answer 21

Bipolar II disorder

1. -
2. +
3. -
4. At least 4 days for hypomania, 2 weeks for MDE

Question 22

Describe the following for Cyclothymic:

1. Mania and MDE
2. Hypomania and MDE
3. Hypomanic and depression symptoms, frequently switching
4. Duration

Answer 22

Cyclothymic disorder

1. -
2. -
3. +
4. At least 2 years

Question 23

Treatment: Some key principles to remember?

3

Answer 23

1. Untreated bipolar is associated with substantial morbidity and mortality
2. Treatment differs from that of unipolar depression
3. Common for bipolar to be missed!

Question 24

Treatment depends on how patient presents and includes a number of medications!
1. These three are your
classic “mood stabilizers” 3
2. WHat are your atypical antipsychotics you would treat with?
5

Answer 24

1. Lithium (Eskalith)
2. Valproate (Depakote)
3. Carbamazepine (Tegretol)

Atypical antipsychotics

1. Quetiapine (Seroquel)
2. Risperidone (Risperdal)
3. Olanzapine (Zyprexa)
4. Ziprasidone (Geodon)
5. Clozapine (Clozaril)

Question 25

Obstacles for Bipolar Management | 2

Answer 25

1. Many patients like mania - When patients feel good, they don’t want to take medication! 2. Remember… education is the key!

Question 26

``` 1. The reason I wanted to show this is because the majority of the time you will NOT get a Paul or Paula! Most of the time you will catch bipolar because a person presents with what? ``` 2. And you have to ask about what???

Answer 26

1. depressive symptoms and 2. you ask about a history of manic or hypomanic episodes!!!

Question 27

Excellent Questions to Ask Bipolar disorder pts? 4

Answer 27

1. “Have you experienced sustained periods of feeling uncharacteristically energetic?” 2. “Have you had periods of not sleeping but not feeling tired?” 3. “Have you felt your thoughts were racing and couldn’t be slowed down?” 4. “Have you had periods where you were excessive in sexual interest, spending money, or taking unusual risks?”

Question 28

The primary difference between hypomania and mania is what? | 2

Answer 28

that with hypomania there is a 1. lack of significant impairment in social or occupational functioning and 2. the absence of psychosis or symptoms that necessitate psychiatric hospitalization

Question 29

1. Drugs such as cocaine and amphetamines can cause what? | 2. What else can mimic the signs of mania as well?

Answer 29

1. substance-induced mood disorder. 2. Hyperthyroidism Therefore, in all patients that present with hypomania or mania, it’s critical to check a toxicology screen and thyroid function tests.

Question 30

1. A what is NOT required in order to make a diagnosis of Bipolar I? 2. That being said, the VAST majority of the time in the VAST majority of patients, ___________ symptoms will predominate!

Answer 30

1. major depressive episode | 2. depressive