If you are following along in the suggested curriculum you have now finished the first two themes (psychotic disorders and depressive disorders). Nice work! Today will be our first day of the third theme in the Bullet Psych curriculum which is bipolar disorder. This will include Bipolar I and II and cyclothymia. Today we will provide an introduction, provide definitions, discuss clinical features, and overview diagnostic criteria including various specifiers.
Today's Content Level: Beginner; Intermediate (Review)
INTRODUCTION
"Bipolar" = two poles or extremes. The two poles of mood are:
Mania (elevated/expansive mood).
Depression (low mood).
•Bipolar disorder is an illness that involves episodes of mania and/or hypomania. It also commonly involves episodes of major depression.
•It is also known as manic-depression.
WHAT IS MANIA ANYWAY?
•Mania or a "manic episode" is a distinct period of abnormally and persistently elevated mood. It is sometimes described as elevated, expansive, or irritable.
•Picture someone with high energy, intense eye contact, speaking loudly and rapidly, acting impulsively, and discussing their ambitions. At a later point we will discuss the important elements of the mental status exam in these patient which will give you a better visualization.
•To be considered a manic episode it must last at least 1 week (or less if the patient requires hospitalization).
•Hypomania is similar to a manic episode, however it is less severe and does not cause impairment in social or occupational functioning and there are no psychotic features present.
•To be considered hypomania the symptoms must last at least 4 days.
The clinical features of mania are commonly remembered from the mnemonic-> DIG-FAST.
Distractibility
Impulsivity*
Grandiosity*
Flights of ideas / racing thoughts
Activities/Agitation
Sleepless (decreased need for sleep)
Talkativeness/pressured speech
Additional notes:
Impulsivity = excessive involvement in pleasurable activities that have a high risk of negative consequences. Examples could include shopping sprees and sexual indiscretions.
Grandiosity = excessive confidence. May describe larger-than-life feelings of superiority and invulnerability.
Activities/Agitation = increased goal-directed activity/psychomotor agitation.
Pressured speech = rapid and uninterruptible.
BIPOLAR SPECTRUM
There are three different diagnoses that lie along the bipolar spectrum.
Bipolar I disorder
Bipolar II disorder
Cyclothymia
BIPOLAR I DISORDER
•The only requirement for the diagnosis of Bipolar I is the occurrence of a manic episode. A manic episode is defined as:
Mood is elevated, expansive, and/or irritable.
Symptoms ≥ 1 week (or requires hospitalization).
3 DIGFAST symptoms if mood is elevated or expansive.
4 DIGFAST symptoms if mood is only irritable.
•Even though the diagnosis only requires one episode of mania these patients commonly experience hypomanic and depressive symptoms interspersed between manic episodes and euthymic periods. In fact only around 5% of patients experience only manic episodes.
•Like any psychiatric disorder make sure that manic symptoms are not attributable to the effects of a substance (drug or medication) or another medical condition. We will discuss this more in a later post.
BIPOLAR II DISORDER
•Bipolar II disorder requires at least one hypomanic episode AND at least one episode of major depression. It is sometimes called recurrent major depressive episodes with hypomania.
A hypomanic episode is similar to the criteria listed above for mania and includes the same criteria for mood + DIGFAST symptoms, but with the following differences.
Symptoms last ≥4 days (and does not require hospitalization).
No marked impairment in social/occupational functioning.
No psychotic features (if psychiatric features it is mania or psychotic disorder)
CYCLOTHYMIA
•Cyclothymic disorder is marked by alternating periods of symptoms of hypomania and periods of depressive symptoms.
•Please note, however, that the symptoms cannot meet full criteria for hypomania or a major depressive episode to receive this diagnosis. The symptoms merely resemble these conditions.
•Symptoms resembling hypomania and depression must persist for >2 years and patient must not be symptom free for >2 months during that time period.
•This is similar to the diagnosis of persistent depressive disorder, however it is along the bipolar spectrum.
•Cyclothymic disorder may resemble the bipolar disorders, borderline personality disorder, or substance abuse among other differential diagnoses. Rule these pathologies out before diagnosis of cyclothymic disorder.
MISCELLANEOUS CLINICAL FEATURES
Depression
The defining clinical presentation of bipolar disorder is a manic episode, however depressive episodes are often the biggest contributor towards the morbidity of this disorder.
The first mood episode is usually major depression.
Patients typically have more and longer depressive episodes than episodes of mania/hypomania.
Psychosis
While not apart of the diagnostic criteria for bipolar disorder, psychotic features are sometimes present including hallucinations, delusions, and/or disorganized speech/behavior.
Greater than 50% of manic patients have psychotic symptoms.
Always include bipolar I on your differential for a psychotic patient, as psychotic features can be present in both manic and depressive poles of bipolar I disorder.
"Rapid Cycling"
Some patients have a high rate of recurrent manic and depressive episodes. This is an important subset of patients with bipolar disorder because treatment and response can differ.
Defined by the occurrence of ≥4 mood episodes in 1 year.
Episodes can be major depressive, hypomanic, or manic.
Mixed Features
Depressive symptoms and mania/hypomania occur simultaneously.
Symptoms co-occur during the majority of days during mania/hypomania.
Examples include depressed mood, loss of interest (anhedonia), psychomotor slowing, fatigue or loss of energy, feeling worthless, and thoughts of death or suicide.
CONCLUSION
Congrats on finishing day 1 of the bipolar disorder theme. Next post we will discuss the epidemiology, etiology, and expected course and prognosis in these patients.
Resources for today's post include DSM-V, Kaplan & Sadock's Synopsis of Psychiatry, First Aid for Psychiatry, and Pocket Psychiatry.
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