Updated: 11/30/2019

Bipolar Disorder

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Snapshot
  • A 25-year-old male is brought into the emergency room by his family when he spent over $100,000 on building supplies and was found naked in his back yard building a boat so he can sail the world to teach English to the people of England.  His family and friends said that for the last 2 weeks he had been increasingly grandiose, had been sleeping 3 hours per night, and had not gone to work.  Prior to this episode, the patient had been relatively normal, however, he had experienced a bout of depression 12 months ago.  The patient's speech seems pressured as he began to explain his idea to solve world homelessness with his program "Hammocks for the Homeless."  The patient's wife further offers that he has had a significantly increased sexual drive lately.  His urine tox screen was negative in the ED.
Introduction
  • Epidemiology
    • seen in 1% of population
    • genders equally affected
    • often presents in young people (most common onset between 20-30 years)
  • Subtypes
    • bipolar I 
      • manic episode with or without major depressive episodes
    • bipolar II
      • hypomanic episodes with at least one major depressive episode
    • rapid cycling
      • > 4 episodes of mania/depression/mixed within 1 year
    • cyclothymic
      • alternating hypomanic episodes with dysthymia
        • psychotherapy is best initial step in management
        • some evidence suggests valproic acid is better than lithium for these patients
Presentation
  • Symptoms
    • manic symptoms
      • DIG FAST
        • Distractibility
        • Insomnia
        • Grandiosity
        • Flight of Ideas
        • Agitation
        • Sexual indiscretions/pleasurable activities
        • Talking (pressured speech)
    • hypomanic symptoms
      • similar but does not lead to marked impairment
      • no psychotic symptoms present
      • impulsivity is present
Evaluation
  • Diagnosis
    • episodes should last > 1 week and be continous
    • must rule out cocaine or amphetamine use
      • always do a urine toxicology for patients presenting with mania
Treatment
  • Lithium     
    • first-line mood stabilizer (can take 1 week to work)
    • check creatinine before initiating therapy 
    • renal failure, hyponatremia, and dehydration all increase likelihood of lithium toxicities
    • can cause hypothyroidism, and Epstein's anomaly in pregnant patients
    • shown to have a reduction in mortality from suicide
  • Hospitalization
    • often involuntary as manic patients do not recognize their illness
  • Benzodiazepines
    • may assist in acute sedation if patient is agitated
  • Antiepileptics  
    • valproate (useful for patients with renal dysfunction) or carbamazepine 
      • second line mood stabilizers
      • atypical antipsychotics can also be used (risperidone can be first-line
      • may begin antidepressant therapy only after mood stabilizers are started
    • lamotrigine also used (can be first-line)
    • haloperidol 
      • used as a first-line of treatment in pregnant patients with acute mania
      • first-line in acute mania in patients with severe symptoms
  • Atypical antipsychotics or antipsychotics  
    • quetiapine or olanzapine 
      • can be used as second line 
      • side effects of weight gain, thus often avoided in obese patients
    • haloperidol
      • can be used first line in pregnant patients 
  • SSRI's
    • can induce mania (e.g., if started in patients misdiagnosed with major depressive disorder) 
Prognosis, Prevention, and Complications
  • Prognosis 
    • worse than major depression
    • high prevalence of alcohol/substance abuse
    • high risk of suicide - worst during a mixed episode 
      • lithium is the only drug shown to reduce mortality from suicide (2015)
  • Prevention
    • if less than 3 lifetime relapses, it is possible to treat for 1 year followed by a mood stablizer taper 
    • if 3 or greater lifetime relapses, it is necessary to remain on lifetime mood stabilizer treatment 
 

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Questions (7)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M3.PY.16.8) A 35-year-old female presents to her PCP at the request of her husband after 3 weeks of erratic behavior. The patient has been staying up all night online shopping on eBay. Despite a lack of sleep, she is "full of energy" during the day at her teaching job, which she believes is "beneath [her], anyway." She has not sought psychiatric treatment in the past, but reports an episode of self-diagnosed depression 2 years ago. The patient denies thoughts of suicide. Pregnancy test is negative. Which of the following is the best initial treatment? Review Topic | Tested Concept

QID: 105825
1

Valproate

25%

(1/4)

2

Valproate and venlafaxine

25%

(1/4)

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Valproate and olanzapine

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Haloperidol

25%

(1/4)

5

Electroconvulsive therapy

25%

(1/4)

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(M3.PY.12.3) A 20-year-old woman is brought in by police for trying to break into a museum after hours. The patient states that she is a detective on the trail of a master collusion scheme and needs the artifacts from the museum to prove her case. Her family reports that she has been acting strangely for the past week. She has been up perusing the internet all night without taking breaks. Her husband states that she has had increased sexual interest for the past week; however, he did not report this to the physician when he first noticed it. The patient is unable to offer a history as she cannot be redirected from her current theory. Her temperature is 99.0°F (37.2°C), blood pressure is 122/81 mmHg, pulse is 97/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable only for a highly-energized patient. Laboratory studies are ordered as seen below.

Urine:
Color: Yellow
Nitrite: Negative
Bacteria: Negative
Leukocytes: Negative
hCG: Positive
Benzodiazepines: Negative
Barbiturate: Negative
Cocaine: Negative
Acetaminophen: Negative

Which of the following is the most appropriate next step in management?
Review Topic | Tested Concept

QID: 103738
1

Electroconvulsive therapy

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2

Fluoxetine

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Haloperidol

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Lithium

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Valproic acid

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Evidences (13)
Topic COMMENTS (29)
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