Bipolar and Related Disorders
Approximately what percentage of individuals who experience a single manic episode will go on to have recurrent mood episodes? A. 90%. B. 50%. C. 25%. D. 10%. E. 1%.
90%. Explanation: Bipolar disorders are highly recurrent, and more than 90% of individuals who have a single manic episode go on to have recurrent mood episodes.
The course of bipolar II disorder would likely be worse for individuals who have an onset of the disorder at which of the following ages? A. Age 10 years. B. Age 20 years. C. Age 40 years. D. Age 70 years. E. None of the above; there is no association between onset age and course.
Age 10 years. Explanation: Compared with adult onset of bipolar II disorder, childhood or adolescent onset of bipolar II disorder may be associated with a more severe lifetime course. The 3-year incidence rate of first-onset bipolar II disorder in adults older than 60 years is 0.34%. However, distinguishing individuals older than 60 years with bipolar II disorder by late versus early onset does not appear to have any clinical utility.
Which of the following is more common in men with bipolar I disorder than in women with the disorder? A. Rapid cycling. B. Alcohol abuse. C. Eating disorders. D. Anxiety disorders. E. Mixed-state symptoms.
Alcohol abuse. Explanation: Although bipolar I disorder affects men and women equally, hypomanic, mixed-state, and rapid-cycling symptoms are more common in women. Alcohol abuse is higher in men than in women in all cases, although it should be noted that women with bipolar disorder have a higher rate of alcohol abuse than do women in the general population. Compared with bipolar men, bipolar women are more likely to experience rapid cycling and anxiety and have higher rates of lifetime comorbid eating disorders.
A patient with a history of bipolar I disorder presents with a new-onset manic episode and is successfully treated with medication adjustment. He notes chronic depressive symptoms that, on reflection, long preceded his manic episodes. He describes these symptoms as "feeling down," having decreased energy, and more often than not having no motivation. He denies other depressive symptoms but feels that these alone have been sufficient to negatively affect his marriage. Which diagnosis best fits this presentation? A. Other specified bipolar and related disorder. B. Bipolar I disorder, current or most recent episode depressed. C. Cyclothymic disorder. D. Bipolar I disorder and persistent depressive disorder (dysthymia). E. Bipolar II disorder.
Bipolar I disorder and persistent depressive disorder (dysthymia). Explanation: This patient's presentation does not meet the full criteria for a major depressive episode and thus would not qualify for a diagnosis of bipolar I disorder, current or most recent episode depressed. If the patient meets criteria for persistent depressive disorder (dysthymia) and bipolar I disorder, both should be diagnosed. The presence of a manic episode makes bipolar II disorder, cyclothymic disorder, and other specified bipolar and related disorder inappropriate.
A 50-year-old man with a history of a prior depressive episode is given an antidepressant by his family doctor to help with his depressive symptoms. Two weeks later, his doctor contacts you for a consultation because the patient now is euphoric, has increased energy, racing thoughts, psychomotor agitation, poor concentration and attention, pressured speech, and a decreased need to sleep. These symptoms began with the initiation of the patient's new medication. The patient stopped the medication after 2 days, as he no longer felt depressed; however, the symptoms have continued ever since. What is the patient's diagnosis? A. Substance/medication-induced bipolar and related disorder. B. Bipolar I disorder. C. Bipolar II disorder. D. Cyclothymic disorder. E. Major depressive disorder.
Bipolar I disorder. Explanation: Manic symptoms or syndromes that are attributable to the physiological effects of a drug of abuse (e.g., in the context of cocaine or amphetamine intoxication), the side effects of medications or treatments (e.g., steroids, L-dopa, antidepressants, stimulants), or another medical condition do not count toward the diagnosis of bipolar I disorder. However, a fully syndromal manic episode that arises during treatment (e.g., with medications, electroconvulsive therapy, light therapy) or drug use and persists beyond the physiological effect of the inducing agent (i.e., after a medication is fully out of the individual's system or the effects of electroconvulsive therapy would be expected to have dissipated completely) is sufficient evidence for a manic episode diagnosis (Criterion D). The diagnostic features of substance/ medication-induced bipolar and related disorder are essentially the same as those for mania, hypomania, or depression. A key exception to the diagnosis of substance/medication-induced bipolar and related disorder is the case of hypomania or mania that occurs after antidepressant medication use or other treatments and persists beyond the physiological effects of the medication. This condition is considered an indicator of true bipolar disorder, not substance/medication-induced bipolar and related disorder.
A 42-year-old man reports 1 week of increased activity associated with an elevated mood, a decreased need for sleep, and inflated self-esteem. Although the man does not object to his current state ("I'm getting a lot of work done!"), he is concerned because he recalls a similar episode 10 years ago during which he began to make imprudent business decisions. A physical examination and laboratory work are unrevealing for any medical cause of his symptoms. He had taken fluoxetine for a depressive episode but self-discontinued it 3 months ago because he felt that his mood was stable. Which diagnosis best fits this clinical picture? A. Bipolar I disorder. B. Bipolar II disorder. C. Cyclothymic disorder. D. Other specified bipolar disorder and related disorder. E. Substance/medication-induced bipolar disorder.
Bipolar I disorder. Explanation: This patient most likely meets criteria for bipolar I disorder, current episode hypomanic, which is defined as a current hypomanic episode in an individual with a previous history of at least one manic episode. The history of a past manic episode rules out bipolar II disorder, and the time course and absence of numerous episodes of hypomania rule out cyclothymic disorder. Although antidepressants can precipitate manic episodes, the long period since medication discontinuation (more than 5 half-lives) makes this episode unlikely to be medication induced.
A 25-year-old graduate student presents to a psychiatrist complaining of feeling down and "not enjoying anything." Her symptoms began about a month ago, along with insomnia and poor appetite. She has little interest in activities and is having difficulty attending to her schoolwork. She recalls a similar episode 1 year ago that lasted about 2 months before improving without treatment. She also reports several episodes of increased energy in the past 2 years; these episodes usually last 1-2 weeks, during which time she is very productive, feels more social and outgoing, and tends to sleep less, although she feels energetic during the day. Friends tell her that she speaks more rapidly during these episodes but that they do not see it as off-putting and in fact think she seems more outgoing and clever. She has no medical problems and does not take any medications or abuse drugs or alcohol. What is the most likely diagnosis? A. Bipolar I disorder, current episode depressed. B. Bipolar II disorder, current episode depressed. C. Bipolar I disorder, current episode unspecified. D. Cyclothymic disorder. E. Major depressive disorder.
Bipolar II disorder, current episode depressed. Explanation: With her current major depressive episode combined with a past history of elevated mood and activity, this patient likely has a bipolar disorder. Because her periods of mood elevation do not cause distress or impairment, they are probably hypomanic episodes, hence a diagnosis of bipolar II disorder. The lack of any current hypomanic symptoms rules out a mixed episode of the illness. The presence of major depressive episodes rules out cyclothymic disorder, and this patient's hypomanic episodes rule out major depressive disorder. This vignette is illustrative of the clinical observation that patients with bipolar II disorder generally present for treatment only when they experience depressive symptoms.
Which of the following statements accurately describes a change in DSM-5 from the DSM-IV criteria for bipolar disorders? a. Diagnostic criteria for bipolar disorders now include both changes in mood and changes in activity or energy. b. Diagnostic criteria for bipolar I disorder, mixed type, now require a patient to simultaneously meet full criteria for both mania and major depressive episode. c. Subsyndromal hypomania has been removed from the allowed conditions under other specified bipolar and related disorder. d. There is now a stipulation that manic or hypomanic episodes cannot be associated with recent administration of a drug known to cause similar symptoms. e. The clinical symptoms associated with hypomanic episodes have been substantially changed.
Diagnostic criteria for bipolar disorders now include both changes in mood and changes in activity or energy. Explanation: Although the essential elements describing the clinical symptoms associated with depressive, manic, and hypomanic episodes have not substantially changed, there are a number of changes in the DSM-5 criteria for bipolar disorders. Diagnostic criteria for bipolar disorders now include both changes in mood and changes in activity or energy, with the addition of "and abnormally and persistently increased activity or energy" to Criterion A for manic and hypomanic episodes. The DSM-IV diagnosis of bipolar I disorder, mixed episodes—requiring that the individual simultaneously meet full crite- ria for both mania and major depressive episode—is replaced with a new spec- ifier, "with mixed features." Particular conditions can now be diagnosed under other specified bipolar and related disorder, including categorization for individuals with a past history of a major depressive disorder who have too few symptoms of hypomania or too short a duration of a hypomanic episode to meet criteria for the full bipolar II disorder syndrome. Mania or hypomania that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is considered to be sufficient evidence for a bipolar disorder diagnosis, not substance/medication-induced bipolar and related disorder.
For an adolescent who presents with distractibility, which of the following additional features would suggest an association with bipolar II disorder rather than attention-deficit/hyperactivity disorder (ADHD)? A. Rapid speech noted on examination. B. A report of less need for sleep. C. Complaints of racing thoughts. D. Evidence that the symptoms are episodic. E. Evidence that the symptoms represent the individual's baseline behavior.
Evidence that the symptoms are episodic. Explanation: ADHD may be misdiagnosed as bipolar II disorder, especially in adolescents and children. Many symptoms of ADHD, such as rapid speech, racing thoughts, distractibility, and less need for sleep, overlap with the symptoms of hypomania. The double counting of symptoms toward both ADHD and bipolar II disorder can be avoided if the clinician clarifies whether the symptoms represent a distinct episode and if the noticeable increase over base-line required for the diagnosis of bipolar II disorder is present.
Which of the following factors is most predictive of incomplete recovery between mood episodes in bipolar I disorder? a. Being widowed. b. Living in a higher-income country. c. Being divorced. d. Having a family history of bipolar disorder. e. Having a mood episode accompanied by mood-incongruent psychotic symptoms.
Having a mood episode accompanied by mood-incongruent psychotic symptoms. Explanation: Incomplete interepisode recovery in bipolar I disorder is more common when the current episode is accompanied by mood-incongruent psychotic features. Being separated, divorced, or widowed and having a family history of bipolar disorder are risk factors for bipolar I disorder; however, they are not predictors of course. Bipolar I disorder is more common in high-income than in low-income countries (1.4% vs. 0.7%), but higher income does not predict incomplete interepisode recovery.
A patient with a history of bipolar disorder reports experiencing 1 week of elevated and expansive mood. Evidence of which of the following would suggest that the patient is experiencing a hypomanic, rather than manic, episode? A. Irritability. B. Decreased need for sleep. C. Increased productivity at work. D. Psychotic symptoms. E. Good insight into the illness.
Increased productivity at work. Explanation: The primary factor that differentiates manic and hypomanic episodes is that manic episodes cause marked impairment in social or occupational functioning or necessitate hospitalization to prevent harm to self or others, or there are psychotic features (Criterion C of bipolar I disorder). In hypomania, "The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization" (Criterion E of bipolar II disorder). Both types of episodes can cause irritability or decreased need for sleep. Insight is not included in the diagnostic criteria.
Which of the following statements about postpartum hypomania is true? A. It tends to occur in the late postpartum period. B. It occurs in less than 1% of postpartum women. C. It is a risk factor for postpartum depression. D. It is easily distinguished from the normal adjustments to childbirth. E. It is more common in multiparous women.
It is a risk factor for postpartum depression. Explanation: Childbirth may be a specific trigger for a hypomanic episode, which can occur in 10%-20% of females in nonclinical populations and most typically in the early postpartum period. Distinguishing hypomania from the elated mood and reduced sleep that normally accompany the birth of a child may be challenging. Postpartum hypomania may foreshadow the onset of a depression that occurs in about half of females who experience postpartum "highs." Accurate detection of bipolar II disorder may help in establishing appropriate treatment of the depression, which may reduce the risk of suicide and infanticide.
How does the course of bipolar II disorder differ from the course of bipolar I disorder? a. It is more chronic than the course of bipolar I disorder. b. It is less episodic than the course of bipolar I disorder. c. It involves longer asymptomatic periods than the course of bipolar I disorder. d. It involves shorter symptomatic episodes than the course of bipolar I disorder. e. It involves a much lower number of lifetime mood episodes than the course of bipolar I disorder.
It is more chronic than the course of bipolar I disorder. Explanation: Despite the substantial differences in duration and severity between manic and hypomanic episodes, bipolar II disorder is not a "milder form" of bipolar I disorder. Compared with individuals with bipolar I disorder, individuals with bipolar II disorder have greater chronicity of illness and spend, on average, more time in the depressive phase of their illness, which can be severe and/or disabling. The number of lifetime episodes (both hypomanic and major depressive episodes) tends to be higher for bipolar II disorder than for major depressive disorder or bipolar I disorder. The interval between mood episodes in the course of bipolar II disorder tends to decrease as the individual ages. While the hypomanic episode is the feature that defines bipolar II disorder, depressive episodes are more enduring and disabling over time.
A 32-year-old man reports 1 week of feeling unusually irritable. During this time, he has increased energy and activity, sleeps less, and finds it difficult to sit still. He also is more talkative than usual and is easily distractible, to the point of finding it difficult to complete his work assignments. A physical examination and laboratory workup are negative for any medical cause of his symptoms and he takes no medications. What diagnosis best fits this clinical picture? A. Manic episode. B. Hypomanic episode. C. Bipolar I disorder, with mixed features. D. Major depressive episode. E. Cyclothymic disorder.
Manic episode. Explanation: In DSM-5, the definition of a manic episode has been broadened to include both an abnormal mood (elevated, expansive, or irritable) and increased activity for at least 1 week. The person must also experience at least three (four if the mood is irritable) of the following symptoms: 1) inflated self-esteem or grandiosity, 2) decreased need for sleep, 3) more talkative than usual or pressure to keep talking, 4) flight of ideas or subjective experience that thoughts are racing, 5) distractibility, 6) increase in goal-directed activity or psychomotor agitation, and 7) excessive involvement in activities that have a high potential for painful consequences.
In which of the following ways do manic episodes differ from attention-deficit/hyperactivity disorder (ADHD)? A. Manic episodes are more strongly associated with poor judgment. B. Manic episodes are more likely to involve excessive activity. C. Manic episodes have clearer symptomatic onsets and offsets. D. Manic episodes are more likely to show a chronic course. E. Manic episodes first appear at an earlier age.
Manic episodes have clearer symptomatic onsets and off-sets. Explanation: ADHD and manic episodes are both characterized by poor judgment, excessive activity, impulsive behavior, and denial of problems. Patients with ADHD have an earlier onset of illness (i.e., before age 7 years), show a more chronic course (manic episodes are more episodic), and lack clear onsets and offsets of symptoms. In addition, ADHD patients tend not to have an unusually elevated mood or psychotic symptoms.
Which of the following features confers a worse prognosis for a patient with bipolar II disorder? A. Younger age. B. Higher educational level. C. Rapid-cycling pattern. D. "Married" marital status. E. Less severe depressive episodes.
Rapid-cycling pattern. Explanation: A rapid-cycling pattern is associated with a poorer prognosis. Return to previous level of social function for individuals with bipolar II disorder is more likely for individuals of younger age and with less severe depression, suggesting adverse effects of prolonged illness on recovery. More education, fewer years of illness, and being married are independently associated with functional recovery in individuals with bipolar disorder, even after diagnostic type (I vs. II), current depressive symptoms, and presence of psychiatric comorbidity are taken into account.
In which of the following aspects does cyclothymic disorder differ from bipolar I disorder? A. Duration. B. Severity. C. Age at onset. D. Pervasiveness. E. All of the above.
Severity. Explanation: The essential feature of cyclothymic disorder is a chronic, fluctuating mood disturbance involving numerous periods of hypomanic symptoms and periods of depressive symptoms that are distinct from each other (Criterion A). The hypomanic symptoms are of insufficient number, severity, pervasiveness, or duration to meet full criteria for a hypomanic episode, and the depressive symptoms are of insufficient number, severity, pervasiveness, or duration to meet full criteria for a major depressive episode. During the initial 2-year period (1 year for children or adolescents), the symptoms must be persistent (present more days than not), and any symptom-free intervals must last no longer than 2 months (Criterion B). The diagnosis of cyclothymic disorder is made only if the criteria for a major depressive, manic, or hypomanic episode have never been met (Criterion C).
How do the depressive episodes associated with bipolar II disorder differ from those associated with bipolar I disorder? A. They are less frequent than those associated with bipolar I disorder. B. They are lengthier than those associated with bipolar I disorder. C. They are less disabling than those associated with bipolar I disorder. D. They are less severe than those associated with bipolar I disorder. E. They are rarely a reason for the patient to seek treatment.
They are lengthier than those associated with bipolar I disorder. Explanation: The recurrent major depressive episodes associated with bipolar II disorder are typically more frequent and lengthier than those associated with bipolar I disorder. The depressive episodes can be very severe and disabling; because of this, DSM-5 stresses that bipolar II disorder should not be consid- ered a "milder" form of bipolar I disorder. Bipolar II patients are more likely to seek treatment when depressed than during hypomanic episodes.
