10/12 Mood Disorders: Bipolar - Palmeri Flashcards Preview

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types of bipolar disorder and related disorders

1. type 1 → manic

2. type 2 → hypomanic

  • both feature presence of at least one manic (I) or hypomanic (II) episode
  • depression may not be present but usually is at some point

3. cyclothymic

4. substance/medication-induced

5. due to another medical condition


bipolar type 1

must meet criteria for a manic episode

  • may be preceded or followed by hypomanic or major depressive episodes


what is a manic episode?

  1. elevated (euphoric/infectious), expansive, or irritable mood
  2. persistently increased goal-directed activity or energy

lasting at least 1 week and present during most of day, nearly every day in this period

patients do not perceive they are ill


at least 3 (4 if irritable mood) symptoms present during this pd:

  • inflated self esteem
  • decreased need for sleep
  • more talkative or pressured
  • flight of ideas
  • distractibility
  • incr in goal directed activity or psychomotor agitation
  • engagement in pleasurable but potentially harmful behavior


NOT ATTRIBUTABLE to substance/med condition


what is a hypomanic episode

diff from mania is in degree of intensity of sx and impairment

  • lite version of mania
  • must last at least 4 days

doesn't have to result in hospitalization, can go on for years

almost always followed by depression


behavior not characteristic of the individual

observable by others

doesn't cause marked impairment

NOT ATTRIBUTABLE to substance/medical cond


specifies for bipolar/related disorders


with anxious distress

2 or more sx:

  • feeling keyed up/tense
  • feeling restless
  • difficulty concentrating due to worry
  • fear that something awful will happen
  • feeling that pt might lose control of self


specifies for bipolar/related disorders


with mixed features


for manic/hypomanic, episodes must have 3 or more sx:

  • dysphoria
  • depressed mood
  • diminished interest
  • psychomotor retardation
  • fatigue
  • worthlessness/guilt
  • recurrent thoughts of death/suicide


specifies for bipolar/related disorders


with mixed features


for depressive, episodes must have 3 or more sx:

  • elevated, expansive mood
  • inflated self esteem
  • more talkative than usual
  • flight of ideas
  • incr in energy or goal directed activity
  • risky behavior
  • decr need to sleep


specifies for bipolar/related disorders


with rapid cycling

  • at least 4 mood episodes in last 12 months meeting criteria for manic, hypomanic, or depressive episodes
  • period of partial/full remission of at least 2 mo


v bad disease!


specifies for bipolar/related disorders


with psychotic features

  • delusions and hallucinations present
  • mood congruent (punishment, guilt)
  • mood incongruent (atypical)


specifies for bipolar/related disorders


with catatonia

3 or more symptoms

  • stupor (no psychomotor activity)
  • catalepsy (passive induction of posture)
  • wavy flexibility (move like wax)
  • mutism (little or no verbal response)
  • negativisim (opposition to instruction)
  • posturing (posture against gravity)
  • mannerism (odd caricatures)
  • stereotypy (repetitive, nonsense movements)
  • agitation
  • grimacing
  • echolalia, echopraxia


specifies for bipolar/related disorders


with peri partum onset

sx occur during preg or in 4 weeks following delivery with or without psychosis

  • may be more common in first preg
  • presentation with psychotic features more likely within second episode or with hx of MDD/bipolar


specifies for bipolar/related disorders


with seasonal pattern

regular relationship with onset of hypomanic/manic/depression and time of year (fall/winter)

  • full remission or switch to depression/hypomania/mania occurs at a characteristic time of year
  • last 2 years, 2 episodes without episodes at other times of year
  • more seasonal than non-seasonal depressions


bipolar disorders ddx

  • MDD
  • cyclothymic disorder
  • GAD, panic, PTSD
  • medical/substance-induced states
  • schizophrenia
  • personality disorders


bipolar type 1


67-75% of bipolar 1 case have depression as first episode

10-20% have manic episodes only

  • manic episodes can last 3mo
  • 90% of pt have more than one episode
  • time between episodes can decrease

5-15% are rapid cyclers

90% of pt never fully remit


bipolar disorder type 1


poorper prognosis than MDD alone

poorer prognosis:

  • young age of onset
  • alcohol dependence
  • psychotic ft
  • lack of interepisode remission
  • male gender
  • poor social supports

good signs: short manic episodes, no comorbidity, older age of onset, good social supports


30% show severe impairment lifetime


bipolar disorder type 1


  • anxiety disorder (75% patients)
  • ADHD, impulse control or conduct disorder
  • substance use disorders (50%)
  • metabolid syndrome, migraines


bipolar disorder type 2

course and prognosis

onset: mid20s

  • 5-15% will ultimately develop a manic episode

initial episode may be depressive; more time is spent in depressive episodes

15-20% may not recover between episodes


occupational cognitive decline


bipolar disorder type 2

risk, prognosis, gender

risk highest among relatives

10-20% of postpartum women may experience a hypomanic episode


risk: rapid cycling

good signs: late age of onset, higher education, marriage


bipolar 2 and suicide

1/3 of patients report a suicide attempt

lethality of attempt potentially greater in type 2 than type 1



pharmacologic tx of bipolar 1 and bipolar 2

1. mood stabilizers

2. ECT

3. v v cautious use of antidepressants

  • caution because can swing patients into hypo/mania → will inevitably swing back into depression


mood stabilizers for bipolar 1/2

  • lithium carbonate
  • antiepileptic drugs (valproate/valproic acid, carbamazepine, lamotrigine)
  • atypical antipsychotics (olanzapine, risperidone, quetiapine, aripiprazole, lurasidone)


psychotherapeutic tx for bipolar 1/2

  • crisis intervention
  • supportive psychotherapy
  • cognitive behavioral therapy
  • family therapy



chronic, fluctuating disorder of at least 2 yr duration marked by many periods with hypomanic sx that dont meet bipolar 2 criteria and many periods of depressive sx that dont meet criteria for MDD

  • sx present for at least half of 2 years of hypomania and minor depression
    • diff from bipolar2 bc depression is NOT MAJOR
  • periods are usually brief, unpredictable, and change abruptly
  • irritability is common

longest period free of sx: 2mo


v rarely diagnosed

  • most common in 15-25 yr olds
  • good chance that it will progress to bipolar 1 or 2
  • potentially more sensitive to "switching" to hypo/mania with antidepressants


cyclothymic disorder tx

similar to that of major depression or bipolar illness

  • be even more cautious with antidepressants → more sensitive to switching into hypo/mania


substance/med-induced bipolar/related disorders


elevated, expansive, irritable mood with evidence that mood change is direct consequence of/temporally related to a substance or medication

  • medication, toxic substance, illicit substance (stimulants, PCP, steroids)


factors associated with depression in primary care

  • compaints in multiple organ systems (neuro, GI, cardiac)
  • recurrent emotionality
  • sleep disturbances
  • frequent/urgent visits
  • chronic pain