Bipolar Disorder: criteria, types, symptoms, and treatment

welcome back to the dirty medicine series, dirty psychiatry, in this video we will talk about all the

bipolar

spectrum

disorder

s. This is what we will cover today. We will begin by discussing the

symptoms

of the entire

bipolar

spectrum. Disorders and these are sometimes called rapid

symptoms

. Then we'll specifically touch on bipolar one

disorder

, bipolar two disorder, and cyclothymia. We'll also briefly touch on some of the

treatment

s for bipolar disorder, but the

treatment

s for bipolar disorder that are for and great mood stabilizers will be covered in their own video, so let's start by talking about the symptoms that typically occur in someone. who suffers from one of these bipolar spectrum disorders.

You may have heard of sig ecaps symptoms when people talk about major depressive disorder. and like in major depression with its cigarette caps symptoms, mania, which is the focal point of bipolar spectrum disorders or the classic presentation is made up of its own acronym of symptoms and these symptoms are called dig fast d IG FA s T and you You should be familiar with what each of these letters mean because each of these symptoms is part of the

criteria

for things like bipolar one, bipolar two, and cyclothymia, so let's go over this. The d stands for distraction, so this is the ability to distract someone.

They start a task and then they see some kind of stimulus in the left part of their eye and then they stop what they're doing and do something else and then they do another task and then they stop what they were doing. What we're doing because someone starts talking to them and then they engage with that person so they jump around like that and get easily distracted is called distractibility. doing some things like getting on a moving train and riding on top of the train or climbing an electric pole and going down the wire to the next pole, a very impulsive, risky and dangerous behavior that is not typical of what the patient normally I would if I wasn't manic, grandiosity is what G stands for, so grandiosity means you think you are more important than you really are and when someone has bipolar disorder and is manic, they may believe they are Jesus. or that they are God, so that's grandiosity, sometimes they might believe that they have special abilities or that someone who's never been to university before could understand really complex astrophysics or something, so that's grandiosity, the F stands for flight of ideas and flight of ideas is simply a fast, uninterrupted idea that reaches the brain and usually comes out of your mouth in the form of very fast, uninterrupted speech, so when you talk to someone who is manic, you are talking to a patient who has either In bipolar spectrum disorders, you may notice that the pace of their speech is so fast that you can't even interrupt them to say a word, so the flight of ideas is the part of the thought content and then it comes out of your mouth like really fast speech, which is the T at the end of this mnemonic, which is talkative, so a flight of ideas and talkativeness go hand in hand with the flight of ideas, it is the content in your brain that is translates into really fast, rapid, uninterrupted speech, which is the T and the talkativeness that comes out of your mouth the a is activity and this is increased goal-directed activity classically manic patients will start projects or have some kind of endeavor that they are Starting off, an example could be someone who wants to save all the starving children in Africa, so they go to a bookstore and buy thousands of books and then they go to a UPS or FedEx store and buy all these boxes to ship all these books and they arrive at the store. and they realize they don't have enough money and then they abandon that task and start a different task to save all the starving children in Africa, so they go back to the supermarket and start buying all the bags of Hershey bars. that they are there in the checkout aisle because they are going to send all these Hershey bars to Africa and they are bouncing from one goal to the next even though in most cases they will never be completed and it is not realistic. and specifically this is a reduced need for sleep.

This is really important and I want to pause for a second. Both depressed patients and manic patients will have changes in their sleep and it is very important that they understand this difference, especially for step two level two and beyond because test writers can reach this far, so the depressed patient will usually have problems to sleep, but even if you have trouble sleeping, you will still be tired the next day because if you only sleep two or three hours a night, obviously you will feel tired the next day because you didn't sleep, that's your depressed patient, it's like you or me, if we don't sleep, we will be tired, but in the manic patient there is a lesser need for sleep, so not only do they sleep two or three hours, but they still maintain that incredibly high energy level and they are not tired, so it is a less need for sleep, not problems sleeping and that subtlety is very high performance because if a test writer writes a question they might include in the question that the patient only slept two hours and then it is their job to find out if this depression is the depressive phase of a bipolar illness because, as you will learn later in this video, patients who are bipolar fluctuate between high energy manic states and low energy depressive states or it is someone who is simply depressed and has major depressive disorder and only has depression that would be called unipolar unipolar depression for a survey because you're just depressed and depressed you're not bipolar bipolar surveys you're not up and manic and depressed and depressed so that's a very high performance point about sleeping and then drinking tea again we've already talked about this that is talkativeness so these are called rapid digging symptoms and these are tomainia what are siggy caps for depression, so it is absolutely necessary to know these symptoms because they will be described in the clinical vignettes of your questions, So now that you understand what the symptoms look like, let's talk. about bipolar one specifically, so the

criteria

for bipolar one is that you have a manic episode plus or minus a depressive episode, okay, so it doesn't matter whether or not you know that you were ever depressed or if He heard that he once was. depressed if the patient has a manic episode they are immediately diagnosed with bipolar disorder one stop doing what you are doing the diagnosis is bipolar one so you don't have to worry about bipolar 1 versus bipolar 2 versus cyclothymia if they have a manic episode it is bipolar 1 ended the discussion, so let's talk about what a manic episode actually consists of, so a manic episode is 4 out of 7, research the rapid symptoms, so those symptoms that we just talked about, if you have at least four of them , it is a manic episode if it lasts at least a week, so 4 out of 7 find that rapid symptoms that last at least a week are a manic episode or now this is the very high performance point for step two, level two and further, if the patient is hospitalized and goes to a medical center. acute inpatient psychiatric unit or present with psychotic features and there is a known history of any bipolar spectrum disorder, it automatically qualifies as a manic episode, it automatically qualifies as a bipolar one, so I want to be very clear here if you are taking your test and they give you the least four of those dickfist symptoms that last at least a week and will always give you the timeline, so make sure you read it in the question if there are at least four quick dig symptoms that last at least seven days.

It's a manic episode and that means because it's mania it's bipolar one, so in bipolar two you don't have mania, you get something else called hypomania and we'll touch on that in a moment in cyclothymia, you alternate hypomania with something called dysthymia. which we'll get to in a moment, but the only disorder on the bipolar spectrum that actually presents a true manic episode is bipolar one, so I'm repeating myself several times here because this is very high-yield. Please know this 4 of 7, dig in quickly. symptoms that last at least a week make you bipolar, stop what you're doing and choose the answer or if you have a patient who sounds like in the vignette who could be bipolar, maybe the asker is a real pain in the ass . the ass and they give you like three symptoms of digging quickly but they tell you that the patient ends up admitted to psychiatry it is a bipolar disorder because while they admit him to the hospital he automatically qualifies as bipolar The same thing happens with psychotic symptoms.

Don't worry about the niceties here, just memorize four out of seven. Take symptoms fast for at least a week. It is a manic episode and that qualifies as bipolar disorder. Now the depressive episode is more or less there because you. I've probably been taught that bipolar means two poles and you're switching between mania, which is the up, and depression, which is the down, and it's absolutely true that the patient will have manic and depressive episodes, but it's the manic episode that will seal it. the diagnosis for you so how do you remember this correctly? How do you remember this really important high-yield clinical information that I've probably already repeated five or six times for bipolar disorder?

I want you to remember that mania is a fun week, so you have a fun week, it lasts seven days, it's four out of seven symptoms for at least seven days or at least a week, so it's a fun week and if we compare it to major depressive disorder, MDD, major depression are two blue weeks, so there's a fun week. for mania and two blue weeks for depression, okay, one fun week for bipolar disorder and two blue weeks for depression, really amazing mnemonic, easy to remember, please memorize this four of seven for at least one week is bipolar.

Now, this is what we've talked about. We've talked so far and I want to illustrate this in a little graph so you can understand what bipolar disorder looks like in terms of its clinical fluctuation, so here is young Mia in the middle of the graph and youth amia simply means mood normal. you are not depressed you are not depressed you are not manic you are not up but a bipolar disorder on a chart looks like this, so in the red phase of the chart the patient is manic, so up his mood is more expansive, such more irritable, it comes from juvenile thymio, so it's manic and the depression phase is obviously in blue, so if you know you're going down and you're getting worse than you think, then you're going to be depressed, so it's This fluctuation between the manic episode and the depressive episode is what categorizes bipolar one disorder and again it is important to remember that for bipolar one one has to have a manic episode plus or minus the depressive episode, so in bipolar one disorder if we wanted To treat this, what we would do is fix the mania and reduce it to the juvenile amia that is seen in the red phase of the graph and if we wanted to treat the depression, we would want to push that blue part of the graph back to your thigh Mia and we treat the depression and the way we do it is with different medications and this is going to be just a quick overview of mood stabilizers but mood stabilizers will have their own video to fix the manic part that would use mood stabilizers such as lithium, valproic acid, carbamazepine, olanzapine and risperidone, now mood stabilizers, although it is a large category that are mood stabilizing drugs, they are actually drugs that come from different categories, so lithium in itself is considered a mood stabilizer, but valproic.

Acid and carbamazepine are actually antiepileptic medications used as mood stabilizers. Olanzapine and risperidone are atypical or second-generation antipsychotics used as mood stabilizers, so they are actually used in their own category, although each of these medications come from different categories. and then to solve the depressive phase of bipolar disorder, you would also use mood stabilizers, which are things like lithium, again, lamotrigine, olanzapine, plus an SSRI, adona, quetiapine, so again we are taking different medications from different categories and using them to treat the bipolar spectrum. disorders because all these medications, whether antipsychotics or antiepileptics, have mood stabilizing properties and correct the manic episode or the fluctuation between mania and depression.

Now, something that is incredibly important to know is that you never ever give an SSRI alone to a manic patient or a patient who has bipolar disorder and is in the manic portion or bipolar two is in the hypomanic portion, you never give them an SSRI alone. and the reason is, let's take an example, let's say you had a patient who had this change from mania to depression and you want to treat the depressed face. Maybe notyou knew he had bipolar disorder. Let's assume for a second that you said, "Hey, I see someone has symptoms of depression." maybe it's a major depressive disorder, let me give them an SSRI, so you give them an SSRI and when you introduce the SSRI, you push the depressed part of this graph up to the young amia and say, oh great, I'm an amazing medical student. suggested that the patient receive an SSRI and now his depression is gone, but what happens to the patient with bipolar disorder is that you push him beyond his Thema and unfortunately you turn it into mania because by reversing the depressed part you overcorrect and make him turns directly into mania, so never give an SSRI alone to a manic patient.

So this is what we've talked about so far and again, mood stabilizers in terms of mechanism of adverse drug reactions and all the high-throughput clinical data will have their own video and that's coming, but now Let's change the subject and talk about bipolar two disorder. so bipolar two disorder is very similar to bipolar one disorder and the main difference here is that instead of a manic episode these patients have hypomanic episodes, they usually have hypomanic episodes with a much more prominent major depressive episode, but the difference here is which instead of mania it's hypomania, so hypo means less, so it's less mania, so it's a manic episode which is a little less than a true manic episode, so let's talk about the criteria for hypomania.

You need to 3 out of 7 quickly investigate the symptoms for at least four days and they are never. manic, so they don't have 4 or more symptoms for 1 week, which was the criteria for mania and bipolar 1, and they never have psychotic features because if they had psychotic features they would be diagnosed with bipolar one disorder or they would be diagnosed with something like bipolar one disorder. schizoaffective type bipolar, but in this case it's 3 out of 7, so it's less than the criteria for mania and it's only for four days instead of 7, so it's mania from hypomania, so they'll have symptoms that sound like if they were manic their speech may be very rapid and they may have more goal directed activity, maybe they will be a little grandiose but they won't have the full spectrum of symptoms that would lend themselves to a diagnosis of mania and therefore bipolar , so this is bipolar two hypomania so how do you remember this criterion?

I have an amazing mnemonic for you so I want you to remember hiccup mein threa so hiccup has four letters that remind me that you need this for at least four days and instead of saying mania I say three main a' three main a' three because you need three out of seven rapid symptoms so hypomania is like I remember the hypomanic episode criteria and again hypo is four letters so it lasts at least four days and three main three three four three out of seven explore the rapid symptoms so that's the bipolar two and just to illustrate this, let's go back to the graph, so this is the graph that I showed you for bipolar one, there was a manic episode that turned into depressive episodes and the patient alternated between the two, but since the hypomania is a little bit less than mania, if we just lower the red part of the graph a little bit, this is what bipolar 2 disorder looks like, so the patient will alternate between these hypomanic episodes and these major depressive episodes. three out of seven investigate rapid symptoms for at least four days when they are in the hypomanic part and when they are in the major depressive part, it is just the criteria for major depressive disorder, so you know that you have at least five cap siggy symptoms for at least two weeks, so that's bipolar two and the way we treat it is really the same way we treat bipolar one with a little more emphasis on the mood stabilizers in the blue column here, so more in the area of ​​administering quetiapine. or larezo Doane, which are second generation atypical antipsychotics, but the subtleties of that are beyond the scope of this lecture and the mood stabilizers we'll have their own video, so that's bipolar two disorder, let's talk about cyclothymia, for what many people, many medical people. students get really caught up in exams with the terminology here of cyclothymia and dysthymia and all the things that end with thymio, so let's talk about criteria, so cyclothymia cycle means cycling or alternation and thigh mia is how we relate to the state of spirit, so youth is normal. mood in time eeeh is disgust, dysphoric mood does not work, which usually means someone is slightly depressed, so cyclothymia is an alternate mood state, so what is the criteria for the Does the patient have hypomanic and dysthymic episodes?

I'll talk about what each of these terms refers to. so we already talked about hypomanic episodes, in fact, we just talked about that, it's 3 out of 7 delve into the rapid symptoms for more than 4 days, so 3 at least 4 days 3 out of 7 investigate the rapid symptoms so that the patient have hypomanic episodes, but when they are non-hypomanic they are having dysthymic episodes and the dysthymic episodes are greater than 2 and less than 4 or less than 4 excuse me, it should say greater than 2 and no more than 4, so 4 or less symptoms of siggi caps and it doesn't meet the criteria for major depressive disorder, so it's kind of like childhood depression, so if you want to think about cyclothymia in a really simple way, baby mania alternates with baby depression, they never meet the criteria. criteria for mania, they never meet the criteria for a major depressive episode, but still a little hypomanic and sometimes they are a little depressed, so they switch between them, so if we put this on a graph instead of mania and major depression, It will be hypomania and dysthymia, so the patient will alternate like this. they have episodes where they are high but not completely high because they are just hypomanic and then in those red parts of the graph they will have three out of seven rapid digging symptoms for at least four days, but when they are low they are not going to get to the point where the You will diagnose or think that they have major depressive disorder, but they will still be as if you are a little depressed.

They will have at least two, but no more than four, CPE symptoms. of depression that never meets the criteria for MDD, this is what cyclothymia looks like on our mood chart. It is very important to know, so just memorize that cyclothymia, which means alternating mood, is hypomanic episodes mixed with ODE of dis imma kepis and this alternation occurs for at least two. years of high performance occurs for at least two years, okay, that's cyclothymia. Let's briefly finish this video by just talking about some other mania that you may see on your exams and it won't be things like bipolar one, bipolar two or cyclothymia, but the patient will still present with the big rapid symptom, so these are some things to have note: steroids, if a patient is started on steroids for some type of inflammatory condition, they may become manic due to the steroid, they may have substance-induced mania, so If someone is using cocaine or methamphetamine, any stimulant It can actually cause drug-induced mania, so I'm not talking about illicit drugs.

I mean, you know, like prescription medications, different drugs are known to cause mania and that's really all you need to know for the purposes of the step. one level one step two level two and then you can have autoimmune induced mania so some people with autoimmune diseases like lupus can become manic if the disease is not managed properly neurosyphilis and HIV can cause mania subacute combined degeneration due to a vitamin b12 deficiency can cause mania hyperthyroidism is huge Zaira's disease is the great masker Lyme disease Lyme disease that I didn't put on this slide can cause mania and then you know Wilson's disease there are many more causes, but only I'm listing some things that you might see pop up above because there are neuropsychiatric manifestations of all of these disease processes, so keep them in the back of your mind, but that's it for this video.

I hope you now understand the bipolar spectrum of disorders. I hope you understand the quick symptoms, the criteria for each one. of these three different disorders and how they look on the charts, if you have enjoyed this video, know that there will be more psychiatry videos and you will be an expert by the time they are done.