Bipolar Disorder

Question 1

“A 35 year old businessman is brought to you by his wife as his work colleagues have been concerned that he has become increasingly irritable, demanding, talkative and is starting new schemes and investments which they consider unwise. He does not think that he needs to see you. Discuss how you would manage this clinical situation.
2020 stem: Woman voluntarily comes into ED with partner following intentional quetiapine overdose following an argument with her partner. Works as a makeup artist. Differentials. Formulate and manage.”

Answer 1

Impression
Given irritability and concerns of financial indiscretions as well as lack of insight, concerned about a manic episode as a part of Bipolar 1 disorder. Mania is considered a medical emergency and requires acute assessment and management

DDx to consider:
Mood
- Bipolar 2
- anxiety disorder
Non-affective
- First presentation psychosis
- schizophrenia/schizoaffective
- other psychotic (brief psychotic, schizophreniform)
Other
- withdrawal
- medication interaction
- drug-induced pyschosos

Priorities:

• conduct full assessment, characterise risk profile for patient
• institute appropriate acute and long-term patient management

Question 2

Bipolar Disorder - Assessment

Answer 2

Assessment

• Mania is medical emergency
• Would make considerations for personal, staff, and patient safety, ensure appropriate location secured for beginning full psychiatric assessment

History

• PC: DIG FAST (distractibility, indiscretions, grandiosity,, flight of ideas, etc)
• HPI: precipitating factors (stress, medications, physical illnesses, drug use)
• Past psych history
• substances
• rest of psych history
• collateral history as required/appropriate

Exam:
- MSE

Investigations
- would order full set of bloods and other investigations to rule out potential organic causes of the presentation (including acute intoxication/withdrawal)

Question 3

Bipolar Disorder - Management

Answer 3

Management
Short-term
1) Safety and location
- schedule
- move to quiet room/area of ward
- close observation/monitoring

2) Pharmacological
- start anti-psychotic (olanzapine, respiradone) immediately to alleviate sx of mania (only use short term and cease once mania resolved)
- start mood stabilise (lithium, sodium valproate, carbamazepine)
- consider treating acute agitation with benzodiazepine (diazepam, clonazepam)
- other supportive medications and monitoring

3) Non-pharmacological
- therapeutic alliance and rapport
- psychotherapy (e.g. CBT) on out-patients basis
- consider ECT for sx non-responsive to pharmacological treatment
- may require tribunal hearing for CTO for ongoing treatment plan arrangements

4) social/cultural
- legal issues
- employment
- co-morbid conditions