Definition
A.Manic episode (see Table 9.1).
1.Distinct period of abnormal and persistent elevated, expansive, or irritable mood and abnormally and persistent increase in goal-directed activity or energy, lasting at least a week and nearly all day.
2.During the period of mood disturbance and increased energy or activity, three of the following symptoms (four if mood is irritable) are present to a significant degree and represent a noticeable change from usual behavior.
a.Inflated self-esteem or grandiosity.
b.Decreased need for sleep.
c.More talkative.
d.Flight of ideas.
e.Distractibility.
f.Increase in goal-directed activities.
g.Excessive involvement in activities that have a high risk for painful consequences.
3.The mood disturbance is sufficiently severe to cause marked impairment in social, occupational functioning, or to necessitate hospitalization to prevent harm to self or others.
4.The episode is not attributable to the physiological effects of a substance or to another medical condition.
5.NOTE: A full manic episode that emerges during antidepressant treatment but persists at a fully syndromal level beyond the physiological effect of treatment is sufficient evidence for a manic episode.
B.Hypomanic episode (see Table 9.1).
1.Distinct period of elevated expansive or irritable mood, lasting at least 4 days, that is clearly different from non-depressed mood.
2.Three or more (four if mood is irritable): Grandiosity, decreased sleep, pressured speech, racing thoughts, hyperverbal, distractible, increase in goal-directed activity, and excessive involvement in pleasurable activities that may have negative consequences.
3.Change in behavior is uncharacteristic for the person.
4.Other people notice the change in mood and functioning.
5.Episode does not cause marked impairment in social or occupational functioning, it does not require hospitalization, and there is no psychosis.
6.Symptoms are not due to substance use or a general medical condition.
C.Bipolar depression.
1.Prolonged sadness.
2.Pessimism.
3.Changes in appetite.
4.Indifference.
5.Loss of energy.
6.Persistent lethargy.
7.Inability to concentrate.
8.Recurring thoughts of death or suicide.
D.Bipolar I or bipolar II disorder.
1.Bipolar I: Has one or more manic episodes or mixed episodes: A distinct period of abnormally and persistently increased goal-directed activity or energy lasting at least 1 week and present nearly every day, for most of the day, with three or more of the following: Grandiosity/inflated self-esteem, decreased need for sleep, more talkative/pressured speech, flight of ideas/racing thoughts, distractibility, increase in goal-directed behavior, or excessive engagement in high-risk activities. The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) has six separate criteria sets.
a.bipolar disease (BPD) I single manic episode.
b.Most recent episode hypomanic.
c.Most recent episode manic.
d.Most recent episode mixed.
e.Most recent episode depressed.
f.Most recent episode unspecified.
2.Bipolar II: Has one or more major depressive episodes and at least one hypomanic episode.
a.Specifiers are used to indicate the nature of the current episode: hypomanic or depressed.
b.If depressed, specifiers are mild, moderate, severe without psychotic features or severe with psychotic features, chronic, with catatonic features, with melancholic features, with atypical features, or with postpartum onset.
Incidence
A.12-month prevalence for bipolar I disorder is 0.6% with lifetime male-to-female ratio of 1:1.
Age of onset is about 18 years of age, earlier than in major depressive disorder.
B.90% of individuals with a single manic episode have a recurrent mood episode.
C.60% of manic episodes occur immediately before a major depressive episode.
D.12-month prevalence for bipolar II disorder is 0.3%.
TABLE 9.1 Mania and Hypomania Comparisons
Source: Adapted with permission from Morrison, J. (2014). DSM-5 made easy: The clinician’s guide to diagnosis. New York, NY: Guilford Press.
Pathogenesis
A.Up to 70% to 80% heritability.
B.Brain changes.
1.Decreased size and activity in the prefrontal cortex with limbic hyperactivity and decreased hippocampal volume.
2.The amygdala is larger and more active in bipolar disorder.
3.Disrupted glutamate and gamma-aminobutyric acid (GABA) regulation with greater norepinephrine and dopamine activity in mania.
Predisposing Factors
A.Environmental: Separated, widowed individuals have higher rates.
B.Genetics: Family history is one of the strongest and most consistent predictors for bipolar disorder. Individuals with psychiatric features likely have subsequent episodes with psychotic features.
C.Gender: Females are more likely to have rapid cycling and mixed states and are more likely to have depressive episodes along with a greater likelihood of alcohol use disorders.
D.Suicide: Lifetime risk is 15 times greater than that in the general population.
Subjective Data
A.Common complaints/symptoms.
1.Mania.
a.Racing thoughts.
b.Flight of ideas.
c.Increased focused activity.
d.Thoughts of grandiosity.
e.Excessive talking or pressured speech.
2.Depressive episodes.
a.Depressed mood.
b.Loss of energy or fatigue.
c.Diminished interest in anything.
d.Weight loss.
e.Feelings of worthlessness.
B.Common/typical scenario.
1.A typical scenario starts with an unusual shift in mood and energy. The person may have excessively elevated mood for about a week and then become depressed.
C.Family and social history.
1.Inquire about family history of mental illness.
2.Inquire about periods of depression or manic episodes.
3.Inquire about patterns of prolonged sleep alternating with excessively elevated mood.
4.Inquire about lifestyle and stressful life events.
D.Review of systems.
1.Noncontributory.
Mental State Examination
A.Conduct a Mental State Examination.
B.General description: Manic patients are excited, talkative, and sometimes amusing. Hyperactivity is common and at times is psychotic and disorganized.
C.Mood and affect: Mood is euphoric but also can be irritable. A low frustration tolerance is common as is labile mood with shifts from laughing to crying to irritability.
D.Perceptual disturbances.
1.Delusions are common in manic patients.
2.Mood-congruent manic delusions have themes of wealth, extraordinary abilities, or power.
3.Hallucinations may also be present.
E.Thought: Distractibility and flight of ideas are common.
F.Impulse control: 75% of manic patients are assaultive and threating.
G.Judgment and insight: Impairment is a hallmark.
H.Reliability: Commonly unreliable historians.
Diagnostic Tests
A.Used to rule out a medical cause of the psychiatric symptoms.
B.Endocrine disorders.
1.Hyperthyroid.
2.Diabetes.
3.Cushing’s syndrome.
4.Addison disease.
C.Neurological disorders.
1.Epilepsy.
2.Cerebrovascular disease.
3.Tumors.
4.Head trauma.
5.Lupus.
6.Multiple sclerosis.
D.Infectious disease.
1.HIV/AIDS.
2.Lyme disease.
3.Syphilis.
E.Medications/substances associated with mania.
1.Amphetamines.
2.Cocaine.
3.Corticosteroids.
4.Hallucinogens.
5.Levodopa.
6.Opiates.
7.Phencyclidine (PCP).
F.Screening instruments: Positive screen DOES NOT indicate a disorder; REQUIRES validation with comprehensive interview/assessment.