Case history

Case history #1

A 20-year-old man presents to the accident and emergency department accompanied by his parents, owing to a change in mental status and behaviour, marked by uncharacteristic argumentativeness, eruptions of laughter, excessive talking, and unusual thoughts. He reports being treated for depression and insomnia, and has recently been drinking more alcohol. For the past 2 weeks he has missed college classes, while staying up most nights until 4 or 5 a.m., writing feverishly in several notebooks. When asked, he reports that he is writing two novels at the same time and also documenting his accomplishments in an autobiography. He denies any illicit substance use but describes an increase in alcohol consumption 'like all the great novelists do'. Efforts by his family to understand his recent change in thinking and behaviour have been met with loud and rambling discourses, and he angrily accuses them of wanting him to stay 'subjugated by the tyranny of depression'. Based on the presence of elevated and irritable mood, with associated symptoms including decreased sleep, increased energy, impulsivity, increased goal directed activity, and grandiosity, lasting longer than 1 week, the recent episode meets criteria for a mania episode, as part of a bipolar I diagnosis.

Case history #2

A 32-year-old nurse presents to her primary care provider complaining of frequent headaches, irritable bowel, insomnia, and depressed mood. She currently takes no medication and has no history of substance use or major medical problems beyond treatment for a single depressive episode when she was a college first-year student. Her physical examination, routine labs, and computed tomography of the brain are all within normal limits. Her family history is notable for several ancestors who have been affected by psychiatric illness, including depression, bipolar disorder, and schizophrenia. Her paternal grandfather and a maternal aunt died by suicide. She has had three prior episodes of several weeks' duration characterised by insubordinate behaviour at work, irritability, high energy, and decreased need for sleep. She regrets impulsive sexual and financial decisions that she took during these episodes and reports that she has recently filed for personal bankruptcy. For the past month her mood has been persistently low and she has had reductions in sleep, appetite, energy, and concentration, with some passive thoughts of suicide. The depressive periods appear to rise to the level of major depressive episodes, while past periods of increased impulsivity appear to meet criteria for hypomania episodes, leading to a bipolar II diagnosis.

Other presentations

Individuals may present with other variants or with complex comorbidities that can make diagnosis challenging. Approximately one third of people with bipolar mania meet criteria for mixed (depressive) features, and approximately one third of people with bipolar depression meet criteria for mixed (manic or hypomanic) features.[3]​ Mixed episodes may represent a more difficult-to-treat state, and are associated with an increased risk of suicide.[4][5] Mixed symptoms may be continuously present, or may manifest sporadically.[5]

Rapid-cycling bipolar disorder is characterised by 4 or more mood episodes in a 12-month period; it is more resistant to pharmacological treatment and may be worsened by traditional antidepressants.

In women who have recently given birth (typically 3-10 days after birth, but it may also occur beyond 4 weeks postnatal), the first presentation of bipolar disorder may be with postnatal psychosis.[1][6]

Some people with bipolar disorder experience severe psychotic symptoms and thought disorder which may mimic schizophrenia.

Most people with bipolar disorder suffer with at least one comorbid condition that can complicate diagnosis and treatment. The most common comorbidities include substance use disorders, anxiety disorders, panic disorders, attention-deficit disorder, personality disorder, and common medical conditions such as obesity, diabetes, hypertension, migraine, and irritable bowel syndrome.[7][8][9][10][11][12][13][14][15][16]

People may also initially present with symptoms diagnostic of major depressive disorders, and only later develop mania or hypomania; although figures in the literature vary, rates of diagnostic conversion from depression to bipolar disorder may be as high as 30% within three years.[17][18]​​

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