Bipolar+Disorder

(This page was created by Tai Roe using materials copied, pasted and reformatted from the "Behavioral Medicine" page. I am unsure who originally created this material)

1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week. 2. 3 out of 7 of these: grandiosity, decreased need for sleep, more talkative, racing thoughts, distractible, increased goal directed activities, increased pleasurable activities- hypersexuality, spending sprees, etc.
 * DSM criteria** for a manic episode (needed for bipolar I diagnosis):

The only real difference with a hypomanic episode (needed for bipolar II diagnosis)- 4 days of symptoms rather than 1 week, and symptoms are not severe enough to cause marked impairment in social or occupational functioning.

Seems easy right?


 * Misdiagnosis is very common**.
 * 70% of people with bipolar receive an initial diagnosis other than bipolar disorder. The most common misdiagnosis is depression, followed by anxiety, psychotic disorders, personality disorders.
 * There have been several robust studies showing that for the patients with bipolar disorder who are initially misdiagnosed, there is a 10 year! lag time from symptom onset to the correct bipolar diagnosis. Longer time to treatment = worse outcomes.
 * There are several reasons why the diagnosis is so difficult- comorbidities (60% of patients with bipolar disorder have axis I comorbidities), symptom overlap with other disorders, presence of mixed episodes- mood episodes that have both depressive and manic or hypomanic symptoms, it is a spectrum disorder comprising a range of presentations. Anyone with a mood disorder, substance use, or anxiety must be screened for the other two because they co-occur so often.
 * Depression is the most common misdiagnosis- some of the reasons: people are less likely to report manic or hypomanic symptoms. The depressive symptoms often last longer than the manic or hypomanic symptoms. Sometimes there are mixed states- where there may be depression but also agitated, irritability, restlessness, increased energy. 60% of the initial presenting symptoms of bipolar disorder are depressive in nature.
 * If antidepressants are not effective for treatment of depressive symptoms- they may not work or can cause further mood instability or even manic episodes in those with bipolar disorder. If there are a series of abnormal responses to antidepressants, always must consider that this is bipolar depression.
 * If suspicious but not sure- curbside consult, or full consult is appropriate.

Brief review of some typical differences between the two disorders: 1. Age of onset- rarely over 7 y/o for ADHD, rarely under 7 y/o for bipolar 2. Course of illness- persistent in ADHD vs. episodic in bipolar 3. Psychosis- more prevalent in bipolar 4. Suicidality- more prevalent in bipolar 5. Euphoria- more prevalent in bipolar 6. Grandiosity- more prevalent in bipolar 7. Hypersexuality- more prevalent in bipolar Keep in mind that they can co-occur.
 * In children, ADHD is a diagnosis often very difficult to distinguish from bipolar disorder**:


 * Ways to help with the diagnosis**
 * Good screening questions for mania- []
 * Bipolar Screening should follow any positive depression screen. Evaluate Bipolar disorder in depressed patients who have a history of irritability and insomnia. Always ask about mania and hypomania before starting depression therapy.
 * Examples of questions to illicit history of mania and hypomania:
 * "Have you every felt the complete opposite of depressed, when friends and family were worried about you because you were too happy?"
 * "Have you every had excessive amounts of energy running through your body, to the point where you did not need to sleep for days?"
 * Family history of bipolarity- the presence of family history of bipolar disorder doubles the risk of having bipolar disorder compared with those with no family history.

Always consider that there may be substances involved- put a drug screen on the normal panel of labs.


 * Treatment**
 * Depressive phase- Seroquel, Abilify, Lamictal, Lithium. these in combination as well- Lithium/lamictal combo effective
 * Per John Echols, 9/30/11, a good option is Seroquel XR 300 mg, once per day, at 7 PM. This particular dose is covered by CCHP. Seroquel has advantage that it is also indicated for depression (so if you aren't certain if pt has major depression vs. bipolar, you can still use it). Common side effects include somnolence, orthostatic symptoms (at first), and metabolic changes (increased triglycerides, cholesterol, weight, and diabetes risk).
 * A word on antidepressants for bipolar depression- they can work, but carry risks- if you are going to use one, probably best to also have a mood stabilizing medication as well.
 * Manic phase- all mentioned above in addition to all atypical antipsychotics, Depakote, Tegretol.
 * Psychotherapy is important- different types of therapy shown to be helpful such as social rhythms therapy- to briefly describe, people with bipolar disorder have difficulty with routine given the ups and downs of their mood- trying to schedule activities to be similar each day regardless of how they are feeling- when and how long they sleep, when and how much they eat, how much they work or exercise, etc. And also psychoeducation for the patient and family is important in improving insight and adherence. Important to get patients to recognize and anticipate when an episode is about to occur so they can contact their doctor, and try to avoid a severe episode.

1. Misdiagnosis is common in psychiatric disorders, particularly bipolar 2. Anyone with a mood disorder, anxiety disorder, or substance abuse needs to be screened for the other two. 3. Can use screening questions for bipolar 4. always consider other factors- family history of bipolarity, abnormal response to antidepressants 5. can always consult psychiatry
 * Take home points**: