questions 13

Bipolar Disorder

Topic updated on 10/08/17 12:05pm

  • A 25-year-old male is brought into the emergency room by his family when he spent over $100,000 on building supplies and was found naked in his back yard building a boat so he can sail the world to teach English to the people of England.  His family and friends said that for the last 2 weeks he had been increasingly grandiose, had been sleeping 3 hours per night, and had not gone to work.  Prior to this episode the patient had been relatively normal, however he had experienced a bout of depression 12 months ago.  The patient's speech seems pressured as he began to explain his idea to solve world homelessness with his program "Hammocks for the Homeless."  The patient's wife further offers that he has had a significantly increased sexual drive lately.  His urine tox screen was negative in the ED.
  • Epidemiology
    • seen in 1% of population
    • genders equally affected
    • often presents in young people (most common onset between 20-30 years)
  • Subtypes
    • bipolar I
      • manic episode with or without major depressive episodes
    • bipolar II
      • hypomanic episodes with at least one major depressive episode
    • rapid cycling
      • > 4 episodes of mania/depression/mixed within 1 year
    • cyclothymic
      • alternating hypomanic episodes with dysthymia
        • psychotherapy is best initial step in management
        • some evidence suggests valproic acid is better than lithium for these patients
  • Symptoms
    • manic symptoms
      • DIG FAST
        • Distractibility
        • Insomnia
        • Grandiosity
        • Flight of Ideas
        • Agitation
        • Sexual indiscretions/pleasurable activities
        • Talking (pressured speech)
    • hypomanic symptoms
      • similar but does not lead to marked impairment
      • no psychotic symptoms present
      • impulsivity is present
  • Diagnosis
    • episodes should last > 1 week and be continous
    • must rule out cocaine or amphetamine use
      • always do a urine toxicology for patients presenting with mania
  • Lithium  
    • first-line mood stabilizer (can take 1 week to work)
    • check creatinine before initiating therapy 
    • renal failure, hyponatremia, and dehydration all increase likelihood of lithium toxicities 
    • can cause hypothyroidism, and Epstein's anomaly in pregnant patients
    • shown to have a reduction in mortality from suicide
  • Hospitalization
    • often involuntary as manic patients do not recognize their illness
  • Benzodiazepines
    • may assist in acute sedation if patient is agitated
  • Antiepileptics  
    • valproate or carbamazepine 
      • second line mood stabilizers
      • atypical antipsychotics can also be used (risperidone can be first-line
      • may begin antidepressant therapy only after mood stabilizers are started
    • lamotrigine also used (can be first-line)
    • haloperidol 
      • used as a first-line of treatment in pregnant patients
      • first-line in acute mania in patients with severe symptoms
  • Atypical antipsychotics
    • quetiapine or olanzapine 
      • can be used as second line
      • side effects of weight gain
  • SSRI's
    • can induce mania in patient's being that have been misdiagnosed with only depression
Prognosis, Prevention, and Complications
  • Prognosis 
    • worse than major depression
    • high prevalence of alcohol/substance abuse
    • high risk of suicide - worst during a mixed episode 
      • lithium is the only drug shown to reduce mortality from suicide (2015)
  • Prevention
    • if less than 3 lifetime relapses, it is possible to treat for 1 year followed by a mood stablizer taper 
    • if 3 or greater lifetime relapses, it is necessary to remain on lifetime mood stabilizer treatment


Qbank (10 Questions)

(M3.PY.3) A 20-year-old woman with a past medical history of bipolar I disorder is brought in by police after attempting to commit suicide by jumping from a bridge. Her family reports that for the past week she had been sleeping one hour a night, spending all day shopping for clothes, and exhibiting rapid and uninterruptible speech. The patient denies any history of auditory/visual hallucinations or paranoid/disorganized thinking. As she is brought into her room she exclaims, "You can't do this to me, I'm a graduate of an Ivy League medical school!" The medical student on call suggests to the team that she be started on lithium or valproic acid. After a thorough chart review, interview, and laboratory testing, the attending psychiatrist states that haloperidol would be preferable. Which of the following medical diagnoses might have influenced this choice? Topic Review Topic

1. Pregnancy
2. Diabetes
3. Panic disorder
4. Generalized anxiety disorder
5. Bipolar II disorder

(M3.PY.10) A 52-year-old male is referred to psychiatry by his PCP after 3 weeks of erratic behavior. The patient has been driving to a casino 60 miles away after work every night to gamble and returning directly to work the following morning. He stresses, however, that "it isn't a problem" because he is still "full of energy" during the day at his banking job, which he "could do in [his] sleep anyway." He has not sought psychiatric treatment in the past, but reports an episode of self-diagnosed depression 2 years ago. The patient's medical history is significant for diabetes, hypertension, hepatitis C, stage II chronic kidney disease, and congenital long QT syndrome. The patient's toxicology screen is negative for illicit drugs in the PCP's office. EKG is shown below (Figure A). Which of the following of the patient's medical conditions is a contraindication for lithium therapy? Topic Review Topic
FIGURES: A          

1. Type II diabetes mellitus
2. Hypertension
3. Prolonged QT
4. Hepatitis C
5. Chronic kidney disease

(M2.PY.7) A 30-year-old female is brought to the emergency department (ED) by her husband after refusing to sleep for a week and spending the couple’s entire savings account on a collection of fur coats. In the ED, the patient refuses physical examination and insists that she wear a black sequin dress rather than a hospital gown. For several hours, the patient is overcome by fits of laughter and refuses to answer questions. She then insists that she be allowed to leave the hospital immediately. Urine toxicology is negative. Which class of drugs should be administered? Topic Review Topic

1. Selective serotonin reuptake inhibitor (SSRI)
2. Serotonin-norepinephrine reuptake inhibitor (SNRI)
3. Benzodiazepine
4. Zolpidem
5. Antipsychotic

(M2.PY.9) A 22-year-old woman is brought to the ER by her roommate after bizarre behavior for the last week. She has been suffering from insomnia, grandiosity, irritability, and racing thoughts. Her past medical history is unknown. Which of the following lab values would be a contraindication to starting lithium for long-term maintenance therapy? Topic Review Topic

1. Microcytic anemia
2. Elevated AST
3. Hypertension
4. Elevated creatinine
5. Elevated serum glucose

(M2.PY.13) A 25-year-old woman is brought to the ED by EMS after being found naked in a busy downtown square. She had been having symptoms of grandiosity, impulsivity, and decreased sleep for the past week. All of the following pharmacologic agents are accepted agents for long-term mood stabilization EXCEPT: Topic Review Topic

1. Lithium
2. Quetiapine
3. Olanzapine
4. Sertraline
5. Lamotrigine

(M2.PY.27) A 29-year-old man presents to clinic for a general health exam. He is 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. Regarding this patient, which of the following is true? Topic Review Topic

1. His behavior is consistent with a manic episode but does not meet criteria for bipolar I disorder
2. His behavior is consistent with a manic episode and also meets criteria for bipolar I disorder
3. His behavior is consistent with a manic episode and also meets criteria for bipolar II disorder
4. His behavior is consistent with a major depressive episode
5. His behavior is consistent with dysthymia

(M2.PY.43) A 47-year-old man with a 20-year history of bipolar disorder type I presents to clinic for a general health exam. He is accompanied by his wife. On greeting the patient, you notice he is easily distracted. His speech is pressured. The patient's wife reports that he has not had a normal night of sleep for the past several weeks and that she had to cancel his credit cards because he began spending recklessly. When asked about his sleep pattern, the patient gets agitated. The patient's wife reports that there have been no recent changes in his medication. He is on lithium for bipolar disorder and lisinopril for hypertension. The physical exam is benign and the patient's vital signs are within normal limits. Regarding this patient's medication regimen, what is the next step in management? Topic Review Topic

1. Discontinue all medications
2. Begin fluoxetine
3. Begin valproic acid
4. Begin clozapine
5. Begin venlafaxine

(M2.PY.44) A 23-year-old female with no past medical history presents to general medical clinic. She is accompanied by her mother. Her mother reports that over the past several months, her daughter has not "been herself." She graduated with highest honors as a history major and has no history of behavioral issues. In general, she has always been quite shy. However, recently, she has been striking up long conversations with strangers. Her friends have noticed that they can't cut her off and that she'll keep speaking for an hour without giving them a turn. She has been staying up all night reading, cleaning the house, and running on the treadmill. She has been driving recklessly and received two tickets for speeding. Her mother has tried to approach her about her behavior but she insists nothing is wrong and gets very angry when her mother confronts her. Which of the following is true regarding this patient's illness? Topic Review Topic

1. This disease carries a better prognosis than major depressive disorder
2. This disease carries a lower suicide risk than major depressive disorder
3. This patient may be treated for one year with lithium then tapered off
4. This patient requires a life long mood stabilizer
5. Selective seratonin reuptake inhibitors may be used for the depressive phase of this illness

(M2.PY.82) A 63-year-old patient with a history of bipolar I disorder is admitted to an inpatient psychiatric ward after a suicide attempt. She reports that she has attempted suicide 7 times, usually overdosing on whatever pills she has "lying around the house." During which of the following mood states is a patient with bipolar I disorder most likely to attempt suicide? Topic Review Topic

1. Manic episode
2. Depressive episode
3. Mixed episode
4. No episode carries a higher risk of suicide than another
5. Patients with bipolar I do not have an increased risk of attempting suicide

(M2.PY.110) A 26-year-old male presents to your clinic after experiencing a week of elevated mood and irrational behavior resulting in a gambling and drug abuse binge. This is his third such episode. He has been intermittently adherent with his lithium therapy. He asks you: "If I agree to be 100% compliant with this medication, and remain symptom free, how long must I be on it?" Topic Review Topic

1. For 6 months followed by a gradual taper
2. For 12 months followed by a gradual taper
3. For 18 months followed by a gradual taper
4. For 5 years followed by a gradual taper
5. For the remainder of the patient's life

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