Bipolar Disorder: Depressive and Mixed Episodes — MCQs

10 questions

A patient with depression was given Imipramine for 2 weeks. Relatives noticed increased excitement, colorful clothes, and increased talking. What is the next step in management?

A patient complains of sadness of mood, increased lethargy, early morning awakening, loss of interest and reports no will to live and hears voices asking her to kill self. What is the diagnosis?

Cyclothymia is classified as which type of mood disorder?

First agent shown to be effective in manic phase of Bipolar Disorder -

Which of the following is a first-line treatment for bipolar affective (manic-depressive) disorder:

Double depression is seen in:

What deficiency may contribute to relapse in a patient who has experienced remission with selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs)?

A 30-year-old male was brought for evaluation, with a history of his 3-year-old son's death, 5 months prior, following a car accident. At the time of the accident, the patient was a witness. Since then, he has experienced symptoms of sadness, crying spells, feelings of hopelessness, poor sleep, and poor appetite. He has had suicidal thoughts on two occasions, but has not acted on them. He has not been attending work for the past 5 months. What is the likely diagnosis?

Which of the following is false about bipolar disorder?

Q10

A 6 year old child who does not interact with other children of his age group and prefers playing alone with repetitive behaviors, is likely to be suffering from:

Bipolar Disorder: Depressive and Mixed Episodes Indian Medical PG Practice Questions and MCQs

Question 1: A patient with depression was given Imipramine for 2 weeks. Relatives noticed increased excitement, colorful clothes, and increased talking. What is the next step in management?

A. Continue Imipramine alone
B. Manage with Valproate alone
C. Discontinue Imipramine and start Valproate (Correct Answer)
D. Antipsychotic with Imipramine continued

Explanation: ***Discontinue Imipramine and start Valproate*** - The patient's symptoms (increased excitement, colorful clothes, increased talking) after starting an antidepressant like **Imipramine** suggest a **manic switch**, indicating undiagnosed **bipolar disorder**. - **Imipramine** should be discontinued as it can exacerbate mania, and a mood stabilizer like **Valproate** is necessary to treat the manic episode. *Continue Imipramine alone* - Continuing Imipramine would likely worsen the manic symptoms, leading to increased agitation and potential harm. - Antidepressants can trigger or worsen manic episodes in individuals with underlying bipolar disorder. *Manage with Valproate alone* - While Valproate is an appropriate treatment for acute mania, simply managing with Valproate alone without discontinuing the offending antidepressant would be suboptimal. - The continued presence of Imipramine would counteract the mood-stabilizing effects of Valproate. *Antipsychotic with Imipramine continued* - Adding an antipsychotic might manage some acute manic symptoms, but continuing Imipramine would maintain the driving force behind the manic switch. - The primary action should be to remove the causative agent (Imipramine) and replace it with a mood stabilizer.

Question 2: A patient complains of sadness of mood, increased lethargy, early morning awakening, loss of interest and reports no will to live and hears voices asking her to kill self. What is the diagnosis?

A. Schizophrenia
B. Major depressive disorder plus psychosis (Correct Answer)
C. Schizoaffective disorder
D. Schizotypal personality disorder

Explanation: ***Major depressive disorder plus psychosis*** - The patient presents with classic symptoms of **major depressive disorder**, including persistent sadness, **anhedonia (loss of interest)**, **lethargy**, and **early morning awakening**. - The presence of **auditory hallucinations** (hearing voices asking her to kill herself) indicates **psychotic features** accompanying the severe depression, leading to the diagnosis of major depressive disorder with psychotic features. *Schizophrenia* - While schizophrenia involves psychosis, the primary presentation here is a prominent **depressive syndrome** rather than the typical **positive symptoms (delusions, hallucinations)**, **negative symptoms (alogia, avolition)**, and **disorganized thought** processes characteristic of schizophrenia. - The depressive symptoms are too pervasive and central to the clinical picture to be solely schizophrenia. *Schizoaffective disorder* - This disorder requires a period of **at least two weeks of psychotic symptoms** (hallucinations or delusions) **without prominent mood symptoms**, which is not described. - In this case, the **psychotic symptoms are congruent with the depressed mood** (e.g., voices urging self-harm, reflecting hopelessness), rather than independent. *Schizotypal personality disorder* - This is a pervasive pattern of **social and interpersonal deficits** marked by acute discomfort with, and reduced capacity for, close relationships, as well as by **cognitive or perceptual distortions** and eccentricities of behavior. - It does not involve persistent, severe depressive episodes with overt psychotic symptoms as described, nor significant functional impairment to the extent seen here.

Question 3: Cyclothymia is classified as which type of mood disorder?

A. Major depression
B. Dysthymia
C. Persistent mood disorder
D. Bipolar mood disorder (Correct Answer)

Explanation: ***Bipolar mood disorder*** - **Cyclothymia (Cyclothymic Disorder)** is classified under **Bipolar and Related Disorders** in both DSM-5 and ICD-11, making it part of the bipolar spectrum. - It is characterized by **chronic, fluctuating mood disturbances** lasting at least 2 years (1 year in children/adolescents) with numerous periods of hypomanic and depressive symptoms that do not meet full criteria for hypomanic or major depressive episodes. - The alternating, less severe mood swings share the fundamental **bipolar pattern** of mood elevation and depression, hence its classification under bipolar mood disorders. *Major depression* - **Major depressive disorder** is a unipolar mood disorder involving persistent feelings of sadness, loss of interest, and other depressive symptoms that significantly impair daily functioning, **without any episodes of mania or hypomania**. - Cyclothymia involves **mood instability with both elevated and depressed periods**, which distinguishes it from unipolar major depression. *Dysthymia* - **Dysthymia** (now termed **Persistent Depressive Disorder** in DSM-5) is characterized by chronic, low-grade depressive symptoms lasting at least 2 years, **without manic or hypomanic episodes**. - While both involve sub-threshold symptoms, cyclothymia includes periods of **hypomanic symptoms** (elevated mood, increased energy), which are absent in dysthymia. *Persistent mood disorder* - This is a broad, non-specific descriptive term rather than a formal diagnostic category in DSM-5 or ICD-11. - While cyclothymia is indeed a persistent condition, it is **specifically categorized under Bipolar and Related Disorders** due to the presence of both elevated (hypomanic) and depressed mood states.

Question 4: First agent shown to be effective in manic phase of Bipolar Disorder -

A. Valproate
B. Lithium (Correct Answer)
C. Lamotrigine
D. Carbamazepine

Explanation: ***Lithium*** - **Lithium** was the first mood stabilizer specifically demonstrating efficacy in treating the **manic phase of bipolar disorder**, revolutionizing its management. - Its discovery in the 1940s and subsequent clinical trials established it as the **gold standard** for acute mania and maintenance therapy. *Valproate* - While effective in treating **acute mania** and bipolar depression, **valproate** was introduced later than lithium as a mood stabilizer. - It works by **enhancing GABAergic transmission** and modulating voltage-sensitive sodium channels. *Lamotrigine* - Primarily indicated for the treatment of **bipolar depression** and as a maintenance therapy to prevent depressive episodes. - It has **limited efficacy** in treating acute manic episodes. *Carbamazepine* - An **anticonvulsant** that also possesses mood-stabilizing properties, effective in some cases of acute mania and rapid cycling. - Its use in bipolar disorder followed the introduction of lithium, and it is considered a **second-line treatment**.

Question 5: Which of the following is a first-line treatment for bipolar affective (manic-depressive) disorder:

A. Chlorpromazine
B. Haloperidol
C. Diazepam
D. Lithium carbonate (Correct Answer)

Explanation: **Lithium carbonate** - **Lithium** is a well-established and highly effective **mood stabilizer**, considered a first-line treatment for managing both **manic** and **depressive episodes** in bipolar disorder. - It helps prevent recurrent episodes and reduces the severity of mood swings, acting as a prophylactic agent. *Chlorpromazine* - **Chlorpromazine** is a **first-generation antipsychotic** that is primarily used to treat **schizophrenia** and other psychotic disorders. - While it can be used acutely to manage severe manic agitation, it is not a first-line agent for the long-term mood stabilization characteristic of bipolar disorder. *Haloperidol* - **Haloperidol** is another **first-generation antipsychotic** often used for acute treatment of **psychotic symptoms** or severe agitation, including in mania. - It is not a primary long-term mood stabilizer for bipolar disorder due to its side effect profile and lack of efficacy in preventing future mood episodes compared to lithium. *Diazepam* - **Diazepam** is a **benzodiazepine** primarily used for treating **anxiety**, muscle spasms, and acute seizures. - While it can help manage acute agitation and insomnia during a manic episode, it does not have mood-stabilizing properties and is not a long-term treatment for bipolar disorder.

Question 6: Double depression is seen in:

A. Depression with dysthymia (Correct Answer)
B. Depression with anxiety attack
C. Major depression with OCD
D. Major depressive disorder from 2 years

Explanation: ***Depression with dysthymia*** - **Double depression** is a specific mood disorder characterized by the co-occurrence of a **major depressive episode** on top of a pre-existing **dysthymic disorder** (persistent depressive disorder). - This means an individual experiences the chronic, milder symptoms of dysthymia, which are then worsened by the more severe symptoms of a major depressive episode. *Depression with anxiety attack* - While depression and anxiety attacks can co-occur, this specific combination is not referred to as **double depression**. - **Anxiety attacks** are acute episodes of intense fear and discomfort, often associated with panic disorder, and are distinct from chronic low-grade depressive symptoms. *Major depression with OCD* - **Obsessive-compulsive disorder (OCD)** is a distinct anxiety disorder characterized by obsessions and compulsions, which can co-occur with major depression. - However, the term **double depression** specifically refers to the combination of major depression and dysthymia, not other psychiatric comorbidities. *Major depressive disorder from 2 years* - Experiencing **major depressive disorder for 2 years** implies a chronic course of major depression. - If the symptoms meet the criteria for major depressive disorder continuously for at least two years, it might be termed **chronic major depressive disorder**, but not double depression, unless there was an underlying dysthymia.

Question 7: What deficiency may contribute to relapse in a patient who has experienced remission with selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs)?

A. Pyridoxine
B. Cobalamin
C. Ascorbate
D. Folate (Correct Answer)

Explanation: ***Folate*** - **Folate (vitamin B9) deficiency** is strongly linked to depression and is a well-established cause of relapse in patients treated with antidepressants. - Folate plays a crucial role in the **one-carbon metabolism pathway**, which is essential for the synthesis of monoamine neurotransmitters including **serotonin, norepinephrine, and dopamine**. - Studies show that **low folate levels** are associated with poor response to SSRIs and TCAs, and folate supplementation can improve antidepressant efficacy. - Approximately **30% of depressed patients** have folate deficiency, making it a clinically significant factor in treatment resistance and relapse. *Cobalamin* - **Cobalamin (vitamin B12)** deficiency can cause neuropsychiatric symptoms including depression and cognitive impairment. - While B12 is important for myelin formation and neurotransmitter synthesis, it is less specifically implicated in antidepressant relapse compared to folate. - B12 deficiency more commonly presents with **cognitive and neurological symptoms** rather than pure mood symptoms. *Pyridoxine* - **Pyridoxine (vitamin B6)** is a cofactor in neurotransmitter synthesis, including serotonin and dopamine. - While B6 deficiency can contribute to mood disturbances, it is not commonly implicated as a primary cause of relapse in antidepressant-treated depression. *Ascorbate* - **Ascorbate (vitamin C)** is an antioxidant with some role in neurotransmitter metabolism. - Severe vitamin C deficiency (scurvy) can have psychiatric manifestations, but it is not typically associated with relapse in patients treated with SSRIs or TCAs.

Question 8: A 30-year-old male was brought for evaluation, with a history of his 3-year-old son's death, 5 months prior, following a car accident. At the time of the accident, the patient was a witness. Since then, he has experienced symptoms of sadness, crying spells, feelings of hopelessness, poor sleep, and poor appetite. He has had suicidal thoughts on two occasions, but has not acted on them. He has not been attending work for the past 5 months. What is the likely diagnosis?

A. Post-traumatic stress disorder (PTSD)
B. Normal grief reaction
C. Adjustment disorder with depressed mood
D. Major depressive disorder (Correct Answer)

Explanation: ***Major depressive disorder*** - The duration of symptoms (5 months) and severity, including **suicidal ideation** and significant occupational impairment, exceed what is typically expected for **normal grief** or **adjustment disorder**. - Symptoms like **sadness**, crying spells, feelings of hopelessness, **poor sleep**, and poor appetite are classic for **major depressive disorder**, especially when persistent and functionally debilitating. *Post-traumatic stress disorder (PTSD)* - While experiencing a traumatic event (witnessing his son's death) is a prerequisite for PTSD, the patient's primary symptoms are **depressive** rather than the characteristic re-experiencing, avoidance, negative alterations in cognitions and mood, or hyperarousal associated with PTSD. - There is no mention of **flashbacks**, nightmares, or significant **avoidance behaviors** directly linked to the trauma beyond general withdrawal. *Normal grief reaction* - While grief is expected after the death of a child, the severity (suicidal ideation) and significant functional impairment (not attending work for 5 months) suggest a reaction beyond **normal grief**. - **Normal grief** typically doesn't involve persistent, severe functional impairment or recurrent suicidal thoughts over such a prolonged period without additional significant depressive symptoms. *Adjustment disorder with depressed mood* - **Adjustment disorder** usually resolves within 6 months of the stressor or its consequences ceasing, and symptoms are generally less severe than those seen in major depression. - The presence of **suicidal ideation** and profound, persistent functional impairment for 5 months makes **major depressive disorder** a more fitting diagnosis.

Question 9: Which of the following is false about bipolar disorder?

A. Unipolar mania is more common than bipolar disorder (Correct Answer)
B. Genetic factors play important role
C. Rapid cycling is more common in females
D. Age of onset is earlier than unipolar depression

Explanation: ***Unipolar mania is more common than bipolar disorder*** - This statement is **false** because **unipolar mania is extremely rare**, while **bipolar disorder (which includes both manic and depressive episodes)** is significantly more common. - **Unipolar mania** refers to recurrent manic episodes without any depressive episodes, a presentation that is seldom observed clinically. *Genetic factors play important role* - This statement is **true**, as **bipolar disorder has a strong genetic component**, with **heritability estimated between 60-80%**. - **First-degree relatives** of individuals with bipolar disorder are at a significantly higher risk of developing the condition. *Rapid cycling is more common in females* - This statement is **true**; **rapid cycling (4 or more mood episodes per year)** occurs more frequently in females with bipolar disorder. - **Women with bipolar disorder** are also more likely to experience **mixed features** and **more depressive episodes** compared to males. *Age of onset is earlier than unipolar depression* - This statement is **true** because the **typical age of onset for bipolar disorder is in early adulthood (late teens to early 20s)**, whereas **unipolar depression often has a later average onset**, though both can occur at any age. - An earlier age of onset in bipolar disorder is linked to poorer prognosis and more severe illness course.

Question 10: A 6 year old child who does not interact with other children of his age group and prefers playing alone with repetitive behaviors, is likely to be suffering from:

A. ADHD
B. Autism (Correct Answer)
C. Depression
D. Bipolar disorder

Explanation: ***Autism*** - Difficulties in **social interaction** and **communication**, along with **repetitive behaviors** and restricted interests, are core diagnostic features of **Autism Spectrum Disorder (ASD)**. - The child's preference for playing alone and lack of interaction with peers are hallmark signs of **social deficits** in ASD. *ADHD* - **Attention-Deficit/Hyperactivity Disorder (ADHD)** primarily involves difficulties with **inattention**, **hyperactivity**, and **impulsivity**. - While children with ADHD may struggle socially, repetitive behaviors and a complete lack of interest in peer interaction are not typical primary symptoms. *Depression* - **Depression** in children often presents with **sadness**, **loss of interest** in previously enjoyed activities, changes in sleep or appetite, and irritability. - Social withdrawal in depression is usually due to low mood or anhedonia, rather than a fundamental difficulty in social understanding or a preference for repetitive play. *Bipolar disorder* - **Bipolar disorder** in children involves distinct episodes of **mania** (elevated mood, increased energy, decreased need for sleep) and **depression**. - The symptoms described do not align with the characteristic mood swings and episodic nature of bipolar disorder.

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