This page is dedicated to organizing various examples of standardized exam questions whose answer is bipolar disorder. While this may seem a odd practice, it is useful to see multiple examples of how bipolar disorder will be characterized on standardized exams (namely the boards and the shelf exams). This page is not meant to be used as a tradition question bank (as all of the answers will be the same), however seeing the classic “test” characterization for a disease is quite valuable.
KEY CHARACTERISTICS OF THIS CONDITION (ON EXAMS)
When it comes to standardized exams, each condition has its own “code” marked by key buzzwords, lab findings, clues, etc. If you are well versed in this code you will be able to more quickly identify the condition that is being discussed, and get the right answer on the exam you are taking. Below is the “code” for bipolar disorder.
- Acting strangely: may be noted by others around the patient
- Depression/sadness: patients may present with depressive symptoms, and also have a history of manic/hypomanic episodes revealed in their history.
Patient History/Clinical Workup:
Symptoms precipitated by treatment for depression: SSRI usage can precipitate manic episodes
Symptoms precipitated by recent death of a close person to patient: this seems to be a common trigger for manic episodes on standardized exams.
Depression can often be present in the patient. They are common in bipolar type I, and are necessary for a diagnosis of bipolar type II.
DIGFAST Criteria Present (Manic Episodes):
- Flight of ideas or racing thoughts
- Activity, Agitation (increased working/sexual activity)
- Speech (pressured or rapid talking)
- Thoughtlessness/reckless behavior such as engaging in pleasurable activities with negative consequences (gambling/shopping sprees).
Question # 1
A 22 year old college student is brought to the emergency department by the police after she was caught trying to scale the fence to enter a celebrity’s house. She seems highly agitated and will not stop pacing around the exam room. During the medical interview she explains that she flew in from outside the state to try and meet with the celebrity to try and discuss a “screenplay that will change modern cinema forever”. The patient has not slept much for the past week due to working on this screenplay. She speaks rapidly but will stop at times to angrily express her frustration at the medical staff keeping her from sharing her “masterpiece” with others. The interview was cut short when she began banging on the door and demanding to leave. Her family history is notable for major depression in her mother. Her temperature is 98.8°F, blood pressure is 140/80, pulse is 98/min, and respirations are 21/min. Her urine drug screen is negative for any substances. What is the most likely diagnosis?
Explanation # 1
Agitation + grandiosity (screenplay opinion) + insomnia + rapid speech = bipolar disorder
Question # 2
A 34 year old businesswoman comes to the clinic because of poor energy. She explains that “my energy level is so low I could sleep 20 hours a day. Even when I force myself to go to work, i barely get anything done because I am just not motivated and can’t pay attention to the task at hand! I feel like I am a horrible mother and wife. I don’t want to go out anymore and don’t see my friends at all anymore. All I want to do is stay in my room, hide from the world, and sleep”. The patient has a past history of 3 prior episodes of depression dating back to when she was a teenager. She was also hospitalized 2 years ago for aggressive behavior following the unauthorized usage of her company’s funds to finance a personal business project. A the time, she had excessive energy, was sleeping only 1.5 hours a night, and believed that she had a brilliant idea that would revolutionize business practice in her industry. The patient has no history of substance or alcohol usage. There is a family history of depression in her mother, who was treated successfully with tricyclic antidepressants. mental status exam is remarkable for psychomotor retardation, tearfulness, a depressed mood, and suicidal thoughts. What condition does the patient have?
Explanation # 2
Thoughtless behavior (use of company funds) + insomnia/decreased need for sleep + grandiosity (brilliant idea) = bipolar disorder
Question # 3
A 30 year old man is brought to the office by his wife because she is concerned that he has “not been himself” these past 3 weeks. She explains that he is withdrawn and dressed, sleeps 13 hours a day, and has no interest in looking for work or participating in any activities. The patient was hospitalized 7 months ago for an episode in which he became very aggressive toward his wife. This occurred when she confronted him about staying up all night, gambling away their savings, and investing a very large sum of in a start-up tech company that soon went bankrupt. During that episode, the patient spoke very rapidly and was very convinced that he had a wonderful plan to bring about world peace. He has experienced a another similar episode about 2 years ago. He received treatment, but then discontinued treatment shortly thereafter. What condition this this patient most likely have?
Explanation # 3
Agitation (toward wife) + insomnia + thoughtless behavior (gambling/investing money in risky business) + rapid speech + grandiosity (plan for world peace) = bipolar disorder
Question # 4
A previously healthy 30 year old woman is brought to the emergency department by her boyfriend because of a 7 week history of hearing daily voices that have convinced her that she is Christ. She is convinced that she can help the sick, and requests that she be allowed to see all the patients at the hospital. During the past 4 weeks she has had a 20 lb weight loss. She has not slept more then 1.5 hours for the past couple of weeks. The she is awake at night, she watches TV or calls strangers on her cellphone. She does not drink alcohol or use illicit substances. Her BMI is 26 kg/m². Her temperature is 98.9°F, pulse is 115/min, blood pressure is 155/95 mm Hg. Physical exam does not show any other abnormalities. Mental stupas exam shows restlessness and agitation. She flirts with male members of the staff and tries to convince them of her powers. She has pressured speech and talks without stopping for long periods of time. There is no suggestion of any visual hallucinations. The patient can not concentrate so recall memory is not tested effectively. Long term memory appears to be intact. The patient is oriented. What is the most likely diagnosis?
Explanation # 4
Grandiosity (thinks she is Christ) + insomnia + agitation + thoughtless behavior (sexual promiscuity) + pressured speech = bipolar disorder
Question # 5
A 50 year old man is brought to the clinic by his wife because he has been “more then a handful” for the past 2 weeks. His wife explains that he has been talking about various inventions constantly, and just recently bought a new recreational vehicle (despite the couple never traveling long distances). He constantly is telling his wife “its time to bring in the money and cash our checks”. He has been openly critical of their priests sermons during their church services. He believes that the pastor is a “hack” because “God has been speaking to me, not that guy”. His wife explains that this episode of behavior had also happened in the past (10 years ago) but it was much more tolerable. He has past history of peptic ulcer disease (with is treated with ranitidine) and hypertension (which is treated with a thiazide). He does not smoke or drink alcohol. His vitals are within normal limits. His physical exam is not remarkable. Mental status exam demonstrates that he is relaxed and talkative, jumping from one topic to anther quickly. He explains that his wife does not understand him, and that she has been plotting with the pastor against him. He does not feel as though he has any issues, and feels he is “capable of great things”. Lab studies are unremarkable except for a urine toxicology screen that is positive for marijuana. What is the likely diagnosis for this patient?
Explanation # 5
Thoughtless behavior (financially) + grandiosity (God is speaking to him/capable of great things) + flight of ideas (jumping topic to topic) = bipolar disorder
Question # 6
A 30 year old female comes to the clinic complaining of depression. She has broken up with her boyfriend recently, and explains that she has been very sad, and has had difficulty getting out of bed. She states that she sleeps 14 hours a day, has had an increased appetite, a 15 lb weight gain, and no longer wants to go out and socialize with her “gal pals”. When she is asked to describe the last time she was feeling well, she explains a period of time last year where she felt very confident and capable. She was able to successfully juggle 3 different jobs, and felt well rested despite only getting 2 hours of sleep each night. What condition might this patient have?
Explanation # 6
Depression (various symptoms/SIGECAPS) + episode of grandiosity/decreased need for sleep/increased ability = bipolar disorder (type II)
Question # 7
A 26 year old female come stoeckled the clinic because she has been suffering from low energy, a loss of appetite, and difficulty sleeping at night. She explains that she has even lost 10 lbs over this past month. The patent has no notable a past medical history, and she denies alcohol/tobacco usage. The patent is started on a treatment for her depression and sent home. About 1 month later the patient is brought to the ER by her friend because she has been acting strangely. She explains that she has not slept for the past 5 nights, but dons not feel tired. She has also spent her life savings on a boat, and plans to sail around the world so that she can bring peace to those “less capable” than her. What condition may this patent have?
Explanation # 7
Symptoms precipitated by treatment for depression (SSRI) + insomnia + thoughtless financial behavior + grandiosity = bipolar disorder
Question # 8
A 24 year old male is brought to the hospital by his wife. She explains that he has been acting very differently for the past 10 days. The patient has not slept for the past 6 days, and instead has been working on home improvement projects around their house. He has spent a large portion of their savings to finance these home renovations. When asked about his recent activity, he refers to himself as a “architectural wizard” and explains that he is turning his home into a “work of art”. The physician notes that when talking with the patient, his speech is rapid and pressured. What condition might this patient have?
Explanation # 8
Insomnia + thoughtless behavior (financially) + grandiosity + rapid/pressured speech = bipolar disorder
Question # 9
A 35 year old male is brought to the ER by a concerned friend because he has been “acting crazy” for the past week. His friend explains that earlier today he was driving up to 120 miles per hour on the freeway, and that he almost caused a number of accidents to his reckless driving. The patient works in the law firm, and recently his coworkers have been impressed that he has been working all night on cases without having to take any breaks. A few of his other friends have started to also get concerned because he has been trying to get them to invest with him on various startup businesses all over town. The patient speaks very quickly during with the physician, and is difficult to understand. He states that he has received secret messages that have revealed which investments are a “sure” thing, and tries to get the physician to commit to investing in them with him. A urine toxicology screen is conducted and is negative. What is the likely diagnosis in this patient?
Explanation # 9
Thoughtless behavior (driving) + insomnia + rapid speech = bipolar disorder
Question # 10
A 25 year old female is brought to the ER because she has been actin bizarre since the sudden death of her husband 6 weeks ago. Her father explains that for the past 2 weeks she has been going on a very expensive shopping spree. During this period of time she also has not been eating regularly, and has seemed to have lost the need to sleep. The patient has a past medical history of depression that has been treated with an SSRI. During the patient interview she jumps quickly from one topic to another, and appears to have psychomotor agitation. What is the likely diagnosis in this patient?
Explanation # 10
Thoughtless behavior (shopping spree) + insomnia + flight of ideas + agitation = bipolar disorder
Question # 11
A 50 year old female is brought to her PCP because her husband has noticed a change in personality after she lost her mother 1 month ago. He explains that she has been irritable lately, does not sleep much at night, and speaks very rapidly (often jumping from one topic to another). He states that she has not had symptoms like this before, but has had previous episodes where she sleeps excessively, has severe fatigue, and loses interest in reading (her favorite pastime). A mental status exam reveals loud, rapid speech, and the patient seems to be easily distracted by some of the items present on the physician’s desk. She gets up and starts to pace around the room during the interview. She explains that her friend’s death has elevated her to the “next level” and explains that her friend’s voice still speaks to her. What is the diagnosis in this patient?
Explanation # 11
Insomnia + rapid speech + flight of ideas + distractibility + agitation = bipolar disorder
TESTABLE FACTS ABOUT THIS CONDITION (BEYOND ITS IDENTIFICATION)
Many questions on standardized exams go beyond simply recognizing the underlying condition. Often there are specific testable facts regarding some aspect of the disease’s pathophysiology/management/clinical implications that are commonly asked. Some of these are listed below:
- Lithium: a very common mood stabilizer used for bipolar disorder (used for manic episodes, depressive episodes, and maintenance).
- Valproate: this medication can also be used to treat seizures in patients (ideal for those who have both bipolar disorder and a seizure disorder). Used for manic episodes and maintenance.
- Carbamazepine: also an anti-epileptic and first line medication for trigeminal neuralgia. Used for manic episodes and maintenance.
- Lamotrigine: used for focal seizures and depressive episodes in bipolar disorder.
Side Effects Of Treatment:
- Ebstein anomaly can be seen in children born to mothers who used lithium during pregnancy.
Page Updated: 09.12.2016