Bipolar disorder

Bipolar disorder US Medical PG Question 1: A 35-year-old man is brought to the emergency department by his wife. She was called by his coworkers to come and pick him up from work after he barged into the company’s board meeting and was being very disruptive as he ranted on about all the great ideas he had for the company. When they tried to reason with him, he became hostile and insisted that he should be the CEO as he knew what was best for the future of the company. The patient’s wife also noted that her husband has been up all night for the past few days but assumed that he was handling a big project at work. The patient has no significant past medical or psychiatric history. Which of the following treatments is most likely to benefit this patient’s condition?

• A. Antidepressants
• B. Valproic acid (Correct Answer)
• C. Haloperidol
• D. Psychotherapy
• E. Clozapine

Bipolar disorder Explanation: ***Valproic acid*** - This patient presents with symptoms highly suggestive of a **manic episode**, including grandiosity (believing he should be CEO), decreased need for sleep (up all night for days), pressured speech (ranting), and impulsivity with poor judgment (disruptive behavior at a board meeting). - **Valproic acid** is a **first-line, guideline-recommended mood stabilizer** for acute mania. It is particularly effective for managing the core symptoms of mania including mood elevation, irritability, and impulsivity. - It has a relatively rapid onset of action and a favorable side effect profile compared to typical antipsychotics, making it an excellent choice for initial management of acute mania in the emergency setting. *Antidepressants* - Administering **antidepressants** during a manic or hypomanic episode can exacerbate symptoms, potentially leading to a rapid cycling pattern or worsening mania. - Antidepressants are primarily used for depressive episodes in bipolar disorder, typically in conjunction with a mood stabilizer, never as monotherapy in a patient presenting with mania. *Haloperidol* - **Haloperidol** is a typical antipsychotic that can be used for acute agitation in mania, but it does not address the underlying mood dysregulation. - While it may help with immediate behavioral control, mood stabilizers like valproic acid or lithium are preferred as primary treatments because they target the core pathophysiology of bipolar disorder. - Haloperidol also has a higher risk of extrapyramidal symptoms and does not prevent future mood episodes. *Psychotherapy* - **Psychotherapy** is a crucial component of long-term management for bipolar disorder but is not effective as a sole treatment for acute mania. - Patients in acute mania are often too agitated, impulsive, and lack sufficient insight to meaningfully engage in therapeutic interventions. - Psychotherapy should be initiated after mood stabilization with pharmacotherapy. *Clozapine* - **Clozapine** is an atypical antipsychotic reserved for treatment-resistant schizophrenia or treatment-resistant bipolar disorder, particularly with prominent psychotic features that have not responded to multiple other medications. - Given its significant side effect profile, including agranulocytosis requiring regular blood monitoring, it is not a first-line or even second-line treatment for an initial presentation of mania. - This patient has no psychiatric history and requires standard first-line treatment, not a medication reserved for refractory cases.

Bipolar disorder US Medical PG Question 2: A 58-year-old man with a past medical history of diabetes, hypertension, and hyperlipidemia was brought into the emergency department by his wife after she observed him go without sleep for several days and recently open and max out several credit cards. She also reports that he has quit his bartending job and has been excessively talkative and easily annoyed for the last several weeks. The patient has no previous psychiatric history. Routine medical examination, investigations, and toxicology rule out a medical cause or substance abuse. Lab results are consistent with chronically impaired renal function. What is the single best treatment for this patient?

• A. Valproic acid (Correct Answer)
• B. Lithium
• C. Gabapentin
• D. Pregabalin
• E. Lamotrigine

Bipolar disorder Explanation: ***Valproic acid*** - This patient presents with symptoms highly suggestive of **acute mania (Bipolar I disorder)**, including decreased need for sleep, impulsivity (maxing out credit cards), grandiosity (quitting job), pressured speech (excessively talkative), and irritability. **Valproic acid** is a first-line treatment for **acute mania**, particularly when kidney function is impaired. - Given the patient's **chronically impaired renal function**, valproic acid is preferred over lithium as its excretion is primarily hepatic, minimizing the risk of drug accumulation and toxicity in the context of renal impairment. *Lithium* - While **lithium** is a highly effective mood stabilizer for bipolar disorder, it is predominantly cleared renally. - The patient's **impaired renal function** would significantly increase the risk of **lithium toxicity**, making it a less safe and unsuitable choice in this scenario. *Gabapentin* - **Gabapentin** is an anticonvulsant primarily used for neuropathic pain and seizure disorders, sometimes used off-label as an adjunct for anxiety or sleep. - It is **not a primary mood stabilizer** and lacks sufficient evidence for monotherapy treatment of acute mania in bipolar disorder. *Pregabalin* - **Pregabalin**, similar to gabapentin, is an anticonvulsant and neuropathic pain medication. - It is **not indicated as a first-line treatment** for acute mania due to insufficient efficacy as a mood stabilizer. *Lamotrigine* - **Lamotrigine** is an effective mood stabilizer, particularly for the **depressive phases of bipolar disorder**, and for maintenance therapy. - However, it has limited efficacy in treating **acute manic episodes**, making it less suitable for the patient's current presentation.

Bipolar disorder US Medical PG Question 3: A 33-year-old woman is brought to the physician by her husband because of persistent sadness for the past 2 months. During this period, she also has had difficulty sleeping and an increased appetite. She had similar episodes that occurred 2 years ago and 9 months ago that each lasted for 4 months. Between these episodes, she reported feeling very energetic and rested after 3 hours of sleep. She often went for long periods of time without eating. She works as a stock market trader and received a promotion 5 months ago. She regularly attends yoga classes on the weekends with her friends. On mental status examination, she has a blunted affect. She denies suicidal thoughts and illicit drug use. Which of the following is the most likely diagnosis?

• A. Major depressive disorder with seasonal pattern
• B. Persistent depressive disorder
• C. Bipolar II disorder (Correct Answer)
• D. Major depressive disorder with atypical features
• E. Cyclothymic disorder

Bipolar disorder Explanation: ***Bipolar II disorder*** - The patient exhibits recurrent episodes of **major depression** (sadness, sleep difficulties, increased appetite) interspersed with periods of **hypomania** (energetic, reduced need for sleep, long periods without eating, successful work performance with promotion) - This pattern is characteristic of **Bipolar II disorder**: major depressive episodes plus at least one hypomanic episode - No evidence of **frank mania** (e.g., psychosis, severe impairment requiring hospitalization) is present, which distinguishes this from Bipolar I disorder *Major depressive disorder with seasonal pattern* - While the patient presents with depressive symptoms, the episodes of **hypomania** (increased energy, decreased need for sleep) rule out unipolar depression - The history of episodes at various times (2 years ago, 9 months ago, current) does not fit a **seasonal pattern** - The **hypomanic phases** between depressive episodes are inconsistent with any form of major depressive disorder *Persistent depressive disorder* - This condition involves **chronic depressive symptoms** lasting at least 2 years, but typically less severe than major depressive episodes - The presence of distinct, severe **major depressive episodes** and recurrent **hypomanic periods** contradicts this diagnosis - Persistent depressive disorder does not include hypomania or mood elevation *Major depressive disorder with atypical features* - Atypical features include **increased appetite**, **hypersomnia**, leaden paralysis, interpersonal rejection sensitivity, and mood reactivity - While increased appetite is present during depressive phases, the alternating periods of **hypomania** exclude this from being major depressive disorder - Any form of major depressive disorder is ruled out by the presence of hypomanic episodes *Cyclothymic disorder* - Cyclothymic disorder involves numerous periods of **hypomanic symptoms** and **depressive symptoms** for at least 2 years, but symptoms do not meet full criteria for major depressive or hypomanic episodes - This patient explicitly experiences **major depressive episodes** (persistent sadness, neurovegetative symptoms lasting 4 months), which exceed the threshold for cyclothymia - The severity and duration of depressive episodes make Bipolar II disorder the correct diagnosis

Bipolar disorder US Medical PG Question 4: A 24-year-old woman is brought to the emergency department by her roommate because of bizarre behavior and incoherent talkativeness for the past week. Her roommate reports that the patient has been rearranging the furniture in her room at night and has ordered a variety of expensive clothes online. The patient says she feels “better than ever” and has a lot of energy. She had absence seizures as a child and remembers that valproate had to be discontinued because it damaged her liver. She has been otherwise healthy and is not taking any medication. She is sexually active with her boyfriend. She does not smoke, drink alcohol, or use illicit drugs. Physical and neurologic examinations show no abnormalities. Her pulse is 78/min, respirations are 13/min, and blood pressure is 122/60 mm Hg. Mental status examination shows pressured and disorganized speech, flight of ideas, lack of insight, and affective lability. Which of the following is the best initial step before deciding on a therapy for this patient's condition?

• A. Obtain CBC, liver function studies, and beta-HCG
• B. Obtain TSH, β-hCG, and serum creatinine concentration (Correct Answer)
• C. Obtain BMI, HbA1c, lipid levels, and prolactin levels
• D. Perform urine drug testing and begin cognitive behavior therapy
• E. Assess for suicidal ideation and obtain echocardiography

Bipolar disorder Explanation: ***Obtain TSH, β-hCG, and serum creatinine concentration*** - This patient presents with symptoms highly suggestive of **mania** (bizarre behavior, incoherent talkativeness, grandiosity, increased energy, pressured speech, flight of ideas). Before initiating treatment, it's crucial to rule out other medical conditions that can **mimic mania**, such as **hyperthyroidism** (TSH), **pregnancy** (β-hCG), or **kidney dysfunction** (creatinine), which can impact medication choice and dosage. - TSH levels are essential as **hyperthyroidism** can cause symptoms like agitation, rapid speech, and increased energy, mimicking mania. A **pregnancy test (β-hCG)** is critical for women of childbearing age to ensure that any potential psychiatric medications are safe for both the mother and fetus. **Serum creatinine** helps assess kidney function, which is important for dosing many psychotropic medications eliminated by the kidneys. *Obtain CBC, liver function studies, and beta-HCG* - While a **β-hCG** is appropriate, **CBC** and **liver function studies (LFTs)** are typically obtained if there are specific concerns for anemia, infection, or liver damage (which the patient mentions about valproate in childhood, but there's no immediate indication for current LFTs before diagnosis confirmation). - Although LFTs are important for certain antidepressant or mood stabilizer monitoring (e.g., valproate, carbamazepine), they are not the most immediate initial screen for ruling out medical mimics of mania in this context as **TSH** and **renal function** are more critical. *Obtain BMI, HbA1c, lipid levels, and prolactin levels* - These tests are important for **monitoring long-term metabolic side effects** of certain antipsychotics and mood stabilizers, but they are not the best initial steps for ruling out acute medical causes of manic symptoms. - **BMI, HbA1c, and lipid levels** are typically assessed *after* diagnosis and initiation of treatment to establish a baseline for future metabolic monitoring. **Prolactin levels** might be checked if there is concern for hyperprolactinemia, which is a side effect of some antipsychotics, but not usually a cause of acute mania. *Perform urine drug testing and begin cognitive behavior therapy* - While **urine drug testing** is often performed in acute psychiatric presentations to rule out substance-induced mania, it is not listed as the *best initial step* alone, as other medical conditions also need to be ruled out concurrently. - **Cognitive behavioral therapy (CBT)** is not an appropriate initial treatment for acute mania due to the patient's severe symptoms, lack of insight, and disorganized thought processes. **Pharmacotherapy** is the cornerstone of acute mania management. *Assess for suicidal ideation and obtain echocardiography* - Assessing for **suicidal ideation** is crucial in every psychiatric evaluation, but it is a mental status component rather than a diagnostic lab test. While important for patient safety, it doesn't rule out medical mimics of mania. - **Echocardiography** is not indicated in the initial work-up of acute mania unless there are specific cardiac symptoms or a history that suggests underlying heart disease.

Bipolar disorder US Medical PG Question 5: A 21-year-old female is brought to the emergency department by her roommate. Her roommate says that the patient has been acting “strangely” for the past 10 days. She has noticed that the patient has been moving and talking on the phone at all hours of the night. She doesn’t think that the patient sleeps more than one to two hours a night. She also spends hours pacing up and down the apartment, talking about “trying to save the world.” She also notices that the patient has been speaking very fast. When asking the patient if anything seems different, the patient denies anything wrong, only adding that, “she’s made great progress on her plans." The patient said she has felt like this on one occasion 2 years ago, and she recalled being hospitalized for about 2 weeks. She denies any history of depression, although she said about a year ago she had no energy and had a hard time motivating herself to go to class and see her friends for months. She denies hearing any voices or any visual hallucinations. What is the most likely diagnosis in this patient?

• A. Bipolar II disorder
• B. Bipolar I disorder (Correct Answer)
• C. Major depressive disorder
• D. Persistent Depressive Disorder
• E. Schizoaffective disorder

Bipolar disorder Explanation: ***Bipolar I disorder*** - The patient exhibits clear symptoms of a **manic episode**, including decreased need for sleep, grandiosity ("saving the world"), pressured speech, and increased goal-directed activity, which are characteristic of Bipolar I disorder. - The history of a prior hospitalization for similar symptoms ("felt like this on one occasion 2 years ago, and she recalled being hospitalized") and self-reported depressive episodes ("she had no energy... for months") further supports the diagnosis of Bipolar I disorder, which requires at least one manic episode. *Bipolar II disorder* - Bipolar II disorder involves at least one **hypomanic episode** and at least one major depressive episode. - The severity of the patient's current symptoms, including significant functional impairment and a prior hospitalization for similar symptoms, indicates a **manic episode**, not a hypomanic episode. *Major depressive disorder* - This diagnosis is characterized solely by **major depressive episodes** without any history of manic or hypomanic episodes. - The patient's presentation clearly includes symptoms of **mania**, ruling out a sole diagnosis of major depressive disorder. *Persistent Depressive Disorder* - This disorder is characterized by **chronic, mild depressive symptoms** lasting at least two years. - The patient's current presentation of severe manic symptoms and past episodes of clear mania differentiates her condition from persistent depressive disorder. *Schizoaffective disorder* - Schizoaffective disorder involves a period of uninterrupted illness during which there is a **major mood episode (depressive or manic) concurrent with symptoms of schizophrenia**, such as hallucinations or delusions, for at least two weeks in the absence of a major mood episode. - The patient **denies hearing any voices or visual hallucinations**, making schizoaffective disorder less likely; her symptoms are primarily mood-related.

Bipolar disorder US Medical PG Question 6: A 55-year-old man presents to his primary care physician with complaints of fluctuating mood for the past 2 years. He feels great and full of energy for some months when he is very creative with tons of ideas just racing through his mind. He is noted to be very talkative and distracted by his different ideas. During these times, he is very productive and able to accomplish much at work and home. However, these periods are frequently followed by a prolonged depressed mood. During this time, he has low energy, poor concentration, and low self-esteem. The accompanying feeling of hopelessness from these cycling “ups” and “downs” have him eating and sleeping more during the “downs.” He does not remember a period within the last 2 years where he felt “normal.” What is the most likely diagnosis?

• A. Dysthymic disorder
• B. Bipolar II disorder
• C. Persistent depressive disorder
• D. Bipolar I disorder
• E. Cyclothymic disorder (Correct Answer)

Bipolar disorder Explanation: ***Cyclothymic disorder*** - The patient experiences chronic **fluctuating moods**, with numerous periods of **hypomanic symptoms** (elevated energy, racing thoughts, increased productivity) and numerous periods of **depressive symptoms** (low energy, poor concentration, hopelessness) over at least 2 years. - The symptoms are not severe enough to meet full criteria for a **manic episode**, **hypomanic episode**, or **major depressive episode**, and there has been no period longer than 2 months without symptoms. *Dysthymic disorder* - This is the **DSM-IV term** for what is now called **persistent depressive disorder** in DSM-5, involving a **chronic depressed mood** that lasts for at least 2 years. - It does not include periods of significant elevated mood or hypomania. - The patient's presentation includes distinct periods of **elevated mood and energy**, which are not characteristic of dysthymic disorder. *Bipolar II disorder* - Bipolar II disorder requires at least one **major depressive episode** and at least one **hypomanic episode**. - While the patient exhibits hypomanic and depressive symptoms, the periods of depression do not meet the full criteria for a **major depressive episode** (e.g., duration, number of symptoms) and the hypomanic symptoms are subsyndromal. *Persistent depressive disorder* - This is the **DSM-5 term** for chronic low-grade depression (formerly called dysthymic disorder), characterized by depressed mood for at least 2 years without manic or hypomanic symptoms. - The patient's history of elevated mood and energy precludes this diagnosis. *Bipolar I disorder* - Bipolar I disorder requires at least one **manic episode**, which is characterized by a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and causing significant impairment. - The patient's "ups" are described as productive and not causing significant impairment or involving psychotic features, indicating **hypomanic symptoms** rather than full mania.

Bipolar disorder US Medical PG Question 7: A 23-year-old woman is brought to the physician by her father because of irritability, mood swings, and difficulty sleeping over the past 10 days. A few days ago, she quit her job and spent all of her savings on supplies for a “genius business plan.” She has been energetic despite sleeping only 1–2 hours each night. She was diagnosed with major depressive disorder 2 years ago. Mental status examination shows pressured speech, a labile affect, and flight of ideas. Throughout the examination, she repeatedly states “I feel great, I don't need to be here.” Urine toxicology screening is negative. Which of the following is the most likely diagnosis?

• A. Schizoaffective disorder
• B. Bipolar disorder type II
• C. Bipolar disorder type I (Correct Answer)
• D. Delusional disorder
• E. Attention-deficit hyperactivity disorder

Bipolar disorder Explanation: ***Bipolar disorder type I*** - The patient's presentation of lasting **elevated mood**, decreased need for sleep, increased energy, pressured speech, flight of ideas, and impulsive behavior (quitting job, spending savings) are hallmark symptoms of a **manic episode**. - A diagnosis of **Bipolar I Disorder** requires the occurrence of at least one manic episode, which is clearly evident here and distinguishes it from other mood disorders, especially given her prior history of major depressive disorder. *Schizoaffective disorder* - This disorder involves a period of illness during which there is an uninterrupted period of major mood episode (depressive or manic) concurrent with symptoms of **schizophrenia**, such as delusions or hallucinations, for at least 2 weeks in the absence of a major mood episode. - The patient's symptoms are primarily mood-driven and do not include the characteristic psychotic features that persist independently of mood disturbances. *Bipolar disorder type II* - Bipolar II Disorder is characterized by at least one major depressive episode and at least one **hypomanic episode**. - The patient's current symptoms, including significant impairment in social/occupational functioning, are indicative of a **manic episode**, not a hypomanic episode, which by definition does not cause marked impairment or require hospitalization. *Delusional disorder* - This disorder is characterized by the presence of **non-bizarre delusions** that last for at least one month, without other prominent psychotic symptoms or significant impairment in functioning. - While the patient's "genius business plan" might seem delusional, her pervasive mood disturbance, flight of ideas, and significant functional impairment are not consistent with the primary features of delusional disorder. *Attention-deficit hyperactivity disorder* - ADHD is characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, often presenting in childhood. - While there is some overlap in symptoms like impulsivity and difficulty sleeping, the episodic nature, the extent of **mood disturbance**, grandiosity, and **pressured speech** are more characteristic of a manic episode than ADHD.

Bipolar disorder US Medical PG Question 8: A 25-year-old woman is brought to the emergency department by EMS after being found naked in a busy downtown square. The patient stated that she is liberating people from material desires and was found destroying objects. Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 120/min, respirations are 22/min, and oxygen saturation is 98% on room air. Physical exam is deferred due to patient combativeness. The patient is given diphenhydramine and haloperidol and transferred to the psychiatric ward. On day 1 on the ward, the patient is no longer aggressive or agitated and has calmed down. She states that she feels severely depressed and wants to kill herself. The patient is started on a medication and monitored closely. On day 3 of the patient's stay in the hospital she is found in her room drawing up plans and states that she has major plans to revamp the current energy problems in the country. Which of the following is the most likely medication that was started in this patient?

• A. Quetiapine
• B. Olanzapine
• C. Lamotrigine
• D. Sertraline (Correct Answer)
• E. Lithium

Bipolar disorder Explanation: ***Sertraline*** - This patient exhibits classic **bipolar I disorder** with rapid mood cycling from **mania** (naked in public, grandiose delusions, destroying objects) to **severe depression** (suicidal ideation on Day 1) and back to **mania** (grandiose plans on Day 3). - The key clinical clue is the **rapid return to mania by Day 3** after starting medication during the depressive phase. This suggests **antidepressant-induced mania/mood switch**, a well-known complication of using **SSRI antidepressants** (like sertraline) **without adequate mood stabilization** in bipolar disorder. - **Antidepressants can precipitate manic episodes** within days in bipolar patients, which is why they should be avoided or used only with concomitant mood stabilizers. This question tests recognition of this critical psychiatric principle. *Lithium* - Lithium is a first-line **mood stabilizer** for bipolar disorder and would be appropriate for long-term management. However, lithium **prevents manic episodes** rather than causing them. - Lithium takes **1-2 weeks to reach therapeutic levels**, so it would not explain the rapid mood switch to mania by Day 3. If lithium had been started, we would expect **stabilization or improvement**, not a return to mania. *Quetiapine* - Quetiapine is an **atypical antipsychotic** effective for both acute mania and bipolar depression. It can provide rapid mood stabilization. - If quetiapine was started on Day 1, we would expect **mood stabilization or sedation**, not a switch back to mania. Quetiapine does **not precipitate manic episodes**. *Olanzapine* - Olanzapine is another **atypical antipsychotic** used for acute mania and maintenance in bipolar disorder. - Like quetiapine, olanzapine would **stabilize mood** and reduce manic symptoms, not trigger them. It would not explain the return to mania on Day 3. *Lamotrigine* - Lamotrigine is a mood stabilizer particularly effective for **preventing depressive episodes** in bipolar disorder, though less effective for acute mania. - Lamotrigine **does not precipitate manic episodes** and takes weeks to titrate to therapeutic doses due to risk of Stevens-Johnson syndrome. It would not explain the rapid mood switch observed here.

Bipolar disorder US Medical PG Question 9: A 26-year-old female college student is brought back into the university clinic for acting uncharacteristically. The patient presented to the same clinic 6 weeks ago with complaints of depressed mood, insomnia, and weightloss. She had been feeling guilty for wasting her parent’s money by doing so poorly at the university. She felt drained for at least 2 weeks before presenting to the clinic for the first time. She was placed on an antidepressant and was improving but now presents with elevated mood. She is more talkative with a flight of ideas and is easily distractible. Which of the following statements is most likely true regarding this patient’s condition?

• A. The patient may have psychotic features.
• B. Her diagnosis of unipolar depression is incorrect. (Correct Answer)
• C. The patient may have a history of mania.
• D. Antidepressants are inappropriate.
• E. Her new symptoms need to last at least 7 days.

Bipolar disorder Explanation: ***Correct: Her diagnosis of unipolar depression is incorrect.*** The patient initially presented with symptoms consistent with a **depressive episode**, but the subsequent emergence of **elevated mood, increased talkativeness, flight of ideas, and distractibility after antidepressant use** strongly suggests a shift to a **manic or hypomanic episode**. This antidepressant-induced mood switch is a hallmark feature revealing **bipolar disorder** that was initially misdiagnosed as unipolar depression. This statement most directly addresses **what is true about this patient's condition** - that the fundamental diagnosis is incorrect. Once we establish the correct diagnosis of bipolar disorder, all treatment and management decisions follow from this. *Incorrect: The patient may have psychotic features.* While patients with severe **mania** can develop **psychotic features** (e.g., delusions, hallucinations), the provided symptoms (elevated mood, increased talkativeness, flight of ideas, distractibility) do not describe psychotic symptoms. There is no information suggesting the presence of **delusions or hallucinations**, which are necessary to diagnose psychotic features. The word "may" makes this theoretically possible but not supported by the clinical presentation described. *Incorrect: The patient may have a history of mania.* While patients with bipolar disorder often have previous undiagnosed episodes, this statement is speculative about her **past history** rather than addressing what is most directly evident from the **current presentation**. The vignette focuses on the antidepressant-induced mood switch, which immediately reveals that the current diagnosis of unipolar depression is incorrect. Whether or not she had previous manic episodes is less relevant than recognizing the misdiagnosis now. *Incorrect: Antidepressants are inappropriate.* This statement is clinically **true in principle** - antidepressants as monotherapy are generally inappropriate for bipolar disorder due to the risk of inducing mania or hypomania. However, this option addresses **treatment implications** rather than directly stating what is true about **the patient's condition itself**. The more fundamental and direct truth is that **her diagnosis is wrong** (bipolar, not unipolar depression). Once the correct diagnosis is established, then the inappropriateness of antidepressant monotherapy follows. Additionally, at the time of initial presentation with pure depressive symptoms, the antidepressant prescription was reasonable based on the information available - the inappropriateness only became clear retrospectively after the mood switch occurred. *Incorrect: Her new symptoms need to last at least 7 days.* For a diagnosis of **mania**, symptoms must last at least **one week** (or any duration if hospitalization is required). However, for **hypomania**, symptoms need to last only **4 consecutive days**. The vignette does not specify whether this is mania or hypomania, nor does it clearly state the duration of the current symptoms beyond "now presents." Therefore, we cannot definitively say a 7-day duration is required - it could be hypomania requiring only 4 days. This statement is not necessarily true.

Bipolar disorder US Medical PG Question 10: A 29-year-old man comes to the physician with his wife because she has noticed a change in his behavior over the past 2 weeks. His wife reports that he is very distracted and irritable. His colleagues have voiced concerns that he has not been turning up for work regularly and behaves erratically when he does. Previously, her husband had been a reliable and reasonable person. The patient says that he feels “fantastic”; he only needs 4 hours of sleep each night and wakes up cheerful and full of energy each morning. He thinks that his wife is overreacting. The patient has been healthy except for a major depressive episode 5 years ago that was treated with paroxetine. He currently takes no medications. His pulse is 98/min, respirations are 12/min, and blood pressure is 128/62 mm Hg. Mental status examination shows frenzied speech and a flight of ideas. Which of the following is the strongest predisposing factor for this patient's condition?

• A. Advanced paternal age
• B. Genetic predisposition (Correct Answer)
• C. Higher socioeconomic class
• D. Maternal obstetric complications
• E. Being married

Bipolar disorder Explanation: ***Genetic predisposition*** - A strong **genetic predisposition** is a primary predisposing factor for bipolar disorder, as evidenced by a significantly higher concordance rate in monozygotic twins compared to dizygotic twins or the general population. - The patient's presentation with **manic symptoms** (decreased need for sleep, euphoria, irritability, frenzied speech, flight of ideas, erratic behavior) following a history of a **major depressive episode** is highly suggestive of **bipolar I disorder**. *Advanced paternal age* - While advanced paternal age has been associated with an increased risk of some neurodevelopmental disorders like **schizophrenia** and **autism spectrum disorder**, its link to bipolar disorder is less robust and not considered the strongest predisposing factor. - The primary risk factor for bipolar disorder involves heritability rather than specific parental age. *Higher socioeconomic class* - There is **no consistent evidence** to suggest that higher socioeconomic class is a predisposing factor for bipolar disorder. - Bipolar disorder affects individuals across all socioeconomic levels. *Maternal obstetric complications* - Maternal obstetric complications, such as **prenatal infections** or **hypoxia**, have been implicated in the development of certain psychiatric disorders, particularly **schizophrenia**. - However, for bipolar disorder, genetic factors play a far more significant and direct role than obstetric complications. *Being married* - **Marital status** does not serve as a predisposing factor for the development of bipolar disorder. - While relationship challenges can be a consequence or stressor for individuals with bipolar disorder, marriage itself is not a cause.

Bipolar disorder Flashcard 1 of 10

Question: Is lithium used to prevent relapse or treat acute mania in bipolar disorder? _____

Answer: Both

Bipolar disorder Flashcard 2 of 10

Question: Is lamotrigine used to prevent relapse or treat acute mania in bipolar disorder? _____

Answer: Prevent relapse (maintenance), only

Bipolar disorder Flashcard 3 of 10

Question: A hypomanic episode must last at least _____ consecutive days

Answer: 4

Bipolar disorder Flashcard 4 of 10

Question: Patients with bipolar disorder have a high risk of _____

Answer: suicide

Bipolar disorder Flashcard 5 of 10

Question: What is the general treatment for bipolar disorder? _____

Answer: Mood stabilizers

Bipolar disorder Flashcard 6 of 10

Question: In addition to mood stabilizers, bipolar disorder may also be treated with _____

Answer: antipsychotics

Bipolar disorder Flashcard 7 of 10

Question: _____ is an ion that is used as a mood stabilizer for bipolar disorder

Answer: Lithium

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Bipolar disorder Flashcard 8 of 10

Question: What is the general treatment for manic episodes? _____

Answer: Atypical antipsychotics

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Bipolar disorder Flashcard 9 of 10

Question: Patients with bipolar disorder have a high risk of _____

Answer: suicide

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Bipolar disorder Flashcard 10 of 10

Question: In addition to mood stabilizers, bipolar disorder may also be treated with _____

Answer: antipsychotics

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