Difference between revisions of "Bipolar disorder"

(Diagnosis)
 
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==Background==
 
==Background==
*mental disorder characterized by periods of elevated moods and periods of depression
+
*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
+
*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===
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===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
+
*Abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week
*at least 3 of the following symptoms (4 if only irritable)
+
*At least 3 of the following symptoms (4 if only irritable)
**inflated self esteem or grandiosity
+
**Inflated self esteem or grandiosity
**decreased need for sleep
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**Decreased need for sleep
**more talkative/pressured speech
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**More talkative/pressured speech
**flight of ideas/racing thoughts
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**Flight of ideas/racing thoughts
**easily distractible
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**Easily distracted
**increase in goal-directed activity or psychomotor agitation
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**Increase in goal-directed activity or psychomotor agitation
**involvement in high pleasure, high risk activities  
+
**Involvement in high pleasure, high risk activities  
***gambling, shopping sprees, sexual indiscretions
+
***Gambling, shopping sprees, sexual indiscretions
*sufficient to cause impairment in functioning, relationships, or hospitalization
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*Sufficient to cause impairment in functioning, relationships, or hospitalization
*not as a result of substance abuse or medical condition (e.g. hyperthyroid)
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*Not as a result of substance abuse or medical condition (e.g. hyperthyroid)
  
===Hypomanic Episode===
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===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===
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===[[depression|Major Depressive Episode]]===
*'''<big>S</big>'''leep - increased or decreased
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*'''<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
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*'''<big>G</big>'''uilt - excessive guilt
 
*'''<big>G</big>'''uilt - excessive guilt
  
*'''<big>E</big>'''nergy - feels of fatigue, low energy
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*'''<big>E</big>'''nergy - feels of [[fatigue]], low energy
  
*'''<big>C</big>'''oncentration - cognitive decine, indecisiveness
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*'''<big>C</big>'''oncentration - cognitive decline, indecisiveness
  
 
*'''<big>A</big>'''ppetite - weight loss/gain
 
*'''<big>A</big>'''ppetite - weight loss/gain
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*'''<big>P</big>'''sychomotor agitation or depression
 
*'''<big>P</big>'''sychomotor agitation or depression
  
*'''<big>S</big>'''uicidal ideation
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*[[suicide|'''<big>S</big>'''uicidal ideation]]
  
''Must have 5 symptoms in a 2 week period including depressed mood and loss of interest''
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''Must have 5 symptoms in a 2 week period including depressed mood and loss of interest''<ref name="DSM5"/>
  
===Mixed Episode===
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===Mixed Episode<ref name="DSM5"/>===
*fulfill features of both manic and major depressive episode
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*Fulfill features of both manic and major depressive episode
*must last at least 1 week
+
*Must last at least 1 week
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
 
{{Psych DDX}}
 
{{Psych DDX}}
  
==Diagnosis==
+
==Evaluation==
*usually will not be diagnosed in the emergency department
+
*Usually will not be diagnosed in the emergency department
*needs evaluation by a psychiatrist
+
*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
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*Meets criteria for one manic or mixed episode
*symptoms cause social/occupational distress or impairment
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*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 major depressive episode
*meets criteria for at least one hypomanic episode
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*Meets criteria for at least one hypomanic episode
*does not meet criteria for manic or mixed episode
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*Does not meet criteria for manic or mixed episode
*symptoms cause social/occupational distress or imairment
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*Symptoms cause social/occupational distress or impairment
  
 
===Bipolar NOS===
 
===Bipolar NOS===
*disorder with bipolar features that don't meet criteria for specific bipolar disorder
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*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==
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<references/>
 
<references/>
  
[[Category:Psych]]
+
[[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)
    • Patients with serious mental illness have significantly higher rates of stroke[1], CAD[2], DM[3], cancer[4], HIV, HCV[5]
    • All cause mortality rate is 30-200% higher for patients with bipolar disorder than general population[6]

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

  • 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

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

  • 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

Disposition

  • May need psych eval after medical clearance

See Also

External Links

References

  1. 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
  2. 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.
  3. 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.
  4. https://www.cdc.gov/mentalhealth/data_stats/mental-illness.htm
  5. 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.
  6. https://www.who.int/mental_health/management/info_sheet.pdf
  7. 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.