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Luke: [00:00:00] And so you're an emerge. Your next patient is Devin, a 28 year old pharmaceutical rep. He was brought in after running through his office earlier in the day shouting, I am king of the world. His partner, Ben, says that Devon is not acting like himself and hasn't slept in three nights and isn't making any sense. In his room, Devon has ripped off his shirt and is repeating, I am Jesus, I am your king.
Jordan: [00:00:27] What do you do next?
Luke: [00:00:33] It's rolling now. Perfect. Welcome to psychEd the Educational Psychiatry Podcast for Medical learners by medical learners. I'm Luke out and I'm here with Jordan Box. We are both junior residents at University of Toronto. And today we'll be talking about mania and bipolar disorder. We're joined today by Dr. Mark Sinyor, who is an associate scientist and staff psychiatrist at Sunnybrook Health Science Centre.
Dr. Mark Sinyor: [00:00:58] So thanks for having me. Yep. So I'm a psychiatrist here at Sunnybrook. I do mood and anxiety disorders, mainly outpatient work, and I have an interest in my main research areas in suicide looking either at suicide epidemiology. And we're also doing some some clinical trials. But I also have some interest in some other things like the placebo effect and randomised control trial design.
Luke: [00:01:21] So today we'll talk about the basics of bipolar disorder with a focus on mania and the manic presentation. Jordan, tell us a little bit about just how bipolar disorder affects the world.
Jordan: [00:01:34] Yeah. So whenever we think about mental health disorders, we want to think about how prevalent they are and how often we see them. And that helps us to get a feel for when to watch out for them. So bipolar disorder affects more than 1% of the world's population, irrespective of nationality, ethnic origin or socioeconomic status. And one of the interesting and difficult things about bipolar disorder is that it tends to occur in young adulthood, and that means that it can lead to profound impact on early career and family development.
Luke: [00:02:07] So it kind of in plain English, like what is bipolar disorder?
Jordan: [00:02:13] Bipolar like depression is a mood disorder, meaning it's a mental health disturbance characterised by prolonged, intense, pathologic emotional states. So it's normal to feel happy or sad in response to a life event, say fantastic test mark, or the loss of an important person in your life or the loss of a job.
Luke: [00:02:35] Right? So what makes something pathologic?
Jordan: [00:02:38] Well, it's that the reaction almost takes on a life of its own. So it persists over days and weeks. It's a little bit less reactive to life events and associated with other specific cognitive and behavioural symptoms.
Luke: [00:02:52] So so like in depression, which we already talked about, it was like a sense that the person is feeling sad no matter what was happening around them beyond just responding to life stress.
Jordan: [00:03:03] Mm hmm. Yeah. And in depression, too, it's not just the mood that you're feeling sad, but it's you're almost unable to to become happy, right? That that that serves as that sort of differentiating mark. And we see the same thing in manic episodes, which we're going to talk about, where people have this really intense mood state that seems to be going on irrespective of what's going on around the person.
Luke: [00:03:26] So so you mention this thing called mania manic episodes. What is that?
Jordan: [00:03:33] The meaning in plain English. Why don't we let Dr. Sinyor take a stab at that?
Dr. Mark Sinyor: [00:03:37] Oh, okay. Uh, a manic episode is an episode lasting for at least four days where someone has an intense change in their mood. So either euphoria or irritability, accompanied by a number of other symptoms, almost always with a decreased need for sleep. And a key component of that is not just not needing sleep, but also not feeling tired. So if you're interviewing somebody and they say, Yeah, I had a lot less sleep, but then I was exhausted the next day, that would be quite unusual in mania, and it's typically accompanied with a number of other symptoms, things like an increased rate of speech, increased rate of thoughts, grandiosity. So feeling, you know, more important than usual or like you can do more or be more talented just as a kind of a clinical pearl. When people are asking questions about this, I think people often will say to patients, Did you feel like you had special powers? And nobody almost never do people endorse that. But what they will endorse is feeling more talented than usual. So that's a bit of a pearl. And then other things are distractibility, increased goal oriented behaviour. So you get patients who will do things like clean their whole house in an hour or write a book in a way that they wouldn't otherwise. And then risky behaviours which are usually things like risky sexual behaviours or spending or reckless driving or using drugs and alcohol that they wouldn't typically do.
Jordan: [00:05:01] All right, So you just dove right into the DSM criteria. So maybe let's pause for a second, make that really explicit.
Luke: [00:05:09] Yeah. So I think so. The DSM specifies a criteria for mania. And the core symptom of mania is this idea of the elevated mood. And I think there's kind of this image out there that that people think of of mania as this high, euphoric, happy state. And and that's not always the case.
Dr. Mark Sinyor: [00:05:27] It's definitely not always the case. You'll often find people who are quite irritable or agitated. And it can be an issue, certainly. And, you know, in terms of people getting into trouble in the community, either getting into fights with people or, you know, having to be brought in by police. So definitely don't forget about irritability, although that's the classical mania is someone who's kind of euphoric and, you know, really happy to be that way.
Luke: [00:05:52] And you mentioned many of the other criteria for mania, and there's an acronym that's often taught, at least at the University of Toronto, to to describe them, which is GSTPAID like paid. So maybe we can go through and talk about each of those things that that you touched upon and just kind of blow it up in a bit more detail. So the G is stands for grandiosity. And you mentioned that that the classically were taught to ask, do you have any special powers and actually that very few people really endorse that explicitly. And you mentioned a few other ways of asking about it.
Dr. Mark Sinyor: [00:06:27] Yeah. I mean, I guess it depends. Obviously, often you can see it if someone is acutely manic, but if they're not a manic at the moment, usually you want to ask things like during that period of time, which by the way, I think I just realised I said four days it should be seven, that during that period of time, you know, Were you feeling more talented than usual? Did you feel like you could accomplish things that other people couldn't necessarily or that you usually wouldn't be able to accomplish? And and it sort of connects up a little bit with the one about activities. You want to ask people what they were doing, Were they writing excessively or were they? And then what was the content of that? I was writing something because I was going to make the next great novel and I'm not a writer or I was going to solve all the scientific experiments or equations and things that I have no background in science. That's the kind of thing that you'd see.
Luke: [00:07:15] Like an elevated sense of kind of what they can accomplish.
Dr. Mark Sinyor: [00:07:18] Yes. Self importance and.
Luke: [00:07:20] Self-importance. Yeah. And you also that that also touches upon, I think, the idea of activity which is what the A and GSTPAID. that there's increased goal directed activities.
Dr. Mark Sinyor: [00:07:29] Yes. So almost always people will feel like they're getting more done. I know we're going to get to it later, but the distinction between hypomania and mania, but often in hypomania, people actually are getting things done. When people are floridly manic, usually they're too ill to be able to do things. So what they'll describe, at least in retrospect, is that they thought that they were doing all kinds of they thought that they had written the greatest book. But when you're assessing somebody and they present you with some of the material that they're working on, often it can be gibberish or unintelligible.
Luke: [00:08:01] And some of the other activities that they engage in, which is the P for for pleasure seeking despite painful consequences that also kind of factors into some of the activities that they do.
Dr. Mark Sinyor: [00:08:11] Yeah, if you think about it as being an acute episode where people are, you know, euphoric and don't necessarily have good judgement about what's a good activity or not, they become disinhibited and they, they can do things that they really wouldn't otherwise do. People will talk about having unprotected sex or spending thousands and thousands of dollars that they don't have or, you know, saying, you know, I never touch alcohol. But when I was manic, I, you know, I had 30 drinks in one day and the other. By the way, key point, when you're taking a history either from a patient or from collateral about that is, you know, if it's if they were taking cocaine or a stimulant or something else that could induce a mania, was it before or after? If it happened before, it could actually not be bipolar disorder or it might be a substance induced or an amphetamine induced bipolar disorder as opposed to bipolar one disorder. On the other hand, many, many people with bipolar disorder will say, no, no, no, I was manic for three or four days and I never used cocaine, but then I didn't mind. It was no big deal. So I just had a bunch of cocaine. Right. So that would be more in terms of the risky pleasurable behaviours.
Luke: [00:09:16] And I think you've mentioned some of the S's of the pleasure of activities, sex spending substances which are common spheres that people experience, difficulties that also I think touches upon the idea of impulsivity in bipolar in a manic episode.
Dr. Mark Sinyor: [00:09:38] Right. So, I mean, people in a true manic episode, people don't typically have a lot of control over what they're doing. You know, I don't know if we're going to go into the pathophysiology, not that we know exactly how it works, but sometimes mania has been at least colloquially described as a brain being on fire. Mm hmm. You know, people are just doing everything around them. And if you've ever seen anybody who is manic, it can often be quite, quite jarring.
Jordan: [00:10:02] And I think that ties in nicely with the D in GSTPAID. of Distractibility in that people can be highly responsive to stimuli that are around them. So if you see somebody and they emerge and they're in a manic episode, you can see them kind of paying attention to people who walk by the room. They're shuffling papers, they're rummaging through things. They become kind of like really focussed on a fold in the clothes that they're wearing or a pattern that they see. So it's interesting how all of these things blend together. So we've covered grandiosity. So the G, the P, the A, the D. And I think now maybe you mentioned the sleep thing.
Luke: [00:10:42] Yeah. You were talking about like the increased energy of doing all of that. And you mentioned that that rarely do you ever see a mania without the sleep component.
Dr. Mark Sinyor: [00:10:51] Yes. I mean, I think I think the other thing is that sleep is often the trigger for mania. I don't know if we get to that, but when I see patients who have this diagnosis, we spend a lot of time talking about things like making sure you never have an all nighter and don't work, shift work and be extra careful about your medications when you're going overseas or might be jet lagged. We know that pretty much all antidepressants can induce a mania so people can become manic on standard antidepressants. They can become manic when they get ECT which is an anti depressant. They can become manic with light. Often mania happens in kind of March, April, May, the time period where there's a sudden increase in light. And we know that light is an antidepressant for people, especially with seasonal depression. And so total sleep deprivation actually is an anti depressant and major depression. The problem is it also, like all these other things, induces a mania. And so it's not only an important feature of mania, but it's often one of the most important causes. And one of the major treatments is actually to tell people that they absolutely must protect their sleep if they have a risk of this.
Luke: [00:11:56] So sleep is both a symptom and a cause of manic episodes in some ways.
Jordan: [00:12:01] And just to be explicit that we're talking about a decreased sleep. So the classic question that you'll see kind of experience psychiatrist asking emerges, are you finding that you're needing to sleep less but your energy as still as hot or even higher? And, you know, I've talked with patients who are sleeping like one hour a night for four or five nights, and they don't have any problem with that whatsoever. The last two, I believe, that are in GSTPAID. are two related topics, ones that I've often got confused in the past. The T stands for Talkative.
Dr. Mark Sinyor: [00:12:34] So people definitely will have a kind of a motor mouth phenomenon. One of the mental status aspects of patients who are in the midst of a mania is at least loosening of associations, if not flight of ideas. And what that means in plain speech is going from one topic to another topic to another topic in terms of their thoughts without necessarily being able to connect them up. And so that manifests in the same sort of thing orally when people talk.
Luke: [00:13:04] So there are two kind of different manifestations of that's very similar, or this may be the same and the same phenomenon.
Dr. Mark Sinyor: [00:13:09] Yeah, I mean, it's the it's the vocalisation of what's happening inside.
Jordan: [00:13:14] So that was the T for talkative and then the I for ideas as in racing thoughts or speech that presents ideas all over the place. And you'll hear psychiatrists use the term flight of ideas to kind of like almost describe it as though these ideas are taking off.
Luke: [00:13:29] And so in order to be diagnosed with a manic episode, then you need to have the core symptom, which is what we talked about, of the elevated or irritable mood, as well as at least three out of the seven of these of these criteria. In addition, and as you alluded to, Dr. Sinyor, this episode has to at least for at least one week, for it to be classified as a mania with certain caveats that if a patient requires hospitalisation before that time, then this becomes the episode is automatically classified as a mania for this syndrome.
Dr. Mark Sinyor: [00:14:00] Yeah. I mean, we can get into a couple of the difficulties of of the DSM classification. One of the things is that, you know, retrospectively, you know, part of the reason for the seven day choice is because many people can feel giddy or hyper for all sorts of different reasons for a few hours. And they want to really try to distinguish these things. But, you know, if someone has all of these symptoms for four or five days, is that not a mania? I think this is where we need to all use our kind of clinical expertise and judgement.
Luke: [00:14:27] Absolutely. The other thing that we should touch on is the idea of the mania can present with or without psychosis. So psychosis, which we'll cover in detail at a later episode, is in essence the presence of either delusions or ideas that are fixed and false in a patient's mind. Or hallucinations which can be auditory or visual in nature and and or presentation, the disorganisation of their thought process. So there are presentations of mania which present with psychosis and without.
Dr. Mark Sinyor: [00:15:01] Right. And the an important point is that typically the psychosis in mania is a is a grandiose delusion. So a belief that the person is the messiah or that they're going to be the next Bill Gates or, you know, the next president of the United States. You should also just generally for all mood disorders, that would be what's called mood syntonic delusion. Sometimes you can get dystonic delusions. So in other words, if you have someone who's depressed, who has a grandiose delusion about being the Messiah, that would be kind of opposite. And in the same way, if you're manic and you have a delusion that you're going to lose all your properties or your body is rotting from the inside, you know that that would be dystonic. There isn't much to say about that other than dystonic delusions seem to be a poor prognostic sign. And also, if you have both, you also have to think about a mixed episode, whether there are also symptoms of depression at the same time.
Luke: [00:15:57] Mm hmm. So. Grandiosity, less sleep, more talkative, more pleasure seeking, more activity. Flight of ideas and distractibility. That just sounds like somebody who's just in in a summary, like someone who's just way too wired. And it sounds like it kind of describes the initial case quite well.
Jordan: [00:16:20] Yeah. So, you know, it's kind of interesting because somebody who is in the throes of like a full manic episode, like in our case, they're actually pretty easy to diagnose. This guy comes in almost like right out of the textbook. So just to summarise and touch on some of the symptoms and connect them to the criteria that we just went over. Grandiosity. He is saying that he is Jesus, that he's a king. So that's a symptom of grandiosity or a sign of grandiosity. His he seems like he's talking fast in the brief experiences that we've had there. So that's two we know from his partner when he came in that he hasn't slept in three days. So there's sleep. It doesn't seem like his mood was elevated from the way that he was describing it and kind of the way that he's acting.
Luke: [00:17:09] So he's taking off a lot of the boxes already.
Jordan: [00:17:12] Yes. Yeah.
Luke: [00:17:13] So he's so so we haven't even seen him. But based on what we know already, it sounds like he could be manic. So so the next step is really kind of going to see him interviewing him and trying to see if we can find out more. And in assessing someone who is in the throes of a manic episode, can can pose some pretty unique challenges.
Jordan: [00:17:32] Yeah. So I think this is where it would be great to hear your sort of take on this as well, Doctor SINYOR. But, you know, I can start things off from my own experiences in the Emerge. An acutely manic patient can be one of the harder, more intimidating patients that you can see and emerge. And part of that is because of the intensity of their affect and also their distractibility and impulsivity so they can be so distractible and sped up that they cannot provide clear answers or they may be very irritable, impulsive, to the point where safety becomes a concern. So, you know, the approach that I take is in contrast to many other patients that you interview in a mental health setting, you want to try and keep your questions actually quite closed. An open ended question with a patient who you have a high suspicion of mania is just going to allow for room for their flight of ideas, and then you're stuck in a situation where you have to cut them off, which can be tricky. So it's better to actually try and stay one step ahead of that and ask really simple, close ended questions with simple answers and move at a rapid pace. So you need to come in quite prepared with sort of your list of questions and saying, okay, this is my agenda, I'm going to try and move through it.
Dr. Mark Sinyor: [00:18:46] Yeah. So as you were saying, Jordan, I mean, you know, for everybody, the first step is always safety. And these certainly I mean, for the most part, you're not really in danger with a manic patient, but some of them might be. And so, you know, you have to be cautious when you're going in your attention to sort of your distance from the door, not necessarily barring access, but being able to to kind of get out safely and not necessarily hovering over or being within too close distance with the patient. And I agree with you with your approach. You know, the the most important thing to do when you have a patient who's manic is to take a mental status. The mental status may actually give you everything or at least the most that you're going to be able to get. And then my I agree with your kind of approach to say, you know, what are high yield questions about things like psychosis or about what what moods been like or just trying to get some understanding of what the person is thinking at that specific time about whether there are any grandiose delusions? You know, how you know, what have you been doing recently? What you know, what are your.
Dr. Mark Sinyor: [00:19:42] Are there any special talents that have been coming up recently? And then I think as we're about to get to most of what you're really going to try to do is to get collateral history. That's going to be the most important thing. So the good news, just to comment about the interview, you know, I don't want to ever send a medical student or a resident or anybody to go see a patient and not take a complete history. But if you really think mania is what's going on, and that becomes should become fairly apparent in the kind of case that you're describing, you're not discharging the person. A mania is a you know, is it a medical emergency, a psychiatric emergency. And so and with the most important thing of getting the person to sleep, you know, fairly rapidly. So what you want to do is do the kind of assessment that you can get, whatever data, you can get that collateral and then give them the right treatment to to arrest the manic episode as quickly as possible.
Jordan: [00:20:33] And I wonder if this is maybe a good point. For an aside, this is something that sometimes I will say to patients or to patients family members is that it seems like we're increasingly realising that manic episodes are like neurotoxic in a way. And so it's not just like, you know, are we is this person a risk of safety to themselves and others at this present time? But like, are we letting a pathological process go on if we don't treat it, that has implications down the line. Do you want to speak to any of that research or.
Dr. Mark Sinyor: [00:21:01] Well, there's there's definitely a research suggesting a kindling phenomenon which essentially suggests that initial manic episodes are often provoked by a very significant either physiological or life stressor, and they're usually fairly easily treated and people who tend to have repetitive. Manic episodes seem to be able to get into them faster and to be harder to treat. And so for very much the kind of reasons that you're describing. And so that's the reason it really is an emergency. And what you want to do is to try to arrest it as quickly as possible. And then in many cases, just like you see in patients with schizophrenia and other severe and persistent mental illness, you have patients who say, well, I like being manic. It was really great. Please can't I just do that again? And part of the education is really around what you're describing, which is to say, you know, to commiserate. Yeah, I know that you liked it, but remember that you had to be hospitalised and it wasn't, you know, in the end it wasn't very good. And number two, I can treat you now, but I may not be able to treat you as effectively in the future if we don't make sure this doesn't happen.
Jordan: [00:22:02] So coming back to some of the tips about interviewing an acutely manic patient, some of the other things that I think were passed on to me and I really value is remembering that the emotion in the room can be infectious and you can really see that with mania. If someone is really euphoric and they're silly, you can find yourself laughing. Or if somebody is really irritable, you can find yourself getting irritable or nervous. And it's important to sort of think about how their emotions are going to impact your emotions and how to sort of handle that during the interview to still be an effective clinician. Another thing is that often these patients can become very person like try to relate to you personally. They can ask like intense personal questions. They may be sexually inappropriate. And so that's something to be aware of and to be prepared for it, really. And if that happens to deflect and not engage in that way.
Dr. Mark Sinyor: [00:22:56] It's not written anywhere as a diagnostic sign, but perceptiveness and incisiveness and being able to kind of get get at specific things that are really going on. Often manic patients will give incredibly insightful comments about something that's going on. You know, if you're really tired or something, they'll they'll pick up on it because they are attending very much more to everything in the environment. But yeah, I mean, I think the key thing is obviously to attend to your professional boundaries and when you're doing interviews in all of psychiatry, what you want to do is to, you know, you have to find a way to empathise with a patient, right? So if you have a depressed patient, you know, you don't want to be laughing and being silly. That would be an empathic and unkind. But you also don't want to start taking on their depression. The interview won't work and it won't go anywhere. So it's sort of the same sort of thing. In mania, you kind of want to show the patient that you're listening and that you're attentive to what's going on, but you don't want to mimic their their mood.
Jordan: [00:23:48] So some of the you mentioned some of these already, but for our listeners out there to rehash it, some of the key content, if you have a limited time with the patient, some of the key content that you want to try and find out are recent stressors. Have they changed their living arrangement? Is something going on at work? Is there a financial situation? Is there a relationship issue? You know, is there any thing you can pick up about concrete events that would give you a clue that somebody has been doing risky behaviour? Like have they been sexually active more so than usual? Have they been gambling more so than usual? Have they been speeding? And it's nice to try to tie these to concrete events to give you real kind of data to go off of if you can. It can be hard, but try and pin down a timeline for the mood change. So is this something that's been going on for hours? Is it days? Is it weeks? That has very different implications. And really and we'll mention this over and over, the sleep is just so important. So if you could get one thing out of somebody who you're suspicious might be manic to get a sleep history. And again, concrete data like how many hours have you been sleeping and how many days has that been going on?
Dr. Mark Sinyor: [00:24:55] I would add to this list, although I know for sure you would ask it anyway, or of the collateral, but medications and substances essentially for for two reasons. One is for diagnostic clarity. The substances can sometimes help and a very large percentage, or at least some large percentage of these patients are going to have are going to have an anti depressant or some other medication on board. The median length of time to an appropriate diagnosis of bipolar disorder is 12 years. So it's easy when the first episode is a manic episode, but for a very large percentage of patients, they're going to get multiple depressive episodes and then become manic. And often that will happen on an anti depressant inducing a mania. And of course, you want to stop that right away if someone comes in. So that's the other the other thing you really need to know right off the bat.
Luke: [00:25:36] So armed with with this kind of thought about the approach to interviewing the patient, we're going to go we're going to the room to try to interview Devin. And and what ends up happening is he just keeps saying, I am king of the world and then starts kind of going off on tangents and you ask about sleep and he says, Sleep country, I'm king of sleep country, da da da da da. Just kind of goes off on tangents. We can't get very much, even when we try to ask close ended questions.
Jordan: [00:25:57] As Dr. Senor said, the mental status there, even just a couple of minutes, is almost enough for you to make a diagnosis there. So we see that that's flight of ideas. And now we go back to take a collateral history, which in patients in an acute manic episode is extremely important. And I'm not sure if we've explicitly described a collateral history before, but basically it. Means going to friends, family. Anybody who knows this person well to try and hear about what's been happening with them. And that, I should add, is one of the things, if you're seeing somebody who you suspect is currently in a manic episode and you have very limited time and you know that nobody's brought them to emerge, that's something that I'll try and do is like, can I get a phone number for like anybody who's been hanging out with you the last little while so we can try and hear a bit about what's going on.
Luke: [00:26:45] So in Devon's case, we have his partner who brought him to the merge so he can talk to him. So this is what we find out. Devon has been busy with work and sleeping poorly for the past two months, and about two weeks ago, he received an interview for a dream job in his field. And that's when Ben started to notice changes in Devon's mood and behaviour. He was sleeping even less, but instead of being fatigued, he was more energetic. And he started saying that it was the best he's ever felt in his life. He became filled with ideas for the interview, some of which didn't make a lot of sense. Started making a list of hundreds of things that he could do, like making a documentary for pharmaceutical development. But then he would drift from one thing to another and never really complete anything. And Ben initially thought this was all excitement and anticipation to do with the job interview. But then about five days ago, it reached a breaking point when Devon started talking about using his new job to take over the world and that he had a vision from God and that Ben checked their joint bank account and realised that he had spent thousands of dollars online. He tried to convince Devon's to stay home and rest, but then Devon ran off to work and he ran through the office. And that's how he ended up being brought in to the hospital.
Jordan: [00:27:47] Okay, So now we know he's got decreased need for sleep, increased pleasure seeking despite painful consequences, and which would be the spending and increased goal directed activity, which was that sort of unfruitful activity that he was doing to try and prepare for his interview. So I would say at this point in time, he almost definitely meets criteria for a manic episode.
Luke: [00:28:07] So one of the most important information that we can get from assessing the patient in the room is the mental status exam. And so I want to spend a few minutes maybe talking about what some of the common things we might see for somebody who's in an acute manic episode.
Jordan: [00:28:20] Yeah. So for our listeners who have listened to the earlier episode on depression, we use the mental status exam that goes through appearance, behaviour, cooperation, speech, thought, form, thought, content, perception, mood affect and safety in different institutions, you'll see a slightly different order. Maybe the terms are used interchangeably, but in general this should cover the majority of the standard sort of mental status assessment. So usually we start with appearance. So what does the patient look like and something you can do from outside the room? What are some of the things that you might expect looking if you're if someone is in a manic episode, what sort of things might you notice about their appearance?
Luke: [00:29:06] Well, I think you're looking for signs of the symptoms that we talked about previously. And so if they're feeling really grandiose and they're let's say they believe that they are the president or they are God, they may dress to to represent that in ways that are atypical or in our patient's case right now, I think he's ripped a shirt off and running around the emergency room half naked. So that's one of the things that that that we might see in terms of behaviour. I think we also talked about the increased energy, the increased kind of activity in the room. So we might even call that agitation or psychomotor agitation, pacing, gesturing, and we talked about maybe kind of not not as respectful of personal space and being kind of flirtatious or even aggressive with people. Other people in the room sometimes say in terms of cooperativeness, I think there's you can see a very variety of presentations depending on what their mood is like at that point in time. If they're feeling elated and grandiose, they may be very happy to talk to you, even though their speech may not make sense. But if they're feeling irritable, they may be insulted or slighted by the smallest thing you do, and they may tell you to to get out or or do their swear at you.
Jordan: [00:30:22] In terms of speech. This is one that you would almost certainly expect to be abnormal in someone who's in an acute manic episode. So they'll have a lot to say. So there's an increased increased production of speech, There's a high volume of speech. Sometimes there's more prosody, like there's more emotion and fluctuations in their speech. And there's you can comment on their reduced turn taking. So they're kind of just talking over and over and over you. They don't really allow for a natural pause in a conversation for which you normally sort of expect. And do people having a conversation.
Luke: [00:30:59] It's an interesting point about pressured speech is that I've often you know, it's the you think of classically the really fast speech, but I've seen presentations of mania where it's not very fast, but it's just there's very no breaks in their speech. So they're not talking extremely fast, but there's really no endpoint. And they keep going and going and going, and it's really hard to cut it unless you're thinking about doing that.
Dr. Mark Sinyor: [00:31:20] And that, by the way, for the listeners is actually the definition of pressured speech. So that's a term that people may hear. It actually implies uninterruptability. It's difficult to get a word in edgewise. That's the definition.
Luke: [00:31:32] And that might be reflected in the way that their thought process is also in that that they would go from one idea to another to and to another. And so, you know, in someone who can you can follow logically, we would call that logical and goal oriented in mania that that may progress to tangential reality where they're taking their ideas or taking off from one thing to another. Or circumstantiality where they seem to be over-inclusive, but they do eventually come back. And in the most extreme of cases, we have what's called flight of ideas, where it's even it's hard for for you to even follow along exactly what the association is that the patient is making.
Dr. Mark Sinyor: [00:32:11] I think part of the distinction is in circumstantial thought people are over inclusive and they may be including detail that is unnecessary, but they're kind of they're going from point A to point B, There's something that's in between called loosening of associations where they're kind of going from point A to B to C, and you can kind of see the connection between the two, but it's not that logical. It's sort of starting to break free a little bit from the way that one would normally think in flight of ideas. The definition is literally that you're bouncing from one idea to the next with no clear kind of connection between any of them.
Jordan: [00:32:45] Sometimes I've seen patients in acute manic episodes make like their their sentences are connected by rhymes or word structures. So you can see some pretty interesting speech and thought form abnormalities. In terms of thought content, you're looking for mostly grandiose themes in a patient who you're expecting would be in an acute manic episode. They may describe themselves as possessing a secret or greatly important knowledge. And we've sort of talked about this idea of like, Oh, I'm going to write a novel, but I've never done that before, or I'm going to cure cancer, even though I have no background in cell biology or something of that nature.
Luke: [00:33:31] And we talked about kind of mood congruent themes and mood incongruent themes in terms of delusions that people may have and similar to that. So other psychotic features that you're looking for would be perceptual abnormalities. So auditory or visual hallucinations, are they responding to different stimuli in the room that you may or may not be aware of? And just trying to get a sense for that?
Jordan: [00:33:56] Yep. And then coming back to Mood, which is how somebody was describes their own mood and so they might say it's fantastic, excellent. Never been better. But it can also be very irritable. And so they may report being really angry, frustrated, especially if they feel that they're in they emerge inappropriately or angry. And as a reminder to listeners, we separate mood, which is what a person sort of says about how they're feeling with affect, which is how we perceive their emotional state. And here we can see a pretty wide range. So it's an expansive so it seems like they just. I it's hard it's almost hard to really concretely describe, but it's like they feel connected to other people. Like they feel like they can just talk to anybody. They feel like they're kind of, I don't know, they're almost in like this flow state versus, you know, you can see someone who's being like, joyous or euphoric and you can also see people who are very angry.
Dr. Mark Sinyor: [00:35:00] Another component I would just add to that is that you often see lability. So being able to rapidly switch from one thing to another. So you might have someone who's laughing and giggling and then suddenly they'll become irritable for some reason and then they can bounce back and forth. Mm hmm.
Jordan: [00:35:13] Yeah. Because when we describe affect, it's not just the quality of what we're seeing, but we're commenting on like, what's the range, what's the reactivity and.
Luke: [00:35:22] The intensity.
Jordan: [00:35:22] Intensity and all of these things. We expect to be sort of more extreme. More extreme, Yeah. And then lastly, of course, as an important part of any mental status exam and any psychiatric assessment is safety. And when we talk about safety, we talk about suicidal ideation, so safe self safety and homicidal ideation or the intention to harm others. And manic patients can be very impulsive. They may be more likely to use substances. They may develop psychotic symptoms related to persecution or paranoia. And these factors really can heighten the risk of a harmful event.
Dr. Mark Sinyor: [00:35:57] And just on the point of suicidality, as a as a researcher in the area, I feel obliged to comment on it. The I mean, as people might expect, it's more likely to die from suicide and bipolar disorder during the depressive phase of the illness. But people do die if they're manic. They might have an idea that to join God, they need to do something to end their lives or something, you know, something of that nature. So definitely you need to ask. And don't just assume because they're super happy and elated that that isn't a concern.
Luke: [00:36:23] I've also seen safety risks where people believe they can fly as part of their grandiosity, and so they jump off a building. So not not explicitly with an intention to kill themselves, but resulting in potential significant safety concerns.
Jordan: [00:36:36] Yeah. And also related to there's some of their impulsive behaviour, like I've seen people who are speeding, like they're going like 200 kilometres an hour on the VW because they just, you know, that's not a problem for them.
Dr. Mark Sinyor: [00:36:48] And so it's a bottom line. Attend to safety. Yeah.
Luke: [00:36:52] And so, so you know, so we talked about manic episodes, and manic episodes are kind of associated with the word bipolar disorder. And so the criteria is what's the difference between someone who has a manic episode and someone who has a bipolar one disorder? A diagnosis of bipolar one disorder can be made with the presence of a single manic episode, and there's actually no requirement for a depressive episode in the criteria, even though most commonly patients present in depressive episodes, they spend significantly more time in depressive episodes know in a prototypical bipolar disorder.
Dr. Mark Sinyor: [00:37:24] By the way, for that reason, people who only there there are it's more of the rare patients. Maybe we don't see it as much who have only manic episodes, and that's actually a good prognostic sign. People, you know, who come in and might have one manic episode once every ten years at 20 and 30, actually, generally they do pretty well. It's the folks that fall into multiple depressive episodes that can be in trouble.
Luke: [00:37:47] And in order for you to be diagnosed with bipolar disorder after having had a manic episode, it's important to rule out some of the other diagnoses. One of the one of the diagnoses that we talked about, which is often difficult to separate because the substance is substance induced mania. So, for example, somebody who was high on cocaine coming in, talking really fast, lots of energy, pacing in the room would actually tick off A lot of first of all, even in the phase of acute intoxication, can look like somebody who is presenting in mania. But also there are syndromes whereby even after the substance is cleared, people can have some period where they're meeting criteria for a manic episode.
Dr. Mark Sinyor: [00:38:29] So sometimes that's difficult to disentangle. But you really do expect that after the cocaine is out of the person symptom that it'll resolve. The longer the symptoms persist in the absence of the drug, the more you have to be suspicious of an underlying bipolar disorder. The other just comment about I don't know if we should count this as substances. But the change from DSM four to DSM five in DSM four, if you were put on an antidepressant and you had a so if you were put on an antidepressant or you were put on cocaine and you had mania, it would be considered a substance induced manic episode. In DSM five, it maintains that for cocaine, because everybody who's on cocaine gets a bit manic or most people will have something like that. But it acknowledges the fact that most people, when they start an antidepressant, shouldn't become manic. And so if you have that predisposition and that happens to you, then it puts you somewhere on the bipolar spectrum. And so DSM five says that an antidepressant induced mania still qualifies you for a diagnosis of bipolar disorder.
Jordan: [00:39:31] So when we're trying to make a diagnosis in a patient that we have other than just waiting to see if things clear, we want to make sure if we can we can get a urine tox screen if it's someone that we don't know anything about, to see if there is any substances in their urine and try and get collateral history about drug use and try and sort out the timing as well, because we know that sometimes if people become acutely manic, then they become impulsive and they use substances and so on time, course there is useful.
Luke: [00:40:00] Another one that often get misdiagnosed between bipolar disorder is borderline personality disorder. And that's a pretty complex subject. But in short, people with borderline personality disorder can also present with mood fluctuations that they sometimes self label or label by others as being bipolar. They can have impulsive behaviour and and can present with transient kind of psychotic symptoms. So so how would how does one often separate out kind of a personality disorder from a bipolar disorder?
Dr. Mark Sinyor: [00:40:32] So usually it's actually easier when you're seeing someone in a manic episode, but even then it can be difficult because, you know, patients with borderline personality disorder who are having a borderline crisis or a rage can actually look even in that circumstance like someone with bipolar disorder. So cross-sectional, it can be difficult. Another thing that makes it difficult is you can get people who have both bipolar disorder and borderline personality disorder. But the distinction is that people with borderline personality disorder have poor coping skills and affective dysregulation that's really chronic. I mean, without treatment, it's something that should be there a lot of the time or most of the time in bipolar disorder, if that's all you have, if you don't have a co morbid personality disorder, it should be episodic. The symptoms that we're describing here should start acutely or sort of at least subacute early. They should go on for a period of time. They should be arrested. And then afterwards the person should look back and say, well, I would never act that way. That's not part of my usual experience. And so that's usually the best way to make the distinction is that kind of chronicity versus episodic. You know, the other thing obviously, is that a strong family history of mood disorders and things like that would predispose you more to bipolar disorder phenomena logically. On the other hand, you know, a childhood victimisation and invalidating environments and abuse and things like that would all be kind of push you into thinking more about borderline personality disorder.
Jordan: [00:41:53] A great summary of something that is really challenging and I think the key there is to to certain extent to remain humble when you're seeing a patient in emerge. That cross sectional diagnoses are very challenging and this is where we can use collateral and sort of big picture thinking to say, okay, this is what this person looks like now, but like how are they in the rest of their life? And that really highlights the importance of collateral in these patients to say like, is this something that's been going on for two weeks or 20 years?
Luke: [00:42:22] Another challenging thing to separate out is especially when they're presenting with manic episode, with psychosis, to separate out from a primary psychotic disorder like schizophrenia or or something like schizoaffective disorder.
Dr. Mark Sinyor: [00:42:33] So going back to our DSM criteria, a primary psychotic disorder requires you to have psychotic symptoms for a period of time in the absence of mood symptoms. And you can't figure that out. I mean, certainly when you're just laying eyes on someone who isn't giving you a very good history. So it's back to to Jordan's idea. But, you know, requiring a cross sectional sort of history. And if it isn't so clear to be humble and honest and say, we don't really know and we'll have to follow you and look at what the course is, and then we'll we'll kind of give you a revision about what the diagnosis is.
Luke: [00:43:04] So time is an important factor in separating out some of these differential diagnoses.
Dr. Mark Sinyor: [00:43:09] Can I just one other thing that had come up earlier was the distinction between or actually, I think no, I think you're going to get to it as mania and hypomania. So maybe I'll let you do.
Luke: [00:43:17] Actually, that's perfect. Actually is actually where are we going to go now is talking about this idea of the hypomania versus mania.
Jordan: [00:43:25] Because I think that's I mean, if somebody walks in the door and they meet six out of seven GSTPAID.criteria and they're talking about being king and the messiah, you know, that's pretty clear cut. Right. And but I think what's really tricky and why you we see this data about the median time to diagnosis of bipolar being 12 years is that people don't often walk in in full blown mania. Right. So, Dr. Senior, why don't you walk us through hypomania.
Dr. Mark Sinyor: [00:43:49] Yeah. So for hypomania. So a couple of distinctions. The one that I mixed up at the beginning. So for mania, it needs to be seven days, although again, everybody who's manic for seven days was also manic for one day or two days. So you don't have to wait really for seven days. If the whole picture starts to become clear. Hypomania can happen over a shorter period of time, so it can be only a few days long. You still require three out of the seven g GSTPAID criteria to be present. But the major distinction is around severity and functionality. And actually that was what I was going to jump in to mention. So things that would be markers of higher severity are psychosis. So if there's psychosis as part of the picture that pushes you into mania, if and here you have to make a bit of a judgement call, but if the person is impaired, then that also graduates a person to having mania again with this distinction that people who are hypomanic may feel a bit elated and they may be different, very clearly different from the way that they are when they're not hypomanic, but they're still doing things they may even be achieving more than expected, getting more work done in a productive way, whereas people who are suffering from a mania will not.
Dr. Mark Sinyor: [00:44:58] And so that brings us to the third option, which was mentioned before. That was what I really wanted to clarify was the hospitalisation. So if you've had a hospitalisation, it qualifies you as mania. As far as I know, it's the only case in medicine where the behaviour of the doctor changes the diagnosis. So if we choose to hospitalise, it gives you bipolar one and if we choose to send you home, it's bipolar two. So this illustrates some of the limitations of the DSM. And the key point is that the hospitalisation is a proxy for impairment. I mean, if a person is hypomanic and they've been hospitalised because they don't have anywhere to go that evening, that shouldn't give them a diagnosis of bipolar one disorder. On the other hand, if someone really laid eyes on the person and said that you're impaired, something's really wrong here and they required a hospitalisation, then then that makes sense to kind of elevate it to that kind of more severe diagnosis of a mania rather than a hypomania.
Luke: [00:45:48] So right now in the DSM, we make a distinction between bipolar type one and bipolar type two. As you alluded to and and as we talked about bipolar type one, you only need the presence of mania, even though these patients often spend long periods in depression. For bipolar type two to be diagnosed, you need to meet criteria for hypo for a hypomanic episode, and as well as having a met criteria for a depressive episode at a period in time previously. And my understanding of that is that because hypomanic episodes are often hard to tease out on history, that the requirement for a depressive episode is there is a way to kind of ensure that that you are getting closer to the diagnosis than if someone had come in with four days of feeling better than they normally do and maybe did a few extra stuff.
Luke: [00:46:41] So today we use the case of Devin, our pharmaceutical representative, and we talked about mania and bipolar disorder. We talked about the criteria for mania, some differential diagnoses, presentations, the mental status exam in a manic episode, and some ideas for how to interview somebody and assess somebody who's in the throes of a manic episode. We went into talking about how that fits into the criteria for diagnosing bipolar disorder, bipolar one versus bipolar two, mania versus hypomania. And we talked a little bit about the sticky point of the differentiation between different types of bipolar. This has been psychEd. Thanks for listening.
Jordan: [00:47:18] Thank you all so much for listening into this episode of Psyched. We are eagerly looking for listener feedback and you can give that to us by email directly at info at psychEdpodcasT.com or you can find us at our website psychedpodcast.org and at the bottom of our home page, there's a contact us section. We'd love to hear specific feedback about the episodes, structural feedback about the way we deliver the episodes, feedback about our website, show notes, future episode requests, you name it. We want to hear it from you. Big thanks to everyone who helped to write and produce this episode. Main writers were Jordan Bawks and Lu Gao, with assistance work from some of the other members of the Psyched board, including Alex, Lucy and Carrol in its early stages. Big shout out to our audio, Editor Henry Baron, for putting it together, making it sound real nice. Of course, none of this would be made possible without the support of the Department of Psychiatry at the University of Toronto. And of course, with this episode, a special thank you to Dr. Mark Sinyor for taking the time out of his busy schedule to help us out and provide clinical wisdom. And his expertise was fantastic. We'd also like to acknowledge all of music. Who was the artist responsible for our theme song that we use. So thank you so much for tuning in and hope to have you back soon.