Bipolar Disorder (FL INITIAL Autonomous Practice - Differential Diagnosis)

Bipolar disorders are classified by their extremes in mood (Black & Anderson, 2016). Historically, they were referred to as bipolar affective disorders or manic-depression. They consist of excessive swings in the mood, very different from daily life's normal ups and downs. The shifts in mood, energy, and the ability to function in life that spring from bipolar disease can manifest in several forms ranging from periods of hyper-energy to intervals of deeply morbid depression (Black & Anderson, 2016). There are seven types of bipolar disorders classified in the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) (APA, 2013):

• Bipolar I disorder
• Bipolar II disorder
• Cyclothymic disorder
• Bipolar disorder due to other medical conditions
• Substance/medication-induced bipolar disorder
• Other specified bipolar disorder
• Unspecified bipolar disorder

Often the presence of bipolar disorder goes unrecognized and untreated (Black & Anderson, 2016). When diagnosed, treatment for bipolar disorder differs from that conventionally used for unipolar depression (Gabbard, 2014). The ability of health professionals to recognize signs of bipolar mood disturbances is an important skill, as is the understanding of current treatment and management of this potentially life-altering disorder.

Bipolar disorders are lifelong diseases (Sadock et al., 2015). The onset of significant symptoms may occur at any age from early childhood to late in the 50s and even beyond (Sadock et al., 2015). For many, the age range between 15 and 24 seems to be when significant, disruptive swings in mood and functioning manifest clearly (Sadock et al., 2015).

Genetics is a factor in bipolar disorder, with first-degree relatives seven times more likely to experience bipolar symptoms than a person chosen from the population at random (Malectic & Raison, 2014). However, no direct "bipolar gene" has been identified. Neither race nor sex plays favorites in bipolar disorder as prevalence is distributed equally. However, certain subtypes of bipolar tend to be slightly more common in one sex or the other (APA, 2013).

Biochemistry changes in the brain accompany bipolar disorder. Several neurotransmitter systems show alteration in bipolar brain disease, making it difficult to determine what is going on exactly. Glutamate increases in the brain appear consistent in both bipolar and major depression, while poor regulation of serotonin has been associated with mania (Malectic & Raison, 2014). Hormonal imbalances, along with disruptions of the hypothalamic-pituitary-adrenal axis involved in homeostasis and the stress response, have also been implicated as biochemical contributors to the clinical picture of bipolar disorder (Malectic & Raison, 2014).

Psychodynamic factors that influence cognitive processing also play roles in bipolar disorder (Sharf, 2015). The efforts of the brain to cope with difficult to reconcile feelings of loss or acute and chronic stresses are all implicated as contributors to bipolar disorder (Sharf, 2015).

In 2013, the American Psychiatric Association (APA) published the DSM-5, an update of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) (APA, 2000). The APA made four major changes to bipolar disorders to enhance the accuracy and specificity of their diagnosis in the clinical setting (APA, 2013).

First, the criteria for manic and hypomanic mood episodes now emphasize a change in activity and energy in addition to changes in mood. Second, the diagnosis of bipolar I disorder, mixed episode, has been removed and replaced with the diagnostic specifier, "with mixed features." Third, the APA added a new diagnosis called other specified bipolar disorder, which encompasses patients who meet all the symptomatic criteria but do not meet the duration criterion. Lastly, a new specifier called "with anxious distress" was added to classify patients with prominent anxiety symptoms (APA, 2013).

To fully understand a bipolar disorder diagnosis, nurses and nurse practitioners must learn to differentiate mood episodes. Mood refers to a sustained emotion that paints how a person interprets their life (Morrison, 2014). Nearly 20% of women and 10% of men experience a mood disturbance at some point in their lives (Morrison, 2014).

The DSM-5 outlines three different types of bipolar mood episodes (APA, 2013):

1. manic
2. hypomanic
3. major depressive episodes

While both manic and major depressive episodes must present with severe symptoms to impair the patient's social and occupational functioning, a hypomanic episode does not. Before diagnosing any mood disturbance, the physiological effects of a substance or medical condition must be ruled out.

The DSM-5 includes ten different specifiers that clinicians can append to the bipolar diagnosis to include more information about the current or most recent mood episode (APA, 2013). The ten specifiers and their definitions are included below.

• Anxious distress: Used to describe the most recent mood episode if it can be characterized by feeling keyed up, tense, restless, difficulty concentrating due to worry, fear of impending doom, and feeling like the individual might lose control of him or herself.
• Mixed features: If the most recent mood episode was either manic or hypomanic, this specifier is used to describe prominent dysphoria, depressed mood, tearfulness, fatigue, loss of energy, excessive guilt, feelings of worthlessness, suicidal ideation, psychomotor retardation, and anhedonia. Suppose the most recent mood episode was major depression. In that case, this specifier is used to describe an elevated, expansive mood, grandiosity, pressured speech, flight of ideas, increased goal-directed activity, and decreased need for sleep.
• Rapid cycling: A specifier that describes the presence of at least four mood episodes in the last 12 months.
• Melancholic features: Used to describe a loss of pleasure in activities, lack of reactivity to pleasurable stimuli, depressed mood in the morning, moroseness, profound despondency, early-morning waking, excessive guilt, weight loss, and psychomotor agitation.
• Atypical features: This specifier can be used to qualify a major depressive episode with predominantly atypical symptoms such as mood reactivity, weight gain, increased appetite, hypersomnia, leaden paralysis, and interpersonal rejection sensitivity.
• Psychotic features: The presence of delusions or hallucinations during mood episodes.
• Mood-congruent psychotic features: Psychotic symptoms that mimic the typical themes of a mood episode. For example, mood-congruent psychotic symptoms during a manic episode would include themes of grandiosity, invincibility, and suspiciousness.
• Mood-incongruent psychotic features: The presence of psychotic symptoms that are unrelated to typical themes related to the current mood episode.
• Catatonia: Used to describe a manic or depressive episode with prominent catatonic features.
• Peripartum onset: Used to describe the onset of a mood episode either during pregnancy or within four weeks after delivery.
• Seasonal pattern: This specifier is used when the patient experiences a regular seasonal pattern of mood episodes.

For a patient to be diagnosed with bipolar I disorder, they must meet the criteria for having experienced at least one manic episode. The patient doesn't need to have experienced a major depressive episode. When the diagnosis is made, the current mood episode should be listed and classified as either mild, moderate, or severe. The diagnosis may also include a specifier to provide further information about the patient's current state (Morrison, 2014).

In addition to traditional manic episode symptoms, patients may also report a sharper sense of sight, smell, and hearing. They may dress more flamboyantly, wearing extra makeup or gaudy costumes (Sadock et al., 2015). Gambling, sexual indiscretions, and reckless driving may emerge as well. Some patients will become hostile, delusional, and verbally threatening (Morrison, 2014).

A diagnosis of bipolar II disorder requires both a current or past hypomanic and major depressive episode (Morrison, 2014). At the time of diagnosis, the clinician should decide which type of an episode the patient is experiencing and whether this episode is mild, moderate, or severe. Individuals with bipolar II disorder usually present to treatment during a major depressive episode. The most common feature of bipolar II disorder is impulsivity, which can sometimes lead to suicide attempts and substance abuse disorders (Sadock et al., 2015). Increased levels of creativity are sometimes noted during hypomanic episodes (Sadock et al., 2015).

Cyclothymic disorder is a type of bipolar disorder characterized by hypomanic and depressive episodes that do not meet the full criteria for severity or duration (Morrison, 2014). Furthermore, the cyclothymic symptoms must have been present in the previous two years for at least half the time. The key feature of this disorder is the chronic fluctuating mood episodes with symptom-free intervals lasting less than two months (Morrison, 2014).

The DSM-5 includes two bipolar disorder categories for situations where patients do not fit neatly into the other diagnostic categories: other specified bipolar disorder and unspecified bipolar disorder (APA, 2013).

Other specified bipolar disorder describes a patient's condition that does not meet the full criteria for bipolar I, bipolar II, or cyclothymic disorder. However, they are experiencing significant social or occupational impairment. The "other specified" diagnosis must include one of four designations (APA, 2013):

• Short-duration hypomanic episodes or major depressive episodes
• Hypomanic episodes with insufficient symptoms and a lifetime history of one or more major depressive episodes
• A hypomanic episode without a prior major depressive episode
• Short-duration cyclothymic disorder

Unspecified bipolar disorder refers to a patient who does not meet the full criteria for bipolar I, bipolar II, or cyclothymic disorder. Still, they are experiencing significant social and occupational impairment. The difference between unspecified and other specified is that clinicians do not include one of the four designations listed above. Instead, clinicians do not specify a specific reason why the criteria are not met (APA, 2013).

Physical conditions can create or extend mental health conditions. If nurses and nurse practitioners forget to evaluate for underlying medical conditions, they jeopardize the accuracy of the diagnosis and their patient's health.

Medical conditions that imitate symptoms of bipolar disorder include (Morrison, 2014b):

• Acquired immunodeficiency syndrome
• Brain tumor
• Cerebrovascular disease
• Cryptococcosis
• Cushing's syndrome
• Epilepsy
• Head trauma
• Huntington's disease
• Hyperthyroidism
• Hypothyroidism
• Multiple Sclerosis
• Pernicious Anemia
• Syphilis
• Systemic Lupus Erythematosus

Clinicians should pay close attention to signs, symptoms, and historical information to rule out an underlying medical condition. A mental status exam, in addition to diagnostic imaging and laboratory work, can help rule out medical conditions. A physical cause for mental symptoms is more likely if the patient is experiencing their first mood disturbance or if their patient is 40 years or older (Morrison, 2014b).

Those who have bipolar disorder are at an increased risk of committing suicide. Recent literature reveals that 15 percent of bipolar sufferers complete suicide, with between 25 to 50 percent of bipolar disorder clients attempting suicide at least once during this life-long illness (Sadock et al., 2015).

To help put this into perspective, more clients experiencing bipolar symptoms attempt suicide than in any other psychiatric diagnosis, including unipolar depression. On average, 29.2% of patients diagnosed with bipolar disorder attempt suicide, compared with 15.9% of those with unipolar depression and 4.2% of those with any other psychiatric condition (Sadock et al., 2015).

The emotional roller coaster of bipolar disorder places clients at a heightened risk for suicide not only during depressed episodes but also during manic swings when the executive decision-making process and the ability to make a good judgment is impaired. While suicide is a major risk for all bipolar clients, certain factors tend to affect the potential for suicidal thoughts or acts. Early diagnosis and treatment decrease a patient's risk of suicide; however, the following factors increase the risk of suicide or self-injurious behavior (Sadock et al., 2015):

• Personal or family history of suicidal behavior;
• Severity and number of depressive episodes;
• Alcohol or substance dependency;
• Degree of pessimism;
• Level of impulsivity or aggression; and,
• Younger age of symptom onset.

Geraldo is a 29 y/o Hispanic male admitted after being found unconscious in a parked car outside of his ex-spouse's apartment complex. Empty prescription medication containers were found in the passenger seat next to him by the deputy sheriff, who had been called to investigate a suspicious vehicle.

Medications involved are:

• Paroxetine an SSRI antidepressant
• Methylphenidate hydrochloride is a mild CNS stimulant
• Modafinil is a medication used to combat sleep disorder

Also found with Geraldo was a small spiral-bound notebook of the type commonly issued during counseling for journaling thoughts and feelings. The handwriting on the last few pages of the notebook is difficult to decipher, yet it mentions the loss of friends, spouse, and job due to recurrent bouts of deep depression. No suicide note is present.

Geraldo's former wife reports that she has been without contact with him for several months; however, she recently heard from former friends that he was without a job or a place to live. She reports Geraldo has a longstanding history of "laziness," where he would just lay around the house without bathing or even talking to her, and that he put very little effort into relationships or into maintaining employment.

Geraldo's former wife also reports that his underlying inattentiveness was interrupted by occasional periods of high energy that lasted a few weeks at a time but which occurred infrequently. She further reports that she had pressed Geraldo to seek treatment for depression after losing several jobs. However, even after treatment, nothing seemed to change, so she had decided that the lack of interest he showed in their relationship and in seeking work must be a choice. She adds that someday he will wake up, make a decision, and grow out of it.

Acute treatment of bipolar disorders focuses on which phase of the disease the client is currently experiencing and the severity of symptoms experienced (Gabbard, 2014). Clients in an acute manic episode may display poor judgment that they pose a serious risk to themselves and even those around them. Therefore, they require the safety provided by inpatient treatment (Gabbard, 2014).

Whenever suicidal behaviors are present, inpatient treatment is required. Severe depression also warrants inpatient treatment, while moderate depression or behaviors without risk of injury to the client or others around them may be handled in day treatment clinics or outpatient settings (Yatham et al., 2018).

Importantly, in January 2020, organizations worldwide released an update to the treatment of bipolar disorder: valproate should not be used in women of childbearing potential unless all other options have been exhausted and a pregnancy prevention program is in place. The recommendations came from evidence demonstrating that valproate, when taken during pregnancy, results in malformations in 11% of babies and developmental disorders in 30-40% of children after birth (Irelli et al., 2019).

Bipolar disorders are a life-long ride of hyper-energetic mood highs and deeply depressive lows. Many of those afflicted by this brain disease contemplate, attempt, and succeed in suicide as a means of coping with the intense turmoil bipolar disorder creates in their life. More people have bipolar disorder than are currently diagnosed. The spectrum of illness created by bipolar swings can vary widely yet share the characteristics of significant shifts in mood and ability to function effectively in life. Often bipolar disease goes undiagnosed and untreated. Effective treatment consists of medication, psychotherapy, and ongoing support to minimize the aversive effects of bipolar symptoms while keeping this ever-present disorder in remission.

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• Irelli, E., Morano, A., Enrico, et al. (2019). Doing without valproate in women of childbearing potential with idiopathic generalized epilepsy: implications on seizure outcome. Epilepsia. 2020(61): 107-114. doi: 10.1111/epi.16407.
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• Yatham, L., Kennedy, S., Parikh, S., et al. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders. 20(2):97-170. doi: 10.1111/bdi.12609.