Bipolar Disorders

Question 1

What are the 10 key features of mania?

Answer 1

• Mood: euphoric, excessively cheerful, on top of the world
  
  • Spontaneously start extensive conversations with strangers in public
  • Irritable – substances, when wishes denied
  • In children:
    
    • If mood unusual for child and mood change occurs with other symptoms, more likely BP than normal goofiness/silliness in children
  • May shift very rapidly to anger and depression. Depressive symptoms can occur alongside mania (mixed features – dark high- be careful, high suicide risk here)
• Multiple projects
  
  • Little knowledge of topic
  • Unusual hours of day
• Inflated self esteem
  
  • Uncritical self-confidencegrandiositydelusional
  • Having special relationship to famous person
  • Embark on writing a novel despite lack of experience or talent
• Decreased need for sleep
  
  • Often heralds onset of episode
  • Severe - days without sleep – not tired
• Speech
  
  • Rapid, loud, difficult to interrupt
  • Talk continuously without regard for others wishes to communicate
  • Jokes, puns, amusing irrelevancies, theatricality, dramatic mannerisms, singing, excessive gesturing
  • When irritable – complaints, hostile comments, angry tirades
• Thoughts
  
  • Race faster than can be expressed through speech
  • Continuous flow of accelerated speech with abrupt shifts from one topic to another
  • Severe- speech becomes disorganised, incoherent – becomes difficult to speak
• Distractibility
  
  • Inability to ignore external stimuli (e.g., background noise/conversations)
• Goal-directed activity
  
  • Excessive planning, participation in activities
  • Increased sex drive & fantasies
  • Increased sociability
    
    • Renewing old acquaintances, calling friends/strangers
  • Psychomotor agitation/restlessness – purposeless activity – pacing/holding multiple conversation simultaneously
  • Write excessive letters, emails , textson many topics to friends, public figures, media
  • Children – hard to ascertain. Child taking on many tasks simultaneously, devising elaborate/unrealistic plans for projects, sexual preoccupations – change in child’s baseline behaviour
• Recklessness
  
  • Spending sprees
  • Reckless driving
  • Sexual promiscuity
  • Giving away possessions
• Impairment
  
  • Harm to self and others- financial losses, illegal activities, loss of employment, self-injurious behaviour)

Question 2

What are the differential diagnoses for bipolar I disorder?

Answer 2

• MDD – may be accompanied by hypomanic or manic symptoms (fewer symptoms or shorter duration than required for mania or hypomania)
• Other BP – No mania? BP 2
• Anxiety
  
  • GAD- anxious ruminations can be mistaken for racing thoughts; efforts to minimise – impulsive behaviour
  • PTSD, PD etc
    
    • Episodic nature? Symptom triggers?
• Substance/medication-induced BP – response to mood stabilisers during substance induced mania – not necessarily diagnostic for BP
  
  • BP established if symptoms remain once substance removed
• ADHD – overlap of symptoms – e.g., rapid speech, racing thoughts, distractibility, less need for sleep.
  
  • Do the symptoms represent distinct episode?
• BPD – mood lability, impulsivity overlaps
  
  • Again – distinct episode versus fixed pattern of behaviour over time – what’s baseline?
• Disorders with prominent irritability
  
  • Irritability persistent and severe in child – mood dysregulation disorder more appropriate
  • Change in typical/baseline, episodic versus persistent?
• Schizophrenia/other psychotic
  
  • Psychotic symptoms in absence of mood symptoms

Question 3

What are the differential diagnoses for bipolar 2 disorder?

Answer 3

• MDD – may be accompanied by hypomanic or manic symptoms (fewer symptoms or shorter duration than required for mania or hypomania)
• Other BP –
  
  • Mania = BP 1
  • Cyclothymia = numerous periods of hypomanic & depressive symptoms that don’t meet criteria for MDD. BP 2 distinguished by episodes that meet criteria for MDD.
    
    • If MD episode occurs after first 2 years of cyclothymic disorder – BP 2 added as additional diagnosis
• Anxiety
• Substance use disorders
• ADHD – overlap of symptoms – e.g., rapid speech, racing thoughts, distractibility, less need for sleep.
  
  • Do the symptoms represent distinct episode?
• BPD – mood lability, impulsivity overlaps
  
  • Again – distinct episode versus fixed pattern of behaviour over time – what’s baseline?

Question 4

What’s the difference between mania and hypomania?

Answer 4

• Mania vs. hypomania
  
  • Mania causes impairment – with or without psychosis
  • Hypomania – no impairment, no psychosis
    
    • Shorter - up to 4 days only

Question 5

What are the differences between bipolar 1 and bipolar 2?

Answer 5

• BP 1
  
  • Psychosis – always mania and BP 1
  • Mania always required for diagnosis - at least one lifetime episode
    
    • Must last at least one week OR any duration if hospitalisation necessary
    • Must cause impairment (if no impairment, this is not mania – consider hypomania/BP 2)
  • Hypomanic episodes common but not required for diagnosis
  • MDD episodes common but not required for diagnosis
    
    • Vast majority experience MDD episodes
• BP 2
  
  • One or more MDD episode
    
    • Must last at least 2 weeks
    • Must cause impairment
    • MDD Episodes are more frequent and lengthier in BP 2
  • At least one hypomanic episode
    
    • Must last at least 4 days
    • Does not cause impairment – if it does, this is mania and BP 1
  • NO MANIC EPISODES
    
    • If there are, this is BP 1
  • Individuals typically present for depression, not hypomania, as hypomania does not cause impairment
    
    • Impairment from MDD episodes or persistent pattern of unpredictable mood changes/unreliable functioning.
    • Clinical information from friends/relatives useful for diagnosis
  • Hypomania – don’t confuse for restored energy/activity that follows remission of MDD episode
  • No longer thought as mild condition
    
    • Longer amount of time spent in depression – more chronic illness
    • Instability of mood serious impairment
    • Depression and hypomania can co-occur –mixed features – more common in females