DSM Criteria
How many Bipolar Disorder diagnoses are listed in the DSM?
7:
Bipolar I Disorder
Bipolar II Disorder
Cyclothymic Disorder
Substance/Medication-Induced Bipolar and Related Disorder
Bipolar and Related Disorder Due to Another Medical Condition
Other Specified Bipolar and Related Disorder
Unspecified Bipolar and Related Disorder
How many specifiers are there Bipolar 1?
10
With anxious distress (severity: mild, moderate, moderate-severe, severe)
With mixed features
With rapid cycling
With melancholic features
With atypical features
With mood-congruent psychotic features
With mood-incongruent psychotic features
With catatonia
With peripartum onset
With seasonal pattern
Treatments approved for bipolar depression (non-unipolar depression)
The big 5:
Quetiapine (monotherapy) effective in both bipolar I and bipolar II depression
Lurasidone (monotherapy or adjunctive with lithium/valproate) approved in adults and pediatric patients (10–17 years) minimal weight gain liability
Olanzapine/fluoxetine combination, highest response rate (56.7%) but significant weight gain
Cariprazine (monotherapy) minimal weight gain and metabolic effects
Lumateperone (monotherapy)
A patient has daily emotional reactivity, unstable relationships, chronic emptiness, and impulsive behaviors. Notes poor sleep, feeling of depression with suicidality often, and irritability. Dx to rule out?
Borderline Personality Disorder
Definition of manic episode?
A - distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting ≥1 week (or any duration if hospitalization is necessary), present most of the day, nearly every day.
B - During the mood disturbance, ≥3 of the following (≥4 if mood is only irritable), representing a noticeable change from usual behavior:
Inflated self-esteem or grandiosity
Decreased need for sleep
More talkative than usual or pressure to keep talking
Flight of ideas or racing thoughts
Distractibility
Increase in goal-directed activity or psychomotor agitation
Excessive involvement in high-risk activities (e.g., spending sprees, sexual indiscretions)
C - Sufficiently severe to cause marked impairment, necessitate hospitalization, or include psychotic features.
D - Not attributable to the physiological effects of a substance or another medical condition.
Definition of hypomanic episode?
Same A but lasts 4 or more days
Same B (mood symptoms)
C - Associated with an unequivocal change in functioning uncharacteristic of the individual.
D - The change is observable by others.
E - Not severe enough to cause marked impairment or necessitate hospitalization; if psychotic features are present, the episode is by definition manic.
F - Not attributable to a substance or medical condition.
What is Rapid Cycling specifier?
≥4 mood episodes in the previous 12 months, demarcated by either partial or full remission of ≥2 months or a switch to an episode of opposite polarity. Episodes directly caused by a substance or medical condition are excluded.
What treatment is approved for bipolar maintenance therapy and NOT acute mania
Lamotrigine
Pregnant patient with bipolar disorder history is associated with what risk post-partum?
Post-partum Psychosis
Bipolar 1 Criteria?
Requires at least one lifetime manic episode.
The manic episode may have been preceded or followed by hypomanic or major depressive episodes, but neither depressive episodes nor psychosis are required for diagnosis.
A patient presents with elevated mood, decreased need for sleep, grandiosity, pressured speech, and distractibility lasting 4 days. Psychotic symptoms emerge on day 4. What is this?
Manic episode
Psychotic features make this episode immediately mania
Criteria for peripartum onset specifier of Bipolar Disorder?
Applicable only if onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery
A patient remains severely manic despite adequate trials of lithium, valproate, and multiple antipsychotics. What is next?
ECT
Treatment resistant mania
What diagnosis commonly misdiagnosed as unipolar depression and why?
Hypomania has not been fully assessed or discovered
This feature distinguishes hypomania from mania even when all other symptom criteria are met.
Hospitalization, psychosis, or severe impairment
Bipolar 2 Criteria?
A. At least one hypomanic episode and at least one major depressive episode.
B. There has never been a manic episode.
C. Not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified/unspecified schizophrenia spectrum disorder.
D. The symptoms of depression or the unpredictability caused by frequent alternation between depression and hypomania causes clinically significant distress or impairment.
What are the "atypical features" of bipolar disorder?
A - Mood reactivity (mood brightens in response to actual or potential positive events)
B - Two or more of the following:
Hyperphagia, significant weight gain or increase in appetite
Hypersomnia (≥10 hours/day or ≥2 hours more than when not depressed)
Leaden paralysis (heavy, leaden feelings in arms or legs, generally ≥1 hour/day)
Long-standing pattern of interpersonal rejection sensitivity causing significant social or occupational impairment
C -Criteria are not met for "with melancholic features" or "with catatonia" during the same episode
A patient with history of manic episodes started on lithium for mood stabilization just a few hours ago and has not yet received a dose. He then refuses oral medication and is becoming physically aggressive that evening. Not redirectable and impulsive, dangerous behavior is observed. What is the next best step?
Consider switching to an antipsychotic for acute mania or just adjuncting treatment with an antipsychotic approved for acute mania.
OR
Add benzodiazepine for acute agitation + to break potential mania development.
Short-term behavioral dysregulation should be prioritized over long-term mood stabilization. Antipsychotics typically work more quickly than lithium for acute mania even though both approved.
A pregnant patient stabilized on valproate asks about fetal risks. What does PRITE love to ask next?
Spina Bifida
What is Cyclothymia and its criteria?
A. For ≥2 years (≥1 year in children/adolescents), numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and depressive symptoms that do not meet criteria for a major depressive episode.
B. Symptoms present for at least half the time, with no symptom-free interval >2 months.
C. Criteria for a major depressive, manic, or hypomanic episode have never been met.
D. Not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other psychotic disorder.
E. Not attributable to a substance or another medical condition.
F. Causes clinically significant distress or impairment.
Maximum length symptom-free period in cyclothymia AND how long during cyclothymia must symptoms be present?
2 months max no symptoms
Symptoms must be present more than half the time
The bipolar specifier most strongly associated with treatment resistance and suicide attempts
Mixed features
For a manic/hypomanic episode, ≥3 depressive symptoms are present during the majority of days. For a depressive episode, ≥3 manic/hypomanic symptoms are present during the majority of days.
Give me the FDA approved 2nd generation antipsychotics for acute mania AND 1st gen.
Aripiprazole
Asenapine
Cariprazine
Olanzapine
Quetiapine
Risperidone
Ziprasidone
AND
Chlopromazine
Schizophrenia
Schizophrenia: 80%
Bipolar disorder: 70–85%
However both are highest compared to other disorders
A 23-year-old woman presents with her fifth major depressive episode. She reports several periods lasting 2–3 days in which she sleeps 3 hours per night, feels unusually energetic, talks more than usual, starts multiple projects, and is noticed by friends to be "different." These episodes do not last 4 days. She has never experienced mania. Diagnosis?
Other Specified Bipolar and Related Disorder—short-duration hypomanic episodes and major depressive episodes
Short-duration hypomanic episodes (2–3 days) and major depressive episodes — full symptomatic criteria for hypomania met but duration only 2–3 days