The IT Expert: a casebased discussion on mood disorders

Noreen Marie Garcia Christopher Alec Maquiling ASMPH 2015

Identifying Data
MO, 29 year old, Filipino, Roman Catholic, married, IT specialist, from Mandaluyong who was admitted for the first time at The Medical City on June 16, 2013. Informant: Patient, with fair reliability Chief Complaint: I went cuckoo

History of Present Illness

Timeline
2 weeks PTA

Event
Involved in a sideline (regular work in Globe) business transaction which the px claims to have a very huge socioeconomic implication for the country. He believes that he can save the country if this business deal prospers. Since his involvement in this business, he reports that he cannot stop thinking about it especially because he thinks he can fix a lot of things about the business proposal (My thoughts are racing, I was thinking and thinking and thinking about it) often taking up most of his time throughout the day He has an elevated mood most of the time, and has progressively lacked sleep in the succeeding days (average of 1-2 hours of sleep per day)

History of Present Illness

Timeline 7 days PTA

Event Had a disagreement with his business partner, causing them to split up in good terms However, since then, his preoccupation with the business deal has increased since he wants to continue the business venture on his own. He became more aggressive and disruptive especially when he is at work in Globe. His preoccupation and restlessness continued

History of Present Illness

Timeline 1 day PTA

Event Patient called up a family meeting to discuss about "what he discovered about himself." During the meeting, he would discuss business matters mixed with Einstein theories, numbers, "doing the greater good for mankind" and releasing the universe. The patient's family could not comprehend what the patient was saying and advised him to take a rest, possibly attributing the rambling to fatigue and stress.

History of Present Illness

Timeline Hours PTA

Event Claimed to have a full blown panic attack and realized that someone is out there to kill me (he described this as an AHA moment, and he denied hearing any voices) He then became very agitated, and told his family to get out of the house, and bring weapons. He knocked on the doors of his neighbors in their apartment telling them about his belief about an attempt to claim his life. Persistence of behavioral changes prompted his admission in this institution.

Review of Systems
General: (-) weight changes, (-) fever, (-) fatigue Skin: (-) rashes,(-) sores, (-) itching, (-) dryness, (-) jaundice and (-) discolorations HEENT: Head: (-) headache, (-) blurring of vision. (-) deafness, (-) frequent colds, (-) bleeding gums, (-) sore throat Respiratory: (-) cough, (-) hemoptysis, (-) dyspnea, (-) wheezing Cardiovascular: (-) palpitations, (-) chest pains, (-) syncope GI: (-) dysphagia, (-) nausea/vomiting Urinary: (-) frequency, (-) nocturia, (-) urgency, (-) hematuria and (-) dysuria Endocrine: (-) polyuria, (-) excessive thirst Musculoskeletal: (-) arthritis and weakness Neurologic: (-) seizures, tremors

Previous Illnesses
Past psychiatric History: Unremarkable Medical History: Hyperuricemia No previous hospitalizations or surgeries. Does not take any medications and supplements prior. Family History: His distant cousin was said to have gone crazy (exact diagnosis unrecalled).

Anamnesis

He was born full term to a G1P1 (1001) mother after an unplanned but wanted pregnancy, via NSD. No fetomaternal complications noted. Primary caregiver was the mother. He claims to have a loving relationship with his mother. Patient is the eldest among 4 siblings (2 younger sisters, and a brother who is the youngest). He claims to have a normal relationship with them throughout his life. His father was the disciplinarian in the family.

Anamnesis

As a young kid and throughout his teenage years, he was very interested in science fiction and digital media art. He claims to have a close set of friends, although not many. In school, he claims to have an average performance all throughout (grade school to college) In high school, he realized that he was gifted and had superior level of intelligence. However, he opted not to apply this and purposely tried to lower his grades because he claims to be lazy.

Anamnesis

He took up ECE in DLSU. After graduation, he was hired as an IT specialist in Globe Telecom, where he has been working for 6 years. He claims to enjoy his work there, although he is frustrated with the many number of people who tries to get in his way whenever he wants to fix stuff in his department. He has 2 kids (both females) aged 6 and 8 years old, and another one due on September this year. He says that his children and his wife are his number one priority in his life. He said he wanted to provide all the wants and the needs of my family

Sexual History
Coitus: 20 years old with his wife. During the first few years of their marriage, he claims that there were instances when they did it in the car, finally ending when a police officer caught them and reprimanded them. He also claims that he watches porn and masturbates all the time, which he does everyday, once or twice twice a day.

Personal/Social History
Substance History: non-smoker, non-alcoholic beverage drinker; no known use of illicit substances. Patient lives with his wife and 2 children in an Apartment that they own. They have regular supply of electricity and clean water source. Regular garbage collection. Primary Financier: Patient Primary Decision-maker: Patient Primary Caregiver: Wife

Physical Examination
Vital Signs: BP 140/80, T 36.1, HR 80, RR 20, VAS 0/10 The rest of the PE was unremarkable.

Mental Status Examination

Patient was seen on the couch but opted to stand when being interviewed. He was wearing green shorts and an orange collared shirt. His hair is disheveled. He is of average stature and medium build, looking appropriate for chronological age. He appears anxious, but cooperative and with good eye contact. Speech is hyperproductive and spontaneous. Mood is elated with appropriate affect

Mental Status Examination

He is preoccupied with having no extra underwear, the fixtures needing repair, the lights not having the same design and the medical staff being mostly female. He is also preoccupied with having writing materials to write down ideas for his business. He denies perceptual disturbances. He is oriented to three spheres, with poor insight, judgment, and impulse control.

Problem List
1. Manic episode - racing thoughts, elevated mood, decreased need for sleep, aggressive and disruptive behavior, restlessness, sexual and business preoccupations, grandiosity, hyperproductive speech, elated mood with appropriate affect 2. Paranoid Delusion 3. Difficulty in social, interpersonal and occupational functioning

Initial Impression
Axis I: Bipolar I Mood Disorder MRE Manic w/Psychotic Features Axis II: t/c Narcissistic Personality Disorder Axis III: Hyperuricemia Axis IV: Social and Work-related stress Axis V: GAF 21-30

DSM IV TR Criteria for Bipolar Disorder I

At least one manic or mixed episode No need for a prior depressive episode Episodes of substance-induced mood disorder or of mood disorder due to a general medical condition need to be excluded. In addition, the episodes must not be better accounted for by schizoaffective disorder or superimposed on schizophrenia,schizophreniform disorder, delusional disorder, or a psychotic disorder not otherwise specified.

Criteria for a Manic Episode

Elevated (or irritable) mood for >1 week (check) Three or more of following (four if mood irritable): 1. Grandiosity (check) 2. Decreased need for sleep (check) 3. Pressured speech (check) 4. Flight of ideas, racing thoughts (check) 5. Distractibility 6. Increased goal-directed activity (check) 7. Excessive involvement in pleasurable activities with high risk (check) 6 out of 7: strongly consider a manic episode for this patient.

Differential Diagnosis
1. Mood Disorder secondary to GMC
What is it? Episodes are judged to be a consequence of a medical condition such as multiple sclerosis, stroke or hyperthyroidism. Onset or exacerbation of mood coincides with that of medical condition Rule out: Patient denies any medical conditions besides hyperuricemia. Review of systems were all negative. Further laboratory tests/imaging studies are needed

Differential Diagnosis
2. Substance-induced mood disorder
Episodes are judged to be a consequence of a substance such as an illicit drug, a medication (stimulants, steroids, Ldopa, antidepressants), or toxin exposure. Episodes may be related to intoxication or withdrawal

Rule out: Patient denies history of taking any substances. Needs toxicology/drug screening.

Differential Diagnosis
3. Psychotic disorders (schizoaffective disorder, schizophrenia, brief psychotic disorder, delusional disorder)
Rule in: Paranoid delusion. Delusion of grandeur. Disorganized behavior. Social/occupational dysfunction. Rule out: Schizoaffective: because delusions did not occur in absence of mood symptoms for at least 2 weeks Brief psychotic disorder: chronology of the symptoms is a ruling in factor (more than 1 day but less than 1 month), less than 1 month, but a return to a social functioning should be noted. Moreover, symptoms of the patient fit more of a manic episode. Schizophreniform: Psychotic ssymptoms occurred for less than the prescribed criteria (1 month to less than 6 months) Schizophrenia: psychotic symptoms occurred for less than 6 months. Delusional disorder: msot recent delusion cannot be considered non-bizaare; social and occupational functioning was significantly impaired

Differential Diagnosis
4. Bipolar II Disorder
1. The presence of a hypomanic or major depressive episode. 2. If currently in major depressive episode, history of a hypomanic episode. If currently in a hypomanic episode, history of a major depressive episode. No history of a manic episode. 3. Significant stress or impairment in social, occupational, or other important areas of functioning

Does the patient have a major depressive episode?

Criteria: Five or more symptoms present for 2 weeks 1. Depressed mood- NO 2. Anhedonia- NO 3. Decrease or increase in appetite OR significant weight loss or gain- NO 4. Persistently increased or decreased sleep- YES 5. Psychomotor agitation or retardation- YES 6. Fatigue or low energy- NO 7. Feelings of worthlessness or inappropriate guilt- NO 8. Decreased concentration or indecisiveness- YES 9. Recurrent thoughts of death, suicidal ideation, or suicide attempt- NO DOESN'T FULFILL THE CRITERIA

Does the patient have hypomania?

Criteria: Same symptoms as in manic episode, but with considerable differences: 1. Lasts at least 4 days- YES 2. No marked social or occupational dysfunction- NO 3. Does not require hospitalization- NO 4. No psychotic features- NO

DOESN'T FULFILL THE CRITERIA

Rapid Cycling
Qualifier for either Bipolar I or Bipolar II disorder Four or more mood episodes (any type) within any 1 year period

Axis II Diagnosis
Narcissistic Personality Disorder
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
(1) has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)- YES (2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love- YES (3) believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions) - YES (4) requires excessive admiration- yet to be elicited (5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations- YES (6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends (7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others (8) is often envious of others or believes that others are envious of him or her- YES

Other mood disorders

Major Depressive Disorder- Presence of a major depressive episode; Episode not better explained by another diagnosis; NO HISTORY of mania, hypomania, or mixed episode (unless substance or medical illness related) Dysthymic Disorder- Depressed mood nearly every day for > 2 years; Associated with 2 of the following: decreased or increased appetite, decreased or increased sleep, low energy or fatigue, low self-esteem, poor concentration or indecisiveness, hopelessness, No more than 2 months symptom free Cyclothymic Disorder- Several hypomanic episodes; Several distinct periods of depressive symptoms that do not meet criteria for a major depressive episode; Hypomanic episodes and depressive symptoms alternate over at least 2 years; Symptom-free periods are < 2 months duration

Diagnostic
Rationale for selected laboratory studies. 1. The practitioner needs to perform the tests to determine the diagnosis ("do not miss a treatable medical cause for the mental status.") 2. Bipolar disorder necessitates use of a number of medications that require certain body systems to be working properly. 3. Bipolar illness is a lifelong disorder, performing certain baseline studies is important to establish any long-term effects of the medications. 4. Any of the encephalitides can dramatically manifest as changes in mental status

Diagnostic
Blood studies: CBC with differential, fasting glucose, electrolytes, calcium, proteins, thyroid hormones, BUN, Creatinine: ALL UNREMARKABLE Substance and Alcohol Screening: negative ECG: normal

Clinical Course: Pathophysiology of Bipolar I Disorder (Manic Episode)

The pathophysiology of bipolar disorder has not been determined. However, twin, family, and adoption studies all indicate that bipolar disorder has a genetic component. First-degree relatives of a person with bipolar disorder are approximately 7 times more likely to develop bipolar disorder than the rest of the population. The genetic component of bipolar disorder appears to be complex

Pathophysiology
Structural and Functional Abnormalities: Volumetric in the prefrontal cortex and limbic systems. Neurotransmitter involvement: Deficiency in norepinephrine; Dopamine implicated in the study of mania and psychotic symptoms; Serotonin levels have also been implicated Mitochondrial Dysfunction Abnormalities Data from several lines of evidence is needed for a comprehensive understanding of this illness, and studies examining the symptoms, genetics, and treatment effects will all help to elucidate its pathophysiology.

Psychodynamic Factors in Mania

Most theories of mania view manic episodes as a defense against underlying depression. -May reflect an inability to tolerate a developmental tragedy (e.g. loss of a parent) -Defensive reaction to depression, using manic defenses such as omnipotence (e.g. delusions of grandeur) May also result from a tyrannical superego, which produces an intolerable self-criticism that is then replaced by euphoric satisfaction.

Prevalence
Lifetime: .4-1.6% = in men and women Men>manic episodes Women>dep episodes Women>rapid cycling Ave. age onset = 20. Usually late adolescence or early adulthood. However some after age 50. Late onset is more commonly Type II. Recurrent 60-70% of manic episodes occur before or after a depressive episode Increased prevalence in upper socioeconomic classes

Prognosis (Clinical Course)

Patients with BPI fare worse than patients with a major depression. Within the first 2 years after the initial episode, 40-50% of patients experience another manic attack. Only 50-60% of patients with BPI who are on lithium gain control of their symptoms. In 7% of these patients, symptoms do not recur, 45% of patients experience more episodes, and 40% go on to have a persistent disorder. Often, the cycling between depression and mania accelerates with age. Chronic illness, typically with multiple episodes over lifetime Major cause of distress and disability Chronic mood stabilizer therapy can reduce number and severity of episodes over BUT up to 15% of patients will kill themselves

Prognostic Indicators
Suicidality Presence of a personality disorder Quality of family and social support Substance use History of severity of prior episodes Bipolar I type is most severe Treatment onset-the sooner the better Age of onset-the younger the more severe

Contextual Analysis
Patient is a male IT professional in his late 20's working in a mid-level job in a major telecommunication company, and was currently very preoccupied in a particular business venture that he believes has major socioeconomic implications for this country, which is the primary psychosocial trigger for his recent behavioral changes. Patient's insight is poor to fair. He said that his "going cuckoo" is only caused by his continuous lack of sleep. This will have implications in medication compliance and disease relapse/recurrence. Patient is the primary breadwinner of his own family. He also helps out in the finances of his parents and siblings. So employment status particularly after his confinement in TMC is a major cause for concern for the patient. The reaction of his family, particularly his kids, to his most recent episode of mania and violence, should be processed, since the family has a major role in the success of the interventions that will be done to the patient.

Therapeutic
The patient's safety must be guaranteed. A complete diagnostic evaluation is necessary. A treatment plan that addresses not only the immediate symptoms but also the patient's prospective well-being should be initiated. Treatment should also address the number and severity of stressors in patients' lives.

Therapeutic
Just like long-term illnesses such as diabetes and heart disease, bipolar disorder is an illness that requires medication to improve quality of life Not all medications work for every person Severity of moods and side effects must be weighed Medical management by a psychiatrist is best A combination of medication and talk therapy is most effective, specifically cognitive behavior and family therapy Long-term management of symptoms reduces risk of suicide

Therapeutic
CANMAT and ISBD 2013 updated guideline Lithium, valproate, and several atypical antipsychotic agents continue to be first-line treatments for acute mania. Monotherapy with asenapine, paliperidone extended release (ER), and divalproex ER, as well as adjunctive asenapine, have been added as first-line options. Bipolar depression: lithium, lamotrigine, and quetiapine monotherapy, as well as olanzapine plus selective serotonin reuptake inhibitor (SSRI), and lithium or divalproex plus SSRI/bupropion remain first-line options. Lithium, lamotrigine, valproate, olanzapine, quetiapine, aripiprazole, risperidone long-acting injection, and adjunctive ziprasidone continue to be first-line options for maintenance treatment of bipolar disorder.

Pharmacologic
Lithium- first line therapy for the acute, continuation, and maintenance stages of bipolar disorder.
Potential side effects from lithium include gastrointestinal upset, tremor, sedation, excessive thirst, frequent urination, cognitiveproblems, impaired motor coordination, hair loss, and acne. Excessive levels of lithium can be harmful to the kidneys, and increase the risk of side effects in general. As a result, kidney function and blood levels of lithium are monitored in patients being treated with lithium Therapeutic plasma levels of lithium range of 0.51.5 mEq/L, with levels of 0.8 or higher being desirable in acute mania.

Pharmacologic
Valproic acid is as effective as Lithium in mania prophylaxis but is not as effective in depression prophylaxis. Good for Bipolar Disorders with Rapid Cycling, Mixed episodes, w/comborbid anxiety disorders. Better tolerated than Lithium
Side Effects: Thrombocytopenia and platelet dysfunction Nausea, vomiting, weight gain Transaminitis Sedation, tremor Increased risk of neural tube defect 1-2% vs 0.14-0.2% in general population secondary to reduction in folic acid Hair loss

Pharmacologic
Lamotrigine: bipolar depression (Stevens-Johnson syndrome) Atypical Antipsychotics: Olanzapine, Quetiapine

Psychosocial/Preventive
Psychosocial Therapies: Multifaceted services to educate the patient and family about bipolar disorder, help them understand the pattern of the illness, and teach them to cope with the changes the illness brings about. It also aims to help the patient repair any damage (emotional, social, family, occupational and financial) the illness may have caused. Patient should be encouraged to set goals for treatment= does the patient want to return to life as before or to take up a less demanding life or occupation?

Psychosocial/Preventive
Stress patterns: Patient should draw up a formal life chart that shows the episodes of acute illness on a time basis, together with major life events/stressors. Precipitants should be avoided or minimized Sleep patterns: establishing regular patterns of sleeping can make them feel that other major aspects of life are falling into place.