Psychiatry · Year 3 · from Psychiatry
Case 3: Bipolar Disorder with Mixed Features
Patient Demographics
- Age: 42 years old
- Sex: Male
- Occupation: High school math teacher
Chief Complaint
"I feel like I'm going to explode. I have all this energy but I want to die."
History of Present Illness
The patient presents to the emergency department with worsening symptoms over the past 3 weeks. He describes feeling "revved up" with racing thoughts, increased energy, and decreased need for sleep (4 hours per night). However, unlike previous hypomanic episodes where he felt good, he now feels intensely irritable, agitated, and profoundly hopeless. He reports constant suicidal thoughts, stating "I can't stop thinking about driving into oncoming traffic." He has been snapping at his students and received a reprimand from the principal. He feels worthless and guilty about being a "terrible teacher" while simultaneously feeling superior to his colleagues. He has been pacing at home, unable to sit still, but describes feeling "empty inside." He has a 20-year history of bipolar I disorder and has been on lithium with good stability for the past 5 years. He admits to taking his lithium inconsistently over the past 2 months due to increased urination and thirst.
Mental Status Examination
Appearance: Middle-aged man, appearing anxious and agitated, disheveled, picking at fingernails
Behavior: Psychomotor agitation (pacing, fidgeting), cannot sit still, wringing hands
Speech: Pressured, rapid, loud, but with dysphoric content
Mood: "Terrible. Agitated. Like I want to crawl out of my skin."
Affect: Irritable, dysphoric, labile (tearful then angry), tense
Thought Process: Flight of ideas, tangential, jumps between topics
Thought Content:
- Active suicidal ideation with plan (driving into traffic)
- Hopelessness, worthlessness
- Excessive guilt about teaching performance
- Contradictory grandiose statements about being smarter than colleagues
- No homicidal ideation
- No delusions or paranoia
Perceptions: No hallucinations
Cognition: Alert, oriented x4, distractible, racing thoughts interfere with concentration
Insight: Fair - recognizes he is unwell and needs help
Judgment: Impaired - suicidal ideation with plan
Psychiatric Workup
Screening Tools:
- YMRS: 28 (severe)
- PHQ-9: 24 (severe depression)
- Columbia Suicide Severity Rating Scale: Positive for active suicidal ideation with plan
Laboratory Studies:
- Lithium level: 0.3 mEq/L (subtherapeutic; therapeutic range 0.6-1.2)
- TSH: 4.8 mIU/L (slightly elevated)
- Creatinine: 1.2 mg/dL (at upper limit)
- Urine drug screen: Negative
- CBC: Normal
Diagnosis
Bipolar I Disorder, Current Episode Manic with Mixed Features (F31.2)
DSM-5 Criteria:
- Meets full criteria for manic episode (elevated energy, decreased sleep, pressured speech, flight of ideas, psychomotor agitation, >1 week duration)
- With mixed features specifier (meets 3+ of the following depressive symptoms during the manic episode):
- Depressed mood - present
- Diminished interest - present (not enjoying anything)
- Psychomotor retardation - not present (has agitation)
- Fatigue - not prominent
- Worthlessness/guilt - present
- Suicidal ideation - present
High Suicide Risk:
- Mixed features carry highest suicide risk in bipolar disorder
- Active ideation with plan
- Impulsivity from manic symptoms + hopelessness from depressive symptoms
Treatment Plan
Immediate Management:
- Voluntary psychiatric admission (patient agrees)
- 1:1 observation for suicidal ideation
- Safety precautions (remove sharps, belt, shoelaces)
Pharmacotherapy:
- Resume lithium 600 mg BID with goal serum level 0.8-1.0 mEq/L
- Add valproate 500 mg BID (more effective for mixed states than lithium alone)
- Target valproate level 80-120 mcg/mL
- Add olanzapine 10 mg QHS for acute mood stabilization and sleep
- Avoid antidepressants (can worsen mixed state/cycling)
Monitoring:
- Daily lithium level until stable
- Valproate level at day 5
- CBC, LFTs for valproate
- Monitor TSH (lithium-related thyroid dysfunction)
- Renal function monitoring
Safety Planning:
- Detailed safety plan developed
- Restriction of driving upon discharge
- Means restriction (firearms if any, medications locked)
- Family involvement in safety monitoring
Psychoeducation:
- Critical importance of medication adherence
- Mixed states and suicide risk
- Early warning signs
- Coping strategies for lithium side effects (polyuria management)
Follow-up:
- Intensive outpatient or partial hospitalization upon discharge
- Weekly psychiatry visits initially
- Therapy referral (CBT for bipolar disorder)