A 28-year-old woman from Delhi presents to the psychiatry outpatient department with her husband. She reports a 3-week episode of elevated mood, decreased need for sleep (sleeping only 2–3 hours per night but feeling fully rested), racing thoughts, and increased goal-directed activity. She has been working on multiple projects simultaneously and has spent ₹5 lakhs on unnecessary online shopping. Her husband notes she is more talkative than usual and easily irritated when interrupted. Two years ago, she had a depressive episode lasting 8 weeks that required hospitalization and antidepressant therapy. There is no history of psychotic symptoms during mood episodes. Mental status examination confirms pressured speech, flight of ideas, and psychomotor agitation. What is the most likely diagnosis?

Explanation

## Diagnosis: Bipolar Disorder I, Current Episode Manic ### Key Diagnostic Features Present **Key Point:** The patient meets DSM-5 criteria for a manic episode: a distinct period of abnormally elevated, expansive mood lasting ≥7 days (here 3 weeks), with ≥3 of the following: decreased need for sleep, racing thoughts, increased goal-directed activity, excessive spending, pressured speech, and distractibility. ### Bipolar I vs. Bipolar II Differentiation | Feature | Bipolar I | Bipolar II | |---------|-----------|----------| | **Manic episodes** | Full manic episodes (≥7 days, severe impairment) | Absent | | **Hypomanic episodes** | May occur, but not required | Required (≥4 days, less severe) | | **Depressive episodes** | Present | Required | | **Psychotic features** | May occur during mood episodes | Rare; if present, brief | | **Functional impairment** | Marked; often requires hospitalization | Mild to moderate | **High-Yield:** The presence of a **full manic episode** (not just hypomania) is the defining criterion for Bipolar I Disorder, regardless of depressive history. ### Clinical Pearl: Why This Is Manic, Not Hypomanic - **Duration:** 3 weeks exceeds the 7-day minimum for mania. - **Severity:** Excessive spending (₹5 lakhs), pressured speech, flight of ideas, and psychomotor agitation indicate marked functional impairment. - **Hospitalization history:** The prior depressive episode requiring hospitalization supports a Bipolar I diagnosis; Bipolar II depressive episodes are typically less severe. ### Mnemonic: **DIG FAST** (Manic Episode Criteria) - **D**istractibility - **I**ndiscretion (excessive spending, risky behavior) - **G**randiosity - **F**light of ideas - **A**ctivity increase (goal-directed) - **S**peech (pressured) - **T**hought racing This patient exhibits at least 5 of 7 criteria. ### Why Psychotic Features Are Not Required **Warning:** Absence of psychotic symptoms does NOT exclude Bipolar I. Psychosis in mania is common but not mandatory for diagnosis. [cite:DSM-5 Diagnostic Criteria for Bipolar I Disorder]