Psychiatry · Year 3 · from Psychiatry
Case 1: Bipolar I Disorder - Acute Manic Episode
Patient Demographics
- Age: 24 years old
- Sex: Male
- Occupation: Graduate student in philosophy
Chief Complaint
Brought by parents: "He hasn't slept in 5 days and spent $15,000 on 'investments' with his student loan money."
History of Present Illness
The patient is brought to the emergency department by his concerned parents. Over the past 10 days, he has become progressively more energetic, talkative, and grandiose. He has been sleeping only 1-2 hours per night but claims to feel "more alive than ever." He has been working on multiple "groundbreaking" philosophy papers simultaneously, convinced he has discovered insights that will "revolutionize human understanding." He enrolled in an online cryptocurrency trading platform and invested $15,000 of his student loan disbursement, believing he has a "foolproof system." He has been posting lengthy philosophical treatises on social media at all hours and making numerous phone calls to professors, publishers, and media outlets to discuss his "world-changing ideas." His speech is rapid and difficult to interrupt. He reports increased libido and admits to multiple casual sexual encounters in the past week, which is out of character. He denies drug use but admits to drinking more coffee than usual. He denies hallucinations. He is annoyed that his parents brought him in, stating "I've never felt better in my life."
Past Psychiatric History: One previous depressive episode at age 21 treated briefly with sertraline (stopped after 3 weeks stating he "didn't need it")
Mental Status Examination
Appearance: Young man, appears stated age, dressed flamboyantly (bright colors, multiple accessories), well-groomed but disheveled from lack of sleep
Behavior: Restless, pacing, difficulty staying seated, gesturing dramatically, invading examiner's personal space
Speech: Pressured, rapid, loud, difficult to interrupt, tangential, uses elaborate vocabulary
Mood: "Fantastic!" "On top of the world!"
Affect: Euphoric, expansive, irritable when challenged, labile (laughing then quickly becoming angry)
Thought Process: Flight of ideas, tangential, difficult to follow, loose associations at times
Thought Content:
- Grandiose delusions: Believes he is the "next great philosopher," destined for Nobel Prize
- No paranoid ideation
- Denies suicidal or homicidal ideation
Perceptions: Denies auditory or visual hallucinations
Cognition: Alert, oriented x4, attention impaired (highly distractible), unable to complete cognitive testing due to inability to focus
Insight: Poor - does not believe he is ill, believes parents are overreacting
Judgment: Poor - excessive spending, risky sexual behavior, not sleeping
Psychiatric Workup
Screening Tools:
- Young Mania Rating Scale (YMRS): 42 (severe mania; >20 indicates mania)
- MDQ (Mood Disorder Questionnaire): Positive screening
- AUDIT: 2 (low risk)
- Drug use screening: Denies
Laboratory Studies:
- Urine drug screen: Negative
- TSH: 1.9 mIU/L (normal)
- CBC: Normal
- CMP: Normal
- Blood alcohol: 0
Diagnosis
Bipolar I Disorder, Current Episode Manic, Severe with Mood-Congruent Psychotic Features (F31.2)
DSM-5 Criteria for Manic Episode (DIGFAST mnemonic):
- Distractibility - present
- Insomnia (decreased need for sleep) - present (1-2 hrs/night without fatigue)
- Grandiosity - present (delusions of exceptional abilities)
- Flight of ideas - present
- Activities increased (goal-directed or psychomotor agitation) - present
- Speech pressured - present
- Taking risks (pleasurable activities with painful consequences) - present (spending, sexual behavior)
7/7 criteria present, duration >1 week (10 days), marked impairment requiring hospitalization
Treatment Plan
Acute Management:
- Involuntary psychiatric admission (patient refuses voluntary admission; meets criteria for danger to self due to poor judgment and potential for financial ruin/risky behavior)
- Start lithium 600 mg BID (target serum level 0.8-1.2 mEq/L for acute mania)
- Add olanzapine 10 mg QHS for acute symptom control and sleep
- PRN lorazepam 2 mg for agitation
Monitoring:
- Lithium level at day 5, then weekly
- TSH, creatinine at baseline and periodically
- Monitor for EPS with olanzapine
- Metabolic monitoring (glucose, lipids)
Additional Interventions:
- Low-stimulation environment
- Structured daily schedule
- Sleep hygiene (darkened room, limited caffeine)
- Restrict access to phone/internet/credit cards with family assistance
Psychoeducation:
- Family meeting to discuss diagnosis, treatment, prognosis
- Importance of medication adherence
- Early warning signs of relapse
- Risks of substance use, sleep deprivation
Financial/Legal:
- Social work consultation for financial damage control
- Consider involving university student services
Follow-up:
- Daily evaluation during inpatient stay
- Outpatient follow-up within 1 week of discharge
- Mood charting recommended