Ms. A, aged 20 years, arrived at the hospital with commitment papers from her college counseling services. She had become disruptive in class and was exhibiting psychotic behavior but was unwilling to be hospitalized. After evaluation by both school counseling services and the mobile crises unit, she was committed and transferred to adult psychiatric services.

History of present illness included cocaine use (330 mg in one sitting) three weeks ago followed by an inability to sleep for five days. During that time, Ms. A filled 125 notebook pages with writing. Approximately one week ago, she attempted to get help for her insomnia by going to the emergency department (ED). The ED staff administered an ECG. After an eight-hour wait (during which time she reportedly used meditation to remain calm), she left against medical advice. Ms. A described her current energy level and mood as “great.” 

1. Workup

During the physical and mental examinations, Ms. A assumed various yoga poses and meditated numerous times “to calm down.” Her pulse was 108 beats per minute, temperature 97.3 °F, respiratory rate 18 breaths per minute, and BP 131/77 mm Hg. She was pleasant and maintained good eye contact, and her appearance seemed consistent with her stated age. Although noticeably thin and restless, she did not seem to be in acute distress. Her physical exam was unremarkable except for dilated pupils, which she claimed were not out of the ordinary for her.

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A mental status exam revealed an appropriately dressed woman who was slightly agitated and tense. She exhibited animated behavior, and her speech was rapid, loud, and pressured. Ms. A appeared irritable and classified her mood as “pissed.” She had a labile affect and admitted to having auditory and visual hallucinations when meditating. Her thought process was tangential with loose associations, and her thought content was grandiose. The patient’s memory was intact, and she was of high-average intelligence with poor judgment and insight. She reported having suicidal thoughts without plan, but she had no homicidal thoughts, delusions, or paranoia. Ms. A admitted to smoking cigarettes and marijuana (daily), occasional alcohol use, and the recent experiment with cocaine. She had no allergies and was not taking any medications. During the past three weeks, she had been seen eight times as an outpatient by her college’s counseling services; she had no history of psychiatric hospitalization. Ms. A claimed that she did not feel ill and reported no past medical history. Family history was significant on her mother’s side for schizophrenia and suicide.

2. Laboratory results

Complete metabolic profile, gamma-glutamyltransferase, fasting lipids, complete blood count, and thyroid-stimulating hormone were all within normal limits. A urine drug screen was positive for marijuana.

3. Hospital course

Ms. A was admitted and started on oral medications, including quetiapine (Seroquel) 100 mg nightly, thiamine 100 mg daily for seven days, lorazepam (Ativan) 1 mg t.i.d., and divalproex sodium (Depakote) 500 mg b.i.d. Medications prescribed for agitation were haloperidol (Haldol) 5 mg IM or p.o. every four hours, Ativan 2 mg IM or p.o. every four hours, and diphenhydramine (Benadryl) 25 mg IM or p.o. every four hours, all to be given on an as-needed basis.

The patient’s diagnoses at admission were bipolar affective disorder (BPAD) type 1, marijuana dependence, nicotine dependence, and rule out cocaine abuse. Her Global Assessment of Functioning score was 20 (danger to self and others, minimal hygiene, and incoherent). Ms. A was placed on a regular diet and allowed to participate in group activities (but not away from the unit). She was observed for 24 hours to make sure she was not an elopement risk or a risk to others.

Upon further assessment, Ms. A was asked about activities she pursued in her free time. She stated that she enjoyed music, reading, and being with friends. When asked about skills, she replied that she was good at everything. A question about her family evoked the response that this relationship had not been good for years but had improved a great deal over the past six days. Asked what made her angry, the patient responded, “When people tell me how to live my life.” To a question about how the staff could tell if she was angry, Ms. A said she might punch a wall to let off steam. She claimed that meditation calmed her down.

During an interview with Ms. A’s family members, they revealed that she had exhibited periods of sleeplessness, expansive thinking, emotional lability, and erratic behavior for the past three years. On the day of admission, the patient maintained that she did not need medication, and she was placed on a forced medication protocol. She did not see any negative consequences to her manic state and continued to say that she felt “great.” Five days later, Ms. A still had no insight into her disorder, but her sleep cycle had been restored and she was sleeping six to seven hours at night. However, her mania was still uncontrolled. While awaiting a hearing to see if the commitment papers could be closed, the patient combed her hair incessantly and was in denial about her current state of health. The commitment papers remained open.

4. Analysis

BPAD presents in different forms: Type 1 is characterized by depression and manic episodes, and type 2 features depression with hypomania. Signs of mania include heightened mood (either euphoric or irritable), flight of ideas, pressured speech, increased energy, decreased need for sleep, and hyperactivity. From time of diagnosis (typically after hospitalization), it takes many months before a patient will gain insight into the negative consequences of the disorder. Patients frequently discontinue their medication and become severely depressed (often with suicidality or mania). Alcohol and drugs are commonly used to control racing thoughts. Patients who present in a manic state may appear to be in the early stages of schizophrenia. Leave the patient undisturbed and observe what happens. Patients with paranoid schizophrenia often sit quietly, calmly waiting for the next incident, whereas patients with mania continue their hyperactivity and pressured speech. Individuals with schizophrenia are self-involved and have little contact with those around them.

5. Treatment

Ms. A’s commitment papers were closed after a one-week hospital stay spent under observation. The patient no longer exhibited signs of mania and was discharged on Seroquel 100 mg at night and Depakote 500 mg twice daily. The advantage of Depakote over lithium (also used in the treatment of BPAD) is the rapidity with which it becomes effective when a “loading” strategy is used. Patients often respond to Depakote in a matter of days, compared with the week or two required by lithium. Cognitive behavior therapy used in conjunction with preventive pharmacologic treatment has been shown to reduce the frequency of breakthrough episodes of mania.

The court ordered outpatient treatment and therapy focused on helping Ms. A gain insight into the negative effects of her manic behavior. Her family was instructed to look for signs of mania and remove any means with which she might harm herself. She was discouraged from drinking alcohol, smoking cigarettes, and using illegal drugs and encouraged to continue yoga and exercise. Support was provided in the form of a medical excuse for missing school to assure continued academic success.

Ms. Donato is an instructor at the Medical University of South Carolina College of Nursing in Charleston.

Read on

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