![]() ![]() He became more impulsive, and buying things was the tip of the iceberg. ![]() During that week, he was spacing, had pressured speech, and was talking fast to the point that others around him commented about it. Thus, my first step would be to explain that this patient had at least a week without sleep. That’s bipolar disorder but not bipolar I maybe it’s bipolar II.” In the current case presentation, I can see many of my colleagues saying, “Hey, you’re not giving us enough symptoms of mania. Assuming the patient did not end up in the hospital or in prison, we want to verify the story of mania. Now, the DSM-5 criteria tell us that mania that leads to hospitalization or some negative consequence like incarceration is problematic no matter what the duration is. They feel that this is the way it should be, so they don’t point it out as pathological. When people experience mania, they have excessive energy and excessive activation that creates the need for sleep, and sometimes they like it. Typically, the part of the history that’s hardest to nail down is mania. But in the case of bipolar disorder without psychosis, you expect the patient to be able to give you a solid history. You want to start by making up your own mind, and sometimes the patient is not a good source of information. I think the most important thing to do when somebody comes to you, even if they tell you they have a diagnosis, is to confirm the diagnosis. His TSH level was in the middle of the normal range, and he had no suicidal ideations or psychotic symptoms. He did not have a substance use disorder, which was confirmed by a negative toxicology screen. At the time of presentation, the patient was adhering to the medications. The quetiapine was then augmented with lamotrigine, which was titrated up to 300 mg per day but demonstrated no efficacy. Despite these adverse effects, he continued taking] quetiapine until he decompensated into his third depressive episode. The patient reported sleeplessness and made unnecessary online purchases when unable to sleep, but the quetiapine sleepiness was unacceptable. However, weight gain again became an adverse effect, and he also complained of sedation. He was then cross-titrated to quetiapine, which improved his manic symptoms. During his third manic episode, he started on olanzapine but experienced excessive weight gain. He was switched to valproate however, valproate lacked the efficacy of lithium and caused adverse effects of sedation and weight gain. His lithium level at the time was in the therapeutic range of 0.8 mEq/L. He was treated with lithium, which was highly effective, but he experienced excessive thirst and developed hyperthyroidism. He had his first episode of mania at the age of 20 and 2 subsequent episodes of mania between the ages of 21 and 29. He received a diagnosis of bipolar I disorder about 10 years ago. ![]() A 30-year-old man has taken short-term disability leave from work due to the progression of a depressive episode. Nidal Moukaddam, MD, PhD: Today, we’re going to talk about a new case. ![]()
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