Bipolar and related disorders
| Bipolar I Disorder | History of more mania than depression. Severe mood disorder with mania episodes alternating with depression and psychosis during manic episodes.
Bipolar I = Mania (with or without depression) |
| Bipolar II Disorder | History of more depression than mania. Low-level mania with profound depression; no psychosis.
Bipolar II = Depression + Hypomania |
| Cyclothymic disorder | Alternating hypomanic episodes with a long-standing low mood state (dysthymia) for at least two years.
Cyclothymia = Subthreshold bipolar symptoms for ≥2 years |
| Bipolar Related Disorders | |||||||||
| Bipolar I disorder | Patient will present as → a 27-year-old man accompanied by his girlfriend. In the office, he seems to be running from topic to topic without a clear message. His speech is pressured. The patient’s girlfriend reports that he took steroids recently for a bad sinus infection and since he started them, his behavior has been abnormal. After discontinuing the medication, he has still been having symptoms. He has not had a normal night of sleep for the past ten days, and he just bought a new sports car though he has no need for one or the money to afford it. She also reports that she has caught him with multiple other women in the past few days, though they were in a committed relationship. The physical exam is benign and the patient’s vital signs are within normal limits. Patient who is squandering savings, destroying relationships, neglecting work activities, etc. etc.
DX: DSM-5 — ≥ 1 manic episode with ≥ 3 of 7 symptoms (4 if mood is only irritable) causing marked impairment, hospitalization, or psychosis
TX: Lithium, valproate, or a second-generation antipsychotic
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| Bipolar II disorder | Patient will present as → a 19-year-old male who has had bouts of sadness for a course of 1 year in which he says that often he cannot even get out of bed so he tells his parents he is ill. Jim states that he recently felt so energized that he could not keep his thoughts straight and jumped from one idea to another. During this energized state, he did become irritable and others stated that he was louder than usual and wondered if he took something that increased his energy. During the week of high energy, he maxed out two of his credit cards and is not sure how he will pay them off before he goes to school in the fall. It was only a week later that he became so depressed that he did not find any pleasure in anything he did, was so tired he did not want to get out of bed which has continued to be a struggle today. Hypomania + at least one major depressive episode — there has NEVER been a manic episode
DX: DSM-5 — ≥ 1 hypomanic episode + ≥ 1 major depressive episode, with criteria for a full manic episode never met
TX: Mood stabilizer or second-generation antipsychotic — quetiapine or lurasidone for bipolar depression
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| Cyclothymic disorder | Patient will present as → a 24-year-old male with c/o episodes of depression alternating with times of increased energy, restlessness, and decreased sleep for 2 years. Alternating hypomanic episodes with a long-standing low mood state (dysthymia)
DX: DSM-5 — ≥ 2 years (≥ 1 year in children/adolescents) of numerous hypomanic and depressive symptoms never meeting full criteria for either
TX: Psychotherapy + a mood stabilizer, as in bipolar disorder
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Depressive disorders
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| Depressive Disorders | |||||||||
| Major depressive disorder | Patient will present as →a 33-year-old woman complaining of fatigue and decreased interest in “the things that used to make me happy.” She is sleeping less and eating less, and she says that she is forcing herself to eat “because I know I have to eat something.” She finds herself spending less time with her kids and husband as she retreats to her room. She feels guilty that she lacks the energy and enthusiasm she used to have. ≥ 2 weeks of depressed mood or anhedonia + SIGECAPS symptoms
DX: DSM-5 — ≥ 5 of 9 symptoms for ≥ 2 weeks nearly every day, with ≥ 1 being depressed mood or anhedonia, causing functional impairment
TX: SSRI first-line + psychotherapy (CBT) — combination beats either alone
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| Persistent depressive disorder | Patient will present as → a 30-year-old married male who feels down most of the time for the past three years. He experiences frequent, intrusive thoughts that he is not good enough, despite personal and professional successes. He tries to overcompensate for his thoughts by taking on more than he can handle, which leads to failure and furthers his feelings of inadequacy. His wife suggests that he seek help after finding him crying. A patient with chronic depression for two years or more
DX: DSM-5 — depressed mood most of the day, more days than not, for ≥ 2 years (≥ 1 year in children/adolescents, mood can be irritable) + ≥ 2 of: appetite change · sleep change · low energy · low self-esteem · poor concentration · hopelessness
TX: Psychotherapy + SSRI — combination beats either alone
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| Premenstrual dysphoric disorder |
Patient will present as → a 29-year-old woman with severe irritability, mood swings, and tearfulness beginning the week before each period that vanish within days of the onset of menses. Two months of daily symptom ratings confirm the pattern. Severe mood swings, irritability, and depressed mood in the week before menses that resolve within days of onset of menses
DX: DSM-5 — ≥ 5 symptoms in the final week before menses with ≥ 1 core mood symptom (lability · irritability · depressed mood · anxiety), improving within days of menses onset and minimal postmenstrually
TX: SSRI first-line — continuous or luteal-phase-only dosing
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| Suicidal/homicidal behaviors |
Patient will present as → a 68-year-old recently widowed man with depression who owns a firearm and tells you he has “thought about ending it.” You ask directly about plan, intent, and means and arrange immediate safety measures. Ask directly — asking about suicide does NOT increase risk
DX: Structured risk assessment — ideation → plan → intent → access to lethal means
TX: Imminent risk: hospitalize (involuntarily if necessary) + remove lethal means + safety planning
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