Patient Management Exercise for Bipolar Disorder
Abstract
This exercise is designed to test your comprehension of material presented in 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, on the basis of the information provided, making your decisions as you would with a real-life patient.
Questions are presented at “decision 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. On questions that focus on differential diagnoses, bonus points are awarded if you select the most likely diagnosis as your first choice. At the end of the exercise you will add up your points to obtain a total score.
Vignette part I
“I realize now that I’ve got some major problems and I want to work with you so I can get better. Can I see you weekly?” The patient, Mr. J, shakes your hand with a firm grip, sits down, and immediately begins eating the hard candy from the bowl beside his chair as if he has not eaten all day. “I am still in a partial day program, but I want to wean myself slowly from that intensity by transitioning to weekly outpatient treatments. What do you think?”
You are an adult psychiatrist in independent practice, and this patient was referred to you by a colleague who runs an adult inpatient psychiatric service at the local hospital and who tells you that the patient is ready to move on to individual therapy. He feels that the patient no longer meets the criteria for his day program.
Mr. J is a 52-year-old recently divorced engineer, father of a son and a daughter, both in college. He was hospitalized for the first time after he was brought to an emergency room by ambulance, disheveled, in clothes he apparently had not changed in a week or more, angrily ranting that his wife was a “whore” and “the DEA is after me.” According to the hospitalization notes you received with the patient’s permission, his sister feared he was going to kill himself, after he made threats to do so, and she called for an ambulance. Three weeks before hospitalization, his son moved out of the house and in with his mother (the patient’s ex-wife) because of fears his father was “losing control.”
The patient spent 3 weeks as an inpatient, was started on quetiapine and quickly titrated to 300 mg TID, and fluoxetine titrated to 40 mg daily. After discharge he was admitted to the same hospital’s day treatment program and spent the last 2 weeks there, attending groups and individual therapy for much of the day.
You begin by asking the patient to tell you about himself. “I am the lead engineer at a major construction firm here in town. I’ve been with this company for 24 years and I basically built it. It used to be a small operation and now we’re handling contracts worth $20–50 million. That is all me. My staff grew from two assistants to a staff of about 25 people. I have one boss who is probably my best friend. I have two kids in school, but it was my wife that started this whole thing. My wife and my son’s friend. Well, he’s a friend of mine, too. But really, I need to reevaluate that whole relationship. I’m sure I’m in deep shit about it now, but I finally realized that there’s nothing I can do.” He looks at you, his eyebrows raised. Then he scans the corners of the ceiling without moving his head. “Is there? I mean, if they’re going to come for me, then they’re going to come for me. It is what it is. This is completely confidential, right?”
You tell him that what you talk about is completely confidential unless he makes specific threats for which you have a duty to warn. “Well, if they really want to know something from you I doubt you’d be able to stop them anyway. They’re the government.” You ask about the incident that led to his hospitalization. “There’s no simple way to put this.” With a sigh, he opens another piece of candy. “Let me see if I can sum it up for you: My wife cheated on me, and one of my colleagues—someone I trusted—really. . . well, you are a doctor. . . she gave me herpes and then lied about it. But I know it was her. And Spence, well he’s the reason I’m likely going to jail. And I probably should not have let my daughter and her friends have beer over at the house.”
His speech is rapid and he shifts frequently in his chair. “This medication, though, really helps. You should have seen me before. Since they started this stuff I’ve got my energy back big time.” Beginning approximately 5–6 months earlier he became depressed. About 2 months later he came very close to quitting his job because he was certain they were monitoring his e-mail account and probably watching him with cameras placed strategically in the office, and he now knows he can trust only one other person there. “This is not my imagination,” he insists. “You can tell when something is going on when people start behaving in a way that is very suspicious.” He mentions an incident at a board meeting that took place in Florida at a golf resort, for a company with which he had landed a major contract just before the recent depressive episode. His main contact at that company is the woman he says gave him herpes. “I could see it in her eyes when I walked into the meeting. It was really obvious. From the moment I entered everyone stopped talking. I sat down next to her and she got up and moved to the other end of the table, supposedly to talk with one of her colleagues. But I know she was avoiding me. So I became angry.” He laughs nervously. “I probably should not have let myself go like that. They all thought I was. . . well, I was actually. . . nuts.”
Home from the meeting, he could not get out of bed “for days. I could not move. It was as if I was made out of lead. If I moved, it was to the sofa.” Sometimes he watched the TV; sometimes he simply stared at the clock and watched it move hour after hour. “I had a talk show on the TV every day, but I cannot tell you any details beyond that. I remember thinking that this was a sign I was dying inside.” He goes on: “I thought about all of the things I have done and several times I thought about killing myself.” At his lowest point, he asked his sister to come over to his house and remove his pistol “just in case. But I think I really freaked out my son. He went back to live with my wife.” Then he laughed to himself. “I called her ‘my wife.’ I seem to do that still. She’s not. Not after what she did to me. That was the last straw.” He continued to be depressed with suicidal ideation until “things just fell off the deep end,” and he was taken to the hospital.
Today he is not suicidal. “I do think about it, but it is much less than I had been doing.” Nor is he homicidal. He says he never heard any voices or saw any visual hallucinations, never thought the TV or radio was speaking to him, “but if you are asking me if I’m paranoid, I may be. But it is real. People really are watching me. I can prove it.” He asks you to reiterate that your sessions are confidential, which you do. “I probably did some things I should not have, like keeping copies of certain e-mails and memos, copies of plans, and some other things I will not mention. I stored them away. I also stored away other bits of evidence, especially the e-mails I wrote to my friend in California. He used to be a big druggie back when we were in college. I’m sure that is the connection the DEA is going to use to put me away.”
Since taking the quetiapine, he is getting approximately 8–10 hours of sleep per night. At first he felt groggy from the medication, but now does not feel any morning “hangover.” Right now he does not feel he can handle work, although he plans to return. But he thinks he might get fired in any event. His energy has improved, but he still has difficulty watching an entire TV program and has not read a book in months. His appetite is “tremendous, ” but he thinks that has something to do with the medication. “Do you think there is another medication I could try that will not give me such an appetite?” He does not recall ever going without sleep and tells you that he always talks this fast.
Your session ends, and he asks if he can return in two or 3 days instead of waiting a whole week.
Decision Point A
Given what you know about this patient from the limited history and first session and assuming you can fit him into your schedule as he requested, would you offer him an appointment in 2–3 days as requested?
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A1. _____ Offer the additional appointment. But tell him you will only do this one time because he is also receiving psychiatric care at the partial hospitalization day program.
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A2. _____ Offer the additional appointment. But tell him you only see patients with his type of illness once per week, so you will only do this one time. Your job is to provide medical management. Offer to refer him to a psychologist or social worker for psychotherapy.
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A3. _____ Offer the additional appointment. Tell him you are happy to see him twice per week if he feels he needs the extra support.
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A4. _____ Offer the additional appointment but only if either he can pay out of pocket or if his insurance will cover the cost of the additional visit.
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A5. _____ Do not offer the additional appointment. Tell him that he is still in a partial hospitalization day program and you will not be able to offer him better services than he is already receiving.
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A6. _____ Do not offer the additional appointment. Tell him that you are the doctor and you will decide whether he needs to see you more than once per week. If you feel he needs extra appointments, you will let him know.
Decision Point B
Given what you know about this patient, what is your differential diagnosis? Include rule-outs. (+2) points for correct answers, (−2) points for incorrect answers.
| AXIS I: | |
| AXIS II: |
Vignette part II
Over the next 2 weeks the patient comes twice weekly for appointments. You hear more details about how the DEA is likely to arrest him for his connection to a friend from college he has not seen in more than 25 years who works as a neurologist and who may or may not be using drugs. “My daughter is having trouble at school, staying up all night and unable to work. She’s like me in some ways,” he tells you. There was a party he let his daughter have at his house with her girlfriends, all of whom were 18–19 years of age. He allowed them to have beer and feels guilty about that. There is a small collection of pornographic magazines “from years ago” that he recently put into a plastic box to store along with the e-mails and other items he brought home from his office. Spence, his son’s friend, will soon be in trouble for getting caught outside a fraternity party smoking a marijuana joint, Mr. J suddenly explains, although Spence and his friends were only given warnings by the campus police.
You have trouble redirecting him. “I have so much to tell you,” he responds. “I need to get this all out or you will not understand how deep the shit is.” His wife, for example, never cared about him. She had “the gall” to tell him about her affairs. “I do not know how many she had. She would go out of the house and say, ‘Yes, I’m going out with another man.’ I just could not take that anymore, so one night I had the locks changed as soon as she left. She went to stay with my sister.” They divorced in the last 6 months. Then he admits they are not actually divorced but separated. “I bought her a house across the lake from me. She wants us to stay in close proximity because of the kids.”
He tells you the surveillance at work is getting worse. “I went in, just to check things out. My boss said I can have this time off, but I wanted to see if anything had changed around my desk.” Suddenly smiling, he nods his head. “I could not get into my e-mail. I know they tampered with it. And everyone seems to know what happened to me, although I asked my boss not to say anything.” He still attends the day program at the hospital, but they want him to reduce the amount of time he spends there and try to manage his problems with you.
“Actually, I’m starting to have trouble sleeping. I have so many thoughts spinning around my head. There have been too many hang-up calls, though,” he insists. “I asked Spence to come with me to the place where I put all of the evidence, and there is one box missing. I know he took it. I think he’s going to use it to frame me. I do not know. I’m going to have to do something. Confront him, I guess. But I cannot have him come around the house anymore. I’m not suicidal or homicidal, he recounts. I’m not even depressed, really.” He tells you that Spence liked to use his piano.
He tells you he decreased the amount of quetiapine he takes to 600 mg because he’s gaining weight and he’s feeling “hung over” in the mornings.
Decision Point C
You are concerned about the level of paranoia, which seems to be escalating. What changes, if any, would you make to his medication regimen?
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C1. _____ Increase dose of quetiapine to 1200 mg.
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C2. _____ Maintain quetiapine at the current level and discontinue fluoxetine.
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C3. _____ Increase quetiapine back to 900 mg, keep fluoxetine at the current level, and augment the quetiapine with risperidone, beginning at 1 mg qHS and titrating by 1 mg every 2–3 days until psychotic symptoms abate or a maximum of 6 mg.
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C4. _____ Maintain quetiapine at the current level, discontinue fluoxetine, and augment the quetiapine with risperidone, beginning at 1 mg qHS and titrating by 1 mg every 2–3 days until psychotic symptoms abate or a maximum of 6 mg.
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C5. _____ Maintain quetiapine at the current level, discontinue fluoxetine, augment the quetiapine with risperidone, beginning at 1 mg qHS and titrating by 1 mg every 2–3 days until psychotic symptoms abate or a maximum of 6 mg, and ask for permission to speak with his sister, ex-wife, and children.
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C6. _____ Maintain medications as they are, but ask for permission to speak with his sister, ex-wife, and children before making any changes.
Vignette part III
You make the appropriate changes to his medication regimen, and his paranoia abates to what you estimate to be 20% of what it was. His affect seems calmer and his thoughts are more linear and goal-directed. The patient consents to allow you to speak with his sister, ex-wife, and children. His children are unavailable, but his sister and ex-wife arrive with the patient at his next visit. His sister is visibly upset, becoming tearful. She asks to see you alone first. “I’m so scared,” she tells you. “I think what you are doing is working as long as he takes his medications. But I worry he’ll stop taking them again and I do not want him to kill himself. I’m also afraid he’s going to quit his job for no good reason. You have to understand, his boss loves him. Whatever he might have told you about that firm being so successful because of my brother is true. He has always been a workaholic. They probably take advantage of him for that, but he loves what he does. They’re patient. They’ll wait for him to be ready to return to work. But I do not understand what’s happening to him. His wife never cheated on him. I do not know where that comes from. She does not want a divorce, either. That is why she lives across the lake. She loves him. Did he tell you that she makes him dinner every night still?”
She does not know if their parents had mental illness because they were both adopted. His daughter, however, recently started seeing a psychiatrist for bipolar disorder. You ask if she can recall the first time the patient may have had any mood symptoms. “He used to get depressed when we were kids. It would not last too long, but I remember times when he would go to his room and we could not get him out of there.” Then her eyes light up. “I never told anyone about this. When J. was about 18 or 19, I remember going to a grocery store with him and he started saying, ‘They’re watching me. They’re watching me.’ I did not know if he was kidding or not. But he kept saying it to himself. I asked him about it and he denied the whole thing. Do you think that may have been something?”
The patient and his ex-wife enter the room. You gently ask the patient if it is true that he has dinner with his ex-wife every night. “Yeah,” he replies. “She has been the one rock in my life throughout this whole ordeal.” You ask him about college. “I’ve always been the sort of guy who has to get things done. You asked me if I ever went without sleep and I did not. I always got some sleep. But often that was just 2 or 3 hours if I had lots of work to do. I was president of the engineering fraternity, in the honor society, I had a few different girlfriends at the time, and I even started a small business venture with a friend of mine. I do not know how I did it.” He says he never felt as though he had special powers or gifts, but “I was the guy people came to when they needed anything.” He denied ever going into large amounts of debt because he managed to make a lot of money as a college student through his own business, but he did travel to different countries in Europe, Japan, Hawaii, and he owned a used Porsche. “I could think of several things at the same time and manage them somehow. When I was a kid I always had trouble focusing on any single thing. I always had a three to four things going at the same time.” His sister nods.
Decision Point D
The medication change you made was to maintain the quetiapine at 600 mg, maintain the fluoxetine at 40 mg, and augment the quetiapine with risperidone 4 mg qHS. Given what you learned subsequently from the patient, his progress, and collateral information from his sister regarding his past history and present condition, what changes, if any, would you make to your primary diagnosis?
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D1. _____ Brief psychotic disorder
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D2. _____ Major depression, recurrent, severe with psychotic features
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D3. _____ Bipolar I disorder, most recent episode manic, with psychotic features
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D4. _____ Bipolar II disorder, most recent episode depressed, with psychotic features
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D5. _____ Mood disorder with psychotic features
Decision Point E
Based upon your answer to Decision Point D, what changes, if any, would you make to his medication regimen?
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E1. _____ Keep everything the same for now.
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E2. _____ Slowly cross-taper the quetiapine with lithium or valproate, and maintain the fluoxetine at 40 mg and risperidone at 4 mg for now. Once the patient is off quetiapine, start to wean him from risperidone.
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E3. _____ Discontinue the quetiapine and start either lithium or valproate. Maintain the risperidone at 4 mg and fluoxetine at 40 mg for now.
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E4. _____ Discontinue the fluoxetine immediately, maintain the quetiapine at 600 mg and risperidone at 4 mg and start lithium or valproate. Once the patient is stable with either mood stabilizer, slowly wean him from quetiapine.
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E5. _____ Slowly cross-taper the quetiapine with lithium or valproate, and discontinue the risperidone and fluoxetine.
Decision Point F
Most bipolar disorders begin with depressed episodes, subsequently making the distinction between bipolar or unipolar depressions difficult to diagnose. Which of the following differences in phenomenology between bipolar and unipolar depression are more common in bipolar disorder?
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F1. _____ Atypical symptoms (increased sleep, increased appetite, rejection sensitivity, leaden paralysis, and mood reactivity without marked anhedonia)
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F2. _____ Psychosis
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F3. _____ Depressed mixed state (major depression with manic symptoms that are subthreshold for DSM-IV-TR definition, such as increased psychomotor activity, racing or crowded thoughts, and periods of decreased need for sleep)
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F4. _____ Anxious/agitated depression (the presence of concurrent anxiety in the absence of manic symptoms)
Decision Point G
Which of the following differences in the course of illness are more suggestive of a bipolar depression rather than unipolar depression?
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G1. _____ Early age at onset
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G2. _____ Recurrence
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G3. _____ Postpartum
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G4. _____ Rapid Cycling
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G5. _____ Brief duration of depressive episodes
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G6. _____ Baseline hyperthymic personality
Answers: Scoring, relative weights, and comments
High positive scores (+3 and above) indicate a decision that would be effective, would be required for diagnosis, and without which management would be negligent. Lower positive scores (+2) indicate a decision that is important but not immediately necessary. The lowest positive score (+1) indicates a decision that is potentially useful for diagnosis and treatment. A neutral score (0) indicates a decision that is neither helpful nor harmful under the given circumstances. High negative scores (−5 to −3) indicate a decision that is inappropriate and potentially harmful or possibly life-threatening. Loser negative scores (−2 and above) indicate a decision that is nonproductive and potentially harmful.
Decision Point A
This question requires the reader to consider how willing he or she is to take on what may be a complicated case. It is true that as a psychiatrist you are responsible for the medical management of this patient and are not required to engage the patient in any psychotherapy. However, if you have the skill sets to offer even supportive psychotherapy, there is no need to spread this patient’s care around to too many clinicians. It is true that he is already in a partial hospitalization day treatment program; however, your colleague, who runs the program, has referred the patient to you because he no longer meets the criteria to remain in that setting.
If you have the ability to offer biweekly sessions to this patient, there is no reason not to do so. However, if you feel that the reason the patient wishes to see you biweekly is a transference issue, you must confront your countertransference and determine the sort of relationship you feel is appropriate, necessary, or inappropriate and perhaps unnecessary. Do you wish to see this patient more frequently than once per week? You also might consider a weaning schedule, as he suggested, beginning biweekly and then tapering to once per month or more once the patient is stable.
Consider here the fact that the patient’s symptoms are still somewhat unstable. There is a lot of history and collateral information missing to make an accurate diagnosis at this early stage in a patient with such a complex presentation.
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A1. _____ −5 The patient was referred to you because he no longer meets the criteria for the partial day hospitalization program.
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A2. _____ −3 You may not want to see the patient every week, and because of your own limitations, whether time or the ability to offer yet-to-be-determined therapy. However, you should not tell him how you treat his “kind of illness. ” This statement can be construed as pejorative, especially in a patient who presents in such a fragile state.
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A3. _____ +4 Because there is no “right” answer, only 4 points are given here. This certainly is the most ambitious approach and will allow you to help the patient both with diagnosis and subsequent treatment in a more intensive and possibly rapid fashion, which is his desire.
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A4. _____ 0 This answer is neither right nor wrong. It is a sad fact about our health care system, and more specifically, about mental health benefits.
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A5. _____ −4 Again, he is being discharged from the former treatment. Being confrontational about his needs in this case will probably hurt your therapeutic alliance. However, setting limits is often helpful.
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A6. _____ −5 his answer is needlessly paternalistic with an offensive, punitive tone.
Decision Point B
| AXIS I: | (−5) Brief Psychotic Disorder (+3) Schizophrenia, Paranoid Type (+5) Schizophreniform Disorder (−5) Schizoaffective Disorder (−5) Delusional Disorder, grandiose type (−5) Delusional Disorder, jealous type (−5) Delusional Disorder, persecutory type (−5) Delusional Disorder, mixed type (+5) Major Depressive Disorder with psychotic features (+3) Bipolar I Disorder, most recent episode manic, severe with psychotic features (−5) Bipolar II Disorder, most recent episode hypomanic, severe with psychotic features |
| AXIS II: | (−5) Schizotypal Personality Disorder (−5) Narcissistic Personality Disorder |
Brief psychotic disorder (−5).
This patient’s psychotic symptoms, including paranoia, possible delusions of grandeur, jealousy, persecution, began 2 months after the onset of depression and lasted approximately 4 months before his hospitalization. According to DSM-IV-TR, for brief psychotic disorder his symptoms, including the presence of one or more of the following—delusions, hallucinations, disorganized speech, grossly disorganized, or catatonic behavior—must have lasted between 1 day and 1 month with eventual return to premorbid functioning and not be better accounted for by another psychiatric disorder, medical condition, or substance effect.
Schizophrenia, paranoid type (+3).
The patient elaborated at least 4 months’ worth of delusions, including possible grandeur, jealousy, and persecution, has rapid speech, which he tells you is his baseline, seems to have some looseness of associations in his initial presentation despite treatment with quetiapine, and was brought to the emergency room grossly disorganized, “disheveled, in clothes he apparently had not changed in at least a week or more, and angrily ranting that his wife was a ‘whore’ and ‘the DEA is after me’.” To meet DSM-IV-TR criteria for criterion A symptoms, he requires two or more of delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms. He certainly met the criteria of delusions and disorganization. His delusions, however, were not bizarre, nor did he have hallucinations of a voice keeping up a running commentary on the person’s behavior or thoughts or two or more voices conversing with each other, of which only one is required to meet criterion A.
He did suffer from social/occupational dysfunction, worrying that both he and his activities (work, personal life, and e-mail:) were under surveillance and he would be caught at any time, meeting criterion B. More information would be required to determine if the “prodrome” of depression that occurred before the onset of psychotic symptoms would include only negative symptoms or two or more of the symptoms in criterion A in an attenuated form. Although this may seem unlikely, especially because this patient does not exhibit a reactive affect and his depression is described in terms more consistent with a classic, neurovegetative depression, this cannot yet be ruled out. Subsequently, it is not possible to say that the entire episode lasted at least 6 months, satisfying the duration requirement of criterion C.
Criterion D requires the ruling out of schizoaffective disorder and mood disorder with psychotic features. The patient describes his psychosis as having occurred 2 months after the onset of a major depressive episode, which continued concurrently. The duration of the major depression occurred during the entirety of the subsequent 4 months of worsening psychosis.
There is no evidence of substance abuse or medical illness that could explain his symptoms (criterion E), and although you would require more detailed history to ascertain whether he had a history of autistic disorder or other pervasive disorder, this seems unlikely given his success in both his career and social life (married with two grown children, many friends, and the ability to “land a major contract”) before the onset of the current illness (criterion F).
The paranoid subtype requires that he have a preoccupation with one or more delusions or frequent auditory hallucinations and that none of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect. Until collateral information can be obtained, the delusions of grandeur and jealousy may not be psychotically derived, although his worries about the extent to which his life is being monitored and the imminence of his arrest by the DEA or other authority is a stronger argument for a delusion of persecution. Subsequently, you cannot yet make this distinction.
Schizophreniform disorder (+5).
Criterion A of schizophreniform disorder requires that criteria A, D, and E of schizophrenia be met, which is the case. Criterion B requires that the duration of the episode is at least 1 month but less than 6 months. The patient met the criteria for at least 4 months before treatment.
Schizoaffective disorder (−5).
See comment about schizophrenia criterion B above.
Delusional disorder, grandiose type, jealous type, persecutory type, or mixed type (−5).
Although the delusions of grandiosity and jealousy or persecution are not considered bizarre (criterion A), because criterion A for Schizophrenia was met, that rules out delusional disorder. Additionally, for delusional disorder, his functioning must not be markedly impaired (criterion C), and the mood episodes must have been brief in duration relative to the totality of the delusional symptoms (criterion D), neither of which was the case. Criterion E states that the delusion must not have been better accounted for by the direct physiological effects of a substance or a general medical condition.
Major depressive disorder with psychotic features (+5).
The patient meets both the criteria for psychosis, experiencing approximately 4 months of worsening symptoms, and by his account, a depressed mood, most of the day, nearly every day, with increasing anhedonia and isolation, hypersomnia, psychomotor retardation, loss of energy, poor concentration, and recurrent suicidal ideation for approximately 6 months. His symptoms caused his inability to work or engage others socially. These symptoms were not due to substances or a medical condition and were not accounted for by bereavement. It is therefore appropriate to diagnose a major depressive episode.
Bipolar I disorder, most recent episode manic, severe with psychotic features (+3). The patient describes a major depressive episode as discussed above. For bipolar I disorder, in addition to the major depression, it is possible he experienced a distinct period of abnormally and persistently elevated, expansive, or irritable mood for at least 1 week, although he did not specifically state this. The other caveat to criterion A that is met is hospitalization, although the presenting complaint was related to suicidal ideation, gross disorganization, and psychotic symptoms. What confounds the presentation of bipolar depression is that it may be unipolar depression with psychotic features. More history is required to determine the type of depression; however, his presentation in your office is more suggestive of hypomania or mania.
His statements about how important he is to his company and how he built it from a very small business into a multimillion dollar enterprise (“that is all me”) suggest an inflated self-esteem. He denied having periods of not needing sleep, but he did not describe the more accurate symptom of decreased need for sleep. He was hyperverbal in your office, taking over from the minute he arrived. His story seemed loose at times, suggesting a flight of ideas, although it was not pressured. He describes being easily distracted, and without further information about his marriage, it seems there were enough problems with infidelity (whether his wife actually cheated on him or not, he contracted herpes during an affair), suggesting some increase in goal-directed behaviors or excessive involvement in pleasurable activities that have a high potential for painful consequences.
The patient was started on fluoxetine, a selective serotonin reuptake inhibitor (SSRI), which may have caused him to “flip” into a manic state once treatment started. If his depression was a bipolar and not a unipolar depression, then the likelihood of his becoming manic with the addition of fluoxetine is high.
However, as recent studies suggest that bipolar or schizophrenic depressed patients have less insight into their illnesses than do unipolar depressed patients, it is imperative to obtain collateral information about possible manic or hypomanic episodes. These patients are subsequently, almost by definition, unable to give an accurate account of such episodes. As a result, unless you witness first-hand over time a manic or hypomanic episode, you cannot confidently diagnose bipolar disorder without collateral information, which, in this patient, you do not yet have.
Bipolar II disorder, most recent episode hypomanic, severe with psychotic features (−5). The patient describes his manic symptoms as lasting longer than the 4 days that distinguishes bipolar II from bipolar I disorders. However, by definition, bipolar II disorder cannot feature psychosis.
Note: To more confidently diagnose an axis II disorder, ideally a clinician should wait until he or she has known the patient for a while and preferably not while the patient concurrently has an axis I disorder.
Schizotypal personality disorder (−5).
Although this patient has delusions of paranoia, they are not bizarre or odd, he did not describe any unusual perceptual experiences, he spoke rapidly, but not demonstrative of odd thinking or speech, and his affect and behavior were not odd, eccentric, or peculiar. He did become paranoid and suspicious of others, but he previously had good relationships with peers, was married, had children, and worked partly as a salesman. This excludes the social and interpersonal deficits required for schizotypal personality disorder.
Narcissistic Personality Disorder (−5).
There is no evidence of a pervasive pattern of grandiosity, a need for admiration, or a lack of empathy. What is described by the patient thus far is a fairly well-balanced, fruitful life that fell apart because of either a mood disorder or a psychotic disorder. More evidence, especially from collateral sources who have known the patient for a long period of time is required to make such a diagnosis. One might suggest “strong narcissistic personality traits,” although this would do a disservice to the patient and to those caring for him as it would create a damaging label. Without further evidence to the contrary, the patient’s personality style in this case seems more a reaction to his underlying mood or psychotic disorder.
Decision Point C
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C1. _____ −3 When the patient was receiving a higher dose of this medication, he did not tolerate it well and subsequently decreased his own dose.
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C2. _____ +3 Removing the SSRI with a high level of antipsychotic coverage may be enough to eliminate the manic symptoms, although in this case you should be wary of the very long half-life of fluoxetine. In the outpatient setting, you should make medication changes one at a time to determine the effect of each change. However, given the manic symptoms you witness in your office, plus the symptoms suggestive of bipolar disorder, especially in the context of the new addition of an SSRI, you should consider discontinuing the SSRI because studies have demonstrated that antidepressants, especially SSRIs and tricyclic antidepressants, appear to cause acute manic episodes in approximately 20%–50% of patients with bipolar depression type I more than in patients with type II.
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C3. _____ −3 If the intention is to cross-taper the patient to risperidone because you prefer this atypical anti-psychotic drug over quetiapine, which coincides with the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study results for the treatment of schizophrenic psychosis, you would not increase the quetiapine. However, other considerations in choosing risperidone include significant weight gain and a higher risk of extrapyramidal side effects.
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C4. _____ +1 Augmenting the quetiapine with risperidone has not been demonstrated by any study to be more effective than cross-tapering to a different agent, especially as quetiapine was not tried at its maximum dosing, given the patient’s ability to tolerate it. However, patient response to medication is often idiosyncratic and despite a lack of evidence for augmentation, patients may respond positively to an augmentation strategy for a variety of reasons, some of which are the new constellation of receptor activity and a placebo effect. As stated in C3, the increased risk of significant side effects must be considered. Discontinuing fluoxetine may have a positive effect in reducing manic symptoms, but this is not guaranteed, either, especially because you have not made the clear diagnosis of bipolar disorder.
•
C5. _____ −2 See above. What is more effective about this answer than those above it is the determination to obtain the necessary collateral information required to make your diagnosis and thereby guide your treatment.
•
C6. _____ +3 It is very important to recruit the support of family members, especially as you are trying to stabilize his psychiatric condition. If you see the patient twice per week, and he is maintains his current condition, he is not in any danger. This may be the safest route. However, the patient is not stable and does require some medication adjustment. The risk for suicide in a patient with bipolar disorder or schizophrenia is high enough to warrant extreme caution.
Decision Point D
•
D1. _____ −5 See answers for Decision Point B.
•
D2. _____ −5 See answers for Decision Point B.
•
D3. _____ +5 With the collateral information, this patient clearly has a long history manic symptoms and depressions dating back to his teen years. Because he was adopted, you cannot determine whether his relatives have mental illness; but his daughter has bipolar disorder. The likelihood of his also having bipolar disorder with one first-degree relative (his daughter) diagnosed with bipolar disorder is approximately 25%. He is one of those fortunate individuals who was long able to channel his diminished need for sleep, grandiosity, and other manic symptoms into a highly productive career. On the other hand, his hypomania became mania and eventually, because of lack of treatment, evolved into psychosis. His personal and professional life, as a result, suffered greatly. He may have concurrent cluster B personality traits such as narcissism, but this is more a personality style secondary to a primary mood disorder. In our society, persons who are overachievers, earn a lot of money, help others further their own careers or interests, and are ebullient, charismatic, and confident are held in high esteem. These traits are not necessarily pathological; however, when pathological symptoms are overlooked, these individuals can potentially cause great harm to themselves and others. We cannot lose sight of the 15%–20% suicide rate for individuals with untreated bipolar disorder.
•
D4. _____ −5 See answers for Decision Point B.
•
D5. _____ −5 See answers for Decision Point B.
Decision Point E
•
E1. _____ −5 The patient is clearly not stable with this drug regimen. Additionally, the quetiapine is not tolerated by the patient, so it should be discontinued if the dose cannot be maximized. Because the patient has bipolar disorder, treatment with a mood stabilizer should be started. The antidepressant should be discontinued immediately as this drug is most likely worsening his mood stability, causing anything from a mixed state to mania.
•
E2. _____ −4 Starting a mood stabilizer is the correct direction for this patient once he is stabilized. However, maintaining the combination of quetiapine, which is intolerable to the patient, and fluoxetine, which is probably destabilizing his mood, is not recommended. If he is tolerating the lower dose of quetiapine, the combination with risperidone may be appropriate until the mood stabilizer is therapeutic. A better strategy would be to start the mood stabilizer and then slowly wean the patient from the atypical antipsychotic drug after the patient has been stable for at least a month.
•
E3. _____ −3 The fluoxetine should be discontinued. Discontinuing the quetiapine and starting lithium or valproate could work if the risperidone at 4 mg is able to stabilize the patient. This dose might need to be increased to 6 mg if the quetiapine is discontinued.
•
E4. _____ +4 Because this patient’s medication regimen was already complicated, there is no perfect strategy. There are, however, some underlying principals about the treatment of bipolar disorder that are addressed by this combination. This patient needs a mood stabilizer. He should be maintained on an atypical antipsychotic drug until this is therapeutic. The atypical antipsychotic will help in the short run. An antidepressant should not be part of the regimen unless the patient has intolerably severe depression. In that case, one would probably choose bupropion because it has only a 15%–20% chance of “flipping” a patient into a mixed or manic state compared with other SSRIs that have a 30%–40% likelihood. Additionally, there are some findings in the current literature suggesting that the use of antidepressants in patients with bipolar disorder can cause them to develop a permanent rapid cycling mood disorder. The literature in this area is sparse, however, as randomized controlled studies examining this phenomenon have not yet been done.
•
E5. _____ +2 As long as the cross-taper is very slow and the patient tolerates this exchange of mood stabilizer for atypical antipsychotic, this is a possible solution. It would be safer, especially in the outpatient setting, to start the mood stabilizer with the atypical antipsychotic for support and then slowly taper the atypical antipsychotic.
Decision Point F
For the past 15–20 years, the literature has supported these symptoms as being more likely the phenomenology of a bipolar disorder. This suggests that diagnosing a bipolar mood disorder is easier than one might think, and given what is known about the difference in pharmacology, it is a very important distinction to make.
•
F1. _____ +2 Correct
•
F2. _____ +2 Correct
•
F3. _____ +2 Correct
•
F4. _____ +2 Correct
Decision Point G
As in Decision Point F, the literature supports these symptoms as being suggestive of a bipolar depressive course rather than a unipolar depressive course. It is important to make this distinction, especially in children and adolescents, because of the potential and significant dangers of giving antidepressants to children with bipolar disorder, which may “flip” them into mixed or manic states, and the suggestion that rapid cycling may be permanent.
•
G1. _____ +2 Correct
•
G2. _____ +2 Correct
•
G3. _____ +2 Correct
•
G4. _____ +2 Correct
•
G5. _____ +2 Correct
•
G6. _____ +2 Correct
| Decision Point | Your Score | Ideal Best Score |
|---|---|---|
| A | 4 | |
| B | 13 | |
| C | 7 | |
| D | 5 | |
| E | 6 | |
| F | 8 | |
| G | 12 | |
| Total | 55 |
Note: The treatment options discussed above are based on a situation in which the patient is able to afford ideal medications, is not bothered by blood testing to monitor organ function, and will be reasonably compliant. He did decrease his quetiapine dose because of difficulty tolerating the medication; however, he did not discontinue it.
In the real world, practitioners are faced with treatment decisions that often require consideration of the patient’s socioeconomic status, compliance, and accessibility to health care, especially for ongoing monitoring of symptoms and blood testing. For example, when treating the patient with limited means or inadequate access to health care, one might be faced with a limited choice of medications; lithium carbonate might not be available. Instead, drug choices would be limited to dival-proex, lamotrigine, or atypical neuroleptic drugs as primary agents, or they may be limited to the cheapest generic medications. A patient may refuse blood testing or not be reliable to have it done, necessitating the use of a depot formulations of typical or atypical neuroleptics to give them as much relief of symptoms as possible.
Footnotes
CME Disclosure B. Harrison Levine, M.D., M.P.H., Department of Child and Adolescent Psychiatry, New York Presbyterian Hospital, Columbia and Cornell Universities.
No financial conflict of interest to report.
Ronald C. Albucher, M.D., Adjunct Clinical Professor of Psychiatry, University of Michigan Medical School.
No financial conflict of interest to report.
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