Today we will cover elements of the mental status exam that are particularly important in bipolar disorder. The focus of today will be the MSE in mania/hypomania, since the MSE in depression was covered previously. These are important clues that will help you with diagnosis as well as gauge treatment response.
If you need a refresher on the mental status exam and a description of each component including important terms feel free to review here: Intro to Mental Status Exam.
Today's Content Level: Beginner; Intermediate
REMINDER OF THE MENTAL STATUS EXAM COMPONENTS
•Appearance
•Behavior
•Speech/Language
•Mood
•Affect
•Thought process
•Thought content
•Perceptual Disturbances
•Cognition
•Insight
•Judgement
APPEARANCE & BEHAVIOR
•Like most disorders, there is no one-size fits all when it comes to appearance, but there are classic features.
•On one hand a patient with hypomania may present as well-groomed with appropriate hygiene and on the extreme a patient with severe mania may be grossly disorganized and psychotic and forgotten to bathe or properly groom and dress themselves or appear disheveled.
•Manic patients are energetic, excited, talkative, frequently hyperactive, and sometimes amusing. At times they may also be grossly psychotic, disorganized, or aggressive/hostile.
•Patients may have "intense" eye contact during conversation with less blinking and gaze diversion than expected in regular conversation.
•May have psychomotor agitation which is a term used to describe excessive motor activity associated with a feeling of inner tension. Behaviors seen include hand wringing, hair pulling, pulling of clothes, pacing, fidgeting, and inability to sit still.
SPEECH / LANGUAGE
•One of the hallmark features of mania and bipolar disorder is their speech. It is often described as "pressured".
•Pressured speech = speech that is fast, difficult or impossible to interrupt, and increased in quantity. It is also usually loud and emphatic. A person might not require social stimulation or an audience to speak.
•One manic patient that I spoke in the hospital before being treated did not stop talking for a single second the entire 30 minutes that I spent with him. I don't know how he was breathing he was talking so fast and without any breaks or pauses.
MOOD / AFFECT
Their mood is classically euphoric. Other related terms are elated, elevated, or expansive.
Euphoric: characterized by feeling intense excitement and happiness.
Elation: great happiness.
Elevated: component of euphoria that is positive feelings of enthusiasm, well-being, confidence, and/or energy.
Expansive: an extreme expression of emotion, often accompanied with inflated self-worth, excessive friendliness, grandiosity, or superiority.
•Aside from euphoric, manic patients may also present with irritability, particularly when mania has been present for some time. This is honestly what I have seen more commonly in the hospital setting so far in my training.
•They may also have a low frustration tolerance, which can lead to feelings of anger and hostility.
•They may be labile -> switching back and forth between euphoria, laughter, irritability, and depression in minutes to hours.
•They may have an intense affect -> high emotional intensity and responsiveness.
THOUGHT PROCESS / THOUGHT CONTENT
•Another classic term used to describe bipolar patients is "flight of ideas". Not only is their speech pressured as discussed above, but they quickly bounce from topic to topic.
•Flight of ideas = a nearly continuous flow of accelerated speech with abrupt changes from topic to topic. These shifts in topic are usually based on understandable associations, distracting stimuli, or plays on words. When the condition is severe, speech may have loosening of associations or become completely disorganized and incoherent.
•Thought content is focused on themes of self-confidence and self-aggrandizement. This means they promote themselves as being powerful or important.
•They are often easily distracted.
PERCEPTUAL DISTURBANCES
•Manic patients with delusions or hallucinations are said to have a manic episode with psychotic features. Also consider schizoaffective disorder depending on timing of symptoms.
These features are very common in patients with bipolar disorder. 1
Delusions occur in 75% of all manic patients.
51% experience hallucinations.
47% had paranoid features.
•Mood-congruent manic delusions are often concerned with great wealth, power, extraordinary abilities, or an important "calling in life". Bizarre and/or mood-incongruent delusions and hallucinations also appear in mania. Some studies suggest that mood-incongruent (depressive themes) are actually more common even in manic patients.
COGNITION
•Less has been written about cognitive deficits in patients with mania when compared to schizophrenia, however some deficits can be seen and hypothesized due to diffuse cortical dysfunction in the manic phase.
•Typically orientation and memory are intact although patients may be so euphoric or distracted or grandiose that they may answer orientation testing incorrectly.
INSIGHT / JUDGEMENT / IMPULSIVE
•Does the patient attribute their symptoms to a mental disorder? Are they unconvinced of a problem?
•Impaired judgement is a hallmark of manic patients. This may lead to sexual indiscretion, excessive gambling or poor financial management, breaking the law, etc.
•Manic patients often have little insight into their disorder.
•Manic (and demented) patients are the most likely patient to be assaultive or threatening. Some studies cite that about 75% can have threatening behaviors. They also have a higher rate of suicide and homicide. 2
CONCLUSION
Nice work today. We covered some important factors regarding the mental status exam in patients with bipolar disorder. Next lesson will be a discussion on the medical workup for mania.
Resources used today include Kaplan and Sadock's Synopsis of Psychiatry, The Psychiatric Interview, and Pocket Psychiatry.
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