Psychiatry · Year 3 · from Psychiatry

Case 2: Bipolar II Disorder - Hypomanic Episode

Patient Demographics

  • Age: 35 years old
  • Sex: Female
  • Occupation: Marketing executive

Chief Complaint

"My husband thinks I need help, but I feel better than I have in years."

History of Present Illness

The patient presents with her husband who has become concerned about changes in her behavior over the past 2 weeks. She has been waking at 4 AM (usually wakes at 7 AM) feeling energized and has been going for early morning runs before work. She has taken on several new projects at work and is working 12-14 hour days, which she describes as "finally living up to my potential." She has been more talkative and social, reconnecting with old friends and planning multiple social events. She reports feeling more confident and attractive. Her husband notes she has been more interested in sex than usual. She has started three new hobbies in the past week (pottery, learning Italian, and training for a triathlon). She is sleeping about 5 hours per night but feels rested. She denies any impulsive spending or risky behavior. She is not missing work and her performance has, if anything, improved. She has a history of three depressive episodes over the past 10 years, each lasting several months and treated with various antidepressants with partial response.

Mental Status Examination

Appearance: Well-dressed professional woman, impeccable grooming, stylish attire, appears energetic

Behavior: Animated, enthusiastic, slightly restless, good eye contact

Speech: Increased rate but interruptible, normal volume, coherent

Mood: "Great! Optimistic!"

Affect: Elevated, bright, full range, reactive

Thought Process: Somewhat circumstantial but ultimately goal-directed, occasionally tangential

Thought Content: Optimistic plans, no grandiose delusions, no paranoia, no suicidal or homicidal ideation

Perceptions: No hallucinations

Cognition: Alert, oriented, attention intact though slightly distractible, good concentration

Insight: Partial - acknowledges change in energy but views it positively

Judgment: Largely intact - no dangerous behavior, maintaining work/relationships

Psychiatric Workup

Screening Tools:

  • PHQ-9: 2 (minimal depression)
  • MDQ: Positive
  • YMRS: 14 (hypomania range; <12 is normal, 12-20 is hypomania)
  • HCL-32 (Hypomania Checklist): 20 (positive screen)

Laboratory Studies:

  • TSH: 1.7 mIU/L (normal)
  • CBC, CMP: Normal

Diagnosis

Bipolar II Disorder, Current Episode Hypomanic (F31.0)

DSM-5 Criteria for Hypomanic Episode:

  • Distinct period of abnormally elevated/expansive mood lasting at least 4 consecutive days (2 weeks in this case)
  • Three or more of the following:
  • Inflated self-esteem (present - feels more confident)
  • Decreased need for sleep (present - 5 hours)
  • More talkative (present)
  • Flight of ideas/racing thoughts (mild)
  • Distractibility (mild)
  • Increased goal-directed activity (present - multiple projects, hobbies)
  • Excessive involvement in risky activities (not present)
  • Episode associated with unequivocal change in functioning observable by others (husband)
  • Episode NOT severe enough to cause marked impairment or require hospitalization
  • NOT attributable to substance or medical condition

Bipolar II requires:

  • At least one hypomanic episode AND
  • At least one major depressive episode (patient has history of 3)
  • No history of manic episode

Treatment Plan

Discussion of Diagnosis:

  • Explain difference between Bipolar I (mania) and Bipolar II (hypomania + depression)
  • Emphasize that hypomania can feel positive but is a symptom requiring treatment
  • Discuss risk of depressive episodes and cycling without treatment

Pharmacotherapy:

  • Start lamotrigine 25 mg daily for 2 weeks
  • Increase to 50 mg daily for weeks 3-4
  • Titrate to target dose of 200 mg daily (slow titration required to minimize Stevens-Johnson syndrome risk)
  • Lamotrigine is particularly effective for bipolar depression prevention
  • Consider adding low-dose quetiapine (50-100 mg) if sleep remains reduced

Taper/Discontinue Previous Antidepressants:

  • If currently on antidepressant, taper slowly (antidepressants can trigger hypomania/mania in bipolar disorder)

Psychotherapy:

  • Refer for psychoeducation-focused therapy
  • Interpersonal and Social Rhythm Therapy (IPSRT) particularly helpful for bipolar II
  • Focus on maintaining regular sleep-wake cycles

Lifestyle Interventions:

  • Emphasize importance of regular sleep schedule (7-8 hours)
  • Limit new commitments during hypomanic periods
  • Develop early warning sign checklist with partner

Monitoring:

  • Mood charting daily
  • Follow-up in 2 weeks
  • Watch for switch to depression as hypomania resolves

All cases for this lecture as Markdown