Welcome back to our current theme of bipolar disorder. Up to this point we have covered core features of bipolar disorder, diagnostic criteria, epidemiology, risk factors, and pathogenesis. Today we are going to have a discussion on clinical pearls for bipolar disorder which will include tips on the clinical interview, validated questionnaires, and differential diagnosis. Let's get started.
Today's Content Level: Beginner; Intermediate
CLINICAL INTERVIEW
•Keep in mind that the symptoms of mania or hypomania are often egosyntonic. This means that their feelings/behaviors/symptoms may NOT be distressing or be in conflict to what the patient wants. This means that you need to screen explicitly for these symptoms as they may not be readily disclosed.
Screen for current or past episodes of mania/hypomania by asking if they have had distinct periods of elevated, expansive, or irritable mood + the DIGFAST symptoms. See full criteria here, but here is a brief reminder.
Distractibility
Impulsivity
Grandiosity
Flights of ideas / racing thoughts
Activities/Agitation
Sleepless (decreased need for sleep)
Talkativeness/pressured speech
Here are some sample questions to give you an idea for how you can ask about the DIGFAST symptoms?
Were your thoughts moving so fast that you couldn’t keep up with them? (F)
Did you sleep very little or not at all and still feel full of energy? (S)
Did anyone tell you that you spoke so fast that they couldn’t get a word in? (T)
Did you start several projects but not complete any of them? (D, A)
Other tips on the clinical interview include:
Clarify onset/duration of symptoms with patient and family. Remember to screen for manic AND depressive episodes. The timeline is very important to make an accurate diagnosis.
Carefully document amount of episodes - this is important because the frequency of episodes may impact treatment decisions if a patient is a "rapid cycler".
Screen for how their symptoms are affecting their function to include school/work/social difficulties, poor self care, dangerous/risky behaviors, etc.
Substance use - determine if this is substance/medication induced.
Medical and family history. Remember bipolar disorder has the highest genetic link among all psychiatric diagnoses.
Risk assessment for suicide and aggression - will cover risk/safety assessments in significant detail in later lessons, but remember that patients with bipolar disorder have a very high suicide rate (33–50% attempt; 10–19% complete).
Optional rating scales: Young Mania Rating Scale (YMRS); Mood Disorder Questionnaire (MDQ); Bipolar Depression Rating Scale (BDRS); Bipolar Spectrum Diagnostic Scale (BSDS).
DIFFERENTIAL DIAGNOSIS
•Before making any psychiatric diagnosis it is important to consider other related disorders and appropriately determine the best fit according to the patients symptoms, biological, psychological, and social factors.
Psychiatric differential diagnosis:
Borderline Personality Disorder (BPD): BPD can sometimes be confused with bipolar II as there is significant overlap in symptoms. We will cover personality disorders in a later theme, however symptoms in common include impulsivity, depression, affective instability, occasional aggression, and suicidal ideations. The timeline is important here as mood disturbance in BPD is typically in response to interpersonal stressors and less episodic (lasting hours to days as opposed to days to months in bipolar disorder). Mood stabilizers and second generation antipsychotics can be helpful in both bipolar II and BPD. 1
Schizoaffective Disorder vs Bipolar Disorder with psychotic features: in schizoaffective disorder there must be psychotic symptoms that occur for at least two weeks in the absence of mood episodes. Full criteria here. Bipolar I disorder may have psychotic features (delusions or hallucinations) and can occur during major depressive or manic episodes. Always include bipolar disorder in the differential diagnosis of a psychotic patient.
Schizophrenia: the manic phase of bipolar disorder may resemble schizophrenia as it can sometimes include psychotic symptoms. But consider that in bipolar disorder there is little or no social or occupational impairment between episodes. Also the possible psychotic symptoms are not typically bizarre.
Substance/Drug induced: known causes include cocaine, methamphetamines, levodopa, corticosteroids, anabolic-androgenic steroids, and more. Screen specifically for alcohol and other substance use, as this may cloud accurate diagnosis and there is high comorbidity.
Common psych comorbidities: anxiety disorders, substance use, ADHD, cluster B personality disorders.
Medical causes: manic and psychotic symptoms can also occur directly due to medical causes. See day # 47 for the differential diagnosis for medical causes and the suggested medical workup for mania.
CONCLUSION
I hope you enjoyed these clinical pearls. Today's lesson was geared towards a beginner/intermediate audience, but I hope all of the readers got something out of today's topic. Next we are going to cover mental status exam elements that are relevant to bipolar disorders to improve your evaluation of patients as well as your documentation.
Resources for today's post include: Kaplan and Sadock's Synopsis of Psychiatry, DSMV desk reference, and Pocket Psychiatry.
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