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2.11
I. BACKGROUND. Night sweats are drenching sweats that require a change of bedding (1).
II. PATHOPHYSIOLOGY
A. Etiology.
Night sweats that are caused by fever represent a separate entity and are discussed
in Chapter 2.6. Night sweats are likely to be an autonomic response to some physical or
emotional condition, representing a rather nonspecific symptom that should prompt the
clinician to seek a specific cause.
B. Epidemiology. One study of approximately 800 patients in the practices of several
primary care physicians indicated that about 10% were bothered to some degree by night
sweats; 70% of patients affected reported some trouble, 20% a fair amount of trouble, and
10% a great deal of trouble (2).
III. EVALUATION
A. History.
1. It is helpful to characterize night sweats by determining the onset, frequency, exacerba-
tions, and remissions of symptoms (3). The clinician must thoroughly explore any risk of
exposure to infectious causes of night sweats. This history must include questions about
behaviors that put the patient at risk of HIV-related infections, sexually transmitted
diseases, hepatitis, and tuberculosis. Explorations of travel and occupational exposures
should be carried out.
2. The state of concurrent medical conditions must be determined. Changes in treatment
modalities that are both physician driven as well as those initiated by the patient may
be a causative factor for night sweats. All the patient’s current and recently discontinued
medications must be determined.
3. A thorough review of the systems may point the clinician toward a primary disease that
includes night sweats as a symptom. Psychologic factors that might precipitate night
sweats in healthy individuals should be discussed.
4. Interviewing a sleeping partner is an important source of information that must not be
neglected. A history of snoring or apneic episodes may point to sleep apnea that has been
reported to be a common cause of night sweats (4).
B. Physical Examination. The fact that night sweats in the absence of any other identifiable
cause constitute a physically benign condition makes it imperative that a complete physical
examination be carried out in an effort to determine the presence of any concurrent condi-
tion. The history may direct the physician toward a more detailed examination of a specific
organ system; however, the knowledge that the cause may be multifactorial must be remem-
bered, and no part of the physical examination should be neglected.
C. Testing. The choice of laboratory tests is guided by the history. For those patients with
known medical conditions, appropriate tests for exacerbations should be carried out. The
tests might include a complete blood count to assess the status of the infection, erythrocyte
sedimentation rate, HbA1C, and C-reactive protein. A history of exposure might suggest an
HIV test, a hepatitis panel, or a purified protein derivative skin test for tuberculosis. Thyroid
function testing in individuals identified as at risk should also be carried out. Special testing
may be required in individuals with travel-related exposure.
D. Genetics. There is no reported familial cause of primary night sweats.
IV. DIAGNOSIS
A. Differential Diagnosis.
The diagnosis of night sweats is largely historical (see Table 2.11.1).
B. Clinical Manifestations. Night sweats are most frequently a manifestation of an
underlying illness. As such, the manifestation is most often a part of a much larger symptom
Night Sweats
Richard H. Hurd
28
Taylor’s DifferenTial Diagnosis Manual
complex. The diagnosis centers on discovering the underlying disease entity. When no
cause in evident, watchful waiting is useful in an attempt to let the cause become more
evident (5).
REFERENCES
1. Smetana GW. Diagnosis of night sweats. JAMA 1993;70:2502–2503.
2. Mold JW, Roberts M, Aboshady H. Prevalence and predictors of night sweats, day sweats, and hot
flashes in older primary care patients. Am Fam Med 2004;2(5):391–397.
3. Bajorek M. Night sweats. In: Taylor R, ed. The 10-minute diagnosis manual. Philadelphia, PA:
Lippincott Williams & Wilkins, 2000:31–33.
4. Duhon DR. Night sweats: two other causes. JAMA 1994;271:1577.
5. Chambliss ML. Frequently asked questions from clinical practice. What is the appropriate diagnostic
approach for patients who complain of night sweats? Arch Fam Med 1999;2:168–169.
TABLE 2.11.1 Causes of Night Sweats
Malignancy Infectious Endocrine Rheumatologic Drugs Other
Lymphoma Human
immunodefi-
ciency virus
Hyperthyroidism Rheumatoid
arthritis
– Sleep apnea
Leukemia Tuberculosis Ovarian failure Lupus – Gastroesophageal
reflux disease
Other
malignancy
Endocarditis Diabetes
mellitus
Juvenile
rheumatoid
arthritis
– Angina
Lung infection Endocrine
tumors
Temporal arthritis – Pregnancy
Other infections Overbundling
Extreme heat
2.12
I. BACKGROUND. The definition of syncope is a transient and often abrupt loss of consciousness
with complete return to the preexisting level of function.
II. PATHOPHYSIOLOGY
A. Epidemiology.
Syncope is a common phenomenon occurring in approximately 40% of
adults and accounting for 3% to 5% of emergency room visits and 1% to 6% of hospital
medical admissions. Presenting in a bimodal pattern, 80% of patients experience their first
episode before the age of 30 years and then again as patients age into their 70s and beyond,
they experience a second increase in the incidence. A high percentage of patients (30% to
60%) have no causative diagnosis made after even extensive workups. In a large cohort of
Syncope
Mark D. Goodwin
Chapter 2 • Undifferentiated Problems
29
Syncope
H&P, EKG
Syncope of
unknown etiology
Signs/Symptoms c/w orthostatic
hypotension or vaso-vagal
syncope-treat with fluids/adjust
medications as needed; reassure
the patient for vaso-vagal
Treat structural heart disease and ischemia.
Electrophysiologic testing is best directed at
patients with structural heart disease, particularly
previous myocardial infarction or left ventricular
dysfunction. Consider implantable defibrillator
if the left ventricular ejection fraction is < 0.35;
Single benign
episode
Evaluation
complete
Sinus rhythm
with symptoms
Cardiac evaluation
complete; Consider
tilt table test
Dysrhythmia with
associated symptoms
Cardiac stress test,
echocardiogram and
ischemia evaluation
Normal
Correlate symptoms
with rhythm
Holter or event
monitor
Frequent episodes Infrequent episodes
Implantable
loop recorder
Treat as indicated
Figure 2.12.1. Causes and Evaluation of Syncope.
patients from the Framingham Heart Study, the most frequently identified causes of syncope
were vasovagal (21.2%), cardiac (9.5%), orthostatic (9.4%), medication (6.8%), seizure
(4.9%), stroke or transient ischemic attack (4.1%), other causes (7.5%), and unknown
(37%).
B. Classification. Syncope can be classified using various systems from malignant and
benign conditions to cardiac to noncardiac conditions. However, perhaps the most com-
mon classification system employs the following categories: cardiac (which includes struc-
tural abnormalities and dysrhythmias or arrhythmias), reflex or neurally mediated (which
includes neurocardiogenic, situational, and carotid sinus hypersensitivity etc.), neurologic
(which includes seizure, vertebrobasilar TIA, etc.), orthostatic (often grouped into the reflex-
mediated category and includes drug effects, volume depletion, and autonomic failure), and
miscellaneous (which includes psychogenic, pulmonary embolism etc.) (Figure 2.12.1).
III. EVALUATION
The evaluation of syncope involves developing an appropriate differential diagnosis, determin-
ing how much of an evaluation (including laboratory, radiographic, and other testing) is needed,
whether or not admission is required, and the patient’s overall prognosis.
A. History. Despite the fact that patients will use a variety of terms to describe their signs
and symptoms (dizziness, lightheadedness etc.), as is the case in most of medicine, the his-
tory and physical examination remains the cornerstone for diagnosing the cause of syncope,
with several studies showing a diagnostic yield of approximately 50%. While syncope can
30
Taylor’s DifferenTial Diagnosis Manual
be said to be truly distinct from vertigo, seizures, stroke, coma, and other states of altered
consciousness, one of the biggest challenges facing clinicians can be discerning between
syncope and seizure. Important historical factors to be gleaned include age (with greater age
associated with higher risk of serious conditions), position and activity before the episode,
prodrome (such as aura with seizures, palpitations with dysrhythmia etc.), triggers (such
as pain, fear, or cough, micturition, and defecation common in reflex-mediated syncope),
associated symptoms (such as palpitations, chest pain, shortness of breath, headache,
paresthesias, slurred speech, aphasia, and focal weakness), associated injury, and duration
of symptoms. The patient who presents in a postictal state or with persistent neurologic
symptoms did not, by definition, have a syncopal event. Previous episodes and the workup
of these can help differentiate benign and malignant causes. Finally family history should
be reviewed looking for members with sudden cardiac death, hypertrophic cardiomyopathy,
and prolonged or short QT syndromes. Of course a complete past medical and social history
(including alcohol, prescription, OTC, and illicit drug use) should also be obtained, as well
as any witnesses of the event interviewed.
B. Physical. The physical exam should be complete with a focus on abnormal vitals (such as
orthostasis and an abnormal heart rate), the cardiac exam (to rule out murmurs), a complete
neurologic exam to rule out focal abnormalities, and examination to exclude any trauma
(either as cause of or as a result of the episode). If carotid sinus hypersensitivity is suspected,
a carotid sinus massage can be conducted but is contraindicated in the presence of suspected
or known carotid artery disease or recent CVA or TIA. Auscultation of the carotids before
the procedure is required to rule out an obvious bruit.
C. Testing. Additional testing should include an EKG (although the diagnostic yield is <5%)
and can include an ECG, electrophysiologic testing, exercise treadmill testing, tilt table
testing, short or long term electrocardiographic monitoring, neuroimaging, and EEG if
the history and exam dictate. Routine use of laboratory tests is not recommended and only
targeted laboratory tests should be ordered as indicated by the history and physical.
IV. DIAGNOSIS
If the primary purpose of the evaluation of the patient with syncope is to determine whether
the patient is at increased risk for death then development of a “formula” to establish such risk
would be ideal. To that end, various diagnostic point scoring systems have been developed,
including the European Guidelines in Syncope Study score, the San Francisco Syncope Rule,
and the Risk Stratification of Syncope in the Emergency Department. Each of these has its
advantages and disadvantages and none to date has sensitivity rates above 90%. Management
of syncope patients and the prognosis are both guided by the specific diagnosis.
The decision whether to admit patients who experience a snycopal episode will depend
upon the circumstances of the event as well as the patient’s overall risk for injury (including
age, history of CAD, suspected cardiac structural abnormality or dysrhythmia, etc.) from the
possible cause. The algorithm depicted in Figure 2.12.1, modified from the 2006 AHA/ACCF
Scientific Statement on the Evaluation of Syncope, can be helpful in the work-up and evalua-
tion of patients who present with the often confusing condition of syncope.
REFERENCES
1. Gauer RL. Evaluation of syncope. Am Fam Physician 2011;84(6):640–650.
2.
Angaran P. Syncope. Neurol Clin 2011;29:903–925.
3. Ouyang H. Diagnosis and evaluation of syncope in the emergency department. Emerg Med Clin N Am
2010;28:471–485.
4. Strickberger SA, Benson DW, Biaggioni I, et al. AHA/ACCF scientific statement on the evaluation
of syncope: from the American Heart Association Councils on Clinical Cardiology, Cardiovascular
Nursing, Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes
Research Interdisciplinary Working Group; and the American College of Cardiology Foundation In
Collaboration With the Heart Rhythm Society. J Am Coll Cardiol 2006;47(2):473–484.
Chapter 2 • Undifferentiated Problems
31
I. BACKGROUND. Unintentional weight loss is generally considered to be significant when great-
er than 5% of body weight is lost over a period of 6 months or less. It is often associated with
increased morbidity and mortality, especially among the elderly. Perceived weight loss should
be verified before initiating a workup, because 50% of patients with perceived weight loss do
not have true weight loss. Of patients with confirmed weight loss, an explanation is found in
approximately 75% of cases. In the remainder, an explanation is never found. The prognosis for
patients in whom a diagnosis is not found is generally better. (1) If a physical cause is present
it is usually discovered within 6 months (1–3).
II. PATHOPHYSIOLOGY
The various conditions that cause unintentional weight loss do so through one or more of the
following mechanisms: inadequate caloric intake, excessive metabolic demands, or loss of nutri-
ents through urine or stool. Other conditions that cause weight loss include:
A. Malignant Conditions. Cancer is often the patient’s or physician’s greatest fear.
Malignancy is the cause for unintentional weight loss in 16% to 36% of cases (1–3).
Although any cancer can cause weight loss, the more common malignancies to consider are
gastrointestinal (GI), leukemia or lymphoma, lung, ovarian, and prostate cancers.
B. Benign Medical Conditions. Many chronic medical conditions can cause anorexia,
nausea, diarrhea, or postprandial symptoms that discourage the patient from eating. Medical
conditions may also necessitate limiting salt, fat, or sugar in the diet, leaving the patient less
inclined to eat.
1. GI disorders account for the most common physical cause of weight loss, affecting
approximately 17% of patients (4). These include:
a. Peptic ulcer disease/gastroesophageal reflux disease
b. Inflammatory bowel disease and malabsorptive illnesses
c. Hepatitis, cholestasis
d. Pancreatitis
e. Atrophic gastritis
f. Constipation
2. Cardiac diseases, especially congestive heart failure
3. Respiratory diseases, such as chronic obstructive pulmonary disease
4. Renal disease
5. Neurologic or neuromuscular disorders may affect the ability to swallow. Examples
include:
a. Cerebrovascular accident
b. Parkinson’s disease
c. Scleroderma
d. Polymyositis
e. Systemic lupus erythematosus
6. Endocrine disorders can increase metabolic rate or cause nutrient loss. These include:
a. Hyperthyroidism
b. Diabetes mellitus
c. Other causes, such as pheochromocytoma, panhypopituitarism, adrenal insufficiency
7. Chronic infection, especially tuberculosis, fungal infections, or subacute bacterial
endocarditis. Any prolonged febrile illness can decrease appetite and increase meta-
Unintentional
WeightLoss
Amy K. Jespersen
2.13
32
Taylor’s DifferenTial Diagnosis Manual
bolic demand. Human immunodeficiency virus infection is a special consideration with
patients having multiple causes for weight loss.
8. Dementia
9. Medications can cause anorexia, nausea, abdominal pain, or diarrhea, or inhibit gastric
emptying.
C. Psychiatric Causes. These are responsible for weight loss in 10% to 20% of patients
(1–3).
1. Depression, bereavement, and anxiety
2. Paranoia and psychosis
3. Substance abuse, especially alcoholism
D. Social and Age-Related Causes. These include:
1. Financial hardship
2. Diminished sense of taste and smell
3. Functional inability to shop, prepare food, or feed oneself
4. Poor dentition or ill-fitting dentures
III. EVALUATION
A. History.
A detailed history should be obtained from the patient and caregivers if appli-
cable. Special attention should be given to the types and quantity of food consumed; alcohol
use; history of cigarette smoking (current and remote); exercise patterns; medications; pres-
ence of nausea, vomiting, diarrhea, early satiety, difficulty swallowing; history of GI illnesses,
or previous abdominal surgery; cardiac history; respiratory history; history of kidney disease;
depressive symptoms; social situation, including financial resources; and functional ability to
shop for groceries and prepare meals.
B. Physical Examination.
1. Document weight and compare to previous weights
2. Perform a thorough physical examination, paying special attention to the following areas:
a. Dentition and oral
b. Respiratory
c. Cardiac
d. GI
e. Psychiatric
f. Cognitive
g. Musculoskeletal
C. Testing. Extensive undirected testing is not indicated and is rarely helpful.
1. Initial laboratory tests may include
a. Complete blood count
b. Comprehensive metabolic profile
c. TSH and Free T4
d. Urinalysis
e. Fecal occult blood testing
2. Other tests as indicated by history or physical exam may include
a. Chest x-ray, especially with a history of smoking, cough, or dyspnea
b. Appropriate age- and gender-based screening (mammography, colonoscopy)
c. Upper GI endoscopy
IV. DIAGNOSIS
Diagnosis of unintentional weight loss is made by verifying that a loss of more than 5% of body
weight has occurred. A thorough history and physical examination and directed laboratory and
ancillary tests result in an explanation in three out of four cases. Malignancy is the cause of
unintentional weight loss in up to one-third of the cases. Psychiatric illness, usually depression,
is another common cause. Benign medical conditions and socioeconomic factors make up the
remainder of the identifiable causes. In 25% of cases, no explanation can be found and these
patients have a more favorable outcome. Many patients will have a multifactorial reason for
weight loss. If a physical cause is responsible, but not identified on initial workup, it usually
becomes evident within 6 months (4).
Chapter 2 • Undifferentiated Problems
33
REFERENCES
1. Marton KE, Sox HC Jr, Krupp JR. Involuntary weight loss: diagnostic and prognostic significance. Ann
Intern Med 1981;95:568–574.
2. Rabinovitz M, Pitlik SD, Leifer M, et al. Unintentional weight loss. A retrospective analysis of 154
cases. Arch Intern Med 1986;146:186–187.
3. Thompson MP, Morris LK. Unexplained weight loss in the ambulatory elderly. J Am Geriatric Soc
1991;39:497–500.
4. Huffman GB. Evaluating and treating unintentional weight loss in the elderly. Am Fam Physician
2002;65:640–650.
5. Stajkovic S, Aitken E, Holroyd-Leduc J. Unintentional weight loss in older adults. CMAJ
2011;183(4):443–449.
6. Alibhai S, Greenwood C, Payette H. An approach to the management of unintentional weight loss in
elderly people. CMAJ 2005;172(6):773–780.
34
Taylor’s DifferenTial Diagnosis Manual
CHAPTER 3
Mental Health Problems
Jim Medder
3.1
I. BACKGROUND. The experience of anxiety is ubiquitous in society. Anxiety can be part of an
adaptive or protective response to threat (e.g., the fight–freeze–flight response) or a natural
reaction to physical and emotional stress, but it can also be debilitating and a serious health
concern. At its core, anxiety is a complex biopsychosocial–spiritual experience that requires
comprehensive assessment and treatment. Undiagnosed anxiety disorders contribute to inap-
propriate or overutilization of health-care resources, but as many as 80% of the individuals with
anxiety disorders can be significantly helped through appropriate treatment.
II. PATHOPHYSIOLOGY
A. Etiology.
Many factors contribute to both the development and experience of anxiety.
These include genetic/neurologic predisposition, family history, acute and chronic stressors,
resources for coping, comorbid conditions, and overall physical health. Extreme anxiety
responses, known as anxiety disorders, are often comorbid with mood or substance use
disorders or other chronic health conditions (e.g., respiratory problems and cancer).
Anxiety disorders usually include debilitating physical and emotional symptoms and may
be due, at least in part, to primary medical problems such as hyperthyroidism or hypoxia.
Consequently, anxious patients present to the emergency room or primary care setting with
complaints that can be difficult to assess and diagnose.
B. Epidemiology. According to the National Institute of Mental Health, 40 million
adult Americans (18%) experience an anxiety disorder at any one time. Estimates of the
prevalence of the various anxiety disorders vary from study to study but generally are as
follows: generalized anxiety disorder (GAD)—6.8 million (women twice as likely as men);
obsessive compulsive disorder—3.3 million (equally common among men and women);
panic disorder—6 million (women twice as likely as men); posttraumatic stress disorder
(PTSD)—7.7 million (women more likely than men); social anxiety disorder—15 million
(equally common among men and women); and specific phobia—19.2 million (women
twice as likely as men) (1). The various anxiety disorders affect approximately 10% of
primary care patients (2).
III. EVALUATION
A. History
1. Patients with anxiety disorders frequently describe experiencing physical symptoms such
as chest pain, dizziness, palpitations, fatigue, shortness of breath, tremors, sweating, mus-
cle aches or tension, or a variety of gastrointestinal complaints. Common psychologic
symptoms can include nervousness and worry, fear of dying or going crazy, or a sense of
unreality or detachment from oneself.
Anxiety
Layne A. Prest
35
2. Some patients attribute their anxiety to their physical symptoms (“Of course, I was
anxious. I thought I was having a heart attack”). Consequently, the assessment of
anxiety disorders should include the nature, frequency, and duration of the preceding
symptoms and the extent to which the symptoms have impacted the individual’s life
and activity.
3. The patient should also be asked about precipitants of the symptoms, including stressors,
specific social contexts, medications (e.g., stimulants), and other drug use (e.g., caffeine
and cocaine).
4. Questions about the patient’s general medical condition(s) (e.g., hyperthyroidism) are
also appropriate.
B. Physical Examination. As with all patients, those whose clinical picture is suspected of
including a significant component of anxiety should be examined carefully. The extent of
the physical examination should be dictated by the patient’s personal health and medical
history.
1. The examination may include the following: blood pressure (hypertension and hypovo-
lemia), cardiovascular (angina, arrhythmia, congestive heart failure, and valvular heart
disease), respiratory (chronic obstructive lung disease, pulmonary embolism, and pneu-
monia), and neurologic (tumor, encephalopathy, and vertigo).
2. Patients frequently present with nervous agitation, intermittent eye contact, somewhat
pressured speech, and, in the primary care context, a worried focus on the somatic con-
cerns described in the preceding text.
C. Testing. Useful laboratory tests include serum calcium (hypocalcemia), hematocrit (ane-
mia), and thyroid-stimulating hormone (hyperthyroidism/hypothyroidism). Depending
on the clinical scenario, an exercise stress test to evaluate chest pain or other tests to rule
out organic causes, such as drug screen, oximetry (hypoxia), glucose (hypoglycemia), and
electrolytes, may be useful as well.
IV. DIAGNOSIS
A. Differential Diagnosis
1. GAD is characterized by persistent and excessive worry about a number of issues on
most days for a period of at least 6 months. GAD usually begins by early adulthood, is
exacerbated by situational stressors, and usually involves a combination of psychologic
and physical symptoms.
2. Panic disorder, with or without agoraphobia, presents with recurrent panic attacks—
discrete episodes of anxiety involving shortness of breath, fear of dying, impending
doom or losing control, pounding heart, sweating, chest pain, paresthesias, trembling,
and nausea. The panic attacks may be provoked by identifiable stressors or situations but
often seem to “come out of the blue.” Individuals with panic disorder may be so fearful
of being in a situation in which they have another panic attack and are unable to escape
that they develop agoraphobia (an intense fear of being in open or crowded places, which
often contributes to the individuals being reluctant to leave the perceived safety of their
home).
3. Acute stress disorder (ASD) and PTSD are characterized by reexperiencing (through
intrusive thoughts, flashbacks, and nightmares) an extremely traumatic and possibly life-
threatening experience (e.g., rape, murder, motor vehicle accident, and war), followed
by hyperarousal, panic, depressed mood, sleep disturbance, and hypervigilance. The
individual usually attempts to avoid these memories or the chance of being in danger
again through numbing, dissociation, repression, and behavioral changes. The main
distinction between ASD and PTSD is the duration of symptoms (i.e., in PTSD, the
symptoms last longer than 1 month).
4. Specific phobia is excessive anxiety provoked by exposure to a specific feared object or
situation. Common phobias include fear of animals or insects, natural environment (e.g.,
heights, storms, and water), blood–injection–injury, or situations (e.g., tunnels, bridges,
elevators, flying, and driving).
36
Taylor’s DifferenTial Diagnosis Manual
5. Social phobia is an excessive anxiety provoked by exposure to social or performance
situations and unfamiliar individuals or surroundings. As a result, individuals with social
phobia avoid these types of situations.
6. Obsessive compulsive disorder is characterized by obsessions that cause anxiety (e.g.,
germs on hands) and compulsions (behaviors aimed at reducing the anxiety such as
hand washing). The obsessions usually fall into one or more of the following categories:
infection/contagion, safety, religiosity, sexuality, death/dying, and orderliness.
7. Adjustment reaction with anxious features is a condition in which a patient experiences
significant anxiety in reaction to a specific stressor such as a major life event or inter-
personal conflict. To qualify for this diagnosis, the level of anxiety should be assessed
as being more than expected under the circumstances. In addition to these conditions,
the clinician should investigate the possibility of mood, substance abuse, and other
psychiatric disorders (3).
B. Clinical Manifestations. Most anxious patients present in the primary care setting with
a primary focus on their bodies and somatic symptoms rather than “their minds.” But
inevitably, there is a significant component of worry, fear, and apprehension in the back-
ground. Because an exclusive focus on physical complaints (e.g., chest pain and dizziness)
can obscure the diagnosis, it is important to ask patients about their psychologic state, living
situation, and current stressors as well as evaluate them for underlying medical issues.
RefeRences
1. National Institute of Mental Health. Anxiety disorders. Bethesda, MD: National Institute of Mental Health,
2009. Retrieved from http://www.nimh.nih.gov/health/publications/anxiety-disorders/index.shtml.
2. American Anxiety Disorders Association. Silver Spring, MD. Retrieved from http://www.adaa.org
3. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed.
Washington, DC: American Psychiatric Association, 2000.
3.2
Bipolar Disorder
Daniel S. Felix
I. BACKGROUND. Bipolar I disorder, formerly known as manic-depressive disorder, is a condi-
tion in which a person’s mood swings back and forth between two extremes: the highs of mania
and the lows of depression. Bipolar disorder is distinguished from other mood disorders by the
presence of manic episodes, which typically last for several days or weeks (1, 2) and can lead to
risky behaviors (e.g., excessive spending, gambling, sexual carelessness, or infidelity), damaged
relationships, poor career or school performance, and even accidental loss of life (2). Bipolar
disorder is one of the 10 leading causes of disability worldwide (3) and can be very costly
to treat. In most cases, bipolar disorder can be adequately controlled with medications and
psychotherapy (1). Like diabetes, bipolar disorder is a long-term illness that must be carefully
managed throughout a person’s life.
II. PATHOPHYSIOLOGY
A. Etiology.
Although the exact causes of bipolar disorder are not known, biologic, psy-
chological, and social factors all play a significant role in its genesis and incidence. Studies
of twins give strong evidence for a genetic link, with twins being 40–70% more likely to
have bipolar disorder than another sibling (4). However, not every identical twin develops
the condition, which suggests that environmental factors are also involved in its origins.
Chapter 3 • Mental Health Problems
37