Xanadu and Mood Stabilization
This exercise is designed to test your comprehension of material relevant to this issue of Focus as well as your ability to evaluate, diagnose, and manage clinical problems. Answer the questions below to the best of your ability with the information provided, making your decisions as if the individual were one of your patients.Questions are presented at “consideration points” that follow a section that gives information about the case. One or more choices may be correct for each question; make your choices on the basis of your clinical knowledge and the history provided. Read all of the options for each question before making any selections. You are given points on a graded scale for the best possible answer(s), and points are deducted for answers that would result in a poor outcome or delay your arriving at the right answer. Answers that have little or no impact receive zero points. At the end of the exercise, you will add up your points to obtain a total score.This exercise describes the evaluation and treatment of a patient who has just received a diagnosis of bipolar disorder. Questions and answers examine the use of several agents in his treatment.
Case Vignette
You were covering emergency psychiatric services at the local hospital when the police brought in Mr. Sam Malone for involuntary evaluation and treatment. Mr. Malone was a 23-year-old man who came to the attention of the authorities when he was observed painting a mural on the exterior wall of a municipal building and roller skating wearing only underpants. He had not received authorization for the painting; when approached by police, he offered a rambling story about being guided by Zeus and ancient Grecian muses “to create art and to love one another.” The police said he was generally cooperative with being brought to the emergency department (ED) for care, although he maintained that the only thing wrong was that he was not being inspired that day.
You elicited further historical information from Mr. Malone in the ED. He reported that he had moved from his small hometown to the present city about two months prior, after seeing his twin sister act in a community theater performance of the musical Xanadu (1) and coming to believe that he needed to move to a larger city for inspiration. He reported that he had been interested in art since his teenage years and had studied art at a college in his hometown for a year before dropping out to paint and sculpt. He worked at a convenience store to support himself.
Mr. Malone reported that since moving to the city, he had felt “totally inspired by the energy.” He told you he had been living in low-cost single-room-occupancy hotels for the first month but now was living out of his car. He endorsed having little need for sleep yet feeling abundant energy, and he kept exclaiming “I’m alive!” to describe his excitement in life, almost with amazement. He endorsed smoking up to three joints of marijuana daily, which he felt had helped him to “stay mellow.”
Mr. Malone reported that he had talked with a counselor in high school “a couple of times” because he had felt “kinda moody after my folks died,” but he had never seen a psychiatrist, engaged in ongoing psychotherapy, or been prescribed psychotropic medications. He stated that both his parents had died six years previously in a car accident and that he and his sister had lived with an aunt and uncle until they finished high school. He gave you permission to call his sister for more history and to tell her that he was in the ED.
Consideration Point A
On the basis of what you know of the patient’s history at this point, what information would you prioritize in speaking with the patient’s sister for clarification?
A.1
Any history suggestive of hypomania or mania
A.2
Any history suggestive of delusions or hallucinations
A.3
Any history suggestive of past drug use
A.4
Any history suggestive of attention-deficit/hyperactivity disorder (ADHD)
A.5
Any history suggestive of posttraumatic stress disorder (PTSD)
Case Vignette Continues
A call with Mr. Malone’s sister revealed that, indeed, he had always had an artistic bent that was underappreciated in his small hometown. She confirmed that the siblings saw their parents die in a motor vehicle accident, when their car was struck head on by a drunk driver. The twins were in the backseat, with their parents in the front, and their parents were declared dead at the scene.
Mr. Malone’s sister reported that their maternal aunt and her boyfriend had been “nice enough…when they weren’t high [on opiates]” and that they had provided a roof over the siblings’ heads and food but little emotional support or life guidance after their parents died. Both she and the patient had experienced nightmares for many months, but they had minimized their distress to others and had confided primarily in each other. The two had “that special twins-bond thing,” she noted. The sister was a year away from finishing her college degree as a communications major. She shared that her brother had been majoring in visual arts but “just didn’t click with college classes” and had dropped out.
She reported that her brother had been in good physical health, aside from smoking tobacco and occasional marijuana (“Maybe a joint twice a week”). She said she knew of no other substance use issues for her brother—no hallucinogens, alcohol, cocaine, psychostimulants, heroin, PCP, opiates, benzodiazepines, solvents, or other substances. She asked whether Mr. Malone was going to be admitted, and because he had given you permission to speak with her as his next of kin, you acknowledged that he was already on an involuntary hold for 72 hours.
You then returned to the patient’s room, where he was smiling and looking around intently. As you examined him, the patient was pleasant and cooperative, now wearing a hospital gown over his underwear. You noted prominent psychomotor agitation, with an excess of spontaneous movement. For example, he moved his legs in a pedaling motion when sitting still and shifted around on the gurney. Eye contact was intense. Speech was at a somewhat rapid rate but of normal volume and prosody. Affect was expansive and somewhat labile. Mr. Malone characterized his mood by saying, “I had been in that joyous flow state earlier, but this has all harshed my mellow.”
His thought process was rapid, with loosening of association, nonlinearity, and a preoccupation with specific ideas of reference and delusional beliefs. His thought content was free of suicidal or homicidal ideation but was focused on a belief that he had been inspired by ancient Greek muses who had come to life from a mural “just like in my sister’s show…that’s when I put it all together! I’m like Sonny Malone in the show, and my muse Clio is waiting for me to finish the mural so she can inspire me in the flesh.”
With respect to his cognitive state, Mr. Malone was awake, alert, and oriented to person and place, but he was off on the date by a few days. Memory registration was intact with three out of three stimuli, and recall after delay was correct for two out of three items. He was able to spell the word world forward and backward accurately. He had no difficulty repeating the phrase “No ifs, ands, or buts” but perseverated in repeating it frequently during the rest of the interview.
Mr. Malone’s insight was impaired in that he did not recognize the oddities of his beliefs and behaviors and that the ideas of reference related to the musical were unusual. His judgment was impaired, given that he had been roller skating in only his underwear and painting the mural “under the guidance of Zeus” without permission. You noted no tremors or involuntary movements.
Consideration Point B
In your discussion with the ED physicians, you suggested that they might give the patient which of the following interventions?
B.1
Ketamine intravenously at a subanesthetic dose
B.2
Olanzapine, dissolving oral tablet or intramuscularly
B.3
Divalproex sodium, orally
B.4
Naloxone, intranasally
Case Vignette Continues
The patient was agreeable to the interventions you suggested and said he “felt calmer” within about an hour. The ED’s team was at work trying to find a bed in a psychiatric facility that could accept involuntary patients, but their own ward had closed in a recent round of budget cuts, and the nearest county hospital already had five people on holds in their ED and awaiting beds. In the meantime, the ED staff sought more guidance from you, because the patient was flirting inappropriately with both male and female staff.
Consideration Point C
What other interventions would you now suggest for use in the ED with this patient?
C.1
An additional dose of olanzapine
C.2
Chloral hydrate
C.3
Lorazepam
C.4
Brexanolone
Case Vignette Concludes
The patient accepted the additional medication that was offered to him. He was open to your guidance that the ED staff were made uncomfortable by his behaviors, because they were not familiar with the scene in Xanadu in which Zeus bestows the gift of Xanadu—namely, to create art and love one another. Mr. Malone was transferred to another facility for inpatient evaluation and care, and despite your request for follow-up information for continuity of care, you were given no additional data.
Answers: Scoring, Relative Weights, and Comments
Consideration Point A
A.1
(+3) Any history suggestive of hypomania or mania. The patient acutely exhibited signs of elevated mood and neurovegetative activation, consistent with the DSM-5 criteria for a hypomanic or manic episode in bipolar disorder. The presence of psychotic delusions that influenced his behavior pushes this episode into the manic realm (2).
A.2
(+3) Any history suggestive of delusions or hallucinations. Past delusions or hallucinations would be strongly suggestive of an evolving primary psychotic illness, and at this point in the narrative, we cannot exclude this from consideration (2).
A.3
(+3) Any history suggestive of past drug use. Past use of several types of drugs of abuse can leave a person with psychomotor agitation and delusional thinking (2).
A.4
(0) Any history suggestive of ADHD. Although patients with ADHD may exhibit psychomotor hyperactivity, this patient’s acute history is not consistent with a primary diagnosis of ADHD (2).
A.5
(+1) Any history suggestive of PTSD. The behavior of PTSD patients may be influenced by their traumatic experiences, and PTSD is often comorbid with other diagnoses, but this patient’s upbeat, prosocial, and creative activities are not consonant with a diagnosis of PTSD (2).
Consideration Point B
B.1
(−3) Ketamine intravenously at a subanesthetic dose. Ketamine has been studied as a treatment for depression, and esketamine has been approved by the U.S. Food and Drug Administration (FDA) as an antidepressant, but it is not included among the evidence-based treatments for elevated mood (3).
B.2
(+3) Olanzapine, dissolving oral tablet or intramuscularly. Olanzapine is useful as a mood stabilizer and acutely for manic and hypomanic episodes, particularly when symptoms of psychosis are present (3).
B.3
(+2) Divalproex sodium, orally. Divalproex is an evidence-based treatment for mania (3).
Consideration Point C
C.1
(+3) An additional dose of olanzapine. Rapid effects on bipolar agitation have been observed with this agent (3).
C.2
(0) Chloral hydrate. This agent is used as a sedative-hypnotic, often during electroencephalography studies, but has not been shown as an evidence-based treatment in bipolar disorder (3).
C.3
(+3) Lorazepam. This agent may be helpful in reducing agitation in mania (3).
C.4
(−3) Brexanolone. This neurosteroid has been approved by the FDA for use as a treatment in postpartum depression through IV infusion (5). It has not been shown to have use in mania.
References
1.
Beance DC, Lynne J, Farrar J: Xanadu (musical theater). New York, 2007
2.
Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA, American Psychiatric Publishing, 2013
3.
Practice Guideline for the Treatment of Patients with Bipolar Disorder, 2nd ed. Arlington, VA, American Psychiatric Publishing, 2010
4.
Opioid overdose reversal with naloxone (Narcan, Evzio).Bethesda, MD, National Institute on Drug Abuse, 2018. https://www.drugabuse.gov/related-topics/opioid-overdose-reversal-naloxone-narcan-evzio
5.
FDA approves first treatment for postpartum depression.Silver Spring, MD, U.S. Food and Drug Administration, 2019. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm633919.htm
Information & Authors
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Published in print: Summer 2019
Published online: 18 July 2019
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Funding Information
Dr. Cook reports that the University of California, Los Angeles (UCLA), received research grant funding from NeoSync, Inc., for his work there prior to retirement and that his active biomedical device patents are assigned to the University of California. He has been granted stock options in NeuroSigma, the licensee of some of his inventions, and he currently is on leave as its chief medical officer and senior vice president. Dr. Cook has equity positions and leadership roles in HeartCloud, Inc., and the BrainCloud Corporation.
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