welcome back to dirty medicines dirty psychiatry series in this video we're going to be talking about all of the bipolar spectrum disorders this is what we're going to be covering today we'll begin by discussing the symptoms of all of the bipolar spectrum disorders and these are sometimes referred to as the dig fast symptoms we'll then touch specifically on bipolar one disorder bipolar two disorder and cyclothymia we'll also briefly mention some of the treatments for bipolar disorder but the treatments for bipolar disorder which are by and large mood stabilizers will actually be covered in their own video so let's just begin by talking about the symptoms that typically present in somebody who's suffering from one of these bipolar spectrum disorders now you may have heard of sig ecaps symptoms when people talk about major depressive disorder and just like in major depression with it's ciggy caps symptoms mania which is the the focal point of the bipolar spectrum disorders or the classic presentation is made up of its own acronym of symptoms and these symptoms are called dig fast d IG FA s T and you should be familiar with what each of these letters stands for because each of these symptoms are part of the criteria for things like bipolar one bipolar two and cyclothymia so let's go through this the d stands for distractibility so this is the ability to distract somebody it's like they start one task and then they see some kind of stimulus out of the left part of their eye and then they stop what they're doing and they do something else and then they're doing some another task and then they stop what they're doing because someone starts talking to them and then they engage with that person so sort of bouncing around like that and being easily distracted is called distractibility the I stands for impulsive 'ti and this is classically risk-taking impulsive behavior so the manic patient might do some things like get on top of a moving train and ride on top of the train or climb up an electrical pole and and like move down the wire to the next pole so very impulsive risk-taking dangerous behavior that's out of character for what the patient might typically do if they were not manic grandiosity is what the G stands for so being grandiose means that you believe yourself to be more important than you actually are and when somebody has bipolar one and they're manic they might believe that they are Jesus or that they are God so that's grandiosity sometimes they could believe that they have special abilities or that somebody who has never gone to college before might understand really complex astrophysics or something like that so that's grandiosity the F stands for flight of ideas and a flight of ideas is just a non-stop rapid idea that comes to the brain and usually comes out of their mouth in the form of very rapid and uninterruptible speech so when you're talking to somebody who's manic are talking to a patient which has any of the bipolar spectrum disorders you might notice that the rate of their speech is so fast that you can't even interrupt them to get a word in so the flight of ideas is the thought content portion of it and then it comes out of their mouth as the really rapid speech which is the T at the end of this mnemonic which is talkativeness so a flight of ideas and talkativeness sort of go together with the flight of ideas is the content in their brain which translates into the really fast rapid speech that's uninterruptible which is the T and talkativeness that comes out of their mouth the a is activity and this is increased goal-directed activity classically patients who are manic will begin projects or have some type of endeavor that they're starting an example might be somebody who wants to save all of the starving children in Africa so they go to a bookstore and they buy thousands of books and then they go to a UPS Store or a FedEx and they buy all of these boxes to ship all of these books to and they get to the store and they realize that they don't have enough money and then they abandon that task and they start a different task to save all of the starving children in Africa so they go back to the supermarket and they start buying all of the bags of Hershey bars that are there at the checkout aisle because they're gonna send all of these Hershey bars to Africa and they're sort of bouncing from one goal to the next even though it's never going to be completed in most cases and it's unrealistic s is sleep and specifically this is a decreased need for sleep now this is really important and I want to pause for a second both patients that are depressed and patients that are manic are gonna have changes in their sleep and it's really important that you understand this difference especially for step two level two and beyond because test writers can actually get you here so in the depressed patient they're gonna usually have trouble sleeping but even though they're having trouble sleeping they're still tired the next day because if you only sleep two or three hours a night you're obviously going to feel tired the next day because you didn't sleep that's your depressed patient it's like you or me we if we don't sleep we're gonna be tired but in the manic patient there's a decreased need for sleep so not only are they only sleeping two to three hours but they still maintain that incredibly high energy level and they're not tired so it's a decreased need for sleep not trouble sleeping and that subtlety is very high yield because if a test writer writes a question they might put in the question stem that the patient only slept for two hours and then it's your job to figure out is this depression that I'm seeing the depressed phase of a bipolar illness because as you'll learn later in this video patients who are bipolar fluctuate between high energy manic states and low-energy depressed States or is this someone who's just simply depressed and has major depressive disorder and they only have depression which would be called unipolar depression unipolar for one poll because you're only down and depressed you're not bipolar bipolar polls you're not up and manic and down and depressed so that's a very very high yield point about sleep and then tea again we've already talked about this that's talkativeness so these are called the dig fast symptoms and these are tomainia what siggy caps are to depression so you absolutely need to know these symptoms because they're going to be described in the clinical vignettes of your questions so now that you understand what the symptoms look like let's talk about bipolar one disorder specifically so the criteria for bipolar one disorder is that you have a manic episode plus or minus a depressive episode okay so it doesn't matter whether or not you you know that they ever were depressed or you hear that they were ever depressed if the patient has a manic episode they are immediately diagnosed with bipolar one disorder stop what you're doing the diagnosis is bipolar one so you don't have to worry about bipolar 1 versus bipolar 2 versus cyclothymia if they have a manic episode it's bipolar 1 done end of discussion so let's talk about what a manic episode really consists of so a manic episode is 4 of 7 dig fast symptoms so those symptoms that we just talked about if you have at least four of them it's a manic episode if it lasts for at least one week so 4 of 7 dig fast symptoms that last for at least one week is a manic episode or now this is the very high yield point for step two level two and beyond if the patient gets hospitalized so they go to an acute inpatient psychiatric unit or they present with psychotic features and there's a known history of some bipolar spectrum disorder it automatically qualifies as a manic episode it automatically qualifies as bipolar one disorder so I want to be very clear here if you're taking your test and they give you at least four of those dickfist symptoms that lasts for at least one week and they'll always give you the time line so make sure you read it in the question if there's at least four dig fast symptoms lasting for at least seven days it's a manic episode and that means because it's mania it's bipolar one so in bipolar two you don't get mania you get something else called hypomania and we'll touch on that in a little bit in cyclothymia you get alternating hypomania with something called dysthymia which we'll touch on in a bit but the only bipolar spectrum disorder that actually features a true manic episode is bipolar one disorder so I'm repeating myself several times here because this is so high-yield please know this 4 of 7 dig fast symptoms lasting for at least one week makes you bipolar one stop what you're doing and pick the answer or if you get a patient that kind of sounds like in the vignette that there they might be bipolar maybe the question writer is a real pain in the ass and they they give you like three symptoms of dig fast but they tell you that the patient ends up admitted to inpatient psychiatry it's bipolar one disorder because as long as they're getting admitted to the hospital it's a it automatically qualifies as bipolar one disorder same thing with psychotic symptoms don't worry about the subtleties here just memorize four of seven take fast symptoms for at least one week is a manic episode and that qualifies as bipolar one disorder now the plus or minus depressive episode is there because you've probably been taught that bipolar means two poles and you're shifting between mania which is the up and depression which is the down and it's absolutely true that the patient is going to have both manic and depressed episodes but it's the manic episode that will seal the diagnosis for you so how do you remember this right how do you remember this really important high-yield clinical information that I've probably repeated five or six times already well for bipolar disorder I want you to remember that mania is one fun week so you have one fun week it lasts for seven days it's four of seven symptoms for at least seven days or at least one week so one fun week and if we compare that against major depressive disorder MDD major depression is two blue weeks so there's one fun week for mania and two blue weeks for depression okay one fun week for bipolar and two blue weeks for depression so really really awesome mnemonic easy to remember please memorize this four of seven for at least one week is bipolar one now this is what we've talked about so far and I want to illustrate this on a little graph so you can understand what bipolar one disorder looks like in terms of its clinical fluctuation so here's youth a Mia in the middle of the graph and youth amia just pretty much means normal mood it doesn't you're not depressed you're not down you're not manic you're not up but bipolar one disorder on a graph looks like this so in the red phase of the graph the patient is manic so they're up their mood is more expansive it's maybe more irritable it's up from youth thymio so it's manic and the depression phase is obviously down in blue so if you're the you know going down and you're getting worse than you think then you're gonna be depressed so it's this fluctuation between the manic episode and the depressed episode that categorizes bipolar one disorder and again it's important to remember that for bipolar one you have to have a manic episode plus or minus the depressed episode so in bipolar one disorder if we wanted to treat this what we would do is we would want to fix the mania and bring it back down to youth amia which you see there in the red phase of the graph and if we wanted to treat depression we would want to push that blue part of the graph back up to your thigh Mia and treat the depression and the way that we do that is with different drugs and this is just gonna be a quick overview of mood stabilizers but mood stabilizers will get their own video so to fix the manic portion we would use mood stabilizers such as lithium valproic acid carbamazepine olanzapine and risperidone now mood stabilizers even though it's one big category which are drugs that stabilize your mood actually are drugs that come from different categories so lithium in and of itself is considered a mood stabilizer but valproic acid and carbamazepine are actually anti epileptic drugs that are used as mood stabilizers olanzapine and risperidone are atypical or second-generation antipsychotics that are used as mood stabilizers so these are really used in in its own category even though each of these drugs comes from different categories and then to fix the depressed phase of bipolar one disorder you would also use mood stabilizers which are things like lithium again lamotrigine olanzapine plus an SSRI laura's adone quetiapine so again we're pulling different drugs from different categories and using them to treat the bipolar spectrum disorders because all of these drugs whether they're antipsychotics or whether they're anti-epileptics all have mood stabilizing properties and fix the manic episode or the fluctuation between mania and depression now something that's incredibly high yield to know is that you never ever give an SSRI alone to a patient that's manic or a patient that has bipolar one and is in the mania portion or bipolar two is in the hypomania portion you never give them an SSRI alone and the reason for that is let's take an example let's say that you had a patient who was exhibiting this this switching from mania to depression and you want to treat the depressed face maybe you didn't know that they had bipolar disorder let's pretend for a second you were like huh I see that someone is having symptoms of depression maybe it's major depressive disorder let me give them an SSRI so you give them an SSRI and when you introduce the SSRI you push the depressed part of this graph up to youth amia and you're like oh cool I'm an amazing medical student I suggested that the patient get an SSRI and now their depression is gone but what happens to the patient with bipolar one disorder is that you push them past you Thema and unfortunately you flip them into mania because by reversing the depressed part you overcorrect and flip them right into mania so high-yield never give an SSRI alone to a manic patient so this is what we've talked about so far and again mood stabilizers in terms of mechanism adverse drug reactions and all of the high-yield clinical tidbits will get their own video and that's coming but now let's switch gears and talk about bipolar two disorder so bipolar two is a lot like bipolar one and the major difference here is that instead of a manic episode these patients get hypomanic episodes they get hypomanic episodes usually with a much more prominent major depressive episode but what what the difference is here is that instead of mania it's hypomania so hypo means less so it's less mania so it's a manic episode that's a little bit less than a true manic episode so let's talk about criteria for hypomania you need 3 of 7 dig fast symptoms for at least four days and they are never manic so they're not 4 or more symptoms for 1 week which was the criteria for mania and bipolar 1 and they never get psychotic features because if they got psychotic features they would either be diagnosed with bipolar one disorder or they'd be diagnosed with something like schizoaffective disorder bipolar type but in this case it's 3 of 7 so it's less than the criteria for mania and it's only for four days instead of 7 so it's hypomania mania so they're so gonna present with symptoms that sound like they're manic right their speech might be really fast and they might have increased goal-directed activity maybe there are little grandiose but they're not gonna have the full spectrum of symptoms that would lend itself to a diagnosis of mania and therefore bipolar one so this is bipolar two hypomania so how do you remember this criteria well I've got an awesome mnemonic for you so I want you to remember hypo mein threa so hypo has four letters which reminds me that you need this for at least four days and instead of saying mania I say main three a' main three a' three because you need three of seven dig fast symptoms so hypomania is how I remember the hypomanic episode criteria and again hypo has four letters so this lasts for at least four days and main three three four three of seven dig fast symptoms so that is bipolar two disorder and just to illustrate this let's go back to the graph so this is the graph that I showed you for bipolar one disorder there was the manic episode that flipped into depressive episodes and the patient would alternate between the two but since hypomania is a little bit less than mania if we just bump that red part of the graph down a little bit this is what bipolar 2 looks like so the patient will alternate between these hypomanic episodes and these major depressive episodes it's three of seven dig fast symptoms for at least four days when they're in the hypomanic part and when they're in the major depressive part it's just the criteria for major depressive disorder so you know you're at least five siggy cap symptoms for at least two weeks so that's bipolar two disorder and the way that we treated is really the same way that we treat bipolar one with a little bit more of an emphasis on the mood stabilizers in the blue column here so more in the realm of giving quetiapine or larezo Doane which are atypical second-generation antipsychotics but the subtleties of that are beyond the scope of this lecture and mood stabilizers we'll get their own video so that's bipolar two disorder let's talk about cyclothymia so a lot of people a lot of medical students get really caught up on exams with the terminology here of cyclothymia and dysthymia and all the things that end with thymio so let's talk about criteria so cyclothymia ciclo means cycling or alternating and thigh mia is how we about mood so right youth a me is normal mood dis time eeeh is dis like dysphoric are not working mood which typically means someone is slightly depressed so cyclothymia is alternating mood so what's the criteria the patient's gonna have hypomanic episodes and dysthymic episodes and I'll talk about what each of these terms refers to so we already talked about hypomanic episodes we in fact we just talked about it it's 3 of 7 dig fast symptoms for greater than 4 days so 3 at least 4 days 3 of 7 dig fast symptoms so the patient has hypomanic episodes but when they're not hypomanic they're having dysthymic episodes and dysthymic episodes are greater than 2 and less than 4 or less than 4 excuse me I should say greater than 2 and no more than 4 so 4 or less siggi caps symptoms and it does not meet criteria for major depressive disorder so it's sort of like baby depression so if you want to think about cyclothymia in a really simple way its baby mania alternating with baby depression they never meet criteria for mania they never meet criteria for a major depressive episode but they're still a little hypomanic and they're a little depressed at times so they're flipping between them so if we put this on a graph instead of mania and major depression it's gonna be hypomania and dysthymia so the patient's gonna alternate like this they're gonna have episodes where they're up but not fully up because they're just hypomanic and then those red parts of the graph they'll have three of seven dig fast symptoms for at least four days but when they're down they're not gonna be down to the point where you're gonna diagnose them or think that they have major depressive disorder but they're still gonna be like you know a little depressed they're gonna have at least two but no more than four sig ECAP symptoms of depression that never meets criteria for MDD so this is how cyclothymia looks on our mood graph so very very important to know so just memorize that cyclothymia which means alternating mood is hypomanic episodes mixed with dis imma kepis ODEs and this alternation happens for at least two years high-yield it happens for at least two years okay that is cyclothymia let's briefly wrap up this video by just talking about some other of mania that you could see on your exams that won't be things like bipolar one bipolar two or cyclothymia but the patient will still present with the big fast symptom so these are some things you should just keep in mind steroids if a patient is being started on steroids for some type of inflammatory condition they can become manic from the steroid you can get substance induced mania so if someone's doing cocaine or methamphetamine any stimulant really can cause mania drug-induced so I don't mean illicit drug I mean you know like prescription drug different drugs are known to cause mania and that's really all you need to know for the purposes of step one level one step two level two and then you can get autoimmune induced mania so some people with autoimmune conditions such as lupus can become manic if the disease is not managed correctly neurosyphilis and HIV can cause mania subacute combined degeneration due to a vitamin b12 deficiency can cause mania hyperthyroidism is huge Zaira disease is the great masquerader Lyme's disease lyme disease which i did not put on this slide can cause mania and then you know wilson's disease there's a lot more causes but I'm just listing some stuff that you might see pop up because there are neuropsychiatric manifestations of all of these disease processes so keep these in the back of your mind but that's it for this video I hope that you now understand the bipolar spectrum of disorders I hope that you understand dig fast symptoms the criteria for each of these three different disorders and what they look like on graphs if you've enjoyed this video please know that more psychiatry videos are coming and you'll be an expert by the time that they are done