Patient Case #1: 27-Year-Old Woman With Bipolar Disorder
- Theresa Cerulli, MD
- Tina Matthews-Hayes, DNP, FNP, PMHNP
Custom Around the Practice Video Series
Experts in psychiatry review the case of a 27-year-old woman who presents for evaluation of a complex depressive disorder.
EP: 1 . Patient Case #1: 27-Year-Old Woman With Bipolar Disorder
Ep: 2 . clinical significance of bipolar disorder, ep: 3 . clinical impressions from patient case #1, ep: 4 . diagnosis of bipolar disorder, ep: 5 . treatment options for bipolar disorder, ep: 6 . patient case #2: 47-year-old man with treatment resistant depression (trd), ep: 7 . patient case #2 continued: novel second-generation antipsychotics, ep: 8 . role of telemedicine in bipolar disorder.
Michael E. Thase, MD : Hello and welcome to this Psychiatric Times™ Around the Practice , “Identification and Management of Bipolar Disorder. ”I’m Michael Thase, professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.
Joining me today are: Dr Gustavo Alva, the medical director of ATP Clinical Research in Costa Mesa, California; Dr Theresa Cerulli, the medical director of Cerulli and Associates in North Andover, Massachusetts; and Dr Tina Matthew-Hayes, a dual-certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.
Today we are going to highlight challenges with identifying bipolar disorder, discuss strategies for optimizing treatment, comment on telehealth utilization, and walk through 2 interesting patient cases. We’ll also involve our audience by using several polling questions, and these results will be shared after the program.
Without further ado, welcome and let’s begin. Here’s our first polling question. What percentage of your patients with bipolar disorder have 1 or more co-occurring psychiatric condition? a. 10%, b. 10%-30%, c. 30%-50%, d. 50%-70%, or e. more than 70%.
Now, here’s our second polling question. What percentage of your referred patients with bipolar disorder were initially misdiagnosed? Would you say a. less than 10%, b. 10%-30%, c. 30%-50%, d. more than 50%, up to 70%, or e. greater than 70%.
We’re going to go ahead to patient case No. 1. This is a 27-year-old woman who’s presented for evaluation of a complex depressive syndrome. She has not benefitted from 2 recent trials of antidepressants—sertraline and escitalopram. This is her third lifetime depressive episode. It began back in the fall, and she described the episode as occurring right “out of the blue.” Further discussion revealed, however, that she had talked with several confidantes about her problems and that she realized she had been disappointed and frustrated for being passed over unfairly for a promotion at work. She had also been saddened by the unusually early death of her favorite aunt.
Now, our patient has a past history of ADHD [attention-deficit/hyperactivity disorder], which was recognized when she was in middle school and for which she took methylphenidate for adolescence and much of her young adult life. As she was wrapping up with college, she decided that this medication sometimes disrupted her sleep and gave her an irritable edge, and decided that she might be better off not taking it. Her medical history was unremarkable. She is taking escitalopram at the time of our initial evaluation, and the dose was just reduced by her PCP [primary care physician]from 20 mg to 10 mg because she subjectively thought the medicine might actually be making her worse.
On the day of her first visit, we get a PHQ-9 [9-item Patient Health Questionnaire]. The score is 16, which is in the moderate depression range. She filled out the MDQ [Mood Disorder Questionnaire] and scored a whopping 10, which is not the highest possible score but it is higher than 95% of people who take this inventory.
At the time of our interview, our patient tells us that her No. 1 symptom is her low mood and her ease to tears. In fact, she was tearful during the interview. She also reports that her normal trouble concentrating, attributable to the ADHD, is actually substantially worse. Additionally, in contrast to her usual diet, she has a tendency to overeat and may have gained as much as 5 kg over the last 4 months. She reports an irregular sleep cycle and tends to have periods of hypersomnolence, especially on the weekends, and then days on end where she might sleep only 4 hours a night despite feeling tired.
Upon examination, her mood is positively reactive, and by that I mean she can lift her spirits in conversation, show some preserved sense of humor, and does not appear as severely depressed as she subjectively describes. Furthermore, she would say that in contrast to other times in her life when she’s been depressed, that she’s actually had no loss of libido, and in fact her libido might even be somewhat increased. Over the last month or so, she’s had several uncharacteristic casual hook-ups.
So the differential diagnosis for this patient included major depressive disorder, recurrent unipolar with mixed features, versus bipolar II disorder, with an antecedent history of ADHD. I think the high MDQ score and recurrent threshold level of mixed symptoms within a diagnosable depressive episode certainly increase the chances that this patient’s illness should be thought of on the bipolar spectrum. Of course, this formulation is strengthened by the fact that she has an early age of onset of recurrent depression, that her current episode, despite having mixed features, has reverse vegetative features as well. We also have the observation that antidepressant therapy has seemed to make her condition worse, not better.
Transcript Edited for Clarity
Dr. Thase is a professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.
Dr. Alva is the medical director of ATP Clinical Research in Costa Mesa, California.
Dr. Cerulli is the medical director of Cerulli and Associates in Andover, Massachusetts.
Dr. Tina Matthew-Hayes is a dual certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.
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A Case Report of Mania and Psychosis Five Months after Traumatic Brain Injury Successfully Treated Using Olanzapine
Giordano f. cittolin-santos.
1 Faculty of Medicine, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
Jesse C. Fredeen
2 Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
Robert O. Cotes
There are few published pharmacologic trials for the treatment of acute mania following traumatic brain injury (TBI). To our knowledge, we present the first case report of an individual being treated and stabilized with olanzapine monotherapy for this condition.
We describe the case of a 53-year-old African American male admitted to an inpatient psychiatric hospital with one month of behavioral changes including irritability, decreased need for sleep, hyperverbal speech, hypergraphia, and paranoia five months after TBI. Using Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria, he was diagnosed with bipolar disorder due to traumatic brain injury, with manic features. He was serially evaluated with clinical rating scales to measure symptom severity. The Young Mania Rating Scale (YMRS) score upon admission was 31, and the Clinician-Rated Dimensions of Psychosis Symptom Severity (CRDPSS) score was initially 9. After eight days of milieu treatment and gradual titration of olanzapine to 15 mg nightly, his symptoms completely abated, with YMRS and CRDPSS scores at zero on the day of discharge.
Olanzapine was effective and well tolerated for the treatment of mania following TBI.
Mania develops in 1.9–9% of individuals after experiencing traumatic brain injury (TBI) [ 1 , 2 ]. Yet, there is a dearth of literature on pharmacologic treatment options for mania following TBI. The guidelines for the pharmacologic treatment of neurobehavioral sequelae of traumatic brain injury, published in 2006, concluded there was insufficient evidence to support the development of standards or guidelines in the treatment of TBI related mania [ 3 ]. Four studies were included in the review, including three case series (each with two patients) and one case report. Treatments successful in treating mania included clonidine [ 4 ], thioridazine/amitriptyline [ 5 ], electroconvulsive therapy [ 5 ], lithium [ 6 ], and valproate [ 6 ]. In addition to the studies presented in the 2006 guidelines, successful trials have been published with carbamazepine/lithium [ 7 ], lithium/thioridazine [ 8 ], lithium monotherapy [ 9 – 11 ], valproate/olanzapine [ 12 – 14 ], valproate monotherapy [ 15 ], carbamazepine/chlorpromazine [ 16 , 17 ], haloperidol [ 16 ], haloperidol/chlorpromazine [ 18 ], haloperidol/clonazepam [ 19 ], and quetiapine [ 20 ]. Here, we present the first case report of successful treatment with olanzapine monotherapy for mania after a traumatic brain injury.
2. Case Presentation
A 53-year-old African American male was brought by Emergency Medical Services (EMS) to the Emergency Room (ER) of an urban, public teaching hospital, due to threatening behavior, irritability, and an inability to care for himself. During the initial psychiatric consultation in the ER, the patient was hyperverbal with pressured speech and a tangential thought process. His mood was elevated, and his affect was labile with sudden and inappropriate bouts of tearfulness. He endorsed decreased need for sleep over the past few days and paranoid and persecutory delusions regarding strange noises around his apartment and his brother stealing money from his father. Per the EMS report, the patient was also emailing and texting neighbors paranoid and threatening messages, which resulted in multiple crisis hotline calls and the patient being brought to the hospital.
His past medical history was significant for a depressive episode treated successfully 25 years ago with sertraline and TBI five months prior to presentation. After the injury, he was followed by an outpatient neurologist for postconcussive syndrome. A brain MRI was ordered three months after TBI, which showed signs of mild white matter small vessel ischemic changes, but no other significant findings. The initial ER workup included a urinalysis, urine drug screen, complete metabolic panel, and thyroid function, all of which were unremarkable. A noncontrast CT scan of the brain was obtained and was unremarkable. He was admitted for inpatient psychiatric hospitalization. Using Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria [ 21 ], he was diagnosed with bipolar disorder due to traumatic brain injury, with manic features.
The patient was started on olanzapine 2.5 mg by mouth at bedtime upon admission. Manic features remained prominent, as he continued to demonstrate decreased need for sleep (three to five hours per night), pressured speech, irritability, emotional dysregulation, and labile affect. He often arose early in the morning and spent multiple hours writing questions for his treatment team. He refused valproate and lithium despite the team's suggestions. Olanzapine was gradually titrated and reached 15 mg on hospital day (HD) 6. Aside from one instance of refusal on HD 5, he was adherent with olanzapine throughout the hospitalization. Olanzapine was well tolerated. He was evaluated with serial clinical rating scales which included the Young Mania Rating Scale (YMRS) and the Clinician-Rated Dimensions of Psychosis Symptom Severity (CRDPSS). On HD 1, the YMRS score was 31 and CRDSS was 9. On HD 6, the YMRS score decreased to 30 and CRDPSS decreased to 7. On HD 7, he displayed significant clinical improvement. He slept throughout the night and on interview no longer had pressured speech. His thought process was logical, linear, and goal-directed, and the psychotic symptoms had also fully abated. On HD 8, the YMRS and CRDPSS scores were 0. He was subsequently discharged from hospital with appropriate outpatient follow-up.
Mania due to TBI is a challenging diagnosis to make with confidence, and this can make the limited research challenging to interpret. TBI may be an independent risk factor for the development of bipolar disorder [ 1 , 22 – 24 ] and the DSM-5 does not report a definitive time course for which the diagnosis of TBI must take place and symptoms must emerge in order for the disorder to be characterized as mania due to TBI [ 21 ]. As in our case, the majority of individuals who ultimately develop bipolar disorder report a depressive episode first [ 25 ], but the later age of onset of manic symptoms and temporal relationship to TBI lends credence to the TBI's primary role in the development of manic symptoms. In the case presented here, the patient exhibited a combination of manic and psychotic symptoms, but manic symptoms were predominant. The duration of the manic episode (likely around 2 months) was within range of other manic episodes reported after TBI. In study of six patients following head injury who experienced mania, the duration of the episode was 2 months, and the mean estimated duration of elevated mood was 5.7 months [ 2 ].
Olanzapine is a second-generation antipsychotic medication effective for the treatment of acute bipolar mania [ 26 ] and recommended for acute mania by various guidelines across the world [ 27 – 29 ]. However, few pharmacologic (and no randomized) trials exist for the treatment of mania following TBI. Olanzapine has been used for acute mania following TBI in several reported cases. Grenne et al. [ 30 ] described a case of a 13-year-old boy treated with olanzapine 10 mg daily and zonisamide who had improvement of auditory hallucinations but continued mania and delusions. A 60-year-old man was treated with an unspecified dose of olanzapine and 2500 mg of valproate five months after a head injury [ 12 ]. A 42-year-old man was treated with olanzapine 15 mg daily and valproate 1000 mg daily for mania emerging three years after a head trauma [ 13 ]. A 69-year-old man eighteen months after TBI was treated with 7.5 mg of olanzapine and 250 mg of valproate three times daily [ 14 ]. In each of these cases, olanzapine was combined with another medication, and of note, valproate alone has been effective in treating mania secondary to TBI [ 15 ], making it challenging to know if the patient improved related to olanzapine or valproate. Furthermore, olanzapine monotherapy has been shown to be effective in treating psychotic symptoms following traumatic brain injury in two case reports [ 31 , 32 ]. In the case presented here, the patient was not agreeable to other pharmacologic treatments despite being offered lithium and valproate augmentation. In a 2014 review article, Jorge and Arciniegas recommended valproate or quetiapine as first-line therapies for bipolar disorder due to TBI [ 33 ]. We conclude that olanzapine could also be considered for this population, as it was effective and well tolerated in this case.
Conflicts of Interest
Dr. Robert O. Cotes has accepted research funding, consultation fees, and/or honoraria from Alkermes, Janssen, and Otsuka Pharmaceuticals. Drs. Giordano F. Cittolin-Santos and Jesse C. Fredeen have nothing to disclose.
Nursing Case Study for Mania (Manic Syndrome)
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Approximately 24 hours after being admitted to a psychiatric facility, Kelli, a 20-year-old suspected bipolar disorder patient, is brought back to the ER. The staff was worried about her behavior and vital signs. The charge nurse from the facility gives a report to the ER nurse saying, “She has not slept at all, talks constantly, and has a flight of ideas. She seems really grumpy and refuses to participate in group activities.”
V/S as follows: BP 170/90 SpO2 96% on Room Air HR 122 bpm and regular RR 20 bpm Temp 37.5°C
What does the nurse understand about the term “flight of ideas?
- Flight of ideas is where your thoughts move very quickly from idea to idea, making links and seeing meaning between things that other people don’t. It differs from racing thoughts (which is when your thoughts go through your head very fast. It can involve them racing so fast that they feel out of control.) Also, it may indicate Kelli is suffering from delirium which, for her, is a sign her condition is worsening.
The nurse should be concerned about what complication Kelli may be experiencing? Why does the nurse think this?
- A more therapeutic way to document the patient being “grumpy” is to describe mood changes, irritability, anxiety, agitation, and/or social isolation. These are all hints that this is a manic episode because irritability is not uncommon and, “Irritable patients often make hostile comments, swear more than usual, or go off on angry tirades.” The term grumpy is too subjective to document as it can mean different things to different people.
Upon entering the exam room, the nurse finds Kelli standing on the stretcher trying to reach the tops of the privacy curtains. Her speech is rapid but clear as she says, “The goddess of creativity talks to me, and I have to change the curtains and I will need paint for the walls. If you can also get me some different clothes so I can dress up for the party.” She proceeds to talk about redecorating her home and school with interspersed comments about clothes and shoes, grades, her friends, and many other topics. She also says that she does not like the facility she was at because the staff is using mind control.
- Psychosis (possibly brought on by delirium from not sleeping) or a medical condition not noticed in the initial ER visit. “In individuals with an acute or exacerbated chronic medical condition, psychosis is a common manifestation of delirium. Careful attention to the key features of acute onset, fluctuating course, altered consciousness, and cognitive decline can help distinguish delirium from primary psychiatric illness. When in doubt, the most useful rule-of-thumb is to assume delirium and attempt to rule out common medical etiologies. This is true even for patients with known psychiatric illness (including dementia), since they, too, are susceptive to delirium when acutely ill.
After sharing her thoughts about possible psychosis with the provider, he concurs and asks the nurse to interview the patient to get more information. He also says he will come in and conduct a mental status exam.
What are some things the nurse should ask during the interview?
- The staff has some background on this patient, but a current assessment of the situation is needed. Questions to help understand what may have triggered or preceded this episode are necessary. Has there been any substance use? Did something happen within the patient’s social support system? Was there trauma (i.e. did someone harm/hurt her at the facility?) Were there new medications administered at the facility?
What does the nurse know about a mental status exam?
- Whenever possible, mental status examinations should be conducted in a quiet room, without distractions. This may be difficult in a busy hospital or clinic setting. For someone experiencing a manic episode, the focus will probably be on the following:
- General behavior and demeanor – Level of awareness of surroundings, cooperation with the interviewer, eye contact
- Assessment of mood – Presence of depression or mania
- Affect – Intensity, appropriateness, lability and range of affect
- Thought process – Loosening of associations, flight of ideas, thought blocking
- Thought content – Paranoia, delusions, referential thinking (messages from television, radio, or others), internal preoccupations, thought control
- Perceptual disturbance – Hallucination (auditory, visual, tactile, olfactory, gustatory)
- Thoughts of self-harm or harm to others
- Cognitive screen – Attention, concentration, memory
Kelli answers questions during both the nurse and provider exams. Her heart rate continues to be elevated and she is sweating profusely.
What type of medication (s) does the nurse anticipate the provider to order?
- Possibly an antipsychotic (examples: Haldol (haloperidol), Thorazine (chlorpromazine), Geodon (ziprasidone). Maybe a benzodiazepine such as lorazepam (Ativan) to treat anxiety dependent on patient symptoms.
The provider verbally prescribes ziprasidone (Geodon) 10 mg IV once now.
Should the nurse clarify this order? Why?
- Ziprasidone is administered either by mouth (PO) or intramuscular (IM). It is not provided in a form that can be given IV.
- “GEODON for Injection (ziprasidone mesylate) should only be administered by intramuscular injection and should not be administered intravenously. Single-dose vials require reconstitution prior to administration.
- Add 1.2 mL of Sterile Water for Injection to the vial and shake vigorously until all the drug is dissolved. Each mL of reconstituted solution contains 20 mg ziprasidone. To administer a 10 mg dose, draw up 0.5 mL of the reconstituted solution. To administer a 20 mg dose, draw up 1.0 mL of the reconstituted solution. Any unused portion should be discarded.
- It is always alright for a nurse to clarify orders that are unclear or ordered incorrectly. This is part of the 6 rights (in this case ROUTE).
What side effects might the nurse expect? Which are the highest priorities for monitoring/intervention?
- Dizziness, drowsiness, weakness, nausea, vomiting, trouble swallowing, feeling restless, tremors, vision problems are listed as side effects. Also, racing heart and shortness of breath. Kelli’s heart rate is already high so watch for worsening. Dizziness/drowsiness should prompt safety concerns due to patient SAFETY. She should be carefully monitored after administration.
Kelli is in on the stretcher with both side rails up. New vitals:
BP 120/60 SpO2 98% on Room Air HR 82 bpm and regular RR 12 bpm Temp 37.1°C
She is released back to the psychiatric facility with a new prescription for risperidone 20 mg PO daily.
What interactions and/or long-term effects should be monitored with this medication if it is prescribed (orally) long-term?
- Extrapyramidal Symptoms which include the following adverse reaction terms: extrapyramidal syndrome, hypertonia, dystonia, dyskinesia, hypokinesia, tremor, paralysis and twitching. None of these adverse reactions occurred individually at an incidence greater than 10% in bipolar mania trials.
- Dizziness which includes the adverse reaction terms dizziness and lightheadedness.
- Akathisia (agitation, distress)
- Abnormal Vision
- Asthenia (weakness, lethargy)
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This nursing case study course is designed to help nursing students build critical thinking. Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process. To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs. If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding. In the end, that is what nursing case studies are all about – growing in your clinical judgement.
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