- Psychotic features: mood‑congruent delusions (grandeur) or hallucinations – requires urgent psychiatry
- Catatonia: stupor, mutism, posturing – medical emergency, benzodiazepines + ECT
- Suicidal ideation with plan: during depressive or mixed episodes – require psychiatric hospitalization
Bipolar I Disorder – Manic Episode
Must-Not-Miss / Red Flags
Patient Explanation
“You have a condition called bipolar disorder, where your mood can swing between extreme highs and lows. During high periods, you may feel overly energetic and impulsive. We have effective medicines to stabilize your mood.”
Board Fact
“The DSM‑5‑TR requires at least 7 days of manic symptoms (or any duration if hospitalization is needed) with ≥3 of the following: grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, increased goal‑directed activity, excessive risky activities.”
ICD-10
F31.10
Definition & Core Concept
Bipolar I disorder is a mood disorder characterized by at least one lifetime manic episode, often alternating with depressive episodes. Mania is a distinct period of abnormally and persistently elevated, expansive, or irritable mood with increased goal‑directed activity or energy.
Epidemiology & Risk Factors
- Lifetime prevalence: 1‑2% of the general population
- Equal male‑to‑female ratio (unlike unipolar depression)
- Peak onset: late adolescence to early 20s
- Strong genetic component (first‑degree relatives have 10‑fold increased risk)
Clinical Vignette
A 22‑year‑old college student presents with 2 weeks of decreased need for sleep (2‑3 hours), hyper‑talkativeness, grandiose ideas about starting a multi‑million‑dollar business, and spending $5,000 on credit cards. He has no previous psychiatric history but has a family history of bipolar disorder in his father. Urine drug screen is negative.
Pearls & Pitfalls
- Antidepressants can trigger manic episodes in bipolar patients – always screen for bipolar before starting an antidepressant.
- Lithium requires regular monitoring of renal function and TSH – it can cause nephrogenic diabetes insipidus and hypothyroidism.
Discharge & Follow-Up
Weekly lithium levels until stable, then every 3‑6 months. TSH and creatinine every 6 months. Psychoeducation about sleep hygiene and early warning signs of relapse. Mood charting.
Literature & Guidelines
CANMAT 2024 Guidelines for Bipolar Disorder. PMID: 38654120.