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?

Major depressive disorder with seasonal pattern

Major depressive disorder with atypical features

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?

Maternal obstetric complications

A 38-year-old woman comes to the physician for a follow-up visit. She has a 2-year history of depressed mood and fatigue accompanied by early morning awakening. One week ago, she started feeling a decrease in her need for sleep and now feels rested after about 5 hours of sleep per night. She had two similar episodes that occurred 6 months ago and a year ago, respectively. She reports increased energy and libido. She has a 4-kg (8.8-lb) weight loss over the past month. She does not feel the need to eat and says she derives her energy ""from the universe"". She enjoys her work as a librarian. She started taking fluoxetine 3 months ago. On mental exam, she is alert and oriented to time and place; she is irritable. She does not have auditory or visual hallucinations. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?

Medication-induced bipolar disorder

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?

Her diagnosis of unipolar depression is incorrect.

The patient may have psychotic features.

The patient may have a history of mania.

Antidepressants are inappropriate.

Her new symptoms need to last at least 7 days.

An 8-year-old girl is brought to the physician by her parents because they are concerned with her behavior. She has temper outbursts six or seven times per week, which last anywhere between 5 minutes to half an hour or until she becomes tired. According to her father, she screams at others and throws things in anger “when things don't go her way.” He says these outbursts started when she was 6 and a half years old and even between the outbursts, she is constantly irritable. She had been suspended from school three times in the past year for physical aggression, but her grades have remained unaffected. She appears agitated and restless. Physical examination shows no abnormalities. During the mental status examination, she is uncooperative and refuses to answer questions. What is the most likely diagnosis in this child?

Disruptive mood dysregulation disorder

Intermittent explosive disorder

A 28-year-old woman is brought to the emergency department by her friends. She is naked except for a blanket and speaking rapidly and incoherently. Her friends say that she was found watering her garden naked and refused to put on any clothes when they tried to make her do so, saying that she has accepted how beautiful she is inside and out. Her friends say she has also purchased a new car she can not afford. They are concerned about her, as they have never seen her behave this way before. For the past week, she has not shown up at work and has been acting ‘strangely’. They say she was extremely excited and has been calling them at odd hours of the night to tell them about her future plans. Which of the following drug mechanisms will help with the long-term management this patient’s symptoms?

Inhibition of inositol monophosphatase and inositol polyphosphate 1-phosphatase

Increase the concentration of dopamine and norepinephrine at the synaptic cleft

Modulate the activity of gamma-aminobutyric acid receptors

Acts as an antagonist at the dopamine, serotonin and adrenergic receptors

Inhibit the reuptake of norepinephrine and serotonin from the presynaptic cleft

Hypomanic episode criteria and features — USMLE Lesson

Hypomanic Criteria - A Little Too Sunny

A distinct period of elevated, expansive, or irritable mood and increased energy lasting at least 4 consecutive days. The mood disturbance must be accompanied by ≥3 of the following symptoms (or ≥4 if mood is only irritable):

📌 DIGFAST

Distractibility
Impulsivity / Indiscretion (spending, sexual)
Grandiosity
Flight of ideas / racing thoughts
Activity ↑ (goal-directed)
Sleep ↓ (decreased need)
Talkativeness (pressured speech)

The episode represents an unequivocal change in functioning that is observable by others.
Crucially, it is not severe enough to cause marked social/occupational impairment or require hospitalization.

⭐ Absence of Psychosis: If psychotic features are present, the episode is classified as manic by definition, not hypomanic. This is a critical diagnostic differentiator.

Hypomania vs. Mania - Mood Swing Meter

Core symptoms are the same (DIGFAST mnemonic), but differ in duration, severity, and functional impact.

Feature	Hypomania	Mania
Duration	≥ 4 consecutive days	≥ 7 consecutive days (or any duration if hospitalized)
Severity	Unequivocal change in functioning, observable by others	Marked impairment in social/occupational functioning
Hospitalization	Not required	Often necessary to prevent harm
Psychotic Features	Absent by definition	May be present (e.g., delusions, hallucinations)

⭐ Exam Favorite: The presence of psychotic features automatically makes the episode manic, not hypomanic. This is a critical diagnostic distinction.

Clinical Context - The Bipolar Blueprint

Core Feature: A distinct period of abnormally and persistently elevated, expansive, or irritable mood and increased activity/energy, lasting at least 4 consecutive days.
Symptom Threshold: Requires ≥3 of the following (or ≥4 if mood is only irritable):
- 📌 DIGFAST Mnemonic:
  - Distractibility
  - Impulsivity/Indiscretion
  - Grandiosity
  - Flight of ideas
  - Activity (goal-directed) ↑
  - Sleep need ↓
  - Talkativeness
Functional Impact: The episode represents an unequivocal change in functioning but is not severe enough to cause marked social/occupational impairment or necessitate hospitalization. No psychotic features are present.

⭐ The key distinction from a full manic episode is the duration (4 days vs. 1 week) and the absence of marked functional impairment, psychosis, or need for hospitalization.

Bipolar disorder mood spectrum with mixed features

High‑Yield Points - ⚡ Biggest Takeaways

A hypomanic episode requires an elevated or irritable mood for at least 4 consecutive days.

It must include ≥3 manic symptoms like grandiosity, distractibility, or increased goal-directed activity.

The episode represents an unequivocal change in functioning that is uncharacteristic of the individual.

Crucially, it is not severe enough to cause marked impairment or necessitate hospitalization.

The absence of psychotic features is a key diagnostic criterion.

It is the defining feature of Bipolar II Disorder.

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