eMedicine Specialties > Psychiatry > Adult

Bipolar Affective Disorder: Differential Diagnoses & Workup

Author: Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Coauthor(s): Lynne Alison McInnes, MD, Associate Adjunct Professor of Psychiatry and Genetics and Genomic Sciences, Department of Psychiatry and Human Genetics, Mount Sinai School of Medicine
Contributor Information and Disclosures

Updated: Sep 10, 2009

Differential Diagnoses

Anxiety Disorders
Posttraumatic Stress Disorder
Cushing Syndrome
Schizoaffective Disorder
Head Trauma
Schizophrenia
Hyperthyroidism
Systemic Lupus Erythematosus
Hypothyroidism

Other Problems to Be Considered

  • Cancer
  • Neurosyphilis
  • Epilepsy (See the Medscape Epilepsy Resource Center.)
  • Fahr disease
  • AIDS
  • Multiple sclerosis
  • Medications (eg, antidepressants can propel a patient into mania; other medications may include baclofen, bromide, bromocriptine, captopril, cimetidine, corticosteroids, cyclosporine, disulfiram, hydralazine, isoniazid, levodopa, methylphenidate, metrizamide, procarbazine, procyclidine)
  • Circadian rhythm desynchronization
  • Attention deficit hyperactivity disorder (ADHD), especially in children and adolescents
  • Cyclothymic disorder
  • Multiple personality disorder
  • Oppositional defiant disorder (in children)
  • Substance abuse disorders (eg, with alcohol, amphetamines, cocaine, hallucinogens, opiates)

Workup

Laboratory Studies

Standard laboratory studies

A number of reasons exist to obtain the following laboratory studies. First, the practitioner needs to perform the tests to determine the diagnosis. Because bipolar disorder encompasses both depression and mania and because a significant number of medical causes for each state exists, an extensive range of tests is indicated. The basic principle remains, "do not miss a treatable medical cause for the mental status." Second, the condition necessitates use of a number of medications that require certain body systems to be working properly; for example, lithium requires an intact genitourinary (GU) system and can affect certain other systems, and certain anticonvulsants can suppress bone marrow. Third, because bipolar illness is a lifelong disorder, performing certain baseline studies is important to establish any long-term effects of the medications.

  • CBC count with differential: This test is used to rule out anemia as a cause of depression. Treatment, especially with certain anticonvulsants, may depress the bone marrow, hence the need to check the red and white blood counts for signs of bone marrow suppression. Lithium may cause a reversible increase in the WBC count.
  • Sedimentation rate: This test is used to look for any underlying disease process such a lupus or an infection. An elevated sedimentation rate would indicate such a disease process.
  • Glucose-level fasting: This test is used to rule out diabetes. Atypical antipsychotics have been associated with weight gain and problems with blood glucose regulation in patients with diabetes.
  • Electrolytes: This test is used to diagnose electrolyte problems, especially with sodium, that are related to depression. Hyponatremia, ie, low sodium can manifest as a depression. Treatment with lithium can lead to renal problems and electrolyte problems. Low sodium levels can lead to higher lithium levels and lithium toxicity. Hence, in screening candidates for lithium therapy as well as those on lithium therapy, checking electrolytes is indicated.
  • Serum calcium: This test is used to diagnose hypercalcemia and hypocalcemia associated with mental status changes, eg, hyperparathyroidism. Hyperparathyroidism, as evidenced by an elevated calcium blood level, produces depression. Certain antidepressants, such as nortriptyline, affect the heart; therefore, checking calcium levels is important.
  • Serum proteins: Low serum protein levels found in patients who are depressed may be a result of not eating. Low serum protein levels increase the availability of certain medications because they have less protein to which to bind.
  • Thyroid studies: Perform thyroid tests to rule out hyperthyroidism (mania) and hypothyroidism (depression). Treatment with lithium can cause hypothyroidism, which may also contribute to the rapid cycling of mood.
  • Substance and alcohol screen: Alcohol abuse and abuse of a wide variety of drugs can present as either mania or depression. For example, speed (ie, amphetamines) and cocaine abuse can present as a manialike disorder, and barbiturate abuse can present as a depressionlike disorder. A number of patients with bipolar affective disorder also have a drug or alcohol addiction; therefore, they have dual diagnoses. Performing a substance screen helps make this dual diagnosis. If the patient has a dual diagnosis, monitoring for these substances is important.
  • Urine copper level: This test is used to rule out Wilson disease, which produces mental changes. It is a rare disease that can be easily missed.
  • Antinuclear antibody: This test is used to rule out lupus.

Infectious screening tests
A number of infections, especially chronic infections, can produce a presentation of depression in the patient. Any of the encephalitides can dramatically manifest as changes in mental status.

  • HIV test: AIDS causes changes in mental status, including dementia and depression.
  • VDRL test: Syphilis, especially in its later stage, alters mental status.

Serum creatinine and BUN

Kidney failure can present as depression. Treatment with lithium can affect urinary clearances, and serum creatinine and BUN can increase. Therefore, carefully and regularly monitor these levels.

Imaging Studies

  • MRI: The total value of performing an MRI in a patient with bipolar disorder remains unclear; however, a couple of reasons do exist for performing an imaging study.
    • Because manic-depressive illness is a lifelong disease, a strong battery of studies rules out any other medical etiology and establishes a baseline.
    • Some investigators report that patients with mania have hyperintensity in their temporal lobes.
  • ECG: Many of the antidepressants, especially the tricyclics and some of the antipsychotics, can affect the heart and cause conduction problems. Lithium also can lead to changes such as reversible flattening or inversion of T waves. A pretreatment ECG is important.

Other Tests

  • The reasons for ordering an electroencephalogram (EEG) in patients with bipolar illness are as follows:
    • EEG provides a baseline and helps rule out any neurologic problems. Use this test to rule out a seizure disorder and brain tumor.
    • If electroconvulsive therapy (ECT) is contemplated, an EEG may be helpful. EEG monitoring during ECT is used to determine the occurrence and duration of seizure.
    • Some studies have shown that abnormalities in EEG findings have been indicative of anticonvulsant effectiveness. Specifically, an abnormal EEG finding may predict the response to divalproex.
    • Some patients may have seizures when on medications, especially antidepressants. Also, lithium can cause diffuse slowing.

More on Bipolar Affective Disorder

Overview: Bipolar Affective Disorder
Differential Diagnoses & Workup: Bipolar Affective Disorder
Treatment & Medication: Bipolar Affective Disorder
Follow-up: Bipolar Affective Disorder
References
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Further Reading

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Keywords

bipolar depression, bipolar disorder, bipolar symptoms, bipolar treatment, manic depression, affective disorder, mood disorder, bipolar affective disorder, bipolar disorder, bipolar I, bipolar II, subthreshold bipolar disorders, bi polar disorder, bipolar treatment, bipolar symptoms, manic-depressive disorder, manic-depressive illness, MDI, manic depression, BPI, BPII, schizophrenia, psychosis, mood disorders, cyclothymia, suicide, mania

electroconvulsive therapy, ECT, electroshock, hypomania, psychomotor agitation, grandiosity, inflated self-esteem, racing thoughts, flight of ideas, distractibility, hypersomnia, insomnia, depression, Mental Status Examination, MSE, aggression

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Contributor Information and Disclosures

Author

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

Coauthor(s)

Lynne Alison McInnes, MD, Associate Adjunct Professor of Psychiatry and Genetics and Genomic Sciences, Department of Psychiatry and Human Genetics, Mount Sinai School of Medicine
Lynne Alison McInnes, MD is a member of the following medical societies: Alpha Omega Alpha, American Psychiatric Association, and American Society of Human Genetics
Disclosure: Nothing to disclose.

Medical Editor

Ronald C Albucher, MD, Chief Medical Officer, Westside Community Services; Consulting Staff, California Pacific Medical Center
Ronald C Albucher, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Iqbal Ahmed, MBBS, Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii
Iqbal Ahmed, MBBS is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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