Updated: 4/9/2021

Bipolar Disorder

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Questions
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Evidence
2
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Videos / Pods
3
Topic
Snapshot
  • A 21-year-old woman is brought to the emergency room by a police officer. She was found wandering around the streets talking very rapidly about her plans to become the CEO of large companies such as Amazon. She did not resist being brought it but continued to delineate her goals, including traveling the world, establishing the world’s best charity, and rescuing all orphans. When her physician was able to reach a family member, they report that she had been acting this way for 2 weeks. She had previously had episodes of depression, but recently she has been sleeping only 1 hour a day, has been easily distracted, and talked very rapidly about her grand plans. Her only medication is an anti-depressant.
Introduction
  • Overview
    • bipolar disorder is characterized by episodes of mania and depression
      • treatment is mood stabilizers or atypical antipsychotics
      • bipolar I
        • at least 1 manic episode, with or without a hypomanic or depressive episode
      • bipolar II
        • hypomanic episode and depressive episode
  • Epidemiology
    • incidence 
      • lifelong prevalence range from 0.9-2.1%
    • demographics
      • mean age of onset is 21 years
      • women often cycle through manic and depressive episodes more frequently
    • risk factors
      • other mood disorders
  • Pathogenesis
    • mechanism
      • may be a genetic susceptibility for bipolar disorder
      • may be atrophy in the brain
Presentation
  • Symptoms
    • mood may normalize between episodes, and patient may be fully functional during this time
    • using antidepressants may destabilize mood and trigger an episode of mania
    • manic episodes (at least 1 week duration and causes marked impairment in function) or hypomanic episodes (at least 4 days duration and may not be severe enough to cause dysfunction) with 3 or more of the following
      • grandiosity
      • decreased sleeping
      • excessive talking and pressures speech
      • racing thoughts and ideas
      • distractibility
      • increased level of goal-focused activity at home, work, or sexually
      • excessive pleasurable activities
    • depressive episodes (2 weeks duration) with 5 or more of the following, including either depressed mood or loss of pleasure or interest in activities
      • depressed mood
      • loss of pleasure or interest in activities
      • weight loss or gain or appetite loss or gain
      • hypersomnia or insomnia
      • psychomotor retardation or agitation
      • loss of energy or fatigue
      • feelings of worthlessness or excessive guilt
      • decreased ability to concentrate or make decisions
      • preoccupation with death or suicide
    • either phase may have psychotic features
  • Physical exam
    • psychomotor agitation or depression
Differential
  • Cyclothymic disorder
    • key distinguishing factors
      • presents similarly but with milder symptoms and lasts 2 years or longer
      • numerous periods of hypomanic symptoms that do not meet criteria for hypomania and depressive symptoms that do not meet criteria for a major depressive episode
Treatment
  • Non-medical
    • psychotherapy
      • indications
        • may help decrease recurrence rates or help improve quality of life
    • inpatient admission
      • indications
        • suicidal behavior or psychosis
    • electroconvulsive therapy (ECT)
      • indications
        • refractory to medications
  • Medical
    • mood stabilizers
      • indications
        • first-line
      • drugs
        • lithium
        • valproic acid 
        • carbamazepine
        • lamotrigine
    • atypical antipsychotics
      • indications
        • if there are features of psychosis
      • drugs
        • ziprasidone
        • quetiapine
        • risperidone
        • aripiprazole
Complications
  • Increased risk of suicide

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(M1.PY.17.4766) A 21-year-old female is brought to the emergency department by her roommate. Her roommate says that the patient has been acting “strangely” for the past 10 days. She has noticed that the patient has been moving and talking on the phone at all hours of the night. She doesn’t think that the patient sleeps more than one to two hours a night. She also spends hours pacing up and down the apartment, talking about “trying to save the world.” She also notices that the patient has been speaking very fast. When asking the patient if anything seems different, the patient denies anything wrong, only adding that, “she’s made great progress on her plans." The patient said she has felt like this on one occasion 2 years ago, and she recalled being hospitalized for about 2 weeks. She denies any history of depression, although she said about a year ago she had no energy and had a hard time motivating herself to go to class and see her friends for months. She denies hearing any voices or any visual hallucinations. What is the most likely diagnosis in this patient?

QID: 109052
1

Schizoaffective disorder

10%

(11/115)

2

Major depressive disorder

2%

(2/115)

3

Bipolar I disorder

56%

(64/115)

4

Bipolar II disorder

19%

(22/115)

5

Dysthymic disorder

10%

(11/115)

M 2 C

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Evidence (2)
VIDEOS & PODCASTS (3)
EXPERT COMMENTS (5)
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