Mania and Hypomania: MCCQE1 Adult Psychiatry

Introduction

Understanding the distinction between Mania and Hypomania is critical for the Medical Council of Canada Qualifying Examination Part I (MCCQE1). These mood episodes are the defining features of Bipolar I and Bipolar II disorders, respectively.

In the context of the CanMEDS framework, a Canadian physician must be a Medical Expert capable of diagnosing these conditions, a Health Advocate for patient safety (recognizing suicide risk and impulsivity), and a Collaborator working with multidisciplinary teams for management.

Definitions and Diagnostic Criteria (DSM-5-TR)

The core difference between mania and hypomania lies in duration, severity, and the presence of psychosis.

Clinical Presentation

The DIG FAST Mnemonic

This is the standard mnemonic for recalling symptoms of Mania/Hypomania.

Mental Status Examination (MSE) Findings

• Appearance: Flamboyant dress, excessive makeup, poor grooming (if severe), intrusive behavior.
• Speech: Pressured, loud, difficult to interrupt.
• Affect: Labile, euphoric, irritable.
• Thought Process: Flight of ideas, tangentiality, circumstantiality, clang associations (rhyming).
• Thought Content: Grandiose delusions (e.g., believing they have special powers or relationships with famous people), paranoid delusions.
• Insight/Judgment: Typically poor.

Differential Diagnosis

It is crucial to rule out “Secondary Mania” (due to medical or substance causes) before diagnosing Bipolar Disorder.

Approach to Diagnosis and Management

Canadian Guidelines (CANMAT) Highlights

Medication Specifics for MCCQE1

• Lithium:

  • Indication: Gold standard for classic euphoric mania and suicide prevention.
  • Therapeutic Index: Narrow (0.6–1.2 mmol/L). Toxicity occurs at >1.5 mmol/L.
  • Side Effects: Tremor, polyuria (Nephrogenic DI), hypothyroidism, teratogenicity (Ebstein’s anomaly).
  • Monitoring: TSH, Creatinine/eGFR, Lithium levels.

• Divalproex (Valproate):

  • Indication: Better for mixed features or rapid cycling.
  • Side Effects: Hepatotoxicity, thrombocytopenia, pancreatitis.
  • Contraindication: Pregnancy (highly teratogenic – neural tube defects).

• Lamotrigine:

  • Indication: Maintenance treatment, specifically for preventing bipolar depression. Not effective for acute mania.
  • Warning: Stevens-Johnson Syndrome (SJS). Start low and titrate slow (“Start low, go slow”).

Key Points to Remember for MCCQE1

1. Bipolar I vs. II: The presence of one Manic episode makes the diagnosis Bipolar I, regardless of history of depression. Bipolar II requires at least one Hypomanic episode and one Major Depressive episode.
2. Hospitalization: If a patient is hospitalized for the mood elevation, it is Mania by definition, not hypomania.
3. Postpartum: Postpartum mania is a psychiatric emergency and is often a presentation of Bipolar I.
4. Elderly: New-onset mania in an elderly patient is medical/neurological until proven otherwise (“Secondary Mania”).
5. Sleep: A decreased need for sleep is a hallmark of mania (unlike insomnia where patients want to sleep but can’t).

Sample Question

Clinical Scenario

A 23-year-old male is brought to the emergency department by police after he was found directing traffic at a busy intersection in downtown Toronto at 3:00 AM, wearing only shorts in October. He is laughing loudly and tells the triage nurse that he has been “chosen to reorganize the city’s flow.” His roommate arrives and reports that the patient has not slept in 5 days but has been full of energy, writing a manifesto on napkins. The patient has a history of two episodes of severe depression in the past. Urine toxicology is negative.

Question

Which one of the following is the most appropriate diagnosis?

• A. Schizophrenia
• B. Bipolar II Disorder
• C. Cyclothymic Disorder
• D. Bipolar I Disorder
• E. Narcissistic Personality Disorder

Explanation

The correct answer is:

• D. Bipolar I Disorder

Detailed Explanation: This patient presents with a classic Manic Episode. The key features are:

1. Duration: Symptoms have lasted 5 days (Mania requires 1 week unless hospitalization is necessary; his behavior necessitated police intervention/hospital assessment).
2. Severity: The behavior is dangerous (directing traffic), bizarre, and socially impairing.
3. Psychosis: He exhibits grandiose delusions (“chosen to reorganize the city’s flow”).
4. Symptoms: Decreased need for sleep, grandiosity, increased activity, psychomotor agitation.

The presence of a single Manic Episode confirms the diagnosis of Bipolar I Disorder. A history of depression supports the diagnosis but is not strictly required for Bipolar I (though almost always present).

• Option A (Schizophrenia): While he has delusions, the prominent mood symptoms (elation, energy, no sleep) and the distinct episodic nature favor Bipolar Disorder. Schizophrenia requires 6 months of disturbance.
• Option B (Bipolar II Disorder): Bipolar II is characterized by Hypomania and Major Depression. Hypomania does not include psychosis and does not result in severe impairment or hospitalization. This patient has psychosis and severe impairment.
• Option C (Cyclothymic Disorder): Involves numerous periods of hypomanic symptoms and depressive symptoms that do not meet full criteria for an episode, lasting for at least 2 years.
• Option E (Narcissistic Personality Disorder): While grandiosity is a feature, NPD is a pervasive pattern of behavior, not an acute episodic change with sleep disturbance and psychosis.

References

1. American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.).
2. Yatham, L. N., et al. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders, 20(2), 97–170.
3. Medical Council of Canada. (n.d.). MCCQE Part I Clinical Decision-Making and Multiple-Choice Question Objectives.
4. Public Health Agency of Canada. (2016). Mood and anxiety disorders in Canada.