Bipolar NOS

[goldennugget]

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I have a patient who endorses periods of elevated mood/confidence, less need for sleep, increased productivity/energy, racing thoughts, and risky behavior that occurs for one day max. Episodes may come out of the blue and may not need to be triggered. She has criteria for depressive episodes as well. Would you still classify this as bipolar NOS? usually I feel more comfortable with that diagnosis with three-day periods of hypomanic sx, but was wondering if anyone would treat this as a bipolar spectrum disorder with mood stabilizers as opposed to antidepressants. She is currently not using drugs; no significant medical problems. Any thoughts?

 

[BobA]

I have a patient who endorses periods of elevated mood/confidence, less need for sleep, increased productivity/energy, racing thoughts, and risky behavior that occurs for one day max. Episodes may come out of the blue and may not need to be triggered. She has criteria for depressive episodes as well. Would you still classify this as bipolar NOS? usually I feel more comfortable with that diagnosis with three-day periods of hypomanic sx, but was wondering if anyone would treat this as a bipolar spectrum disorder with mood stabilizers as opposed to antidepressants. She is currently not using drugs; no significant medical problems. Any thoughts?

How about caffeine? Have you screened for Borderline Personality Disorder?

Are the episodes impairing in some way?

Remember, BPAD, NOS isn't necessarily a real disease - it's just something a committee came up with to explain symptoms clusters. So if it's not impairing I wouldn't worry about it.

 

[SuperSoccer19]

I have a patient who endorses periods of elevated mood/confidence, less need for sleep, increased productivity/energy, racing thoughts, and risky behavior that occurs for one day max. Episodes may come out of the blue and may not need to be triggered. She has criteria for depressive episodes as well. Would you still classify this as bipolar NOS? usually I feel more comfortable with that diagnosis with three-day periods of hypomanic sx, but was wondering if anyone would treat this as a bipolar spectrum disorder with mood stabilizers as opposed to antidepressants. She is currently not using drugs; no significant medical problems. Any thoughts?

could it be *gasp* normal?

Actually being serious.

If there's not dangerousness I'd say let her enjoy it while it lasts.

 

[hamstergang]

I think you guys are missing that there are depressive episodes also, and these seem to be meeting criteria for treatment. The question is, will the patient be best served with an antidepressant or mood stabilizer? If this is just unipolar depression, then an antidepressant should be best. But if this is on the bipolar spectrum, then would a mood stabilizer be safer and more effective for the patient?

 

[goldennugget]

Yes, she spends the majority of her time in a depressive state, which causes signficant impairment . The periods of elated mood do not cause significant impairment, so I wouldn't call them manias..more like possible hypomanias. She does not have any signficant signs of borderline personality. As hamstergang pointed out, my main question is whether she might be best served with antidepressant or mood stabilizer. I know that specific technicalities may not mean much clinicially. However, there is a 4 day cutoff time for a hypomanic episode. Does a 1 day cutoff time suffice enough for bipolar NOS (and therefore treatment with mood stabilizer)?

 

[OldPsychDoc]

Yes, she spends the majority of her time in a depressive state, which causes signficant impairment . The periods of elated mood do not cause significant impairment, so I wouldn't call them manias..more like possible hypomanias. She does not have any signficant signs of borderline personality. As hamstergang pointed out, my main question is whether she might be best served with antidepressant or mood stabilizer. I know that specific technicalities may not mean much clinicially. However, there is a 4 day cutoff time for a hypomanic episode. Does a 1 day cutoff time suffice enough for bipolar NOS (and therefore treatment with mood stabilizer)?

Sometimes a patient who runs more toward the dysthymic will have a "burst of normality"--I think that for them it may FEEL like mania, but if it's just "having a good or better than average day", I wouldn't start slapping a bipolar label (even NOS) on it. It sounds like your target symptom here is depression--treat that--but perhaps be somewhat more vigilant that usual about the development of agitation, sleeplessness, etc. as a side effect of the antidepressant you choose.

[And as far as safety of the treatment--do you really want to have this person on a mood stabilizer? Save the toxic chemicals for those in whom the risks are clearly exceeded by the benefit! ]

 

[PikminOC]

Sometimes a patient who runs more toward the dysthymic will have a "burst of normality"--I think that for them it may FEEL like mania, but if it's just "having a good or better than average day", I wouldn't start slapping a bipolar label (even NOS) on it. It sounds like your target symptom here is depression--treat that--but perhaps be somewhat more vigilant that usual about the development of agitation, sleeplessness, etc. as a side effect of the antidepressant you choose.

[And as far as safety of the treatment--do you really want to have this person on a mood stabilizer? Save the toxic chemicals for those in whom the risks are clearly exceeded by the benefit! ]

Keep close follow up to make sure there is no switch to mania just in case.

 

[goldennugget]

thanks to all for the feedback!

 

[thoffen]

This is the type of situation where collateral should be obtained at all costs. Structured diagnostic interviews and rating scales can also be useful.

Assuming you end up stuck, this is someone you'd probably want to treat anyway given the multiple crisis visits. I might think of SSRI + Seroquel personally. SSRI best for MDD, borderline. Seroquel efficacy in bipolar disorder, augmentation in MDD, borderline.