Bipolar I disorder diagnostic criteria US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Bipolar I disorder diagnostic criteria. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Bipolar I disorder diagnostic criteria US Medical PG Question 1: A 19-year-old woman is brought to the physician by her parents because of irritable mood that started 5 days ago. Since then, she has been staying up late at night working on a secret project. She is energetic despite sleeping less than 4 hours per day. Her parents report that she seems easily distracted. She is usually very responsible, but this week she spent her paycheck on supplies for her project. She has never had similar symptoms before. In the past, she has had episodes where she felt too fatigued to go to school and slept until 2 pm every day for 2 weeks at a time. During those times, her parents noticed that she cried excessively, was very indecisive, and expressed feelings of worthlessness. Two months ago, she had an asthma exacerbation and was treated with bronchodilators and steroids. She tried cocaine once in high school but has not used it since. Vital signs are within normal limits. On mental status examination, she is irritable but cooperative. Her speech is pressured and her thought process is linear. Which of the following is the most likely diagnosis?
- A. Major depressive disorder
- B. Bipolar I disorder
- C. Bipolar II disorder (Correct Answer)
- D. Schizoaffective disorder
- E. Substance abuse
Bipolar I disorder diagnostic criteria Explanation: ***Bipolar II disorder***
- This patient exhibits symptoms consistent with both **hypomania** (increased energy, decreased need for sleep, irritability, distractibility, spending sprees) and past episodes of **major depression** (fatigue, hypersomnia, crying, indecisiveness, worthlessness). The key distinction for Bipolar II is the presence of at least one hypomanic episode and one major depressive episode, without a full manic episode.
- The current symptoms of increased energy and decreased need for sleep for 5 days, along with a significant change in behavior (spending paycheck on a "secret project"), indicate a level of impairment consistent with hypomania, rather than a full-blown mania as the thought process is described as linear.
*Major depressive disorder*
- While the patient has a history of depressive episodes, the current presentation with **elevated mood, increased energy, and decreased need for sleep** is inconsistent with a unipolar depressive episode.
- Major depressive disorder does not involve periods of elevated or irritable mood or increased activity.
*Bipolar I disorder*
- Bipolar I disorder requires the occurrence of at least one **manic episode**. While the patient's current symptoms are suggestive of a mood elevation, they do not meet the criteria for full mania, which typically involves severe impairment, psychotic features, or hospitalization.
- The patient's speech is pressured but her thought process is described as **linear**, which is less typical for a full manic episode where **flight of ideas** or **tangential/disorganized thinking** might be present.
*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 delusions or hallucinations.
- The patient's symptoms are primarily mood-related, and there is no mention of psychotic symptoms independent of the mood disturbance.
*Substance abuse*
- Although the patient used cocaine once in high school, there is no evidence of recent substance use that would explain the current symptoms. The symptoms are sustained over days and include a history of recurrent mood disturbances.
- While the patient received steroid treatment 2 months ago (which can precipitate mood episodes), the timing and clinical presentation are more consistent with a primary mood disorder rather than a substance/medication-induced disorder.
Bipolar I disorder diagnostic criteria US Medical PG Question 2: A 27-year-old woman visits a psychiatrist expressing her feelings of sadness which are present on most days of the week. She says that she has been feeling this way for about 2 to 3 years. During her first pregnancy 3 years ago, the fetus died in utero, and the pregnancy was terminated at 21 weeks. Ever since then, she hasn’t been able to sleep well at night and has difficulty concentrating on her tasks most of the time. However, for the past month, she has found it more difficult to cope. She says she has no will to have another child as she still feels guilty and responsible for the previous pregnancy. Over the past few days, she has completely lost her appetite and only eats once or twice a day. She doesn’t recall a single day in the last 3 years where she has not felt this way. The patient denies any past or current smoking, alcohol, or recreational drug use. Which of the following is the most likely diagnosis in this patient?
- A. Persistent depressive disorder (Correct Answer)
- B. Bipolar disorder
- C. Schizoaffective disorder
- D. Cyclothymia
- E. Major depressive disorder
Bipolar I disorder diagnostic criteria Explanation: ***Persistent depressive disorder***
- The patient exhibits classic symptoms of **persistent depressive disorder (dysthymia)**: chronic depressed mood for **at least two years**, accompanied by other depressive symptoms like **insomnia**, **difficulty concentrating**, and changes in appetite.
- The duration of her symptoms (2-3 years) and the consistent feeling of sadness support this diagnosis, fitting the diagnostic criteria for **dysthymia**.
*Bipolar disorder*
- Bipolar disorder involves distinct episodes of **mania or hypomania** alternating with depressive episodes.
- The patient's history does not indicate any periods of elevated mood, increased energy, or decreased need for sleep, which are characteristic of **bipolar disorder**.
*Schizoaffective disorder*
- Schizoaffective disorder is characterized by a combination of **mood symptoms** (like depression or mania) and **psychotic symptoms** (like delusions or hallucinations) occurring simultaneously or in distinct episodes.
- This patient presents with no evidence of **psychotic symptoms** such as hallucinations or delusions.
*Cyclothymia*
- Cyclothymia is a milder, chronic form of **bipolar disorder** involving numerous periods of **hypomanic symptoms** and numerous periods of **depressive symptoms** for at least two years.
- The patient's presentation lacks any history of **hypomanic episodes**, making cyclothymia an unlikely diagnosis.
*Major depressive disorder*
- While the patient is experiencing a **major depressive episode** currently (as suggested by increased severity in the last month and complete loss of appetite), the underlying chronic nature of her symptoms (2-3 years) and the fact that she has not been symptom-free for more than two months indicate **persistent depressive disorder**.
- A diagnosis of **major depressive disorder** would typically be given if the symptoms were acute (less than 2 years) and severe, without the chronic, pervasive depressive state described.
Bipolar I disorder diagnostic criteria US Medical PG Question 3: A mental health volunteer is interviewing locals as part of a community outreach program. A 46-year-old man discloses that he has felt sad for as long as he can remember. He feels as though his life is cursed and if something terrible can happen to him, it usually will. He has difficulty making decisions and feels hopeless. He also feels that he has had worsening suicidal ideations, guilt from past problems, decreased energy, and poor concentration over the past 2 weeks. He is otherwise getting enough sleep and able to hold a job. Which of the following statement best describes this patient's condition?
- A. The patient may have symptoms of mania or psychosis.
- B. The patient is likely to show anhedonia.
- C. The patient likely has paranoid personality disorder.
- D. The patient has double depression. (Correct Answer)
- E. The patient should be started on an SSRI.
Bipolar I disorder diagnostic criteria Explanation: ***The patient has double depression.***
- The patient describes **chronic low-grade depressive symptoms** ("felt sad for as long as he can remember," "life is cursed," "difficulty making decisions," "hopeless") consistent with **persistent depressive disorder (dysthymia)**, which requires at least 2 years of symptoms.
- The recent worsening of symptoms over the past two weeks, including "worsening suicidal ideations, guilt from past problems, decreased energy, and poor concentration," indicates an additional **major depressive episode (MDE) superimposed on dysthymia**, a condition known as **double depression**.
- This patient currently meets criteria for both conditions simultaneously, not just at risk for developing them.
*The patient may have symptoms of mania or psychosis.*
- There are no symptoms mentioned that suggest **mania**, such as elevated mood, increased energy, decreased need for sleep, grandiosity, or racing thoughts.
- While suicidal ideation is present, there is no evidence of **psychotic features** like hallucinations or delusions.
*The patient is likely to show anhedonia.*
- **Anhedonia** (inability to feel pleasure) is a common symptom of depression and may well be present in this patient.
- However, the patient's presentation specifically highlights the pattern of **chronic dysthymia with a superimposed major depressive episode**, making **double depression** a more precise, comprehensive, and diagnostically specific description of his current condition.
- While anhedonia might be present, it is a symptom rather than a diagnostic formulation.
*The patient likely has paranoid personality disorder.*
- **Paranoid personality disorder** is characterized by pervasive distrust and suspicion of others, interpreting their motives as malevolent, without sufficient basis.
- The patient's feelings of being "cursed" and that "something terrible can happen" reflect **depressive pessimism and negative cognitive distortions**, not paranoid ideation about others' intentions.
- This is consistent with the hopelessness seen in depression.
*The patient should be started on an SSRI.*
- While an **SSRI (selective serotonin reuptake inhibitor)** combined with psychotherapy would likely be appropriate treatment for double depression, making a specific treatment recommendation is premature without comprehensive clinical assessment.
- The question asks for the **best statement describing the patient's condition** (diagnosis), not for treatment recommendations.
Bipolar I disorder diagnostic criteria US Medical PG Question 4: 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 I disorder diagnostic criteria 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 I disorder diagnostic criteria US Medical PG Question 5: A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?
- A. "Does the diarrhea typically precede the constipation, or vice-versa?"
- B. "Is the diarrhea foul-smelling?"
- C. "Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"
- D. "Are the symptoms worse in the morning or at night?"
- E. "Can you tell me more about the symptoms you have been experiencing?" (Correct Answer)
Bipolar I disorder diagnostic criteria Explanation: ***Can you tell me more about the symptoms you have been experiencing?***
- This **open-ended question** encourages the patient to provide a **comprehensive narrative** of their symptoms, including details about onset, frequency, duration, alleviating/aggravating factors, and associated symptoms, which is crucial for diagnosis.
- In a patient presenting with vague, intermittent symptoms like alternating constipation and diarrhea, allowing them to elaborate freely can reveal important clues that might not be captured by more targeted questions.
*Does the diarrhea typically precede the constipation, or vice-versa?*
- While knowing the sequence of symptoms can be helpful in understanding the **pattern of bowel dysfunction**, it is a very specific question that might overlook other important aspects of the patient's experience.
- It prematurely narrows the focus without first obtaining a broad understanding of the patient's overall symptomatic picture.
*Is the diarrhea foul-smelling?*
- Foul-smelling diarrhea can indicate **malabsorption** or **bacterial overgrowth**, which are important to consider in some gastrointestinal conditions.
- However, this is a **specific symptom inquiry** that should follow a more general exploration of the patient's symptoms, as it may not be relevant if other crucial details are missed.
*Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life*
- Quantifying pain intensity is useful for assessing the **severity of discomfort** and monitoring changes over time.
- However, for a patient with intermittent rather than acute, severe pain, understanding the **character, location, and triggers** of the pain is often more diagnostically valuable than just a numerical rating initially.
*Are the symptoms worse in the morning or at night?*
- Diurnal variation can be relevant in certain conditions, such as inflammatory bowel diseases where nocturnal symptoms might be more concerning, or functional disorders whose symptoms might be stress-related.
- This is another **specific question** that should come after gathering a more complete initial picture of the patient's symptoms to ensure no key information is overlooked.
Bipolar I disorder diagnostic criteria US Medical PG Question 6: A 24-year-old woman presents to her primary care physician for a wellness exam. She currently has no acute concerns but has been feeling hopeless, has a poor appetite, difficulty with concentration, and trouble with sleep. She says that she has poor self-esteem and that her symptoms have been occurring for the past 3 years. She has had moments where she felt better, but it lasted a few weeks out of the year. She currently lives alone and does not pursue romantic relationships because she feels she is not attractive. She has a past medical history of asthma. Her mother is alive and healthy. Her father committed suicide and suffered from major depressive disorder. On physical exam, the patient has a gloomy demeanor and appears restless and anxious. Which of the following is the most likely diagnosis?
- A. Major depressive disorder
- B. Cyclothymia
- C. Persistent depressive disorder (Correct Answer)
- D. Seasonal affective disorder
- E. Disruptive mood dysregulation disorder
Bipolar I disorder diagnostic criteria Explanation: ***Persistent depressive disorder***
- The patient exhibits chronic symptoms of depression (poor appetite, poor self-esteem, difficulty with concentration, trouble with sleep, hopelessness) lasting for at least **2 years**, with symptom-free periods lasting no more than **2 months**.
- Her long-standing symptoms (3 years) and the intermittent improvement, but never full resolution for extended periods, are characteristic of **persistent depressive disorder** (formerly dysthymia).
*Major depressive disorder*
- While the patient has many symptoms of depression, **major depressive disorder** is characterized by distinct episodes of at least 2 weeks, with significant functional impairment. The chronic, fluctuating course over 3 years is less typical.
- The presence of depressive symptoms for 3 years, with only brief periods of improvement, points away from episodic major depressive disorder alone and more towards a chronic form.
*Cyclothymia*
- **Cyclothymia** involves numerous periods of hypomanic symptoms and numerous periods of depressive symptoms for at least 2 years, with periods of stability lasting no more than 2 months. The patient describes only depressive symptoms, not hypomanic episodes.
- There is no mention of elevated mood, increased energy, or decreased need for sleep, which are characteristic of **hypomanic episodes** in cyclothymia.
*Seasonal affective disorder*
- **Seasonal affective disorder** is a type of depressive disorder that occurs during a specific season (most commonly winter) and resolves during other seasons; the patient's symptoms are year-round and chronic.
- The patient's symptoms are not described as tied to a particular season, making this diagnosis less likely.
*Disruptive mood dysregulation disorder*
- Predominantly diagnosed in **children and adolescents**, this disorder is characterized by severe recurrent temper outbursts and persistently irritable or angry mood between outbursts.
- The patient's age (24 years old) and the absence of temper outbursts make this diagnosis inappropriate.
Bipolar I disorder diagnostic criteria US Medical PG Question 7: A 19-year-old female college student is brought into the emergency department by her boyfriend. The boyfriend reports that the patient got caught stealing from the company she works for and subsequently got fired. The boyfriend received a text that evening saying “I’ll miss you.” When he arrived at her dorm room, the patient was slumped in the shower covered in blood. The patient agreed to be driven to the emergency room. When asked about what happened, the patient replies “I just want out of this life.” The patient has bipolar disorder, and takes lithium as prescribed. She has a psychiatrist she sees every week, which the boyfriend confirms. She has never had a prior suicide attempt nor has she ever been hospitalized for a psychiatric disorder. The patient’s vitals are stable. Upon physical examination, a 4 centimeter vertical incision is noted on the patient’s left forearm. During the patient’s laceration repair, she asks if she will be admitted. She states, “these ups and downs are common for me, but I feel better now.” She verbalizes that she understands that she overreacted. She asks to go home, and her boyfriend insists that he will stay with her. They both confirm that neither of them have guns or know any peers with access to guns. Which of the following is the most appropriate management for the patient?
- A. Have the patient sign a suicide contract before discharge
- B. Set up a next-day appointment with the patient’s psychiatrist
- C. Involuntarily admit the patient (Correct Answer)
- D. Call the patient’s parents
- E. Discontinue lithium and start valproate
Bipolar I disorder diagnostic criteria Explanation: ***Involuntarily admit the patient***
- The patient's statement "I just want out of this life" combined with the **suicide attempt** (cutting her forearm after a text expressing suicidal ideation) indicates a high risk of self-harm. Despite her current verbalizations of feeling better, the **impulsivity** and severity of the attempt warrant involuntary admission for safety.
- The sudden shift in mood and desire to go home after a serious suicide attempt, stating "these ups and downs are common for me, but I feel better now," suggests potential **lability** and a continued risk that cannot be safely managed with outpatient follow-up alone.
*Have the patient sign a suicide contract before discharge*
- **Suicide contracts** have not been consistently shown to be effective in preventing suicide and can create a false sense of security.
- Given the **actual suicide attempt** and the patient's underlying psychiatric condition, a contract is insufficient to ensure her safety.
*Set up a next-day appointment with the patient’s psychiatrist*
- While follow-up with her psychiatrist is crucial, relying solely on a **next-day appointment** is inadequate given the acute and severe nature of the suicide attempt.
- There is a significant risk of another attempt before the appointment, and the patient needs the **structured environment and constant observation** of an inpatient setting.
*Call the patient’s parents*
- While involving the patient's support system is generally helpful, this action does not directly address the immediate **safety risk** posed by the recent suicide attempt.
- Parental involvement should be considered, but it is not the primary or most appropriate immediate management for a patient at **high risk of self-harm**.
*Discontinue lithium and start valproate*
- Modifying psychotropic medication is a decision made by a psychiatrist after a thorough evaluation, often over time, and is not the immediate or most appropriate "management" in the **emergency setting** for an acute suicide attempt.
- The priority is **safety and stabilization**, not an immediate medication change, especially given that she is already on a mood stabilizer.
Bipolar I disorder diagnostic criteria US Medical PG Question 8: A 16-year-old girl presents with multiple manic and hypomanic episodes. The patient says that these episodes started last year and have progressively worsened. She is anxious to start treatment, so this will not impact her school or social life. The patient was prescribed an anticonvulsant drug that is also used to treat her condition. Which of the following is the drug most likely prescribed to this patient?
- A. Lithium
- B. Phenobarbital
- C. Valproic acid (Correct Answer)
- D. Diazepam
- E. Clonazepam
Bipolar I disorder diagnostic criteria Explanation: ***Valproic acid***
- **Valproic acid** is an **anticonvulsant** commonly used as a **mood stabilizer** in bipolar disorder, especially for rapid cycling or mixed manic episodes.
- Its broad-spectrum anticonvulsant properties make it effective for various seizure types, in addition to its use in bipolar disorder, fitting the description of a drug used for both.
*Lithium*
- While **lithium** is a first-line treatment for **bipolar disorder**, it is not primarily an **anticonvulsant** drug, making it less likely given the specific prompt.
- It has a narrow therapeutic index and requires regular monitoring, which can be a consideration in treatment compliance.
*Phenobarbital*
- **Phenobarbital** is an older **barbiturate anticonvulsant** and sedative, but it is not typically used for treating **bipolar disorder** due to its significant side effects and potential for dependence.
- Its primary use is in seizure control, not mood stabilization.
*Diazepam*
- **Diazepam** is a **benzodiazepine** used for acute anxiety, seizures, and muscle spasms, but it is not a primary **mood stabilizer** for bipolar disorder.
- It would be used for acute agitation or anxiety symptoms, not long-term mood regulation.
*Clonazepam*
- **Clonazepam** is another **benzodiazepine** with anticonvulsant properties, often used for anxiety and panic disorders, but generally not as a primary mood stabilizer in **bipolar disorder**.
- While it can help with acute agitation, it does not address the underlying mood dysregulation of bipolar disorder.
Bipolar I disorder diagnostic criteria US Medical PG Question 9: A 48-year-old woman is brought to the emergency department by her family at her psychiatrist's recommendation. According to her family, she has been more restless than her baseline over the past week. The patient herself complains that she feels her mind is racing. Her past medical history is significant for bipolar disorder on lithium and type 1 diabetes mellitus. The family and the patient both assert that the patient has been taking her medications. She denies any recent illness or sick contacts. The patient's temperature is 100°F (37.8°C), blood pressure is 100/60 mmHg, pulse is 130/min, and respirations are 20/min. She appears diaphoretic, and her cardiac exam is notable for an irregularly irregular rhythm with a 2/6 early systolic murmur. Blood counts and metabolic panel are within normal limits. The patient's lithium level is within therapeutic range. Which of the following laboratory tests would be the most useful to include in the evaluation of this patient?
- A. Thyroglobulin level
- B. Thyroid stimulating hormone and total thyroxine levels
- C. Thyrotropin-releasing hormone stimulation test
- D. Triiodothyronine and thyroxine levels
- E. Thyroid stimulating hormone and free thyroxine levels (Correct Answer)
Bipolar I disorder diagnostic criteria Explanation: ***Thyroid stimulating hormone and free thyroxine levels***
- This patient presents with symptoms highly suggestive of **hyperthyroidism**, including **restlessness**, **tachycardia** (pulse 130/min), **diaphoresis**, and a **racing mind**. These symptoms, particularly in a patient on lithium (which can induce thyroid dysfunction), necessitate a thorough thyroid evaluation.
- While total T4 can be influenced by protein binding, **free T4** is the active form of the hormone and provides a more accurate assessment of thyroid status, along with **TSH** as the primary screening test.
*Thyroglobulin level*
- **Thyroglobulin** is primarily used as a tumor marker in the follow-up of patients treated for differentiated thyroid cancer to detect recurrence.
- It is not a primary diagnostic test for hyperthyroidism and would not be the most useful initial test in this scenario.
*Thyroid stimulating hormone and total thyroxine levels*
- While TSH and total T4 are used, **total T4** levels can be affected by changes in **thyroid-binding globulin (TBG)**, which can be altered by various conditions or medications (e.g., estrogen, liver disease).
- Therefore, **free thyroxine** provides a more accurate reflection of thyroid function than total thyroxine.
*Thyrotropin-releasing hormone stimulation test*
- A **TRH stimulation test** is primarily used to investigate subtle abnormalities in the hypothalamic-pituitary-thyroid axis, often when other thyroid function tests are equivocal.
- It is not a first-line diagnostic test for overt hyperthyroidism and would be overly complex for initial evaluation of this patient's symptoms.
*Triiodothyronine and thyroxine levels*
- While T3 and T4 levels are part of thyroid function assessment, specifying **free thyroxine** versus total thyroxine is crucial for accuracy.
- **Free T4** levels, along with TSH, are generally the most informative initial tests for diagnosing conditions like hyperthyroidism.
Bipolar I disorder diagnostic criteria US Medical PG Question 10: A 9-year-old boy is brought to the psychiatrist due to unusual behavior over the past several months. His mother reports that he has started to blink more frequently than usual. His parents initially attributed this behavior to attention-seeking but he has not stopped despite multiple disciplinary efforts and behavioral therapy from a clinical psychologist. He previously performed well in school but has recently become more disruptive and inattentive in class. He has not been sick recently and denies any drug use. His parents report multiple episodes in the past in which the child seemed overly elated and hyperactive for several days followed by periods in which he felt sad and withdrawn. On examination, he is a well-appearing boy in no acute distress. He is alert and oriented with a normal affect but gets distracted easily throughout the exam. He blinks both eyes several times throughout the examination. Strength, sensation, and gait are all normal. Which of the following medications is most appropriate for this patient?
- A. Fluoxetine
- B. Guanfacine
- C. Amitriptyline
- D. Venlafaxine
- E. Lithium (Correct Answer)
Bipolar I disorder diagnostic criteria Explanation: ***Lithium***
- This patient presents with **episodic mood disturbances** including periods of being "overly elated and hyperactive for several days followed by periods in which he felt sad and withdrawn," which is highly suggestive of **pediatric bipolar disorder**.
- While he also displays **inattention, disruptive behavior, and motor tics** (eye blinking), the prominent **cyclical mood episodes** indicate that the primary diagnosis is a **mood disorder** that requires stabilization before addressing comorbid ADHD or tic symptoms.
- **Lithium** is a **first-line mood stabilizer** for bipolar disorder in children and adolescents. Stabilizing the mood is critical before treating ADHD symptoms, as stimulants or even non-stimulant ADHD medications can exacerbate manic symptoms.
- Lithium requires monitoring of blood levels and thyroid/renal function, but it remains the most appropriate choice for this presentation.
*Guanfacine*
- **Guanfacine** is a **selective alpha-2 adrenergic agonist** used for ADHD and can help with comorbid tics. While this patient has ADHD-like symptoms and a motor tic, the more pressing concern is the **cyclical mood episodes** described.
- Treating ADHD without first addressing the underlying mood disorder in pediatric bipolar disorder can worsen mood instability and manic symptoms.
- Guanfacine would be appropriate as an **adjunct** after mood stabilization is achieved.
*Fluoxetine*
- **Fluoxetine** is an **SSRI** used for depression and anxiety. In a child with bipolar disorder, antidepressants can precipitate **manic or hypomanic episodes** and worsen mood cycling.
- SSRIs should generally be avoided or used with extreme caution (alongside a mood stabilizer) in pediatric bipolar disorder.
*Venlafaxine*
- **Venlafaxine** is an **SNRI** used for depression and anxiety. Similar to SSRIs, SNRIs can trigger **mood destabilization** and mania in patients with bipolar disorder.
- It is not appropriate as monotherapy in a child with suspected bipolar disorder and could worsen the clinical picture.
*Amitriptyline*
- **Amitriptyline** is a **tricyclic antidepressant** with significant anticholinergic side effects and a less favorable safety profile in children.
- Like other antidepressants, it can induce **mania or mood cycling** in bipolar disorder and is not a first-line treatment for this presentation.
- TCAs are generally avoided in pediatric psychiatry due to safety concerns and the availability of better-tolerated alternatives.
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