The Manic Patient
A Patient-Centered, Evidence-Based
Diagnostic and Treatment Process
A Presentation for SOMC Medical Education
Kendall L. Stewart, MD, MBA, DFAPA
January 21, 2011
1My
aim is to offer practical insights you can put to use in your professional life.
let me know whether I have succeeded on your evaluation forms.
2Please
Why is this important?
• The lifetime risk of Bipolar
Disorder is 1 to 2-percent.
• The concordance rate is
– 65 to 85-percent in monozygotic
twins, and
– 20-percent in dizygotic twins.
• Bipolar illness occurs in
relatives with bipolar disorder
much more frequently.
• The peak age of onset is
between 20 and 25 years.1,2
• Mania responds better to
treatment than does depression.
• The prognosis depends on the
severity of the underlying
illness, the response to
treatment and the patient’s
compliance.
1A
• After listening to this
presentation, you will be
able to answer the following
questions:
– Why is this important?
– How do these patients
present?
– What are the diagnostic
criteria?
– What is the differential
diagnosis?
– What is the treatment?
– What are some of the
treatment challenges?
history of hypomania in the patient who presents with recurrent depression is easy to miss.
occurrence of a manic episode in older patients should raise concern about underlying organic
pathology.
2The
What specific diagnoses are included
here?
• Bipolar Disorders
•
•
•
•
Bipolar I Disorder
Bipolar II Disorder1
Cyclothymic Disorder
Bipolar Disorder NOS
• Mood Disorder due to General Medical
Condition (GMC)
• Substance-Induced Mood Disorder2
• Mood Disorder NOS
1Be
2I
sure to ask depressed patients and their families detailed questions about unrecognized hypomania.
once treated a college professor who became floridly manic after being dosed with steroids.
What is natural history of Bipolar I
Disorder?
10
8
6
4
2
Normal 0
Life
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
-2
-4
-6
-8
-10
Symptom Intensity Scale
Week 9
Week 10 Week 11 Week 12
What is natural history of Bipolar II
Disorder?
10
8
6
4
2
Normal 0
Life
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
-2
-4
-6
-8
-10
Symptom Intensity Scale
Week 9
Week 10 Week 11 Week 12
What is natural history of
Cyclothymic Disorder?
10
8
6
4
2
Normal 0
Life
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
-2
-4
-6
-8
-10
Symptom Intensity Scale
Week 9
Week 10 Week 11 Week 12
How do these patients present?
• A 27-year-old graduate student
was brought to the ED by his
fiancée.
• “He’s had a personality change in
the past two weeks.”
• “He’s been more irritable and
suspicious.”
• “He has not slept at all for the
past three nights.”
• “He is convinced that his research
thesis will become the ‘new bible
of the computer age.’”
• “Fearful that his ideas will be
stolen, he has created a
complicated secret code so that
‘only I and my prophets can
understand the text.’”
• “He’s been dressing in a bizarre
way to keep secret agents from
following him.”1,2,3
1These
• The patient initially refused to
speak with the physician, but
then the patient saw that a
syllable in the physician’s name
was the Latin word for “trust.”
• The patient then talked
incessantly and incoherently
about the project that would “rock
the world.”
• The patient was hoarse.
• He was easily distracted by the
ambient sounds in the ED.
• He was incensed that the
physician thought anything was
wrong.
• He only reluctantly agreed to
come into the hospital because his
fiancée was able to persuade him
that he would be safe there.
• Listen to a bipolar patient here.
people can be very persuasive.
of my patients was convinced that Crystal Gaye has stolen his country song.
3Sometimes truth is as strange as delusion. A patient said he had been working on an electric fence.
2One
What are the diagnostic criteria?
• A distinct period of expansive, elevated or irritable
mood
• Lasts at least one week or requires hospitalization
• Three or more of the following have been present to a
significant degree:
–
–
–
–
–
–
–
Inflated self-esteem
Decreased need for sleep
Increased talking
Racing ideas
Being more distractible
Increased psychomotor activity
Excessive involvement in pleasurable but risky
activities
• Not a mixed episode
• Significant impairment
• Not substance-induced.
1Manic
patients are a challenge to interview. Listen attentively for a time with emotional detachment.
Don’t argue. Watch for sudden irritability. Keep interviews short. Get the history from family members.
2Manic patients demand immediate attention. I was attending a hospital picnic in the Black Hills.
What associated features might you
see?
• Lack of insight
• Resistance to treatment
• Excessive, dramatic
writing
• Sexual
experimentation1
• Increased religiosity
• Increased spending
• Increased irritability or
hostility
• Physical aggression
1A
• Difficulties with the law
• Reports of heightened
senses
• Catatonia
• Abrupt shift in mood
• Depressive symptoms
• Mixed symptoms
• Rapid cycling2
• Inappropriate behavior
• Psychotic symptoms
number of my manic patients have declared themselves homosexual only to be puzzled by that later when in remission.
is coded when four or more mood episodes have occurred in the previous 12 months.
2This
What is the differential diagnosis?
• Normal elation
– Winning the lottery1,2
• Other mood disorders
– Bipolar II disorders
– Cyclothymic Disorder
– Bipolar Disorder NOS
• Mania secondary to a general medical
condition
– Multiple sclerosis
– Brain tumor
– Cushing’s syndrome
• Substance-induced mania
– Cocaine
• Grandiosity secondary to other psychiatric
disorders
– Schizophrenia
– Paranoia
1Losing
2I
can trigger a mood disorder too.
was making rounds in the ICU at Mercy Hospital years ago, and observed a sad staff member.
What is the treatment?
•
Mania
–
–
–
–
–
–
–
•
Begin antipsychotic drugs
Suicidal risk
–
–
–
•
Reassure the
Make sure the patient is safe.
Consider hospitalization.
Follow an evidence-based algorithm
for the treatment of bipolar disorder.
Consult a psychiatrist.
Begin lithium carbonate 300 mg
QID and titrate to therapeutic blood
level.2
Consider another mood stabilizer or
antipsychotic drug.
Psychosis
–
•
•
family.1
Conduct a careful risk assessment.
Document your assessment.
Take appropriate precautions.
Insomnia
–
1During
Consider the short-term use of your
favorite sleeper if the antipsychotic
drug does not do the trick.
Other comorbid disorders
–
–
•
Maladaptive attitudes and
behaviors
–
•
Diagnose and treat these conditions
vigorously.
Be careful about using
antidepressants since these may
trigger rapid cycling.
Counseling is not helpful during a
full-blown manic episode.
Education and self help
–
–
–
–
–
–
–
Provide educational resources.
Recommend a daily exercise
regimen.
Recommend a healthy diet.
Suggest healthy distractions.
Recommend meditation.
Recommend online resources with
caution.
Recommend self help groups with
caution.
a florid manic phase, these patients looks a lot sicker than they really are.
lithium is the only effective drug against suicide.
2Remember,
What are some of the treatment
challenges?
• These patients are notoriously non-compliant.1
• A trusting therapeutic relationship is your most effective
tool.2
• These patient will regularly convince you they are fine;
their families always know when they are getting manic,
and family members always turn out to be right.
• You only have a narrow window to start adjunctive antimanic medications.
• Many of these patients do not respond to lithium alone.
• You must follow lithium levels, TSH, BUN and
creatinine levels regularly.
• Untreated or inadequately-treated episodes result in
worsening over time.
• Relapses are harder to treat over time.
• Their episodes of depression are much more difficult to
treat.
• Consider quetiapine or a combination of olanzapine and
fluoxetine.
1A
family physician colleague made a house call and found all of the medications he had previously
prescribed.
2After many years of partial remission, a patient wanted to go off lithium and begin a herbal cure.
The Psychiatric Interview
A Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process
•
•
•
•
•
•
•
•
•
•
Introduce yourself using AIDET1.
Sit down.
Make me comfortable by asking some
routine demographic questions.
Ask me to list all of problems and
concerns.
Using my problem list as a guide, ask me
clarifying questions about my current
illness(es).
Using evidence-based diagnostic criteria,
make accurate preliminary diagnoses.
Ask about my past psychiatric history.
Ask about my family and social histories.
Clarify my pertinent medical history.
Perform an appropriate mental status
examination.
•
•
•
•
•
•
•
•
•
•
Review my laboratory data and other
available records.
Tell me what diagnoses you have
made.
Reassure me.
Outline your recommended treatment
plan while making sure that I
understand.
Repeatedly invite my clarifying
questions.
Be patient with me.
Provide me with the appropriate
educational resources.
Invite me to call you with any
additional questions I may have.
Make a follow up appointment.
Communicate with my other
physicians.
Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment.
Explain what is going to happen next. Thank your patients for the opportunity to serve them.
1
Where can you learn more?
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1,2Please
American Psychiatric Association, Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical
Psychiatry, Third Edition, 20081
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of
Neurology, April 20072
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry
Clerkship, Second Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and
Review, Twelfth Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the
Brain, January 2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving
at Home, Work and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000
note that you must master all of the information in a basic neurology textbook and a basic psychiatry
textbook to do well on the comprehensive, standardized final examination.
Where can you find evidence-based
information about mental disorders?
•
•
•
•
•
•
•
Explore the site maintained by the organization where evidence-based
medicine began at McMaster University here.
Sign up for the Medscape Best Evidence Newsletters in the specialties
of your choice here.
Subscribe to Evidence-Based Mental Health and search a database at
the National Registry of Evidence-Based Programs and Practices
maintained by the Substance Abuse and Mental Health Services
Administration here.
Explore a limited but useful database of mental health practices that have
been "blessed" as evidence-based by various academic, administrative and
advocacy groups collected by the Iowa Consortium for Mental Health here.
Download this presentation and related presentations and white papers at
www.KendallLStewartMD.com.
Learn more about Southern Ohio Medical Center and the job opportunities
there at www.SOMC.org.
Review the exceptional medical education training opportunities at Southern
Ohio Medical Center here.
How can you contact me?1
Kendall L. Stewart, M.D.
VPMA and Chief Medical Officer
Southern Ohio Medical Center
Chairman & CEO
The SOMC Medical Care Foundation, Inc.
1805 27th Street
Waller Building
Suite B01
Portsmouth, Ohio 45662
740.356.8153
StewartK@somc.org
KendallLStewartMD@yahoo.com
www.somc.org
www.KendallLStewartMD.com
1Speaking
and consultation fees benefit the SOMC Endowment Fund.
Are there other questions?
Terry Johnson, DO
OUCOM 1991
www.somc.org
Ryan Foor, DO
OUCOM 2005
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