Trastorno Bipolar Flashcards
6.1.
According to the DSM-5-TR, what is a criterion that
distinguishes a manic from a hypomanic episode?
A. Length of the episode
B. Number of symptoms
C. Level of impairment during a depressive episode
D. Insidious versus gradual onset
E. The need for hospitalization
6.1. E. The need for hospitalization
The main differences between manic and hypomanic episodes are no
marked impairment in functioning and no need for hospitalization in
the latter. However, a person with bipolar II disorder can have
marked impairment and need hospitalization during the depressive
episode. The number of symptoms needed to diagnose a manic or
hypomanic episode is the same. There is no difference in episode
length or onset.
6.2.
A 30-year-old woman presents to her primary care physician
with a chief complaint of “mood swings. Some days I’m up, and
some days I’m down.” She states that she has periods during
which she does not “feel like doing anything. I don’t want to go
to work, but I do anyway, and still do a good job.” During those
times, she does not want to spend any more time with people
than she has to, and will come home and “mindlessly watch TV,
but I’m not really paying attention to it.” She has lost some
friends because “I drop off the face of the earth except for
work.” These symptoms last for a few weeks to a few months at
a time. She denies changes in sleep or appetite, feeling guilty or
worthless, or ever having suicidal ideation. Other times, “I’m
up and ready to go, and feel like I can be the life of the party. I
dress better, I feel better, I’m more productive at work,
sometimes to the point that I almost overlook some details in
order to finish a task.” During those times, which last at least
several weeks, she stays up later than usual, getting about 3
hours of sleep rather than her usual 8, “and I’m not tired the next day. It actually feels pretty good!” She has never seen a
therapist or a psychiatrist or been hospitalized, has no chronic
medical illnesses, takes no medications and denies drug use.
Vital signs are normal and physical examination is
noncontributory. What is the most likely diagnosis?
A. Persistent depressive disorder
B. Borderline personality disorder
C. Cyclothymia
D. Bipolar II disorder
E. Bipolar I disorder
6.2. C. Cyclothymia
This patient exhibits symptoms of both depression and hypomania,
but does not meet full criteria for either. Because there are some
manic symptoms, she cannot be diagnosed with a unipolar
depressive disorder. The manic symptoms do not appear to cause
marked problems with social or occupational functioning, so she
cannot be diagnosed with bipolar I. The depressive symptoms have
led to problems with social functioning. However, she does not
endorse enough symptoms to meet criteria for major depressive
disorder, which also eliminates bipolar I. The diagnosis that most fits
is cyclothymia. Though she starts by saying her moods are up and
down over a period of days, she later clarifies that the distinct moods
last for weeks or months at a time. Mood swings in borderline
personality disorder often occur over hours to days
6.3.
A 21-year-old college student is brought to the emergency
department by his friends who are concerned that he has
stayed up for 3 days straight and “talks so much that he doesn’t
make any sense.” They state that he started seeming “real
hyper” about a week ago, and since then “went into god mode.”
They state that he thinks he knows more than anyone on
campus and talks at length about different subjects, “even
though it’s obvious he has no idea what he’s talking about.” He
stays up all night “writing what he says is a new quantum
physics textbook, even though he’s a history major.” He has
overdrawn his credit card from buying multiple 3D printers
and materials which he says he needs to “print out a scale
model of the universe.” He and his friends say that the patient
does not use drugs. He has had no prior episodes, and no
chronic medical or psychiatric conditions. UDS is negative. The
patient is admitted to the hospital for a week and stabilized on
medication. On the day of discharge, he asks how long he needs
to stay on medication. What is the most accurate reply?
A. At least 1 month
B. At least 3 months
C. At least 6 months
D. At least 1 year
E. Indefinitely
6.3. B. At least 3 months
An untreated manic episode lasts about 3 months, so he should be on
the medication for at least that amount of time. However, given that
he has had one full-blown manic episode, he has a 90% chance of
having another, so many clinicians would be hesitant to discontinue
medication after that length of time.
6.4.
What factor predicts a better prognosis for a patient with
bipolar I disorder?
A. Male gender
B. Advanced age of onset
C. Depressive features
D. Interepisode depressive features
E. A longer duration of manic episodes
6.4. B. Advanced age of onset
While not protective, several factors predict a better outcome in
patients with bipolar I disorder. Among them is an advanced age of
onset. Others are a short duration of manic episodes, few suicidal
thoughts, and few coexisting psychiatric or mental health problems.
Conversely, male gender, depressive features, and interepisode
depressive features are all factors that predict a poor outcome.
6.5.
A 32-year-old woman is brought to the emergency department
by her husband after he found her jogging naked down the
street in their neighborhood in the middle of the night because
she “says she felt like she needed to exercise right then.” He
reports that she has a 10-year history of bipolar disorder, and
that she does well “except when she is off her medications. We
were gone on vacation for 2 weeks and forgot them. We
thought she’d be fine for that amount of time. As soon as we got
home 2 days ago, she took her lithium, but I guess it was too
late.” He notes that she started wanting to spend more and
more money on drinks and expensive jewelry and souvenirs
while they were away. The patient tells the emergency
department all about the vacation, barely stopping to take a
breath. They both report that she has not slept more than 4
hours since returning. What is the most appropriate
disposition?
A. Admission to an inpatient psychiatric hospital
B. Discharge with follow-up the next day with her psychiatrist
C. Admission to a partial hospital program
D. Admission to an intensive outpatient program
E. Discharge with a prescription for a sedative
6.5. A. Admission to an inpatient psychiatric hospital
This patient is floridly manic and putting herself in danger (jogging
naked in the middle of the night). The increase in alcohol use is also
concerning. She needs acute hospitalization for medication that will
break the manic episode as quickly as possible. Rapid titration of
medications should be done in a secured medical environment for
her safety, and discharge to home, even with a follow-up the next
day, would not achieve that. She would also not be in a secure
environment in an intensive outpatient or partial hospitalization
program.
6.6.
What is the most evidence-based medication for acute bipolar
depression?
A. Lithium
B. Fluoxetine
C. Olanzapine
D. Quetiapine
E. Brexpiprazole
6.6. D. Quetiapine
Unlike acute monopolar depression, in which an SSRI would most
likely be the first line of treatment, in bipolar depression, atypical
antipsychotics have shown the most efficacy. Of those medications,
quetiapine has the most evidence. Lithium has only limited evidence
for bipolar depression. Though olanzapine has positive studies or
efficacy, it does not have the best evidence. Brexpiprazole is used as
an adjunct for unipolar, not bipolar, depression.
6.7.
A 45-year-old woman is brought by EMS to the emergency
department following an acute suicide attempt by overdose on
acetaminophen. She states that she has been depressed for the
last several months to the point that she has lost her job
because “I can’t get out of bed.” She is now worried that she
soon will not have the money to care for her daughter. “I’m a
single mother. My daughter deserves to have someone who can
care for her, and that’s not me.” She was diagnosed with
bipolar disorder 15 years ago, and has been on trials of
valproate, olanzapine, carbamazepine, and lithium. However,
she had trouble remembering to take the medications daily.
Mania has been well controlled over the last 2 years with
paliperidone palmitate monthly. However, she still has
breakthrough episodes of depression, and says that she sees no
other way out for herself or her daughter than suicide. She has
not had a previous suicide attempt, stating that she has never
felt this hopeless before. She is emergently admitted to the
hospital. Following medical stabilization, what is the most
appropriate treatment?
A. Lithium
B. Quetiapine
C. Electroconvulsive therapy
D. Valproate
E. Lamotrigine
6.7. C. Electroconvulsive therapy
This patient is in the midst of a severe bipolar depression, has made
a potentially lethal suicide attempt and is still actively suicidal, which
constitutes an acute medical emergency. For those reasons, and
because her history has shown that oral medication compliance is
difficult for her, electroconvulsive therapy is warranted. If that were
not an option, quetiapine would be the medication of choice, as it has
the best evidence for bipolar depression. Though lamotrigine also
has evidence, the acute nature of the depression would preclude
using a medication that will take weeks to titrate. Lithium has
limited evidence for bipolar depression, and valproate is indicated
for acute mania.
6.8.
A 21-year-old college student presents to the student health
center with complaints of depressed mood, decreased appetite,
and poor concentration for the last week. She has been
attending class, but once lecture concludes, goes straight to her
room, studies, and does not spend time with her friends. She
denies suicidal ideation and has had no prior suicide attempts.
She was diagnosed with bipolar II disorder 6 months ago
during a hypomanic episode and was started on valproate. She
is also diagnosed with hypothyroidism for which she is on
thyroid replacement therapy. She states that she has been
unhappy with the valproate, which is leading to weight gain
and contributing to the depression. What is the most
appropriate treatment?
A. Lithium
B. Quetiapine
C. Aripiprazole
D. Fluoxetine
E. Lamotrigine
6.8. E. Lamotrigine
Though lithium could be a viable option for long-term treatment, it
has not shown much efficacy in acute bipolar depression. In
addition, a prior diagnosis of hypothyroidism would make lithium a
less attractive option given its propensity to cause hypothyroidism.
Also to be avoided, if possible, is a medication that can lead to weight
gain, which eliminates most atypical antipsychotics. Fluoxetine and
other antidepressants are less effective for bipolar depression than
for monopolar depression. Lamotrigine is effective for acute bipolar
depression and not likely to lead to weight gain. Given that she is still
somewhat functioning and is not presenting with a level of
depression that would constitute a medical emergency, such as
having active suicidal ideation, lamotrigine is an optimal choice.
