S2E1 – The B in Bipolar Stands for ‘Be Careful’: Diagnosing Bipolar Spectrum Disorders

Welcome back to The Y in Psychiatry <3

Season 2 kicks off with a bang—or should we say a hypomanic burst—as our crew reunites to unpack one of the most enigmatic diagnoses in mental health: Bipolar Disorder.

Join Dr. Amayo, Dr.  Nguyen, Dr. Handratta, and freshly minted PGY-1 Edmund as they peel back the layers on:

• What bipolar disorder really is (spoiler: it’s not just mood swings)
• Why bipolar looks different in kids—and how we often get it wrong
• The fine line between ADHD and mania
• The dangers of mislabeling depression
• Manic vs. hypomanic: it’s all about duration and dysfunction
• Cyclothymia, mixed episodes, rapid cycling, and the misunderstood DMDD

We sprinkle in some laughs, myth-busting, and real clinical pearls that even the most seasoned psychiatrist will appreciate. 

Get ready to dig fast into DIGFAST. 🔍

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Transcript

0:01

Welcome to the Y in Psychiatry! Hi, I'm, uh, Dr. Amayo. I am a consult and liaison psychiatrist. Where we delve into the intricate nuances of psychiatric topics. Hello guys. I'm Dr. Handratta I did my residency from University of Connecticut and then I did my fellowship from Georgetown University in consultation and liaison Each episode features interview style discussions that explore the intersection of the mind medicine and the human experience. My name's Edmond I am a incoming PGY one psychiatry resident. Together we'll uncover the hidden why and the groundbreaking discovery shaping the psychiatric landscape. So grab a seat, warm beverage, tune in, and let's embark on this journey to unlock the mysteries of the human psyche. Only on The Y in Psychiatry. And we are back. That's right guys. Welcome to season two of the Y in psychiatry. Oh boy am I excited for this season. I am so excited. I've been begging these I had to blackmail these guys. To come back to get the band over Oh God. finally did it. As usual, we have the usual suspects. I'll introduce myself and I'll let everyone introduce themselves. Hi, I'm Dr. Amayo. I am a consult and liaison psychiatrist. Hello guys. I'm Dr. Handratta I am Dr. Thanh Nguyen. I'm a child and adolescent psychiatrist. And my name's Edmond and I am a incoming PGY one psychiatry resident. That's right. Edmund joined this psych crew, is a doctor now, and Dr. Handratta is been, is being modest. He is he both certified, trained C/L psychiatrist and the guru behind the Y in Psychiatry let's jump right into it. So this whole season we're gonna be focusing on bipolar disorder. We're gonna start very simple with the question. What is bipolar disorder? I know I've heard it in the street. People are saying I'm bipolar. My mom is bipolar. Dr. Handratta, what is bipolar disorder? Let's talk about bipolar. So I'm gonna actually focus on bipolar adults, and thanh is focus on bipolar disorder in the pediatric population. So as the name suggests, it has two poles One side of the pole is depression and the other side is mania or hypomania. So bipolar disorder is basically a disorder of energy. So patients will have mood symptoms, either they can be euphoric or dysphoric associated, either with increased energy more than normal. So this is abnormally increased energy, or there's an abnormally increased goal directed behavior. So in short for a lay person, this is what bipolar disorder looks like. But if you look at the DSM five TR criteria, you have the mood symptoms, which could be abnormally elevated mood or dysphoric mood which is not normal for the patient, with abnormal increased energy or increased goal directed behavior with at least three or three other symptoms and the mnemonics that a lot of psychiatry residents use is dig fast, right? But there are a lot of other conditions which can mimic bipolar disorders, which we are going to talk about in this particular episode and how to differentiate it. Does it make sense? Made sense. How about Dr. Nguyen how does this differ in the pediatric population? It doesn't. So I say the tongue in cheek because yeah, there's not like any specifiers in there that talks about this is the age limit as to when you can actually make the diagnosis or, this is the age maximum when you can make the diagnosis. But I will say that the prevalence for when you see this emerge is gonna be around late adolescence, young adulthood where you'll see like the center mass of the bell curve where this comes about. So if it's like really anything prior then it is bit more rare. Not to say that it's completely off the table, though if you're gonna play the odds game that's a little bit lower on my list. All of that's to say we still try to be as faithful to the DSM five's diagnostic criteria as much as possible is that, hopefully that answers the question. I think the thing that gets me with bipolar, especially in kids is how can I tell. Bipolar from ADHD or from just a kid being a kid, like at what point would you say this is mania or hypomania versus this is just a hyperactive kid over over whatcha you in the military? Yeah, we'll definitely get into like comorbidities a little bit later down the line. But, when we're talking about kids they are like this moving target because one, their temperament, their mood, their life circumstances, what's going on and their belief system is changing all throughout. And at the same time, you're trying to figure out if this is. What's that saying? If this is a state or if this is a trait at that time to differentiate between the two I think the biggest thing that I would hang my hat on is the collateral reports that come about. So if it's ADHD generally this is something that's gonna be quite persistent and it's not gonna be episodic like you would see in , manic episodes. That's probably like the first thing. The second thing is you wanna really understand the temperament of the child or the adolescent well before you begin to consider if this is a deviation from that. And then lastly, the dysfunction that this is causing as well, if it's just in one setting versus in two settings, right? And more than anything else, how far deviating from its current function. You see the child or adolescent, then those are some of the big things that I would consider when it comes to contrasting ADHD and bipolar. That's pretty good. Dr. Handratta question for you. It's my understanding if someone has bipolar disorder, the first episode or the first mood disorder that they see is typically depression. So when they come to your office, it's for complaints of depression. How can you make sure and I know the treat most of our treatments for depression has an increased chance of causing the man manic disorder, either causing a manic disorder or uncovering a manic disorder. How can you, avoid that pitfall? That's a great question. So that is where the diagnosis of bipolar disorder gets delayed. So the way I evaluate the patient is getting a thorough history, right? So first I want to make sure that I rule out all the other medical causes. That can mimic mania or depression. So for example, make sure that as you have ruled out substance use disorder, you have ruled out that the patient is on any other medications. For example, patients are on steroids. Stimulants also make sure that the patient does not have hyperthyroidism. So I'll rule out all the medical as well as medications as well as substance use. That's one thing. And then I basically suppose, and you're right, more than 70% of the patients with bipolar disorder were present with depression, right? Only 20% of the patients, approximately 20% were present with manic symptoms. Then it becomes easier to diagnose it. The problem is what gives us an idea as to a person with major depressive disorder is gonna convert into bipolar disorder. So a few things that I look for is I look for the age of onset of the depression, right? So typically according to research data, the age of onset of depression in patients with bipolar disorder is very early. It's actually before the age of 25 years, and they would've had multiple depressive episodes before the age of 25 years. They will have had three or more peers episodes. The depression is usually atypical in feature that is there. Basically, they will have a lot of hyperphagia, hypersomnia, rejection sensitivity, leadin paralysis, things like that. Depression with psychotic features is another red flag. Another thing I look for is a family history of bipolar disorder that further increases the risk of bipolar disorder non-response to antidepressants in the past, like they have been on antidepressant, but they have not responded, or the antidepressants made them mad. What the, that is a mnemonic actually. Okay. That basically means that you give an antidepressant and the patient actually has mood instability. Or they have a lot of anxiety or agitation, or they feel dysphoric. That's another red flag. All patients who present with mixed features is another red flag for saying that the patient with depression can switch to a manic episode and also comorbidities, right? For example, if person presents with depression and they have history of substance use disorder. Multiple other medical comorbid conditions. So all these things actually are red flags saying that keep an keep these patients. They might be having depression, but there is a chance that they can switch and educate the patient. Make sense? Then so a patient comes in and they have all these red flags, right? Like they have the red flags that, they have atypical depression in the past. They have the red flag of the medication makes them irritable. They have the red flag of having all these family members. That has bipolar spectrum disorders, would you, and this is first time the patient is coming to you, would you not give them a regular, like an SSRI SNRI for depression, or would you skip that and go through his mood stabilizer? Great question, right? So now there are two parts to this. One is if they have had a previous trial of antidepressants and they've failed multiple antidepressant trials or antidepressants have made caused a lot of mood instability, a lot of anxiety and agitation or dysphoria right now. Remember one thing, whenever you start an antidepressant, even if a person doesn't have bipolar disorder, they can actually complain of feeling anxious, irritable, and restless for the first one to two weeks after you start the antidepressants, right? That's a very normal antidepressant response in patients with depression. So to answer your question, if I have these red flags, do I start them on an antidepressant? Yeah. So suppose that they have never had any hypomanic episodes. According to the patient interview, as well as collateral information, extremely important to get collateral information from family members who knows the patient very well and they never had like manic or hypomanic episode. Yeah, I am going to treat the patient like they have major depressive disorder, but at the same time, I'm definitely going to invest a lot of time in psychoeducation, not just educating the patient, but also the family member with the patient to look for signs. Or switching to a manic or a hypomanic episode. Makes sense. Makes sense. Yeah. And would he do anything differently? The thing that I am usually trying to reassure patients of is that just because someone is mad one second and then happy, maybe five minutes later, but there's no other instance of it. I can see why they would label bipolar, right? It's like they're switching from one side to the next. But I'm usually reassuring them to let them know that is not the case. And I would not use the word bipolar when it comes to that. I guess the only other thing that I would say for at least my population of child and adolescents, I, I talk to everyone. And if I'm having conversion data points that point's actually to it then I am much more likely to have that higher on my diagnostic list. But if I'm getting more noise, and maybe this is a more of a environmental thing, maybe someone's getting bullied. Maybe there's not the best home environment, maybe it's just a very mean teacher. I try and make sure to consider those scenarios as well. Before I have, adolescents acting out as like this pathologized way of saying, oh, this is someone with a manic episode or is bipolar. Did I answer your question? Yeah, you did. Yeah, you did. And you have a little bipolar yourself and just, keep going. Distractability, Yeah. No. We're gonna label that hypomania here. Let's teach the right phrases. Related to that. I just wanna clarify for our readers out there, do you think you guys could clarify manic versus hypomanic and then again, I guess deeper down like the bipolar one versus bipolar two? Just so we have those definitions kind of outline for our listeners. Yeah. Yeah. Actually was gonna suggest that you read my mind. Edmund you must be a psychiatrist. Who wants to I'll take it, I'll take it. Take it. He's got it. don't get too excited then. So I'm very excited. bipolar one and bipolar two, bipolar one is characterized by having a full manic episode. And a manic episode is if it lasts at least one week or till the person is severe enough that they're psychiatrically hospitalized. And it must cause an impairment and functioning right? So this is something people, your friends and family would know, right? It's not something like they don't know, right? People would know there's gonna be severe impairment and functioning and you can have three or four of these kind of symptoms, right? Like you can have grandiosity, inflate self esteem and it's not like I'm feeling good it's like I feel like God, I'm the president type deal. Decreased need for sleep. And so it's not just they're not sleeping. It is, they're not sleeping and they don't feel like they need to sleep. Talkative pressured speech, almost like I am doing right now. Flight of ideas, racing thoughts. Extreme distractability and you see them, they have increased goal movements. So like they're picking up projects, starting projects, not finishing it, having 10 million ideas. That's also part of the racing thoughts And then one big thing again is they get involved in risky behaviors, that have painful consequences. So that's where you see the spending, right? They go to the casino and they blow all their fortune and their 401k type deal. So that is mania. Hypomania is basically like baby mania, hypomania, right? Sometimes the impairment is not bad enough that they need hospitalization, right? That's when you start seeing hypomania. There's some impairment in functioning, but not that bad, right? Like people will be like, that's just a joke, right? That's just Thanh like deal, right? You still have the same things, but also just to a lesser degree, right? You still have the grandiosity. Maybe the less need for sleep, the talkativeness, but again, you can redirect them. It's more controlled. It could be a variant of normal, right? Like in some cases one other big thing again for our listeners to know is typically it's a mood disorder, right? Like bipolar is a mood disorder and the mood in bipolar is elevated mood. It could also be irritable mood. If it's irritable mood. Now you need more criteria, right? So now you need more. The other stuff like sleep, the speech, the ideas, the distractibility the goal directed movement and things like that. Did that answer your question? Yes, that's perfect. One one more thing for you to have bipolar two disorder, there has to be a depressive episode. This is a fun fact. They have to be a depressive episode. In Bipolar one disorder, there's a small population of patients that never have a depressive episode. So there are some people out there that just have many, and I think that's so cool. That is so true actually. And just to add in bipolar one sometimes what happens is that the person actually has the symptoms of like mania, but they're not met the duration criteria, but they're psychotic. Then it becomes bipolar one. That's true. Alright. So they can actually have all the symptoms of bipolar one, but they have not reached the duration criteria, but they're psychotic. That goes as bipolar one. So in simple, mania is nothing but hypomania on steroids, it completely causes a dysfunction. So that's the only thing I wanted to add is the psychotic episode you don't need to have the duration. If they need to go to the hospital, you can almost be sure it's mania. As we're talking about hypomania as well as the distinguishment between mania and if you want to talk about mixed episodes. So mixed episode. It's important to diagnose mixed episode is that once you diagnose mixed episode, you cannot use antidepressants because that will switch them. And plus the suicide risk is also very high in mixed episode. Mixed episode is like either, either you meet a full criteria of major depressive disorder plus it has some features of mania or hypomania, but the mania and hypomania does not meet the full DSM criteria for the manic episode or hypomanic episode. So that is major depressive disorder with mixed episode. Or you can have patients who meet a full criteria of mania and hypomania, plus they will have some symptoms of major depressive disorder that does not overlap with the mania hypomania. So they cannot, three or more of the symptoms, but don't meet the full. Duration or the diagnostic criteria. So that's a mixed episode. And so with that, let's talk about cyclothymic or cyclothymic mood disorder. So Cycl timer is just basically. Noncommittal bipolar disorder, right? It's for at least a period of two years, they have hypomanic symptoms. So think of it as like a mixed episode, but without meeting criteria for any full mood disorder, right? Like without meeting criteria for MDD hypomania or mania. They just have label, right? They just have sprinkle right some hypomania here, some mania here, some depressive symptoms here, but do not meet criteria for anything and it has to go on for two years. Tell me about rapid cycling.'cause I don't believe that's it's a thing. I think that's a myth. So rapid cycling is a thing s o patients with rapid cycling, the criteria is they should have four or more than four episodes of a mood symptom in about a one year time. So this could be depression, mania, or hypomania, four or more than four episodes in a year. That those are rapid cyclers. But they meet the full criteria of those mood disorders, so it's not they have mania for one day and then they stop. It's, they have mania for a week or go to your hospital and then they stop. So yeah, of full, the meet of full criteria of those episodes, or four or more of those episodes in a. So that's mixed and that is rapid cycler. Now to add on to what you mentioned Amayo about cyclothymia you do not meet the full criteria, right? So patients can actually have hypomanic episodes and depressive symptoms, but they don't meet the full criteria of hypomania depression. And they do not meet a full criteria of major depressive disorder in numerous period. And it should last for at least two years. That is what actually Amayo had mentioned. And and the last that I wanna throw in there. Because I do wanna touch a little bit on disruptive mood dysregulation disorder, because I think that's, I think that's quite important because there's a lot of controversy between the idea of like pediatric bipolar and kids getting the diagnosis quite a bit. So in the DSM five, the, one of the new diagnoses that was adopted was the disruptive mood dysregulation disorder. It was to reduce or give a different label to the behaviors that you see with kids that have much more chronic severe irritability. They have frequent tempers and the diagnosis is only up to the age of 18. This is not a diagnosis that you give to adults. And the idea of this was that it would explicitly like curb the over-diagnosis of bipolar disorder in young children. Because when you don't have this offshoot and bipolar is the only thing that you have left I think people were making that diagnosis and as folks are hopefully picking up from at least this episode is that it's not a very light diagnosis because the outcomes from this, or what you are saying when you're making this diagnosis is there's gonna be likely lifelong medications that are gonna be taken from this population or there's gonna be part of this treatment plan for a while. To commit that to children or adolescents and then for the rest of their life to take medications. You definitely wanna be sure that this is the diagnosis, bipolar is the diagnosis that we're gonna be working with, and that there's gonna be a lot of weight if you're gonna plan to make that diagnosis. DMDD was to prevent a lot of that. just a quick question on that. So the DMDD, you said the, that is for the age of onset , less than what age? 10. 10. Okay. Yeah. It's what I was saying before, that pre pubescent kids with pediatric bipolar that is quite rare. And when the diagnosis was being thrown left and right in that population, that's. Part of that controversy. And I think the MDD was the calling or kind of the response to that controversy. So for the individuals who have that diagnosis is the, I guess treatment, is that more focused on like psychotherapy since they're younger or are, Oh no. That's that. Yeah, that's what I'm saying. They're just being treated very similarly. Maybe the symptomology might be interpreted a little bit different, right? There's a little bit more irritability or outbursts or temper or like temper tantrums. Like whatever that state might look like for them, Might be a little bit different in the adolescent population as it would in the adult population. Like the expansiveness, the energy like that, that can still happen, right? But to treat that state that very distinct period, state of lack of insight and judgment, right? It's still generally the same, where we're gonna reach towards mood stabilizers and, if they have like depressive episodes, you want to now treat bipolar depression as opposed to unipolar depression. Most of the clinicians would, or at least for me I would hope generally would get away or try to get away with most of the symptomology reduction with the lowest amount of meds possible, because yes, they're all developing and you're gonna hope that it's not gonna impair or affect much of their development while you're trying to also treat the bipolar. Okay. That makes sense. Yeah. I'll do a quick summary guys, we are super excited for this season and we're super excited for bipolar. I think one of the big takeaways, this is not a light diagnosis, it has a lot of social implications and a lot of long-term implications, especially for our pediatric population. So make sure you what out all that factors, right? Like home, other diagnosis before you slap someone with the bipolar diagnosis because it comes with heavy medications that we'll be talking about in the next few episode. Make sure. It's always starts with depression. Typically starts with depression. So make sure when you're treating your depressive patients that you make, that you screen for bipolar disorder as well. We talked about bipolar one, the bipolar two, hypomania for two. Mania for one. We also talked about cyclonic disorder, so mixed traits, and that's it for bipolar. Do your homework, make sure you have diagnostic clarity for bipolar disorder. And until then, see you next time. All right. Thanks man. All right. Thank you all. Thank you for hanging out with us. Today's ride aboard the Y and psychiatry express. Our crew is already back at the drawing board, brewing up mind-bending topics for the next episode. Don't forget to drop by our website or let us know what you love, what made you think, or what made you Google something at 2:00 AM at the end of the day, we hope we're lighting that little fire of curiosity about psychiatry, whereas we like to call it the why behind the mind. Until next time, keep smiling, keep shining, and above all, stay endlessly curious. See you soon.