Bipolar I disorder

Bipolar I disorder is a safety-heavy diagnosis on case exams: the counselor must recognize mania, protect the client during it, and plan for adherence and relapse prevention afterward.

Criteria at exam depth. Bipolar I requires at least one manic episode — that alone is sufficient. Hypomanic or major depressive episodes may come before or after but are not required. The episodes are not better explained by schizoaffective disorder, schizophrenia, schizophreniform, delusional, or other psychotic disorders. A manic episode means elevated, expansive, or irritable mood plus increased energy for at least 1 week (or any duration if hospitalized), with three or more classic symptoms (four if mood is only irritable) and marked impairment, hospitalization, or psychotic features. A full manic episode that emerges during antidepressant treatment and persists beyond the drug's physiological effect counts toward bipolar I.

Specifiers. Current or most recent episode (manic, hypomanic, depressed, unspecified); severity; with psychotic features (mood-congruent or incongruent); remission status; and with anxious distress, mixed features, rapid cycling, melancholic features, atypical features, catatonia, peripartum onset, and seasonal pattern. Rapid cycling means four or more mood episodes in 12 months. Mixed features means the current episode includes several symptoms of the opposite pole.

Hinge differentials.

• Bipolar II: hypomania only, never mania — any manic episode moves the diagnosis to bipolar I.
• Substance/medication-induced bipolar disorder: mood elevation tied to stimulants, steroids or intoxication that does not persist beyond the substance's effect.
• Schizoaffective disorder: psychosis continues for 2+ weeks without a mood episode.
• ADHD: chronic, not episodic; no decreased need for sleep or grandiosity.
• Borderline personality disorder: mood shifts last hours and are interpersonally triggered.
• Medical causes: thyroid disease, neurological conditions.

On the NCMHCE. During mania, assess safety first: risky spending, sexual behavior, driving, aggression, psychosis, and suicidal ideation (high in depressive and mixed states). Arrange a psychiatric referral and, when judgment is severely impaired or danger is present, consider a higher level of care. Rule out substances and medical conditions. Once stable, the plan centers on medication adherence (mood-stabilizer and antipsychotic classes; antidepressants alone can destabilize mood), psychoeducation for client and family, early-warning-sign and relapse-prevention plans, sleep and routine regularity (interpersonal and social rhythm therapy), family-focused therapy, CBT, and treating co-occurring substance use. Watch for cultural and racial bias that leads to misdiagnosing bipolar disorder as schizophrenia.

Clinical Pearl: One manic episode = bipolar I; depression is not required. Mania that persists beyond an antidepressant's effect still counts.