Bipolar disorder: Difference between revisions
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==Background== | ==Background== | ||
* | *Mental disorder characterized by periods of elevated moods and periods of depression | ||
* | *Spectrum of disorders including Bipolar Type I, Bipolar Type II, and Bipolar NOS | ||
*Be wary of diagnostic overshadowing (e.g. erroneously attributing symptoms to psychiatric disorder when etiology is in fact organic) | |||
**Patients with serious mental illness have significantly higher rates of stroke<ref>Leucht S, Burkand T, Henderson J, Maj M, Sartorius N (2007) Physical illness and schizophrenia: a review of the literature. Acta Psychiatr Scand 116: 317– 333</ref>, CAD<ref>Leucht S, Burkand T, Henderson J, Maj M, Sartorius N (2007) Physical illness and schizophrenia: a review of the literature. Acta Psychiatr Scand 116: 317– 333. </ref>, DM<ref>Mai Q, D’Arcy C, Holman J, Sanfilippo FM, Emery JD, et al. (2011) Mental illness related disparities in diabetes prevalence, quality of care and outcomes: a population-based longitudinal study. BMC Med 9: 118. | |||
</ref>, cancer<ref>https://www.cdc.gov/mentalhealth/data_stats/mental-illness.htm</ref>, HIV, HCV<ref>Disability Rights Commission (2006) Equal Treatment: Closing the Gap. A Formal Investigation into Physical Health Inequalities Experienced by People with Learning Disabilities and/or Mental Health Problems. Disability Rights Commission. London.</ref> | |||
**All cause mortality rate is 30-200% higher for patients with bipolar disorder than general population<ref>https://www.who.int/mental_health/management/info_sheet.pdf</ref> | |||
==Clinical Features== | ==Clinical Features== | ||
===Manic Episode=== | ===Manic Episode<ref name="DSM5">American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Arlington, VA: American Psychiatric Publishing.</ref>=== | ||
* | *Abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week | ||
* | *At least 3 of the following symptoms (4 if only irritable) | ||
** | **Inflated self esteem or grandiosity | ||
** | **Decreased need for sleep | ||
** | **More talkative/pressured speech | ||
** | **Flight of ideas/racing thoughts | ||
** | **Easily distracted | ||
** | **Increase in goal-directed activity or psychomotor agitation | ||
** | **Involvement in high pleasure, high risk activities | ||
*** | ***Gambling, shopping sprees, sexual indiscretions | ||
* | *Sufficient to cause impairment in functioning, relationships, or hospitalization | ||
* | *Not as a result of substance abuse or medical condition (e.g. hyperthyroid) | ||
===Hypomanic Episode=== | ===Hypomanic Episode<ref name="DSM5"/>=== | ||
*Same features as manic episode however less intense | *Same features as manic episode however less intense | ||
*Symptoms only need to persist for 4 days | *Symptoms only need to persist for 4 days | ||
===Major Depressive Episode=== | ===[[depression|Major Depressive Episode]]=== | ||
*'''<big>S</big>'''leep - increased or decreased | *'''<big>S</big>'''leep - increased or [[insomnia|decreased]] | ||
*'''<big>I</big>'''nterest - losing interest or pleasure in activities | *'''<big>I</big>'''nterest - losing interest or pleasure in activities | ||
| Line 29: | Line 33: | ||
*'''<big>G</big>'''uilt - excessive guilt | *'''<big>G</big>'''uilt - excessive guilt | ||
*'''<big>E</big>'''nergy - feels of fatigue, low energy | *'''<big>E</big>'''nergy - feels of [[fatigue]], low energy | ||
*'''<big>C</big>'''oncentration - cognitive | *'''<big>C</big>'''oncentration - cognitive decline, indecisiveness | ||
*'''<big>A</big>'''ppetite - weight loss/gain | *'''<big>A</big>'''ppetite - weight loss/gain | ||
| Line 37: | Line 41: | ||
*'''<big>P</big>'''sychomotor agitation or depression | *'''<big>P</big>'''sychomotor agitation or depression | ||
*'''<big>S</big>'''uicidal ideation | *[[suicide|'''<big>S</big>'''uicidal ideation]] | ||
''Must have 5 symptoms in a 2 week period including depressed mood and loss of interest'' | ''Must have 5 symptoms in a 2 week period including depressed mood and loss of interest''<ref name="DSM5"/> | ||
===Mixed Episode=== | ===Mixed Episode<ref name="DSM5"/>=== | ||
* | *Fulfill features of both manic and major depressive episode | ||
* | *Must last at least 1 week | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Psych DDX}} | {{Psych DDX}} | ||
== | ==Evaluation== | ||
* | *Usually will not be diagnosed in the emergency department | ||
* | *Needs evaluation by a psychiatrist | ||
*Rule out alternative medical explanation for symptoms, as appropriate | |||
{{General ED Psychiatric Workup}} | |||
===Bipolar I=== | ===Bipolar I=== | ||
* | *Meets criteria for one manic or mixed episode | ||
* | *Symptoms cause social/occupational distress or impairment | ||
===Bipolar II=== | ===Bipolar II=== | ||
* | *Meets criteria for at least one major depressive episode | ||
* | *Meets criteria for at least one hypomanic episode | ||
* | *Does not meet criteria for manic or mixed episode | ||
* | *Symptoms cause social/occupational distress or impairment | ||
===Bipolar NOS=== | ===Bipolar NOS=== | ||
* | *Disorder with bipolar features that do not meet criteria for specific bipolar disorder | ||
==Management== | ==Management== | ||
* | *After medical evaluation/"clearance": | ||
* | **Place patient on legal hold if meets local criteria | ||
* | **Arrange psychiatry evaluation (inpatient vs outpatient depending on clinical severity) | ||
{{General ED Psychiatric Management}} | |||
==Disposition== | ==Disposition== | ||
*May need psych eval after medical clearance | |||
==See Also== | ==See Also== | ||
| Line 78: | Line 87: | ||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category: | [[Category:Psychiatry]] | ||
Latest revision as of 15:04, 11 October 2019
Background
- Mental disorder characterized by periods of elevated moods and periods of depression
- Spectrum of disorders including Bipolar Type I, Bipolar Type II, and Bipolar NOS
- Be wary of diagnostic overshadowing (e.g. erroneously attributing symptoms to psychiatric disorder when etiology is in fact organic)
Clinical Features
Manic Episode[7]
- Abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week
- At least 3 of the following symptoms (4 if only irritable)
- Inflated self esteem or grandiosity
- Decreased need for sleep
- More talkative/pressured speech
- Flight of ideas/racing thoughts
- Easily distracted
- Increase in goal-directed activity or psychomotor agitation
- Involvement in high pleasure, high risk activities
- Gambling, shopping sprees, sexual indiscretions
- Sufficient to cause impairment in functioning, relationships, or hospitalization
- Not as a result of substance abuse or medical condition (e.g. hyperthyroid)
Hypomanic Episode[7]
- Same features as manic episode however less intense
- Symptoms only need to persist for 4 days
Major Depressive Episode
- Sleep - increased or decreased
- Interest - losing interest or pleasure in activities
- Guilt - excessive guilt
- Energy - feels of fatigue, low energy
- Concentration - cognitive decline, indecisiveness
- Appetite - weight loss/gain
- Psychomotor agitation or depression
Must have 5 symptoms in a 2 week period including depressed mood and loss of interest[7]
Mixed Episode[7]
- Fulfill features of both manic and major depressive episode
- Must last at least 1 week
Differential Diagnosis
General Psychiatric
- Organic causes
- Psychiatric causes
Evaluation
- Usually will not be diagnosed in the emergency department
- Needs evaluation by a psychiatrist
- Rule out alternative medical explanation for symptoms, as appropriate
General ED Psychiatric Workup
- Point-of-care glucose
- CBC
- Chem 7
- LFTs
- ECG (for toxicology evaluation)
- ASA level
- Tylenol level
- Urine toxicology screen/Blood toxicology screen
- EtOH
- Urine pregnancy/beta-hCG (if female of childbearing age)
- Consider:
- Ammonia (see Hepatic encephalopathy)
- TSH (hypo or hyperthyroidism may mimic mental illness)
- CXR (for Tb screen or rule-out delirium in older patient)
- UA (for rule-out delirium in older patients)
- Head CT (to rule-out ICH in patients with AMS)
- Lumbar puncture (to rule-out meningitis or encephalitis)
Bipolar I
- Meets criteria for one manic or mixed episode
- Symptoms cause social/occupational distress or impairment
Bipolar II
- Meets criteria for at least one major depressive episode
- Meets criteria for at least one hypomanic episode
- Does not meet criteria for manic or mixed episode
- Symptoms cause social/occupational distress or impairment
Bipolar NOS
- Disorder with bipolar features that do not meet criteria for specific bipolar disorder
Management
- After medical evaluation/"clearance":
- Place patient on legal hold if meets local criteria
- Arrange psychiatry evaluation (inpatient vs outpatient depending on clinical severity)
General ED Psychiatric Management
- Non-pharmacologic
- Verbal de-escalation
- Offer comforting items: blanket, meal, pillow, etc
- Quiet room
- Physical restraints (should administer medications if restraints used, as decreases restraint time)
- Pharmacologic: Goal is to calm patient without oversedation
- No history of psychosis
- Haloperidol 0.5mg-5mg +/- lorazepam 0.25-2mg (PO/IM/IV)
- Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM) (reduces dystonia or extrapyramidal reaction)
- Consider risperidone 0.5-2mg PO or olanzapine 2.5-20mg (PO/IM/SL) or ziprasidone 10-20mg IM
- Haloperidol 0.5mg-5mg +/- lorazepam 0.25-2mg (PO/IM/IV)
- Known or suspected underlying psychotic illness
- Continue treatment with previous antipsychotic or
- PO: olanzapine 5-10mg or risperidone 0.5-2mg +/- lorazepam: 0.5-2mg
- IM: olanzapine 2.5-20mg or ziprasidone 10-20mg or
- (PO/IM/IV) Haloperidol 0.5-5mg +/- lorazepam 0.5-2mg
- Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM) (reduces dystonia or extrapyramidal reaction)
- No history of psychosis
Disposition
- May need psych eval after medical clearance
See Also
External Links
References
- ↑ Leucht S, Burkand T, Henderson J, Maj M, Sartorius N (2007) Physical illness and schizophrenia: a review of the literature. Acta Psychiatr Scand 116: 317– 333
- ↑ Leucht S, Burkand T, Henderson J, Maj M, Sartorius N (2007) Physical illness and schizophrenia: a review of the literature. Acta Psychiatr Scand 116: 317– 333.
- ↑ Mai Q, D’Arcy C, Holman J, Sanfilippo FM, Emery JD, et al. (2011) Mental illness related disparities in diabetes prevalence, quality of care and outcomes: a population-based longitudinal study. BMC Med 9: 118.
- ↑ https://www.cdc.gov/mentalhealth/data_stats/mental-illness.htm
- ↑ Disability Rights Commission (2006) Equal Treatment: Closing the Gap. A Formal Investigation into Physical Health Inequalities Experienced by People with Learning Disabilities and/or Mental Health Problems. Disability Rights Commission. London.
- ↑ https://www.who.int/mental_health/management/info_sheet.pdf
- ↑ 7.0 7.1 7.2 7.3 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Arlington, VA: American Psychiatric Publishing.