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Key Features

Essentials of Diagnosis

  • Episodic mood shifts into mania, major depression, hypomania, and mixed states

  • Bipolar I is diagnosed in individuals who have manic episodes

  • Bipolar II is diagnosed in individuals who experience hypomanic episodes without frank mania

General Considerations

  • Manic episodes

    • Begin abruptly and may be triggered by life stresses

    • Last days to months—generally shorter than depressive episodes

  • Cyclothymia

    • Chronic mood disturbances with episodes of subsyndromal depression and hypomania

    • Symptoms are milder than those in a manic or depressive episode, but have at least a 2-year duration

    • Symptoms occasionally escalate to a full-blown manic or depressive episode, warranting a diagnosis of bipolar I or II

Clinical Findings

Symptoms and Signs

  • Manic episodes

    • Mood ranging from euphoria to irritability

    • Over-involvement in life activities

    • Flight of ideas with distractibility

    • Sleep disruption, little need for sleep

    • Racing thoughts

    • Behaviors may initially attract others

    • Irritability, mood lability, aggression, and grandiosity usually lead to problems in relationships

    • Excessive spending, resignation from a job, hasty marriage or divorce, sexual acting out, or exhibitionism may occur

    • Atypical episodes involve gross delusions, paranoid ideations, and auditory hallucinations

    • Patients with four or more discrete episodes of a mood disturbance in 1 year have "rapid cycling"

  • Most depressions

    • Lowered mood, varying from mild sadness to intense feelings of guilt, worthlessness, and hopelessness

    • Difficulty in thinking, including inability to concentrate, ruminations, and lack of decisiveness

    • Loss of interest, with diminished involvement in work and recreation

    • Somatic complaints such as

      • Headache

      • Disrupted, lessened, or excessive sleep

      • Loss of energy

      • Change in appetite

    • Anxiety

  • Some severe depressions

    • Psychomotor retardation or agitation

    • Delusions of a hypochondriacal or persecutory nature

    • Withdrawal from activities

    • Physical symptoms of major severity, eg,

      • Anorexia

      • Insomnia

      • Reduced sexual drive

      • Weight loss

      • Various somatic complaints

    • Suicidal ideation

Differential Diagnosis

  • Schizophrenia and other psychotic disorders

  • Intoxication with stimulants

  • Major depressive episode

  • Hypothyroidism

  • Dysthymia

Diagnosis

Laboratory Tests

  • Consider thyroid-stimulating hormone

  • Consider toxicology screen

Treatment

Medications

  • Mania

    • Olanzapine (2.5–10 mg intramuscularly) or haloperidol (5–10 mg orally or intramuscularly) if behavioral control is immediately necessary; may be repeated as needed until symptoms subside

    • Olanzapine (5–20 mg orally), risperidone (2–3 mg orally), or aripiprazole (15–30 mg), in conjunction with a benzodiazepine if indicated, to treat acute manic symptoms

    • Clonazepam (1–2 mg every 4–6 hours orally; up to 16 mg/day) may be used instead of or in conjunction with a neuroleptic to control acute manic symptoms

    • Lithium (started at 300 mg orally two or three times daily; 1200–1800 mg once daily orally targeted to achieve therapeutic serum level for acute episodes)

      • Effective in acute mania or hypomania, but takes several days to take effect

      • As prophylaxis, can limit the frequency and severity of mood swings in 50–70% ...

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