Review Question - QID 205697

Bipolar disorder is defined by the presence of at least one manic or hypomanic episode. Since this patient's manic symptoms are severe, he should be classified as bipolar I (rather than bipolar II which is defined by a hypomanic episode where the patient is not experiencing full blown mania).

In bipolar disorder, depressive symptoms may not initially be apparent but almost always occur eventually. Standard of care is with a mood stabilizer such as lithium, valproic acid, or carbamazepine. In instances where a patient experiences symptoms while already on a stabilizing agent, an antipsychotic is required. This patient's symptoms are characteristic of a manic episode, which is usually marked by distractibility, irresponsibility, grandiosity, flight of ideas, psychomotor agitation, a decreased need for sleep, and pressured speech. Patients may also become hypersexual. Another illness in this spectrum to remember is cyclothymia, a milder form of bipolar disorder lasting at least two years where the patient alternates between dysthymia and hypomania. In this patient, exposure to steroids likely triggered the manic episode. Patient's predisposed to bipolar disorder may first present after exposure to exogenous steroids.

This case is also useful in describing the difference between a manic and a hypomanic episode. By the DSM, mania is described as a mood disturbance sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. In contrast in hypomania, the mood disturbance is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features. Given the squandering of savings on a new unneeded sports car, this patient's mood dysregulation would qualify as mania rather than hypomania.

Griswold and Pessar review management of bipolar disorder. The disease is commonly diagnosed in patients between 18 and 24 and is commonly comorbid with substance abuse and anxiety disorders. The disease is characterized by variation in mood from elevation and or irritability to depression.

Price and Marzani-Nissen review bipolar disorder and note that mood stabilizers such as lithium and anticonvulsants should be continued indefinitely because of the risk of relapse. Antidepressants are contraindicated in mixed states, manic episodes, and bipolar I disorder because they may worsen symptoms.

Phillips and Kupfer discuss the challenges and future directions of diagnosis for bipolar disorder. Bipolar disorder type II is especially difficult to diagnose accurately because of the difficulty in differentiation of this disorder from recurrent unipolar depression in depressed patients. The identification of objective biomarkers that represent pathophysiologic processes that differ between bipolar disorder and unipolar depression can both inform bipolar disorder diagnosis and provide biological targets for the development of new and personalized treatments.

Illustration A represents the proposed role of lithium, a mainstay in treatment of bipolar disorder. Lithium is thought to be a negative regulator of GSK-3 Beta and a positive regulator of Akt. It acts on signaling pathways that result in both neuroplasticity and neuroprotection.

Incorrect Answers:
Answer 1: One manic episode is enough for a diagnosis of bipolar I.
Answer 3: This episode may be classified as full blown mania rather than hypomania and thus a diagnosis of bipolar I instead of bipolar II is appropriate.
Answer 4: This patient's symptoms are suggestive of mania not depression.
Answer 5: Dysthymia is a mild form of depression lasting at least two years.