# Clinical Cases: Bipolar Disorder ## 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):** - **D**istractibility - present - **I**nsomnia (decreased need for sleep) - present (1-2 hrs/night without fatigue) - **G**randiosity - present (delusions of exceptional abilities) - **F**light of ideas - present - **A**ctivities increased (goal-directed or psychomotor agitation) - present - **S**peech pressured - present - **T**aking 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 --- ## Case 2: Bipolar II Disorder - Hypomanic Episode ### Patient Demographics - **Age:** 35 years old - **Sex:** Female - **Occupation:** Marketing executive ### Chief Complaint "My husband thinks I need help, but I feel better than I have in years." ### History of Present Illness The patient presents with her husband who has become concerned about changes in her behavior over the past 2 weeks. She has been waking at 4 AM (usually wakes at 7 AM) feeling energized and has been going for early morning runs before work. She has taken on several new projects at work and is working 12-14 hour days, which she describes as "finally living up to my potential." She has been more talkative and social, reconnecting with old friends and planning multiple social events. She reports feeling more confident and attractive. Her husband notes she has been more interested in sex than usual. She has started three new hobbies in the past week (pottery, learning Italian, and training for a triathlon). She is sleeping about 5 hours per night but feels rested. She denies any impulsive spending or risky behavior. She is not missing work and her performance has, if anything, improved. She has a history of three depressive episodes over the past 10 years, each lasting several months and treated with various antidepressants with partial response. ### Mental Status Examination **Appearance:** Well-dressed professional woman, impeccable grooming, stylish attire, appears energetic **Behavior:** Animated, enthusiastic, slightly restless, good eye contact **Speech:** Increased rate but interruptible, normal volume, coherent **Mood:** "Great! Optimistic!" **Affect:** Elevated, bright, full range, reactive **Thought Process:** Somewhat circumstantial but ultimately goal-directed, occasionally tangential **Thought Content:** Optimistic plans, no grandiose delusions, no paranoia, no suicidal or homicidal ideation **Perceptions:** No hallucinations **Cognition:** Alert, oriented, attention intact though slightly distractible, good concentration **Insight:** Partial - acknowledges change in energy but views it positively **Judgment:** Largely intact - no dangerous behavior, maintaining work/relationships ### Psychiatric Workup **Screening Tools:** - PHQ-9: 2 (minimal depression) - MDQ: Positive - YMRS: 14 (hypomania range; <12 is normal, 12-20 is hypomania) - HCL-32 (Hypomania Checklist): 20 (positive screen) **Laboratory Studies:** - TSH: 1.7 mIU/L (normal) - CBC, CMP: Normal ### Diagnosis **Bipolar II Disorder, Current Episode Hypomanic (F31.0)** **DSM-5 Criteria for Hypomanic Episode:** - Distinct period of abnormally elevated/expansive mood lasting at least 4 consecutive days (2 weeks in this case) - Three or more of the following: - Inflated self-esteem (present - feels more confident) - Decreased need for sleep (present - 5 hours) - More talkative (present) - Flight of ideas/racing thoughts (mild) - Distractibility (mild) - Increased goal-directed activity (present - multiple projects, hobbies) - Excessive involvement in risky activities (not present) - Episode associated with unequivocal change in functioning observable by others (husband) - Episode NOT severe enough to cause marked impairment or require hospitalization - NOT attributable to substance or medical condition **Bipolar II requires:** - At least one hypomanic episode AND - At least one major depressive episode (patient has history of 3) - No history of manic episode ### Treatment Plan **Discussion of Diagnosis:** - Explain difference between Bipolar I (mania) and Bipolar II (hypomania + depression) - Emphasize that hypomania can feel positive but is a symptom requiring treatment - Discuss risk of depressive episodes and cycling without treatment **Pharmacotherapy:** - Start lamotrigine 25 mg daily for 2 weeks - Increase to 50 mg daily for weeks 3-4 - Titrate to target dose of 200 mg daily (slow titration required to minimize Stevens-Johnson syndrome risk) - Lamotrigine is particularly effective for bipolar depression prevention - Consider adding low-dose quetiapine (50-100 mg) if sleep remains reduced **Taper/Discontinue Previous Antidepressants:** - If currently on antidepressant, taper slowly (antidepressants can trigger hypomania/mania in bipolar disorder) **Psychotherapy:** - Refer for psychoeducation-focused therapy - Interpersonal and Social Rhythm Therapy (IPSRT) particularly helpful for bipolar II - Focus on maintaining regular sleep-wake cycles **Lifestyle Interventions:** - Emphasize importance of regular sleep schedule (7-8 hours) - Limit new commitments during hypomanic periods - Develop early warning sign checklist with partner **Monitoring:** - Mood charting daily - Follow-up in 2 weeks - Watch for switch to depression as hypomania resolves --- ## 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)