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Day # 44: Review Quiz -> Bipolar Part 1

Today will be our first review quiz for the bipolar disorder theme and will also include one question from the depressive disorder theme. Let's check your learning!

1) Which of the following regarding Bipolar I disorder is true?

  • a) In a manic episode mood is elevated, depressed, and/or irritable.

  • b) Symptoms ≥ 2 weeks (or requires hospitalization).

  • c) Requires 4 DIGFAST symptoms if mood is elevated or expansive.

  • d) Patients typically have more and longer depressive episodes than episodes of mania/hypomania.

2) Which of the following is not a common comorbid psychiatric or medical condition with Bipolar disorder?

  • a) Substance use disorder

  • b) Disruptive mood dysregulation disorder

  • c) Migraines

  • d) Generalized anxiety disorder

  • e) Irritable bowel syndrome

3) Transcranial Magnetic Stimulation (TMS). Which of the following is not an FDA approved indication?

  • a) GAD

  • b) MDD

  • c) OCD

  • d) Migraine headaches




Question 1:

From day # 42

Answer: d

Patients typically have more and longer depressive episodes than episodes of mania/hypomania.


•The only requirement for the diagnosis of Bipolar I is the occurrence of a manic episode. A manic episode is defined as:

  • Mood is elevated, expansive, and/or irritable.

  • Symptoms ≥ 1 week (or requires hospitalization).

  • 3 DIGFAST symptoms if mood is elevated or expansive.

  • 4 DIGFAST symptoms if mood is only irritable.

•Even though the diagnosis only requires one episode of mania these patients commonly experience hypomanic and depressive symptoms interspersed between manic episodes and euthymic periods. In fact only around 5% of patients experience only manic episodes.

Question 2:

From day # 43 and 22

Answer: b

Disruptive mood dysregulation disorder


Bipolar disorders are highly co-morbid with other psychiatric disorders as well as general medical conditions. There are multiple reasons for this including shared genetic and environmental vulnerabilities, potential causal relationships, and consequences of treatment.

  • Psychiatric: anxiety disorders are common (generalized anxiety disorder, panic disorder, & social anxiety disorder), ADHD, and any disruptive or impulse-control disorders (IED, ODD, conduct). Substance use use disorder (eg, alcohol use disorder) occurs in roughly half of patients.

  • Medical: irritable bowel syndrome, metabolic syndrome, migraines, and ashtma are shown to be more common in this population.

Disruptive Mood Dysregulation Disorder

  • Severe recurrent verbal and/or physical outbursts out of proportion to the situation.

  • Outbursts occur ≥3x per week and inconsistent with developmental level.

  • Mood between outbursts is persistently angry/irritable most of the day nearly every day and is observed by others.

  • Symptoms for ≥1 year in at least 2 settings. Not symptom free for ≥3 months.

  • Started before age 10, but diagnosis can be made from ages 6-18.

  • Diagnosis cannot coexist with oppositional defiant disorder (ODD), intermittent explosive disorder (IED), or bipolar disorder.

Question 3:

From day # 40

Answer: a



At the time of this post (sep 2020), GAD is not an FDA approved use of TMS,. There is, however, growing evidence for the effectiveness of TMS for treating anxiety disorders and is used for this purpose in clinical practice.


  • Major depressive disorder (MDD): received FDA approval in 2008. Indicated for patients who have failed at least one antidepressant medication. Numerous small-scale studies have demonstrated efficacy in the treatment of major depression; however, studies show less efficacy than for ECT.

  • Migraine headaches: received FDA approval in 2013. Can be used as acute treatment and prophylaxis.

  • Obsessive compulsive disorder (OCD): received FDA approval in 2018.

  • Anxiety disorders and PTSD: limited but growing evidence for the use of TMS in anxiety disorders and trauma-related disorders. The placement of the electric coils and the stimulation parameters are different than the depression protocols.

  • Clinical TMS for psychiatric applications is advancing rapidly and other conditions are currently under investigation and showing promise including bipolar disorder and schizophrenia.


Nice work today! Next post should be very helpful as we will discuss clinical pearls for bipolar disorder including tips for the clinical interview and the differential diagnosis.

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