A 19-year-old college student is brought to student health services by her roommate, who is concerned about her recent behavior. Over the past 4 days, the patient reports feeling “more energized than usual” and sleeping only 3–4 hours per night without feeling tired. She has been more talkative than usual, easily distracted in class, and enrolled in multiple new extracurricular clubs. The roommate states that the patient has seemed more social and upbeat, though she has not exhibited any dangerous or reckless behaviors. The patient denies hallucinations, delusions, or suicidal ideation. She has a history of a prior depressive episode 6 months ago that lasted 3 weeks and was characterized by hypersomnia, fatigue, and difficulty concentrating. She is currently not on any medications. She does not use any illicit substances Her father has a history of depression. Vital signs are within normal limits. On physical examination, she appears cheerful and animated. Speech is rapid but coherent. There are no psychotic features.
C) Bipolar II disorder
Bipolar II disorder is diagnosed when a person has at least one major depressive episode and at least one hypomanic episode, with no history of full mania. A hypomanic episode is a period of elevated or irritable mood and increased energy lasting at least 4 consecutive days, with at least 3 associated symptoms (e.g., decreased need for sleep, talkativeness, distractibility, increased goal-directed activity). Unlike mania, hypomania does not cause marked functional impairment, does not require hospitalization, and does not include psychosis. This patient’s episode meets criteria for hypomania, not mania, in the context of a prior depressive episode - consistent with bipolar II disorder.
Answer choice A: Attention-deficit hyperactivity disorder (ADHD), is incorrect. ADHD is a chronic neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsivity that begins before age 12 years and is evident across multiple settings. It does not present episodically and does not involve periods of elevated mood or decreased need for sleep, which are seen in hypomania.
Answer choice B: Bipolar I disorder, is incorrect. Bipolar I disorder is diagnosed when a person has at least one manic episode, lasting at least 7 days (or any length of time if hospitalization is required), including 3 or more of the following criteria during the manic episode:
- Distractibility
- Insomnia
- Grandiosity (increased self-esteem)
- Flight of ideas or racing thoughts
- Activity/agitation (such as putting significantly more work into projects of increased sexual activity)
- Pressured or rapid speech
- Thoughtlessness (engaging in pleasurable activities with negative consequences)
This patient has hypomanic, not manic, symptoms, and thus does not meet the criteria for Bipolar I disorder.
Answer choice D: Cyclothymic disorder, is incorrect. Cyclothymic disorder is a chronic mood disorder involving fluctuating periods of hypomanic and depressive symptoms that do not meet full criteria for either a hypomanic or major depressive episode, lasting ≥2 years. This patient has had a discrete major depressive episode and a hypomanic episode, which meets full criteria for bipolar II disorder, not cyclothymia.
Answer choice E: Schizophrenia, is incorrect. Schizophrenia is diagnosed when the following criteria are met:
- Two or more of the following symptoms, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one symptom must be from the first three:
- Delusions
- Hallucinations
- Disorganized speech
- Grossly disorganized or catatonic behavior
- Negative symptoms (e.g., diminished emotional expression, avolition)
- Functional decline in one or more major areas (e.g., work, interpersonal relationships, self-care).
- Continuous signs of disturbance for at least 6 months, which must include at least 1 month of active-phase symptoms (criterion A), with periods of prodromal or residual symptoms (e.g., social withdrawal, flat affect).
This patient does not exhibit psychosis or functional deterioration, and her symptoms are best explained by a mood disorder, not schizophrenia.
Key Learning Point
Bipolar II disorder requires at least one major depressive episode and one hypomanic episode, with no history of mania. Hypomania is a milder form of mania that lasts at least 4 days and does not cause functional impairment, hospitalization, or include psychosis.
