1. What psychiatric conditions are commonly associated with acute agitation?

(Pat)
In the emergency department, drug and alcohol intoxication or withdrawal are the most
common diagnoses in combative patients. When a patient has a known psychiatric illness, it is
a risk factor for violent behavior with schizophrenia, personality disorders, mania, and psychotic
depression most associated with violence. Psychotic patients with a history of incarceration due
to violence are likely to act violently again. Patients with psychosis, delirium, or dementia may
lead to violent behavior.

Common and dangerous causes of violent behavior

Toxicologic

● Alcohol intoxication or withdrawal

● Stimulant intoxication (methamphetamine, phencyclidine, cocaine)
● Other drugs and drug reactions (anabolic steroids, sedative-hypnotic)

Metabolic

● Hypoglycemia
● Hypoxia

Neurologic

● Stroke
● Intracranial lesion (hemorrhage, tumor)
● CNS infections
● Seizures
● Dementia

Other Medical Conditions

● Hyperthyroidism
● Shock
● AIDS
● Hypothermia; Hyperthermia

Psychiatric

● Psychosis
● Schizophrenia
● Paranoid delusions
● Personality disorder

Antisocial Behavior

2. What other relevant information in the patient’s history would you like to find out? (Pat)
● Since when did the patient start acting this way?
● Does the patient take illicit drugs? Alcoholic beverages?
● Does the patient have any medications? If yes, what are those medications?
 ● Has this event happened before?
● Does the patient have any previous history of psychiatric conditions?
● Does the patient have any known comorbidities?
● What could have triggered the agitation?
● Can the agitation be observed by other people as well?

3. Considering the patient’s age and gender profiles, what conditions should you likely think of?
(Shannen)
a. Drug intoxication
b. Substance Abuse
c. Anxiety (Anxiety disorders)
d. Depression (Mood disorders)
e. Delusional Disorders
f. Personality Disorders
g. Dissociative Disorders
4. What factors are associated with an increased risk for relapse or recurrence? Which of these
factors are present in Arthur’s situation? (Shannen)
Factors associated with relapse Present in Arthur’s Situation

1. Stressful life events 1. Stressful life events - death of

2. Exciting life events Bruce, Pandemic
3. Lack of regular sleep 2. Lack of regular sleep - Arthur
4. Lack of daily routine is insomniac
5. Tobacco use 3. Abuse of drugs
6. Too much caffeine
7. Abuse of alcohol
8. Abuse of drugs
9. Not taking the medications

5. How do you deal with a patient’s behaviors which have a potential for harm? How do you
assess these behaviors? What are the indications for hospitalization? (Lloyd)

5A) How do you deal with a patient’s behaviors which have a potential for harm?
1. The first rule is to protect yourself (safety).
a. Ensure the safety of the patient and health care staff.
b. Prevent harm by limiting the potential for harm.
c. If needed, medications or physical restraints must be ready and available.
2. Other safety procedures:
a. Weapon screening: not the doctor’s task
b. Door access: The doctor should be closer to the door than the patient, so the
patient cannot run away or lock the door/trap the doctor. Take note of the nearest
exit/all possible exits
c. Method to call for help: e.g. nurse buttons
d. Adequate personnel to respond
 3. Conduct the interview in a quiet, non stimulating environment
4. During the interview, avoid any behavior that could be misconstrued as menacing (e.g.
standing over the patient, staring, touching)
5. If the patient’s agitation continues to increase, you may need to terminate the
interview/consultation.
6. Other Possible Interventions:
a. Verbal intervention/de-escalation (e.g. “you are safe here,” calming the px down,
verbal reassurance, “we are here to help”)
b. Voluntary medication (e.g. “would you like something to help you sleep?”)
c. Offer signs of universal hospitality (e.g. food, beverage, other assistance; do not
buy the food, rather ask someone else to buy)
d. Physical restraint, chemical restraint (e.g. meds)
e. Locked or unlocked quiet room, seclusion

5B) How do you assess these behaviors?

1. Ask the question: is the problem organic, functional, or combination?
a. Organic problems are those due to medical or neurologic conditions
i. Medical: metabolic encephalopathy
ii. Neurologic: epilepsy, delirium
b. Functional problems are due to medicines
i. Use or overuse of (illicit) substances
ii. Drugs: patients can be in withdrawal symptoms
2. Assess: is the patient suicidal or homicidal?
a. Suicide attempts or ideation
b. Previous failed attempts
c. Availability of means for suicide (or homicide) such as firearms
d. Verbalized suicidal ideation
e. Presence of proximal life crisis such as death of a loved one
f. Family history of suicide
g. Pervasive hopelessness
3. Assessment of agitation and violent behavior:
a. These include young, male, unemployed, low SES, history of substance abuse
and intoxication, past hx of violence and aggression, etc
b. Signs include: Recent acts of violence, including property violence,
c. Verbal or physical menacing
d. Carrying weapons or other objects that may be used as weapons
e. Progressive psychomotor agitation
f. Alcohol or other substance intoxication
g. Paranoid features in a psychotic patient
h. Command violent auditory hallucinations

5C) What are the indications for hospitalization?

1. Need for diagnostic procedures/medical care
2. Homicide or suicide attempt/ideation
 a. Assess for previous and ongoing suicide attempt/ideation
b. Presence or availability of lethal weapons or objects (firearms, drugs, etc)
3. Patients with disturbed actions: agitated, violent, or impulsive
4. Gross inability to acquire food/shelter
5. Rapidly progressing symptoms
6. Rupture of patient’s usual support systems: e.g. family problems

6. What other information do you need about Arthur’s symptoms to decide where it is coming
from and what its causes are? (Lloyd)

1. History of medical, neurologic, or psychiatric conditions? (Past medical history)

2. Drug History
a. For comorbidities?
b. For psychiatric drugs? (if with psychiatric condition)
c. Illicit drugs? (Answered already: occasional history of ecstasy use)
d. When was the last time he took drugs? Does this have an effect on the
occurrence of his symptoms?
3. Changes in behavior?
a. Dietary habits? (Anorexic)
b. Sleeping patterns? (Insomniac)
c. Work-related activities? (Increased productivity, then becomes unproductive)
d. Socialization? (To workmates, family, or loved one)
e. Suicidal or homicidal attempts or ideation?
f. Clothing: Does wearing designer clothes normal to him or it only manifested in
the duration of his symptoms?
4. Symptom Analysis
a. How long does each episode of his symptoms occur? First time?
b. Recent or preceeding substance use: illicit drugs, alcohol, smoking?
c. Recent life events? Mourning, break-up, or work-related (ie lost job)?
5. HPI analysis:
a. 6 weeks PTC:
i. Relationship with Bruce? Did they have “romantic” involvement?
1. Did Arthur test to rule out COVID? (Positive or negative?)
ii. Help-seeking behavior
1. Did he share what happened to anyone?
2. Did he ask for help? Psychosocial support?
3. Substance (alcohol, smoking, illicit drugs) use as a coping
mechanism?
b. 1 week PTC
i. What was his previous affect at work? Was he “high” in spirits ever since?
ii. Help-seeking behavior after the depressive episode:
1. Did he share what happened to anyone?
2. Did he ask for help? Psychosocial support?
3. Substance (alcohol, smoking, illicit drugs) use as a coping
mechanism?
iii. “He would rather die”
1. Is this his first verbalized suicidal thoughts?
 2. Any other suicide-related behavior?
c. Few hours PTC
i. Is this the first episode of this behavior?
ii. Did he take any substance (coffee, alcohol, smoking, illicit drugs) prior to
the meeting?

7. What are defense mechanisms? What are the different kinds of defense mechanisms? What
is the main defense used by Arthur in coping with his situation?

Defense Mechanism
● How people distance themselves from full awareness of unpleasant thoughts, feelings,
and behaviors
● Coping techniques that reduce anxiety arising from unacceptable or potentially harmful
impulses
● Most unconscious and are utilized by everyone
Kinds of Defense Mechanism
● Narcissistic-Psychotic Defenses
These defenses are usually found as part of a psychotic process, but may also
occur in young children and adult dreams or fantasies. They share the common note of
avoiding, negating, or distorting reality.
E.g. Projection, Denial, Distortion
● Immature Defenses
These mechanisms are fairly common in preadolescent years and in adult
character disorders. They are often mobilized by anxieties related to intimacy or its loss.
Although they are regarded as socially awkward and undesirable, they often moderate
with improvement in interpersonal relationships or with increased personal maturity.
E.g. Acting out, Blocking, Hypochondriasis, Introjection, Passive-Aggressive
Behavior, Projection, Regression, Schizoid Fantasy, Somatization
● Neurotic Defenses
These are common in apparently normal and healthy individuals as well as in
neurotic disorders. They function usually in the alleviation of distressing affects and may
be expressed in neurotic forms of behavior. Depending on circumstances, they can also
have an adaptive or socially acceptable aspect.
E.g. Controlling, Displacement, Dissociation, Externalization, Inhibition,
Intellectualization, Isolation, Rationalization, Reaction Formation, Repression,
Sexualization
● Mature Defenses
These mechanisms are healthy and adaptive throughout the life cycle. They are
socially adaptive and useful in the integration of personal needs and motives, social
demands, and interpersonal relations. They can underlie seemingly admirable and
virtuous patterns of behavior.
E.g. Altruism, Anticipation, Asceticism, Humor, Sublimation, Suppression
Main Defense used by Arthur: Denial
 Denied there was anything wrong with him, refused to elaborate on his drug use, and got
very angry when he was told he was going to be confined in the hospital. He shouted that he was
too good-looking to be hospitalized and then tried to run out of the ER
Both bipolar manic and depressed groups used the defense mechanism of denial, borderline level
defenses and immature defenses. The manic group showed greater dependence on narcissistic
level defenses.
Bipolar Mania
Denial and the narcissistic level defenses of idealization, omnipotence and devaluation have been
found to be characteristic of mania
Bipolar Depression: Neurotic level defense mechanisms
It appears that the bipolar depressed patients are more comfortable with their distressing emotions
compared to the manic patients, as they do not deny them totally.
https://www.researchgate.net/publication/226192653_Defense_Mechanisms_in_Mania_Bipolar_
Depression_and_Unipolar_Depression
Distortion: Grossly reshaping the experience of external reality to suit inner needs, including
unrealistic megalomanic beliefs, hallucinations, wish-fulfilling delusions, and employing
sustained feelings of delusional grandiosity, superiority, or entitlement. (a million brilliant ideas -
grandiose)
Controlling: The excessive attempt to manage or regulate events or objects in the environment in
the interest of minimizing anxiety and solving internal conflicts.
Suppression: The conscious or semiconscious decision to postpone attention to a conscious
impulse or conflict. (Suppressed his negative feelings and focused on being productive)
Repression: Consists of the expelling and withholding from conscious awareness of an idea or
feeling. It may operate either by excluding from awareness what was once experienced on a
conscious level (secondary repression) or it may curb ideas and feelings before they have reached
consciousness (primary repression). The "forgetting" associated with repression is unique in that
it is often accompanied by highly symbolic behavior, which suggests that the repressed is not
really forgotten. The important discrimination between repression and the more general concept
of defense has been discussed.
Acting Out: The direct expression of an unconscious wish or impulse in action to avoid being
conscious of the accompanying affect. The unconscious fantasy, involving objects, is lived out
and impulsively enacted in behavior, thus gratifying the impulse more than the prohibition against
it. On a chronic level, acting out involves giving in to impulses to avoid the tension that would
result from postponement of their expression

8. What is the significance of his belief of having “a million brilliant ideas”? What
is reality testing? How would you define psychosis from this perspective?

- Significance of “G”- grandiosity

- What is reality testing? Reality testing is the ability to differentiate self-generated stimuli (e.g.
thoughts, imagery, and feelings) from external stimuli (e.g. perceptions) and assign appropriate
meaning to experiences. It requires accurate perception, organized thought processes, and
flexibility in interpersonal interactions.
 - What is psychosis?  Is often defined as an “impaired reality testing” . Mental disorder in which
the thoughts, affective response, ability recognize reality and ability to communicate interfere
grossly with the capacity to deal with reality .The classical characteristics of psychosis are
impaired reality testing, hallucinations, delusions and illusions . Psychosis refers to a deficit in
reality testing with a lack of insight regarding the deficit.

9. What would you look for in the patient’s physical, neurological, and mental status
Examinations?

- Physical Exam

- History:

- Decreased need for sleep

- Increase in goal directed activity (socially, at work, or sexually)

- Involvement in activities that have a high potential for painful

consequences (e.g. shopping sprees, foolish business investments,
sexual indiscretions)

- Impairment in social or occupational functioning

- Substance use and abuse

- Signs of self-injurious behavior (cutting, burning, scratching, biting, pulling out

hair, etc)

- Neurological Exam

- Some perceive a sharper sense of smell, hearing, or vision (DSM-V)

- Mental Status Exam

- General description: Manic patients are excited, talkative, sometimes amusing,

and frequently hyperactive. At times, they are grossly psychotic and disorganized
and require physical restraints.

- Individuals may change their dress, makeup, or personal appearance to a

more sexually suggestive or flamboyant style (DSM-V)

- Mood, affect, and feelings: Manic patients classically are euphoric (“feeling on top
of the world”), but they can also be irritable. They also have a low frustration
tolerance, which can lead to feelings of anger and hostility. Manic patients may
be emotionally labile, switching from laughter to irritability to depression in
minutes or hours.

- Speech: Speech can be rapid, pressured, loud, and difficult to interpret. They are
also intrusive and cannot be interrupted. Their speech is filled with puns, jokes,
rhymes, plays on words, and irrelevancies.
 - Perceptual disturbances: Delusions occur in 75 percent of all manic patients.
Mood-congruent manic delusions are often concerned with great wealth,
extraordinary abilities, or power.

- Thought: thought content includes themes of self-confidence and

self-aggrandizement; frequently there is a flight of ideas

- Sensorium and cognition: orientation and memory are intact

- Impulse control: About 75 percent of all manic patients are assaultive or

threatening.

- Judgment and insight: impaired judgment is the hallmark of mania. They also
have little insight into their disorder.

- Reliability: unreliable because lying and deceit are common in mania.

10. Summarize the significant findings in the patient’s history, PE and MSE.

- Patient history

- 6 weeks PTA

- Arthur became fast friends with a fellow gym goer, Bruce. They hung out
together frequently since meeting.

- Three weeks after meeting, Arthur found out that Bruce tested positive for
COVID-19 and had died of complications for pneumonia. Arthur started to
become sad and withdrawn, insomniac and anorexic, frequently absent
from work, staying home listening to music in bed, wearing all-black
outfits. He was anxious he might get infected with the virus.

- One week PTA

- Arthur was suddenly in high spirits and seemed to be energetic. He would

work all day and night without rest. But he would suddenly drop projects
he was working on and complain that he was overwhelmed by stress. He
would isolate himself, talk to no one, can be heard crying loudly. He is
irritable and arrogant when people try to talk to him, where he insists he
knows what he’s doing. But he would be pathetic and pitiful the next
moment, saying that no one loved him and he would rather die.

- A few hours PTA

- During a client presentation, he presented video clips of Pink Panther and

laughing the whole time. He told everyone to avoid watching Roberto
Benigni’s “The Son of Pink Panther” because it was “a totally atrocious,
non-precious, hideous opus”.

- He suddenly burst into tears, saying that “Benigni never regained the
magnificence that he showed in “Life is Beautiful”
 - He got angry when his brother tried to pacify him and he started yelling
and throwing things around, which forced his brother and his co-workers
to forcibly bring him to the hospital.

- Pertinent Info

- No family history of mental illness.

- Occasional use of ecstasy.

- Physical Exam

- Unremarkable

- MSE

- General Appearance

- Young adult with fairly kempt and disheveled hair

- Wore pink long-sleeved shirt and pants

- Hostile, inattentive, very uncooperative

- Mood, Affect, Feelings

- Dysphoric

- Angry when he was told he was going to be confined

- Thought

- Shouted he was too good-looking to be hospitalized

- Judgment and insight

- Denied anything was wrong with him

11. What condition is the most likely cause of Arthur’s symptoms? -CESS
Bipolar Disorder
(Either Bipolar 1 or Substance-induced Bipolar)
The patient started to present with manic symptoms 1 week PTA, namely:
1.Inflated self-esteem or grandiosity
● suddenly showed up at work and seemed to be in very high spirits.
● told them he thought of a million brilliant ideas for all their ad campaigns *(not
sure if this is part of grandiosity or flight of ideas)
● thought he was the brightest and most brilliant the world will ever know.
2.Decreased need for sleep
● He would be working all day and night and felt he didn’t need to rest.
3.More talkative than usual ​or pressure to keep talking
● He chatted up everyone
4. Distractibility
 ● he would just drop projects he was working on and complain that he was
overwhelmed with stress. He would then isolate himself, refuse to talk to anyone,
and would be heard crying loudly.
5.Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation. -
● colleagues were impressed by the huge amount of stuff that he could accomplish

12. What is mania? Differentiate Bipolar I from Bipolar II. -CESS

Mania (From DSM-V)
A distinct period of abnormally and persistently ​elevated, expansive or irritable mood and
abnormally and persistently increased goal-directed activity or energy​, lasting ​at least 1
week and present most of the day​, nearly everyday (or any duration if hospitalization is
necessary.

During the period of mood disturbance and increased energy or activity, ​three (or more) of the
following symptoms ​(four if the mood is only irritable) are present to a significant degree
and represent a noticeable change from usual behavior:
1.Inflated self-esteem or grandiosity
2.Decreased need for sleep (e.g., feels rested after only 3
hours of sleep
3.More talkative than usual ​or pressure to keep talking
4.Flight of ideas or subjective experience that thoughts are
racing
5.Distractibility (i.e., attention too easily drawn to unimportant
or irrelevant external stimuli) as reported or observed.
6.Increase in goal-directed activity ​(either socially, at work or school, or sexually) or
psychomotor agitation (i.e.,
purposeless non-goal directed activity)
7.Excessive involvement in activities that have a high
potential for painful consequences (e.g, engaging in unrestrained buying sprees, sexual
indiscretions, or foolish business investments)
Mnemonics: ​“DIGFAST”
● Distractibility
● Indiscretion (risk-taking)
● Grandiosity
● Flight of ideas
● Activities (increased goal-directed activity),
● Sleep (decreased need for sleep)
● Talkativeness (increased)

Hypomanic episode - lasts at least 4 days and is similar to a manic episode except that it is
not sufficiently severe to cause impairment in social or occupational functioning, and no
psychotic features are present
 Bipolar I Bipolar II

● Criteria have been met for at least 1
manic episode
→ Can actually present with
subsequent hypomania and major
depressive disorder.
● It is not required to have a major
depressive disorder
● Criteria have been met at least 1
hypomanic episode and at least 1
major depressive episode
● There has never been a manic
episode

May occur in BOTH:

● Mixed feature
○ Episodes of bipolar mania, hypomania, and major depression can be
accompanied by symptoms of the opposite polarity, and are referred to as
mood episodes with mixed features (eg, major depression with mixed features
or hypomania with mixed features)
● Anxious distress
○ defined as the presence of at least 2 of the following symptoms :
■ Feeling keyed up or tense.
■ Feeling unusually restless.
■ Difficulty concentrating because of worry.
■ Fear that something awful may happen.
● Rapid cycling
○ Patients who experience at least four episodes during a 12-month period
● Psychotic features
○ Psychotic features such as delusions (false, fixed beliefs) and hallucinations
(false sensory perceptions) can occur during manic, major depressive, and
mixed episodes; disorganized thinking and behavior can occur as well.
○ By definition, psychosis does not occur in hypomania
● Catatonia
○ Spectrum of motor abnormalities from continuous gesticulation to catatonic
immobility
■ Maintain unusual postures for prolonged periods of time

13. What are the different kinds of Bipolar Disorders? MAU

● Bipolar I Disorder
○ Criteria have been met for at least 1 manic episode
○ It should not be attributable to other psychotic or schizophrenia disorder
○ It is not required to have a major depressive disorder
● Bipolar II Disorder
○ A milder form of Bipolar I Disorder because it only requires 1 hypomanic episode
○ It should be accompanied by a history of at least 1 major depressive episode.

14. Based on the history, PE and MSE findings, what are your differential diagnoses
for the case? Rule in and rule out your differential diagnoses based on DSM
Criteria. MAU

Rule in Rule out

For a diagnosis of bipolar I disorder, it is necessary to meet the following criteria
Bipolar
for a manic episode. The manic episode may have been preceded by and may be
disorder I followed by hypomanic or major depressive episodes.

Manic Episode Manic Episode

A. A distinct period of abnormally and persistently elevated, expansive, or irritable D. The episode is not attributable to
mood and abnormally and persistently increased goal-directed activity or energy, the physiological effects of a
lasting at least 1 week and present most of the day, nearly every day (or any substance (e.g., a drug of abuse, a
duration if hospitalization is necessary). - (refer to the paragraph of one week PTA medication, other treatment) or to
e.g. he suddenly showed up at work and seemed to be in very high spirits) another medical condition.
B. During the period of mood disturbance and increased energy and activity, three
(or more) of the following symptoms have persisted (four if the mood is only Patient mentioned that he uses
irritable), represent a noticeable change from usual behavior, and have been ecstasy but refused to elaborate on
present to a significant degree: it
1. Inflated self-esteem or grandiosity. - (he was the brightest and most brilliant the
world will ever know)
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). - he
would be working all day and night and felt he didn’t need to rest
3. More talkative than usual or pressure to keep talking. - He chatted up everyone
and told them he thought of a million brilliant ideas for all their ad campaigns
4. Flight of ideas or subjective experience that thoughts are racing. - thought of a
million brilliant ideas for all their ad campaigns
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant
external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually)
or psychomotor agitation. - colleagues were impressed by the huge amount of
stuff that he could accomplish
7. Excessive involvement in activities that have a high potential for painful
consequences
(e.g., engaging in unrestrained buying sprees, sexual indiscretions, or
foolish business investments)
C. The mood disturbance is sufficiently severe to cause marked impairment in
social or occupational functioning or to necessitate hospitalization to prevent harm
to self or others, or there are psychotic features. - hypomanic does not require
hospitalization. Started throwing things around.
D. The episode is not attributable to the physiological effects of a substance (e.g.,
a drug of abuse, a medication, other treatment) or to another medical condition.
Note: A full manic episode that emerges during antidepressant treatment (e.g.,
medication, electroconvulsive therapy) but persists at a fully syndromal level
beyond the physiological effect of that treatment is sufficient evidence for a manic
episode and, therefore, a bipolar I diagnosis.
Note: Criteria A-D constitute a manic episode. At least one lifetime manic episode
is required for the diagnosis of bipolar I disorder.

Hypomanic episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable
mood and abnormally and persistently increased activity or energy, lasting at least
4 consecutive days and present most of the day, nearly every day.
B. During the period of mood disturbance and increased energy and activity, three
(or more) of the following symptoms have persisted (four if the mood is only
irritable), represent a noticeable change from usual behavior, and have been Hypomanic Episode
present to a significant degree:
F. The episode is not attributable to
1. Inflated self-esteem or grandiosity.
the physiological effects of a
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
substance (e.g., a drug of abuse, a
3. More talkative than usual or pressure to keep talking.
medication or other treatment).
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant
external stimuli), as reported or obsen/ed.
 6. Increase in goal-directed activity (either socially, at work or school, or sexually)
or psychomotor agitation.
7. Excessive involvement in activities that have a high potential for painful
consequences (e.g., engaging in unrestrained buying sprees, sexual
indiscretions, or foolish business investments).
C. The episode is associated with an unequivocal change in functioning that is
uncharacteristic of the individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by
others.
E. The episode is not severe enough to cause marked impairment in social or
occupational functioning or to necessitate hospitalization. If there are psychotic
features, the episode is, by definition, manic.

Major Depressive Episode

A. Five (or more) of the following symptoms have been present during the same
2-week period and represent a change from previous functioning; at least one of
the symptoms
is either (1 ) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to a medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either Major Depressive Episode
subjective report (e.g., feels sad, empty, or hopeless) or observation made by C. The episode is not attributable to
others (e.g., appears tearful). (Note: In children and adolescents, can be irritable the physiological effects of a
mood.) - sad and withdrawn substance or another medical
2. Markedly diminished interest or pleasure in all, or almost all, activities most of condition.
the day, nearly every day (as indicated by either subjective account or
observation). - frequently absent from work, just staying home in bed listening to Patient only presented with 4
The Beatles songs, wearing an all-black Prada outfit. symptoms in 6 weeks PTA
3. Significant weight loss when not dieting or weight gain (e.g., a change of more
than 5% of body weight in a month), or decrease or increase in appetite nearly Symptoms 5, 7, and 8 only
everyday. (Note: In children, consider failure to make expected weight gain.) - presented 1 week PTA
anorexic
4. Insomnia or hypersomnia nearly every day. - insomniac
5. Psychomotor agitation or retardation nearly every day (observable by others;
not merely subjective feelings of restlessness or being slowed down). - irritable
and arrogant, crying loudly; kept laughing; burst into tears; yelling and throwing
things around Only presented few hours PTA
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be
delusional) nearly every day (not merely self-reproach or guilt about being sick). -
pathetic and pitiful Only presented 1week PTA
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day
(either by subjective account or as observed by others). - he would just drop
projects he was working on and complain that he was overwhelmed with stress
Only presented 1week PTA
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation
withouta specific plan, a suicide attempt, or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social,
occupational,or other important areas of functioning.

Bipolar I Disorder
A. Criteria have been met for at least one manic episode (Criteria A-D under
“Manic Episode” above).
B. The occurrence of the manic and major depressive episode(s) is not better
explained by schizoaffective disorder, schizophrenia, schizophreniform disorder,
delusional disorder, or other specified or unspecified schizophrenia spectrum and
other psychotic disorder.

For a diagnosis of bipolar II disorder, it is necessary to meet the following criteria B. There has never been a manic
Bipolar
for a current or past hypomanic episode and the following criteria for a current or episode.
Disorder II past major depressive episode:
A. Criteria have been met for at least one hypomanic episode (Criteria A-F under Patient does not present with MDD
“Hypomanic Episode” above) and at least one major depressive episode (Criteria - Patient only presented
A-C under “Major Depressive Episode” above). with 4 symptoms in 6
C. The occurrence of the hypomanie episode(s) and major depressive episode(s) weeks PTA
is not better explained by schizoaffective disorder, schizophrenia, - Symptoms 5, 7, and 8
schizophreniform disorder, delusional disorder, or other specified or unspecified only presented 1 week
schizophrenia spectrum and other psychotic disorder. PTA
 D. The symptoms of depression or the unpredictability caused by frequent
alternation between periods of depression and hypomania causes clinically
significant distress or impairment in social, occupational, or other important areas
of functioning.

A. A prominent and persistent disturbance in mood that predominates in the C. The disturbance is not better
Substance/M
clinical picture and is characterized by elevated, expansive, or irritable mood, with explained by a bipolar or related
edication-Ind or without depressed mood, or markedly diminished interest or pleasure in all, or disorder that is not
uced Bipolar almost all, activities. substance/medication-induced.
B. There is evidence from the history, physical examination, or laboratory findings Such evidence of an independent
of both bipolar or related disorder could
(1)and (2): include the following:
1. The symptoms in Criterion A developed during or soon after substance The symptoms precede the onset of
intoxication or withdrawal or after exposure to a medication. - can’t tell because the substance/medication use; the
we don't have the accurate history of drug use symptoms persist for a substantial
2. The involved substance/medication is capable of producing the symptoms in period of time (e.g., about 1 month)
Criterion A. after the cessation of acute
withdrawal or severe intoxication; or
E. The disturbance causes clinically significant distress or impairment in social, there is other evidence suggesting
occupational,or other important areas of functioning. the existence of an independent
non-substance/medication-induced
Note: bipolar and related disorder
A key exception to the diagnosis of substance/medication-induced bipolar and (e.g., a history of recurrent
related disorder is the case of hypomania or mania that occurs after non-substance/medication-related
antidepressant medication use or other treatments and persists beyond the episodes).
physiological effects of the medication. This condition is considered an indicator of
true bipolar disorder, not substance/medication-induced bipolar and related D. The disturbance does not occur
disorder. exclusively during the course of a
delirium.

15.What other diagnostic procedures would you like to request for to establish your
diagnosis?
Serum glucose, thyroid function test, liver function test, renal function test, ECG

16. What are the DSM-V diagnostic criteria for your patient?
For Bipolar I Disorder to be diagnosed, it is necessary to meet the following criteria for
manic episodes. It may be preceded by and may be followed by hypomanic or major depressive
episodes
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood
and abnormally and persistently increased goal-directed activity or energy, lasting at
least 1 week and present most of the day, nearly every day (or any duration if
hospitalization is necessary). - (refer to the paragraph of one week PTA e.g. he suddenly
showed up at work and seemed to be in very high spirits)

B. During the period of mood disturbance and increased energy and activity, three (or
more) of the following symptoms have persisted (four if the mood is only irritable),
represent a noticeable change from usual behavior, and have been present to a
significant degree:
1. Inflated self-esteem or grandiosity. - He was the brightest and most brilliant
the world will ever know
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). - he
would be working all day and night and felt he didn’t need to rest
 3. More talkative than usual or pressure to keep talking. - He chatted up
everyone and told them he thought of a million brilliant ideas for all their ad
campaigns
4. Flight of ideas or subjective experience that thoughts are racing. - Thought of a
million brilliant ideas for all their ad campaigns
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant
external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually)
or psychomotor agitation. - colleagues were impressed by the huge amount of
stuff that he could accomplish
7. Excessive involvement in activities that have a high potential for painful
consequences
(e.g., engaging in unrestrained buying sprees, sexual indiscretions, or
foolish business investments)

C. The mood disturbance is sufficiently severe to cause marked impairment in social or

occupational functioning or to necessitate hospitalization to prevent harm to self or
others, or there are psychotic features. - Hypomanic does not require hospitalization.
Started throwing things around.

D. The episode is not attributable to the physiological effects of a substance (e.g., a drug
of abuse, a medication, other treatment) or to another medical condition.

Note: A full manic episode that emerges during antidepressant treatment (e.g.,
medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the
physiological effect of that treatment is sufficient evidence for a manic episode and,
therefore, a bipolar I diagnosis.

Note: Criteria A-D constitute a manic episode. At least one lifetime manic episode is
required for the diagnosis of bipolar I disorder.

17. Explain the biological and psychosocial theories regarding the etiopathogenesis of
mood disorders.
BIOLOGICAL
1) Biogenic Amines
a) Inherited functional polymorphisms in the serotonin transporter genes
i) Decreased serotonin levels in depression assoc. In functional
dysregulation in the SERT gene
b) NE: downregulation and decreased sensitivity of beta adrenergic receptors in
depression
c) Dopamine: reduced in depression and increased in mania
d) Cholinergic agonists: exacerbate depressive sx and attenuate or reduce mania
e) GABA: decreased in depression
f) Elevated HPA activity in depression
 g) Increased TSH in depression
h) Decreased somatostatin in depression, and increased in mania
2) Genetic Family Studies
a) 1 parent w/ mood d/o suggests a 10-25% risk in their children
b) Both parents w/ mood d/o doubles the risk (20-50%)
c) Adoption studies: biological relatives of bipolar probands suggests a 3-fold
increase in the rate of bipolar and 2-fold increase in unipolar
d) Twin studies: Monozygotic vs Dizygotic there is 70-90% and 16-35%
concordance rate respectively in unipolar and bipolar d/o
e) Linkage studies: chromosome 18 and 22q strongest for bipolar d/o
PSYCHOSOCIAL
1. Life events and environmental stress: stressful life events more often precede the
1st episode of mood disorder
2. Psychodynamic factors in Mania
a. Defense against depression
b. (acc to abraham) Px. has the inability to tolerate developmental tragedy
c. Tyrannical superego -> intolerable self-criticism -> euphoric self-satisfaction
d. (acc. To bertram lewin) Ego is overwhelmed by pleasurable impulses (sex) or
feared impulses (aggression)
e. (Acc to Klein) Defense against depression -> omnipotence (delusions of
grandeur)
3. Psychodynamic themes in depression (Early trauma in the form of the ff. Can lead
to certain depressive d/o)
a. Losses: mau be parental death or separation (acc to Freud)
i. Early loss -> introjection -> ambivalent feelings
ii. Anger turned inwards
b. Abuse or neglect
i. (acc. To Bowlby) abuse or neglect -> insecure attachment -> negative
working models
ii. (acc. To beck) cognitive/negative triad: having negative views abt self,
environment/world, and future
c. Punitive child-rearing: over typical or high expectations of certain significant
caregivers (Bibring & Jacobson)

18. What does the term ‘unipolar’ and ‘bipolar’ mean?

Bipolar disorder is a condition in which people experience extensive mood swings such
as starting off being happy and then go quickly to becoming sad or depressed. It is equally
common in men and women between the ages of 15-25 with no exact reason for the cause of
this disorder, though it has been attributed to life changing situations, medications, lack of sleep
and recreational drug use.

Symptoms for bipolar disorder may last from minutes to days to months and include
● Easy distraction
 ● Feeling of sleeplessness
● Poor judgment
● Loss of temper
● Reckless behavior or lack of self control (drug use, dangerous behavior, reckless driving)
● Very elevated mood (hyperactive nature, increased energy)
● Very involved in activities
● Easily upset or agitate
● Loss of appetite
● Fatigue or lack of energy
● Difficulty concentrating
● Loss of pleasure in activities
● Low self-esteem
● Suicidal thoughts

A few treatments that have been proven effective in treating bipolar disorders are
parental anxiety management, hypnotherapy treatments, herbal treatments, caffeine elimination
and combined treatments

Unipolar disorder is a mental disorder that results in a patient having episodes of

low-mood, low self-esteem, loss of interest, loss of pleasure in enjoyable activities. Major
depressive disorder is an example of unipolar disorder.

Symptoms for the disorder include

● Change in eating and sleeping habits
● Changes in behavior
● Alternation in personal relationships
● State of low mood, loss of appetite, feelings of worthlessness
● Inappropriate guilt or regret
● Helplessness
● Hopelessness
● Self-hatred.

Severe cases can also include symptoms similar to psychosis such as delusions and
hallucinations. Unipolar depression is believed to be caused by a number of factors that affect a
person. It can include psychological, biological and social. Genetics is also known to play a part
in causing depression. Any sudden changes such as death of illness in the family could also
help trigger the disorder. Depression has also been closely linked to drugs and substance
abuse, as well as, withdrawal from drugs and substances.

Unipolar can be treated using antidepressants, behavioral therapy and cognitive therapy.
Therapy can also be used to prevent an onset of the disorder. Electroconvulsive therapy can
also be used when the patient does not respond to therapy or antidepressants.

19. Formulate your acute and long-term pharmacologic and non-pharmacologic

treatment plans for the patient. (Issa)

a. What are the therapeutic goals for this?

- Prioritize patient safety.
- A complete diagnostic evaluation must be done in order to rule out other possible
causes such as medical conditions or substance use which can present with similar
symptoms.
- Treatment plan must address the immediate symptoms and prospective well-being
b. When do you expect symptomatic improvement?
- The effects of mood stabilizers are usually seen after two weeks or more, however the
full effect of the medications happen at around 4-6 weeks.
c. How long should the treatment last?
- It depends on the case. Treatment should continue even though the patient feels okay.
d. Based on the ESSC (Efficacy, Safety, Cost, Suitability) criteria, choose the
most appropriate drug for this patient using your drug of choice.

DRUG EFFICACY SAFETY SUITABILITY COST

Olanzapine Serotonin dopamine Risk for metabolic Oral tablet, oral P99
antagonist (2nd syndrome disintegrating tablet,
generation short- and
antipsychotics) long-acting IM,
5-10mg OD

Lithium Gold standard for Adverse Effects: P39

Carbonate mania hypothyroidism,
pancreatitis

Valproic Acid Anticonvulsant AE: hepatic toxicity, Oral, 500mg daily

pancratitis for initial dose.
Slowly increase to
1000-2000mg daily.

Lamotrigine Bipolar depression AE: toxic epidermal

necrolysis, SJS

e. Write a complete prescription.

Arthur Odinson 25/M Jan 19, 2021

Manila

Rx

Lithium Carbonate 450 mg

Label: Take one tablet twice a day after meals.

 Atreus Kratos, MD
Manila
Lic no. 127343
PTR no. 4738294

f. Enumerate the different short-term structured forms of psychotherapy that can

be applied to this patient. What are the basic aims of each approach?

Short-Term Structured Forms of Basic Aims

Psychotherapy

Cognitive Therapy Follows a schedule with active collaboration

between patient and therapist dealing with
their current problems and resolution

Interpersonal Therapy Improves the quality of the patient’s

interpersonal relationships and social
functioning to help reduce their stress

Behavior Therapy Changing the behavior of the patients to

reduce dysfunction and improve quality of life

Psychoanalytically Oriented Therapy Involves bringing to the surface repressed

memories and feelings

Family Therapy Seeks to improve the function of the family as

a unit, or it subsystems, and the functioning
of individual members of the family

20. What are the epidemiological features, incidence and prevalence rates, and lifetime risk of
mania? What are the risk factors associated with this condition? (Vic)
Estimated lifetime global prevalence: 1-3%
Mean age of onset
● Bipolar I Disorder: 18 years old
● Bipolar II Disorder: 20 years old
Ratio of men to women 1:1
46th over 291 greatest causes of disability (ahead of breast cancer, Alzheimer’s, and other
dementias)
United States
● Lifetime prevalence
 ○ Bipolar I Disorder: 1%
○ Bipolar II Disorder: 1.1%
● Mean age of onset
○ Bipolar I Disorder: 18 years old
○ Bipolar II Disorder: 20 years old
● 18th leading cause of disability
○ Manic/Hypomanic episodes: psychosocial functioning severely impaired in ~70%
○ Major depression episodes: functioning severely impaired in ~90%

RISK FACTORS
1. Genetics
a. Lifetime Risk
i. First degree relative: 5-10%
ii. Monozygotic co-twin: 40-70%
b. CACNA1C gene
i. Encodes a subunit of a calcium channel
2. Advanced paternal age
a. 6x greater in fathers 45 years and older (in comparison to fathers 20-24 years
old)
3. Stressful life events
a. May be associated with the onset and/or a more severe course of illness of
bipolar disorder
b. e.g. childhood maltreatment, sexual abuse, emotional abuse
4. Substance abuse

21. What is the patient’s prognosis?

Poor prognosis factors: low socioeconomic status, exposure to negative events, and high
expressed-emotion (family environments marked by critical comments, hostility, and emotional
over-involvement)

It is a good sign that the patient quickly recovered to normal functioning after the treatment.
However, if the patient does not continue his maintenance medications, he is highly at risk for
recurrent episodes. Furthermore, if he continues to take ecstasy, even only occasionally, this
may trigger a manic episode in the future. It is also important to note that the pandemic is still
going on. If someone close to him is afflicted with COVID-19, this may trigger a depressive
episode, like what happened with Bruce.

22. What advice would you give the patient’s family?

● It is very important that the patient continue the pharmacotherapy as many who stop
maintenance medications will quickly relapse
● Patient may have major depressive episodes wherein he is at risk for suicide, it is
advised that someone stays with him especially during these times
● Patient’s family should be educated on the symptoms of mania and depression and
when to inform a physician.
● Patient’s family should ensure that the patient gets proper sleep as sleep deprivation can
trigger a manic episode
● They should be advised that the patient should avoid alcohol and illicit drugs (especially
ecstasy as the patient was taking it occasionally prior to the illness)
● Patient and their family could attend support groups to help with coping with the lifetime
illness