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Bipolar Disorder - Mania and Hypomania
Bipolar Disorder
Mania and Hypomania
Prepared by: Dr. Anvesh Roy
Psychiatry Resident, University of Toronto
This is a review of Bipolar disorder focusing primarily upon its defining phenomena of Mania and Hypomania. The following text is envisioned to help case based learning of Bipolar Disorder by providing a background context (the video case). This is designed to show how the scenario may present in real life when you are faced with a similar patient rotating through the ER or in an inpatient unit.
Click on the following hyperlinks to arrive at each section with pertinent examples from our video case (commiserate to enabling objectives):
What is Mania and Hypomania? Definition and meaning.
Differential Diagnosis
How to get a history and pertinent information
Objective evaluation: Physical Exam and MSE
What are the investigations?
Management
Short Term, including addressing safety concerns and acute agitation
Long Term
References and further reading (for the so inclined)
Bipolar Disorder - Mania and Hypomania
What is Mania (and Hypomania)?
An extremely disabling and potentially harmful behavioral syndrome that indicates an underlying central nervous system disorder. Mania can lead to harm to self or others, and may be accompanied by features of psychosis. Hypomania is a less severe form of mania, see later on in the text how to differentiate between the two.
Usually, by definition they denote affliction by one of the various forms of Bipolar Disorders or ‘Bipolar Spectrum’ of disorders.
They can be secondary to other causes, but then they are not referred to as such, as will be explained.
DSM5 Dx Criteria:
Manic Episode A. A distinct period (at least one week) of abnormally/ persistently elevated, expansive, irritable mood and abnormally/persistent increased goal directed activity or energy; any duration is enough to diagnose if hospitalization required B. During this period, three or more of (or four if mood is irritable) as remembered by the pneumonic GSTPAID: o Inflated self-esteem or grandiosity - G o Decreased need for sleep - S o More talkative/pressure speech - T o Excessive engagement in activities with high potential for painful consequences - P o Increase in goal directed activity or psychomotor agitation - A o Flight of ideas or subjective racing thoughts - I o Objective or subjective distractibility - D C. Mood disturbance causes impairment in social occupational functioning OR necessitates hospitalization to prevent harm to self OR psychotic features D. Not attributable to a General Medical Condition or substance
Hypomanic Episode A. A distinct period (at least 4 consecutive days) of abnormally/ persistently elevated, expansive, irritable mood and abnormally/persistent increased goal directed activity or energy. B. During this period, three or more of (or four if mood is irritable): a. Inflated self-esteem or grandiosity - G b. Decreased need for sleep - S
Bipolar Disorder - Mania and Hypomania
o Mixed: 36 wks. Average number of lifetime episodes is 7- Bipolar II has higher risk of rapid cycling than Bipolar I (7:1 ratio), as well as a more chronic and recurrent course, with >50% of the time ill (mainly with depressions)
Mania and Hypomania can be present in the following disorders, and these are the diagnostic criteria as per DSM5:
A. Bipolar I o need a current or past manic episode, likely will also have depressive episodes o a full manic episode that emerges during antidepressant treatment (meds, ECT) but persists as fully syndromal level beyond physiological effect of that treatment IS SUFFICIENT EVIDENCE for a manic episode AND THERFORE a bipolar I diagnosis o not better explained by another diagnosis o diagnostic code is based on CURRENT OR MOST RECENT episode and whether its severity, presence of psychotic features, and remission status o bipolar I disorder, most current episode manic, severe, with psychotic features, in partial remission o bipolar I disorder, most recent episode depressed, mild, in full remission o code psychotic features irrespective of severity
B. Bipolar II o Need a current or hypomanic episode AND current or past depressive episode, AND LACK of a manic episode o a full hypomanic episode that emerges during antidepressant treatment (meds, ECT) but persists as fully syndromal level beyond physiological effect of that treatment IS SUFFICIENT EVIDENCE for a manic episode AND THERFORE a bipolar II diagnosis o caution if just one or two symptoms like edginess, irritability or agitation following antidepressant initiation – not a bipolar diathesis o not better explained by another diagnosis o diagnostic code is disorder, current /recent episode, presence of psychotic features, course, and other specifiers o bipolar II disorder, current episode depressed, moderate severity, with missed features
C. For both bipolar I and II, one can add specifiers anxious distress
Bipolar Disorder - Mania and Hypomania
mixed features rapid cycling melancholic features atypical features mood-congruent psychotic features mood-incongruent psychotic features catatonia peripartum onset seasonal pattern – only apply to pattern of depressive episodes
Cyclothymic Disorder: a chronic, fluctuating mood disturbance
A. Two years in adults/one in children - Numerous periods with hypomanic or depressive symptoms B. Hypomanic or depressive symptoms present at least half of the time and individual not without symptoms for more than two months C. Not meeting full syndromal criteria for either hypomania or depression EVER D. Not better explained by other disorder E. Not attributable to substance or GMC F. Impairment
Substance/Medication-Induced Bipolar and Related Disorders
A. Prominent and persistent mood disturbance characterized by elevated, expansive, irritable mood – with or without depressed mood OR markedly diminished interest or pleasure in almost or all activities B. Evidence that these symptoms developed during or soon after exposure/intoxication/withdrawal of a substance that is capable of producing these symptoms C. Not better explained by bipolar disorder or non-substance diagnosis D. Not only in delirium E. Impairment o Code use disorder prior to substance-induced diagnosis and onset during intoxication/withdrawal o Amphetamine-induced bipolar and related disorder, with onset during intoxication o Severe methylphenidate use disorder with methylphenidate-induced bipolar and related disorder, with onset during intoxication
Bipolar and Related Disorders Due to Another Medical Condition
A. Prominent and persistent mood disturbance characterized by elevated, expansive, irritable and abnormally increased activity and or energy
Bipolar Disorder - Mania and Hypomania
Important diagnostic points:
The key difference between mania and hypomania is that mania is associated with significant social or occupational dysfunction whereas hypomania is not. There are also no psychotic features in Hypomania. The minimum duration also differs 4 vs. 7 days.
A mania and hypomania due to the Bipolar Spectrum of Disorders can be diagnosed if precipitated by a substance or medication – and it persists beyond the physiological effect of intoxication or withdrawal syndrome of the substance. For e.g. An SSRI precipitates a manic episode, and this episode persists for more than a week after the SSRI is stopped.
Mixed episode used to be a separate entity in DSM IV but in DSM5 it is a specifier and denotes symptoms of depression co-occurring with the manic or hypomanic episode.
Psychotic symptoms (e.g., delusions, hallucinations) are common in mania, appearing in over one half of manic episodes. In manic states, patients often experience grandiose and paranoid delusions, as well as perceptual abnormalities, resulting in visual, auditory, and olfactory experiences o The psychosis is likely to be ‘mood congruent’ i.e. goes along with the elevated mood and grandiosity or themes of increased energy or power. As seen in the case – pt. feels that she will cause world war 3, as she is the most beautiful woman in the world.
Common Substances and Medical Conditions causing Mania
(From K & S 10th Ed.)
Amphetamines Baclofen Bromide Bromocriptine Captopril Cimetidine Cocaine Corticosteroids (including adrenocorticoid hormone [ACTH]) Cyclosporine Disulfiram Hallucinogens (intoxication and flashbacks) Hydralazine Isoniazid Levodopa Methylphenidate
Bipolar Disorder - Mania and Hypomania
Metrizamide (following myelography) Opiates and opioids Phencyclidine (PCP) Procarbazine Procyclidine Yohombine
Bipolar Disorder - Mania and Hypomania
Obtain Collateral History
The observations of a third party can be invaluable. This is particularly so for issues that patients themselves may have difficulty describing, or may not be aware of, such as: type of onset and evolution overtime, what actual changes have occurred (e.g., in personality and functioning), self-care issues, or fluctuations in state.
Case Notes:
Background Information (provided in as the nurse’s report):
- Catie is a 32 y.o female
- Currently single, divorced 4 years ago, no children
- Works in retail in a fashion store
- Brought to the ED by her sister, who was concerned about her behavior and excessive spending. Told the triage nurse that her sister had ‘Manic Depression’ and left suddenly.
The following history was obtained from a discharge summary when the patient was admitted to the hospital 2 years ago. It is estimated by her sister that she has been non compliant with her medications for about 2-3 weeks.
Past Psychiatric History: 3 prior hospitalizations. The first was 10 years ago where she presented in a manic state and was diagnosed with Bipolar Type 1. The other two ones were for Mania 5 years ago and Depression 2 years ago (this hospital) respectively. She has been known to be noncompliant with her medications.
Medications (last known 2 years ago) Lithium 1200mg QHS Bupropion 300mg QHS
Past Medical History:
Family History:
- Grandmother – suspected Bipolar D/O
- Mother – Bipolar D/O on Lithium
- Reports of an Aunt and two maternal cousins with Bipolar Disorder
Social History:
- Unremarkable, normal milestones
- Grade A student until University, had to drop out due to first episode of Mania
Bipolar Disorder - Mania and Hypomania
- Employed in retail fashion
- Married for 2 years. Reason for divorce was apparently spending couples savings on luxury items amounting to 50000$ and having an affair when she was in a Manic Episode.
Mental Status findings in Mania and its interpretation:
Appearance can be with flamboyant and/or sexually provocative dressing and makeup. Behavior can be hyperactive. Speech is pressured and with an increased rate, often loud. Mood is usually described as great or happy and affect is usually elevated, expansile or euphoric. It can also be irritable and also labile i.e. shift rapidly between all these states. Moreover, the mood is usually not appropriate to the situation. Thought process can be disorganized and sped up as reflected by rapid speech with a ‘flight of ideas’, which may be connected thematically and less so as the severity of mania increases. Thought content usually has grandiose delusions or others (in mania, not in hypomania). Perception may have hallucinations (in mania). Insight and Judgment may be very poor.
Physical exam may have to be deferred, however, take vital signs and perform an exam as clinically indicated. For e.g. Cocaine induced manic symptoms may have additional findings of a very elevated BP and pulse, which would need to be further investigated with an ECG and medical consult. At worst, this pt. may be having an MI.
Case Notes:
MSE exam is documented in the chart. It reads: Ms. Catie Holmes is a 32 y.o female who appears her stated age. Appearance is remarkable for wearing revealing and likely designer clothes with excessive makeup. Behavior is hyperactive and agitated at times. Speech is pressured and with an increased rate, often loud. Mood is described as ‘happy and on top of the world’ and affect is elevated and euphoric. Not appropriate to situation. It is also irritable in parts and quite labile. Thought process is disorganized with apparent flight of ideas connected to grandiose delusional themes. There is no suicidal or homicidal ideation. Thought content has grandiose delusions. Perception appears normal. Insight is poor and Judgment is quite poor – wants to fly to Milan in this state which can lead to unfortunate outcomes. Also, pt. is exercising poor judgment with finances.
Bipolar Disorder - Mania and Hypomania
- Violence to others (imminent)
- At risk for physical impairment i.e. lack of self care to the point that it becomes a danger to the pt. for e.g. the pt. provokes others into a fight due to their irritable state
Depends on level of agitation or need for emergency measures at any point, this is similar to the management of a psychotic pt. if the mania is very severe with psychosis. Refer to that section for details of management and chemical restraints.
A note about Safety:
Always remember that safety is first. If at any point during the interview or later you feel threatened, leave the room and ask for assistance. The assessment can be finished with the help of a nurse, PA or security. At other times, the patient is so agitated that an emergency chemical restraint is necessary before assessment can be completed for the safety of the patient and medical personnel. The assessment may also have to be deferred. However, try to ask questions re SI/HI or other pertinent safety risks in order to be able to make a clinical decision.
Make sure there are no acute medical concerns requiring further assessment and treatment e.g. acute delirium secondary to a toxic substance with unstable vitals
Case Notes:
The psychiatrist offers Catie some PRN medication after explaining the diagnosis calmly. Catie gets very agitated demanding to leave for Milan for her photo shoot. A code white is called and PRN meds are offered orally at first. She refuses even after repeated attempts to convince her. At this point she had to be mechanically restrained and treated with IM Olanzapine 5mg and Ativan 2mg IM.
After 30 mins, a Form 1 is filled out and a Form 42 given to Catie, advising her she needs to stay involuntarily upto 72 hours as she is at a risk for physical impairment to herself. She may go the airport in this state and may be accosted by the authorities or meet with a violent incident attempting to fly in this state. She accepts this calmly, as she is quite sedated.
Assess capacity – usually done after acute stabilization For mania/hypomania doing a Financial Capacity assessment if often necessary and it is the duty of the attending physician to do so. This is to protect the pt. from losing their money due to spending/investing in a manic state. A Form 21 (Certificate of Incapacity for managing property) needs to be filled out and a notice delivered to pt. If pt. is voluntary or involuntary and capable (for treatment decisions) – go ahead and treat with informed consent
Bipolar Disorder - Mania and Hypomania
If involuntary, assess need for a Form 3 (involuntary hospitalization upto 2 weeks) as Form 1 expires in 72 hours. Get patient rights advice. If incapable for treatment decisions do a Form 33 and apply for rights advice and find a SDM If the patient challenges Form 3 and/or 33 and/or 23, prepare and participate in a Consent and Capacity Board hearing and abide by its decision. Ensure ongoing assessment of capacity and the need for a substitute decision-maker Attend to the patient's immediate psychosocial needs e.g. contacting family, legal requirements etc. Can involve social worker. Counsel and support patient/caregiver/family regarding clinical impression/management Refer the patient for specialized care once stabilized e.g. Bipolar Disorder Clinic or First Episode bipolar Disorder clinic.
Psychopharmacology for Acute Management of Mania:
Bipolar Disorder - Mania and Hypomania
Long Term and maintenance therapy for Bipolar Disorder:
Please refer to CANMAT guidelines for an exhaustive review.
Psychotherapy and Social interventions:
Active outreach of patients known to be more severely ill or noncompliant Encouraging patient to become actively involved in self-management Designing a relapse drill (create document with early relapse signs, self-treatment manoeuvres, pre-negotiated treatment approaches) Stress-management techniques (sleep regulation, avoidance of substance misuse) Involvement of family and key friends Connecting patient to other community resources to enhance support and autonomy
Bipolar Disorder - Mania and Hypomania
Upto 50% pregnancies unplanned, important that women with bipolar disorder receive education early Adjunctive psychosocial therapies should be considered early in the course of illness Recommended that all patients first receive psycho-education (group or individual) Evidence that CBT, IPS-RT (Interpersonal Social Rhythm Therapy), and family interventions all improve outcome (reduction in hospitalizations and symptoms).
CBT shown to
Increase adherence Improve functioning Reduce relapse Reduce need for Rx Reduce mood fluctuations Reduce hospitalization
IPS-RT shown to
Reduces sub-syndromal symptoms More time euthymic and less time depressed Did not change relapse risk o Family therapy Reduces relapses and hospitalizations Improves depressive symptoms Improves Rx adherence
Case Notes:
Catie is admitted and then put on a Form 3 and is found incapable of treatment decisions after suitable assessment. A Form 21 is also done after discovering she had maxed out her credit cards buying a first class ticket to Milan and designer clothes. She appeals to the CCB where Form 3 and Treatment incapacity is upheld, but she wins the financial incapacity appeal.
Her Bupropion is discontinued and Lithium restarted and titrated to a blood level of 1.0. Quetiapine XR is added and titrated to a dose of 400mg. After 3 weeks there is considerable improvement. She is worried about the wasted money and says she does not remember the events of the past week or so. She regains her insight and treatment capacity. She agrees to follow-up with her Psychiatrist. She wants a note for work. She is grateful for the help she received. She reunites with her sister and thanks her for bringing her in.
