Internet Journal of Criminology . There is also a bias in.The Diagnosis and Treatment of Bipolar Disorder: Decision- Making in Primary Care. Abstract. Bipolar disorder is a chronic episodic illness, characterized by recurrent episodes of manic or depressive symptoms. Patients with bipolar disorder frequently present first to primary care, but the diversity of the potential symptoms and a low index of suspicion among physicians can lead to misdiagnosis in many patients. Frequently, co- occurring psychiatric and medical conditions further complicate the differential diagnosis. A thorough diagnostic evaluation at clinical interview, combined with supportive case- finding tools, is essential to reach an accurate diagnosis. When treating bipolar patients, the primary care physician has an integral role in coordinating the multidisciplinary network. Pharmacologic treatment underpins both short- and long- term management of bipolar disorder. Maintenance treatment to prevent relapse is frequently founded on the same pharmacologic approaches that were effective in treating the acute symptoms. Regardless of the treatment approach that is selected, monitoring over the long term is essential to ensure continued symptom relief, functioning, safety, adherence, and general medical health. This article describes key decision- making steps in the management of bipolar disorder from the primary care perspective: from initial clinical suspicion to confirmation of the diagnosis to decision- making in acute and longer- term management and the importance of patient monitoring. Clinical Points. Whichever treatment approach is selected, monitoring over the long- term is essential to ensure continued symptom relief, functioning, safety, adherence, and general medical health. Primary care physicians are the first point of contact for many patients with bipolar disorder, and they have a fundamental role in the diagnosis and treatment of this lifelong condition. The diversity of the potential symptoms in bipolar disorder may mean that the condition will remain unrecognized in many patients for several years. Making an inaccurate diagnosis—often of major depressive disorder (MDD)—also may be problematic, as it leads potentially to initiation of inappropriate treatment and a deterioration in symptoms. Bipolar disorder is a chronic illness that is typically experienced first in early adulthood, although onset in childhood or in older age may also occur. Bipolar disorder can be divided into subtypes, including bipolar I and bipolar II disorder. Bipolar I disorder is distinguished by full- blown manic episodes that are more impairing than the hypomanic episodes that characterize bipolar II disorder. Depression, which is the presenting symptom of bipolar disorder in most patients, may impose a greater disease burden, in terms of both duration and impact, than manic symptoms. Depressive symptoms may be of similar severity in bipolar I and II disorder, and, therefore, bipolar II disorder should not be considered a “milder” illness than bipolar I. The form of the disease that individuals experience tends to be stable over their lifetime. For patients with either condition, the primary care physician can play an important role, often working with psychiatric consultants, in both managing treatment and monitoring the bipolar disorder and ensuring that other health care needs are met, including preventive care and managing chronic comorbid medical conditions. Vertigo is the hallucination of movement of the environment around the patient, or of the patient with respect to the environment 1. Bacterial skin and soft tissue infections in adults: A review of their epidemiology, pathogenesis, diagnosis, treatment and. Either a manic episode or a depressive episode may be the first presentation of bipolar disorder. The subsequent disease course is characterized by repeated manic or depressive episodes, which are separated by periods during which symptoms do not meet diagnostic criteria. Even during these “euthymic” periods, patients may continue to experience some symptoms and decreased functioning,3 and brain function continues to be abnormal on functional magnetic resonance imaging (MRI). The timing of the recurrent mood episodes and their polarity (whether manic or depressive), duration, and severity are highly variable between patients and can also vary in the same patient over time. The symptoms typically have a severely debilitating impact on the patient’s functioning, employment or educational prospects, and quality of life, and they can substantially elevate the risk of suicide, particularly during depressive episodes with or without mixed features. Early, accurate diagnosis can substantially reduce the burden of bipolar disorder and improve the long- term outcome for patients. Establishing the diagnosis can, however, be problematic, given the diversity of symptoms that can suggest a number of alternative diagnoses. A high index of suspicion that the symptoms may indicate bipolar disorder is essential. This review recommends key decision- making steps in the management of patients with bipolar disorder—from the initial stages of clinical suspicion, to confirmation of the diagnosis, through acute and longer- term management and monitoring (Figure 1). Decision- Making Steps in Bipolar Disorder Diagnosis and Management. MAKING THE DIAGNOSIS OF BIPOLAR DISORDERDecision steps in the diagnosis of bipolar disorder are summarized in Table 1. 1 STD Surveillance Case Definitions Chancroid (Revised 9/96) Clinical description A sexually transmitted disease characterized by. Clinical Decision Steps in Bipolar Diagnosis. When to Suspect Bipolar Disorder. Patients who first present to primary care with bipolar disorder may show a wide range of mood- related symptoms, including depression, anxiety, mood swings, irritability, fatigue, difficulty in sleeping, and inability to focus and concentrate. Certain psychiatric and medical comorbidities are also extremely common and, by their presence, raise a suspicion of bipolar disorder. The patient’s social history will often show characteristic sequelae of the illness, such as relationship and marital problems, erratic occupational histories, financial troubles, and recurrent legal issues. Diagnosing bipolar disorder in the face of the diverse symptoms and sequelae is a challenge that requires a high index of suspicion. Suspicion of a manic episode. A full- blown manic episode that includes the cardinal symptoms may be readily identifiable in most patients with bipolar I disorder, but the symptomatology can be variable (Table 2). Particular attention should be paid to the symptomatology of mania in patients with comorbidities (eg, anxiety, panic disorder, substance abuse), as these symptoms can further complicate or mask the diagnosis. Patients experiencing a manic episode should receive urgent specialist investigation and treatment because of the high risk of harm to self or others. Manic episodes frequently require intensive outpatient treatment or admission to a psychiatric facility (including involuntary admission) to provide a safe environment during treatment induction. Manic and Hypomanic Episodes: DSM- 5 Criteriaa. Milder episodes of mania, such as hypomania, which is characteristic of bipolar II disorder, are more easily missed. Malnutrition and Nutrition-Focused Physical Assessment Terse Scollard MBA RD LD FAND March 27, 2015 Utah Academy of Nutrition and Dietetics Annual Meeting. Primary care physicians are the first point of contact for many patients with bipolar disorder, and they have a fundamental role in the diagnosis and. Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease of unknown cause. The hallmark feature of this condition is persistent symmetric. For many patients, a hypomanic episode represents a period of “wellness” after an episode of depression, and they may not report hypomanic symptoms unless specifically questioned. These patients may even challenge their bipolar diagnosis. The provision of information in the form of written materials, recommended Web sites, and support group details can help these patients to accept their diagnosis. Suspicion of a depressive episode. Depressive symptoms are experienced most frequently and for the longest duration in bipolar disorder, and are the most common reason for patients to seek care (Figure 1). The symptoms of depression in bipolar disorder closely resemble those in MDD,5,1. Table 3). Patient characteristics that can help to differentiate bipolar depression and MDD are included below and in Figure 2. A history of mania or hypomania. This is the major differentiator of bipolar disorder from MDD (mania in bipolar I and hypomania in bipolar II disorder). All patients with depression should be questioned about current or prior manic or hypomanic symptoms (see Table 2). As discussed later, use of a bipolar screening tool in all patients diagnosed with a major depressive episode may represent a time- efficient practice routine as a first step, followed by a confirmatory clinical interview guided by the responses.(2) Age at onset. The age at onset for bipolar depression is typically earlier than for MDD, with first symptoms often manifesting between the ages of 1. By contrast, the symptoms of MDD first manifest, on average, in the mid- to late 2. Atypical features. Patients with bipolar disorder more often experience “atypical” features of depression, such as hypersomnia, hyperphagia, and rejection sensitivity, when compared with MDD. Mood lability, psychotic symptoms, psychomotor retardation, and pathological guilt are also more predictive of bipolar disorder.(4) Course of illness. Bipolar disorder is characterized by more frequent and more rapid onset of recurrences than MDD. A history of frequently recurring depression, especially with melancholic or psychotic features, may be an indicator of bipolar disorder.(5) Treatment history. A history of lack of response to antidepressants may point to a bipolar diagnosis. Antidepressant monotherapy may also increase the risk of rapidly “switching” a bipolar patient from a depressive to a manic episode. Family history. A history of mood disorders in the family is a strong predictor for bipolar disorder. Major Depressive Episode: DSM- 5 Criteriaa. Key Differentiating Features of Depressive Symptoms in Bipolar Disorder Versus Major Depressive Disorder (MDD)a. Suspicion of mixed features. Patients with concurrent manic and depressive symptoms may experience significant energy, impulsivity, and irritability in combination with depression and hopelessness. The presence of mixed states is a particular danger to patients, because the combination of dysphoria, high energy, and decreased sleep places them at high risk for suicide.
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. Archives
December 2016
Categories |