History
Gathering the history of present and past disturbances of mood, behavior, and thought is critical to proper diagnosis of a psychiatric condition such as bipolar disorder. Unlike clinicians working in other areas of medicine, who often rely on laboratory or imaging studies to identify or characterize a disorder, mental health professionals rely almost exclusively on descriptive symptom clusters to diagnose mental disorders. As a consequence, the history is an essential part of the patient examination.
The fundamental problem might be classified as being primarily related to a physical health issue or primarily related to a mental health issue. Thus, the appropriate first step in evaluating a person for a psychiatric disorder is to ensure that no other medical condition is causing the mood or thought disturbance. Therefore, evaluation of the patient is best started by obtaining their oral history of current and past medical and behavioral symptoms and treatments.
To further clarify the problem, gathering additional information from family, friends, and perhaps other physicians who know the patient is always urged for a person experiencing an altered mood or behavioral state. Because bipolar disorder may cause a transient but marked impairment of judgment, insight, and recall, several sources of information are crucial to understand a particular patient. Therefore, family members, friends, teachers, caregivers, or other physicians or mental healthcare workers may be interviewed to fill out the clinical picture.
Nonetheless, the patient's subjective experience is essential in the evaluation and treatment processes, and the establishment of a therapeutic alliance and trust early in the assessment is vital to obtaining an accurate and useful history from the patient.
Knowledge of the family's psychiatric history is another essential part of the patient’s history because bipolar disorder has genetic transmission and familial patterns. A genogram may be developed to further describe a particular patient’s risk bipolar disorder based on familial and genetic attributes in the family system.
While obtaining the history, the physician must explore the possibilities that substance abuse or dependence, trauma to the brain in the present or past, or seizure disorders may be contributing to or causing the current symptoms of illness. Central nervous system (CNS) insults, such as encephalopathy or medication-induced mood changes (ie, steroid-induced mania), must also be considered.
Delirium should be excluded first in persons presenting with altered mental states or acute disturbances of mood and conduct, especially when encephalopathy of an infectious, metabolic, or toxic origin is possible. It is critical to take a careful history of alcohol use or abuse, including substance-abuse patterns, as acute drug-intoxication states may mimic bipolar disorder. There is as high as a 60% lifetime prevalence of bipolar disorder and substance misuse disorders in the United States. [46]
In communities of lower socioeconomic status or in the presence of stressful life events, parental substance use or disruptive behavior, substance use should be part of the differential diagnosis, especially huffing and ingestion of toxic substances such as methyl alcohol (wood alcohol, gasoline), glue, and sprays. Use of these substances is extremely common among adolescents and can result in a very rapid deterioration of mental status. In addition, such activities may result in hypoxia, potentially leading to permanent brain damage. In this setting, appropriate screening tests of blood, urine, and arterial blood oxygen and organ system function may be life-saving. [47]
Sleep disturbances often aid in defining abnormal mood states of bipolar disorder in either the manic or the depressed state. As such, it is helpful to determine the patient’s baseline euphoric state sleep pattern (eg, does the patient often get up early or stay up late?).
A profoundly decreased need for sleep in the absence of a sense of fatigue is a strong indicator of a manic state. A change in the patient’s usual sleep pattern (eg, from being a "night owl" to an "early riser") may predict a significant change in the patient’s mood state. Sleep studies of the CLOCK genetic areas have utilized functional magnetic resonance imaging (fMRI) to differentiate groups of children and adolescents with bipolar disorder. [48]
An uncomfortable reduction of sleep is a pattern of an atypical depression episode in which more sleep is wanted but cannot be achieved. Conversely, a typical depression episode may be indicated by hypersomnolence, an excessive and irresistible need for sleep. [28]
The biology that drives these sleep anomalies in mood disturbances is not fully appreciated. Some suggest that neurochemical and neurobiologic shifts cause these episodic sleep disturbances in conjunction with other shifts that occur in the evolution of manic or depressed states.
Physical Examination
After interviewing the patient, perform a physical examination. The examination must include a general neurologic examination, including examination of the cranial nerves, muscular bulk, and tone and deep tendon reflexes. Cardiovascular, pulmonary, and abdominal examinations are also essential because abnormal pulmonary function or poor vascular perfusion of the brain may cause abnormal mood, behavior, or cognition.
Both physical and laboratory thyroid examination should be performed because of the potential mood alteration in hypothyroid and hyperthyroid states and because of the need for baseline studies to ensure safety before and during medication treatment (see Workup).
If the physical examination does not reveal a medical condition contributing to the patient’s mental state, a thorough mental health evaluation is appropriate. Through observation and interviewing, mental health professionals may learn of mood, behavioral, cognitive, or judgment and reasoning abnormalities.
The mental status examination (MSE) is the essential component of a mental health evaluation. This examination goes beyond the mini-mental status examination (MMSE) often used in the emergency department (ED). Rather, the MSE is used to assess the general appearance and demeanor, speech, movement, and interpersonal relatedness of the patient with the examiner and others.
Mood and cognitive abilities (eg, orientation to circumstance; attentiveness; immediate-, short-, and long-term modes of memory) are assessed in the MSE. The assessment should be age-appropriate (eg, serial 3s test in younger children).
Some of the most important components of the MSE are those addressing issues of safety of individuals and members of a community. Therefore, suicidal and homicidal issues are explored. Likewise, screens for the more subtle forms of psychosis, such as paranoid or delusional states, in addition to screens for overt psychosis, such as observing the patient responding to unseen others or other non–reality-based internal stimuli, are explored.
Finally, insights into the patient’s mental and physical states, current circumstances of medical or mental healthcare, and ability to show age-appropriate insight and judgment are assessed and integrated into the evaluation of the patient’s global mental state at that moment. As examples, a child might be evaluated on his or her ability to verbalize potential environmental dangers (eg, explaining why not to accept candy from a stranger, why not to run into the street, or how to avoid picking a fight with an older peer).
Complications
Sexual and/or physical abuse is common with bipolar disorder, especially in very young children (< 6 years) and particularly in individuals with comorbid posttraumatic stress disorder (PTSD), psychosis, or conduct disorder. A positive family history of abuse may increase the risk for suicide. [49] Prompt identification and treatment are warranted.{ref39
Polymorphism of the Val66Met BDNF gene may be associated with early experiences of adversity and maladaptive rumination, increasing the risk of suicide for some individuals. [50]
Many persons with bipolar disorder exhibit excessive risk-taking behaviors, potentially predisposing them to injury or dehydration. In contrast, individuals who experience periods of depression may be at higher risk of developing deep venous thrombosis (DVT) and cardiovascular complications due to hypersomnia and excessive bedrest.
In general, a protracted and severe course of illness is associated with an early age of onset of bipolar disorder. [31]
There have been isolated cases of neuroleptic malignant syndrome associated with quetiapine treatment of bipolar disorder in youth. [51]
Tables
| Behavior | Bipolar | DMDD | ADHD | Conduct Disorder |
|---|---|---|---|---|
| Self-esteem | Inflated | Deflated/irritable | Inflated and/or deflated | Inflated and/or deflated |
| Pleasure | Euphoric in mania Dyphoric in mixed or depressed state |
Variable | Often dysphoric or euthymic | Pleasure in violating societal norms, especially if not caught |
| Attention | Distractible | Distractible | Distractible | Normal to vigilant |
| Hyperactivity | Goal directed | Variable | Unproductive | Goal directed |
| Sleep | Episodic disturbances such as decreased need in mania | Often poor due to avoiding bedtime | Chronic poor sleep; often late bedtimes | Not known to be disrupted except with substance abuse |
| Speech | Pressured or rapid in mania; slow in depression | Rapid/normal rate | Often rapid; may be pressured | May be normal |
| Impulsivity | Externally driven/reactive | Reactionary | Internally driven | May engage in predatory or reactionary acts |
| Social | Often good | Often poor | Often poor | Often poor |
| Academic | Often good | Varies | Often poor | Often poor |
| Psychomotor activity | Agitated in mania or mixed states; retarded in depressed states | Easily agitated | Chronically agitated | Easily agitated |
| ADHD—attention deficit/hyperactivity disorder |
Medication |
Common Adverse Effects |
Pediatric Doses |
Special Concerns |
Lithium carbonate (Lithobid) |
GI distress, lethargy or sedation, tremor, enuresis, weight gain, alopecia, cognitive blunting |
10-30 mg/kg/d; dose must be adjusted by monitoring serum level and patient response; up-titrate on twice-daily schedule |
Hypothyroidism, diabetes insipidus, toxic in dehydration, polyuria, polydipsia, renal disease; drug-drug interactions and sodium intake may alter therapeutic serum levels Approved for patients 12 y and older |
Sodium divalproex/valproic acid (Depakote, Depakene) |
Sedation, platelet dysfunction, liver disease, alopecia, weight gain |
15-30 mg/kg/d; dose must be adjusted by monitoring serum levels; up-titrate on twice- or thrice-daily schedule |
Elevated liver enzymes or liver disease, drug-drug interactions, bone marrow suppression Approved for patients 12 y and older |
Aripiprazole (Abilify, Abilify Discmelt) |
Less likely to cause prolactinemia than risperidone; may cause Stevens-Johnson syndrome; as with other atypical antipsychotics, may cause tardive dyskinesia, dystonia, parkinsonism, hyperglycemia; use with caution in seizure disorders and cardiac disorders, including problems with cardiac contractility and electrical activity |
2 mg once daily can be increased to 5 mg, 10 mg, 15 mg, to a maximum of 30 mg to start titrate upwards at weekly to bimonthly intervals |
levels may need to be adjusted in patients who are concurrently receiving lamotrigine, topiramate, Depakote, lithium, or other serotonin-norepinephrine reuptake, selective serotonin reuptake, or cytochrome P450 inhibitors Do not administer if there is an unstable seizure disorder Approved for patients 12 y and older |
Carbamazepine (Equetro) |
Suppressed WBCs, dizziness, drowsiness, rashes, liver toxicity (rare) |
10-20 mg/kg/d; dose must be adjusted by monitoring serum blood levels; up-titrate on twice-daily schedule |
Drug-drug interactions, bone marrow suppression |
Asenapine (Saphris) |
Somnolence, oral paraesthesia |
2.5 mg SL q12h initially; may increase to 5 mg SL q12hr after 3 days and to 10 mg SL q12hr after 3 additional days |
Pediatric patients are more sensitive to dystonia with initial dosing when recommended escalation schedule not followed Approved for patients 10 y and older |
Risperidone (Risperdal, Risperdal Consta, Risperdal M-Tab) |
Weight gain, sedation, orthostasis |
0.25 mg bid or 0.5 mg at bedtime initially; titrate as tolerated to target dosage of 2-4 mg/d; not to exceed 6 mg/d |
Galactorrhea, extrapyramidal symptoms Approved for patients 10 y and older |
Quetiapine (Seroquel, Seroquel XR) |
Sedation, orthostasis, weight gain |
50 mg bid initially; titrate as tolerated to target dosage of 400-600 mg/d |
Decrease dosage with hepatic impairment, may cause neuroleptic malignant syndrome or hyperglycemia Approved for patients 10 y and older |
Olanzapine (Zyprexa, Zyprexa Zydis, Zyprexa Relprevv) |
Weight gain, dyslipidemia, sedation, or orthostasis |
2.5-5 mg at bedtime initially; titrate as tolerated to target dosage of 10-20 mg/d |
Metabolic syndrome, extrapyramidal symptoms |
Clonazepam (Klonopin) |
Sedation, abnormal coordination, ataxia |
0.01-0.04 mg/kg/d PO at bedtime or divided bid |
Caution with renal/hepatic impairment and asthma |
Fluoxetine (Prozac) |
Headache, nausea, insomnia, anorexia, anxiety, asthenia, diarrhea, somnolence |
10 mg PO qd; may consider increasing to 20 mg/d after 1 wk |
Long half-life; potential to exacerbate manic symptoms when not coadministered with an antimanic or mood-stabilizing agent |
Ziprasidone (Geodon) |
Akathisia, nausea |
Off-label: 20 mg PO at bedtime; can increase to 40 mg (not to exceed 60 mg), usually in 2 divided doses for children |
Risk of sudden cardiac death due to torsades des pointes due to prolonged QT prolongation, which makes this medication undesirable for individuals with a family history of cardiac sudden death related to cardiac conduction abnormalities |
WBC—white blood cell. |
|||
