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Psychiatric-Mental Health (PMHNP)

Psychiatric-Mental Health NP Certification Examination

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The Anatomy of a Question


Question

A 35-year-old woman presents to the clinic complaining of increased irritability and decreased concentration for the past ten days. She also notes that she feels rested after four hours of sleep for the past ten nights, and has received two speeding tickets in the past week. On exam, the patient is unable to sit still and exhibits pressured speech and easy distractibility. Which of the following additional elements of her history would help lead to a diagnosis of bipolar I disorder?


Answer choice options
  • A. She has been married for 12 years and has been employed with the same company for 15 years
  • B. She has not been hospitalized for any reason
  • C. She is experiencing increased energy and has completed 350 pages of her “memoirs” in the past ten days
  • D. Two months ago she felt “down” and stayed in bed for seven days

The incorrect options (distractors) are not totally wrong. These options can be diagramed as follows:

Most Correct
Least Correct
  • C.
    She is experiencing increased energy and has completed 350 pages of her “memoirs” in the past ten days Bipolar I is associated with expansive, elevated, or irritable mood and increased energy and goal-directed behavior.
  • D.
    Two months ago she felt “down” and stayed in bed for seven days May be a depressive episode, or may just have had an isolated event in the past causing sadness.
  • B.
    She has not been hospitalized for any reason Likely rules out a metabolic cause of mania but does not exclude Bipolar I.
  • A.
    She has been married for 12 years and has been employed with the same company for 15 years Bipolar I is associated with unstable rather than stable relationships.

The Anatomy of an Explanation

Bipolar I disorder must be distinguished from bipolar II disorder, cyclothymic disorder, substance abuse related bipolar disorder, and bipolar disorder secondary to another medical condition. Patients with bipolar I disorder experience manic episodes which often lead to hospitalization due to their severity. The manic episodes lead to severe interruptions in social and professional functioning. In contrast, bipolar II disorder involves hypomanic episodes. These episodes have many of the elements of mania, but to a lesser degree and for a shorter duration (four days or less). Likewise, patients with cyclothymic disorder have symptoms of mania which fall short of the diagnostic criteria for either mania or hypomania. Bipolar I disorder is characterized by at least one manic episode, as evidenced by expansive, elevated, or irritable mood and increased energy and goal-directed behavior. Manic symptoms must last for at least one week, nearly every day for most of the day. If elevated mood predominates, three of the following symptoms must also be present for a diagnosis of mania: grandiosity, decreased need for sleep, increased talkativeness or pressured speech, flight of ideas, distractibility, psychomotor agitation, and excessive involvement in pleasurable activities despite potential negative consequences. However, if irritable mood predominates, then four of the aforementioned symptoms must also be present. Patients with bipolar I disorder often also suffer episodes of major depression. For diagnosis as a major depressive episode, depressive symptoms must be present for at least two weeks duration. If the patient in the above vignette admitted to increased energy and writing many pages of a memoir, she would be exhibiting an increase in goal-directed behavior and energy, which is a crucial element in the diagnosis of bipolar I disorder. First-line treatment for bipolar I disorder presenting with acute mania is with lithium, anticonvulsants such as valproic acid, or antipsychotics.

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