Patient Management Exercise for Bipolar Disorder

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?

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.

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?

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?

Decision Point E

Based upon your answer to Decision Point D, what changes, if any, would you make to his medication regimen?

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?

Decision Point G

Which of the following differences in the course of illness are more suggestive of a bipolar depression rather than unipolar depression?

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.

Decision Point B

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

Decision Point D

Decision Point E

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.

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.

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.