COMPLEX CASE STUDY PRESENTATION

Endah Fomuki-Munde

COMPLEX CASE STUDY PRESENTATION

Subjective:

CC (chief complaint): ''I frequently feel like a bomb ready to explode"

BPI: K.G. is a 17-year-old African-American male accompanied to the clinic by his dad for a psychiatric evaluation. Dad reported that the patient began having symptoms over two years ago. Dad reported three manic episodes over the past year that lasted for over seven days each. The patient also reported that about two years ago, he had manic episodes that lasted 2-3 days but thought it was normal. He reported getting only 2-3 hours of sleep and sometimes went for over four days without getting any sleep. The patient reported spending most of his time at the gym when his energy level is up. During his manic episodes, he reported increased mood swings and being easily irritable, having anger problems, and engaging in risky activities like fighting. Dad added that K.G. was increasingly being hyper, and talkative, and calls himself General K.G. in the neighborhood. Dad reported that the patient had periods when he became both physically and verbally aggressive. Two weeks ago, dad reported that K.G. had two fights in his neighborhood. The patient reported that he lacks the trust of people. Dad reported that K.G. had been spending money even on things he doesn't need. The patient reported that he was depressed most of the time. Reported low energy, increased isolation, poor appetite, lack of motivation, decreased concentration, and worrying a lot about what people think about him. The patient reported that he had severe depression after his last three manic episodes. The patient denied the use of illicit drugs. He endorsed the use of cigarettes during his manic periods to calm him. He denied alcohol use. The patient denied currently taking any medications. He reported that going to the gym was

the only thing that helped him when his mood was elevated, and avoiding people improved his depressive symptoms.

Past Psychiatric History: Per dad, K.G's paternal grandmom and uncle had bipolar disorder. His mom was diagnosed with an Anxiety disorder at the age of 30.

Psychosocial History: K.G. is a 17-year-old African-American male who was born and raised in Houston by both parents. He is an only child. He is an 11th-grade student who goes to school and misses several days without going to school. He lives in a community that is very diverse in population and culture. K.G. refuses to attend church with his family and hangs around peers in his neighborhood. He enjoys biking and working out in the gym. He is planning to quit school after 12 grade to start his own business.

Substance Current Use: Smokes cigarettes during manic episodes to calm him. Denies use of unwanted substances or alcohol.

Medical History:

· Current Medications: No current medications.

· Allergies: No drug or food allergies.

· Reproductive Hx: Not married, never had a girlfriend, and has no children.

ROS:

· GENERAL: K.G. had no cough, fever, or weight gain.

· HEENT: K.G. had no hearing or vision loss. No eye, ear, or throat infection. No neck pain was reported.

· SKIN: No skin infections, bruises, or lesions.

· CARDIOVASCULAR: No unusual heart rhythm, palpitation, or edema on lower extremities.

· RESPIRATORY: No abnormal breathing, congestion, wheezing, coughing, sputum

production, or respiratory infections.

· GASTROINTESTINAL:No digestive or bowel problems and no blood m stool reported.

· GENITOURINARY: Urine change in urine color and no pain involved with urinating.

· NEUROLOGICAL: No reported seizures, dizziness, headaches, and no numbness, or tingling. K.G. had good body balance.

· MUSCULOSKELETAL: No fractures, broken bones, or muscle pain.

· HEMATOLOGIC: No anemia, bleeding disorder, or blood infections.

· LYMPHATICS: No enlargement of lymph nodes.

· ENDOCRINOLOGIC: K.G. has no night sweats, polydipsia, or polyuria.

Objective:

Vital signs: BPl 10/65, T 97.8. RR20, 02, 99%

Diagnostic results: Baseline labs CBC, CMP, TSH, T3, and T4, lipid panel, hepatic function, B12 level, and UA. (All within normal).

Assessment:

Mental Status Examination: The patient is a 17-year-old African-American male who looked his stated age. He was alert and oriented, casually dressed, and poorly groomed. He had minimal eye contact. His thought process was clear and coherent, talked rapidly and loudly. No looseness of association. No evidence of delusional thoughts, hallucinations, or disorganized behaviors. He appeared slightly distracted during the evaluation. His affect was dull and his mood depressed. He denied any thoughts or intent to hurt himself or others. His memory was intact but had little insight into the disease process.

Diagnostic Impression:

Main diagnosis, Bipolar I Disorder: Per the DSM-5 criteria, to diagnose an individual with this disorder, the manic episode must be preceded by a hypomanic or depressive episode. The manic episode must last for at least seven days characterized by persistently elevated mood, and goal directed activity. During the period of the elevated mood disturbance, the individual experiences increased energy level or activity. The individual presents any three of the following, grandiosity, decreased need for sleep, talkative, increased goal-gated activities, flight of ideas, distractibility, or engaging in risky activities (Bobo, 2017). The mood disturbance is severe enough to cause a disturbance in the individual's social, academic, or occupational functioning. The disturbance must not be associated with the use of substances, an underlying medical condition, or another mental disorder (Bobo, 2017). K.G. meets the full criteria for this diagnosis as he had three manic episodes within the past year lasting up to seven days each, he is hyper, talkative, aggressive during manic episodes, and engages in risky activities such as fighting. Also, his manic episodes are followed by episodes of depression with K.G. reporting feeling depressed, low energy, increased isolation, lack of motivation, decreased concentration, and loss of appetite. This makes Bipolar I disorder the primary diagnosis for my patient.

Deferential diagnosis:

Major depression: Per the DSM-5 and Van et al., (2022), individuals diagnosed with major depression must meet the following criteria, the individual must have at least five of the following symptoms within two weeks, depressed mood for most of the day and nearly everyday, diminished interest or pleasure in previously enjoyed activities nearly everyday, significant weight loss from poor appetite or significant weight gain from overeating, insomnia, fatigue, feeling worthless, decreased ability to concentrate, or recurrent thoughts of suicide/homicide ideation. The symptoms cause clinically significant distress to the individual's functionality in important areas, the disturbance is not associated with a medical problem, or the use of illicit substances (Van et al., 2022). G.K. presents with depressive symptoms, as seen in the history of his present illness. He is also easily irritable and agitated which could be confused with manic episodes. However, despite having longer depressive periods, the patient is more worried about his manic episodes which makes Bipolar I disorder his primary diagnosis.

Generalized Anxiety disorder(GAD): Per the DSM-5 and (Brown & Tung 2018), to diagnose an individual with this disorder, the individual must present with excess anxiety/worrying occurring more than 50% of the time for at least six months. The anxiety or worrying must not be associated with the use of illicit substances, a medical condition, or another mental disorder. The individual must present with a minimum of three of the following symptoms restlessness, fatigue, impaired concentration, irritability, muscle tension, and sleep disturbances. The disturbance must also cause significant distress to the individual's social, academic, occupational, or other important areas of functioning (Brown & Tung 2018). K.G. presents with at least three

symptoms of GAD which include sleep disturbances, fatigue, decreased concentration,

irritability, and worrying a lot about what people think about him. However, per the history of present history, these symptoms have not occurred most of the time, almost every day for at least six months thus making GAD my second differential diagnosis.

Borderline Personality Disorder (BPD): Per the DSM-5 and per Calvo et al., (2016), this disorder is a pattern of instability in interpersonal relationships, self-image, and affects, and is marked by impulsivity that usually begins from early adulthood. The individual expresses this behavior in five or more of the following context, imagined abandonment, a pattern of unstable and intense interpersonal relationships, marked identity or self-image disturbance, impulsivity in at least two areas that are self-damaging, recurrent suicidal thoughts/gestures, chronic feelings of emptiness, intense anger or difficulty managing anger, or stress-related paranoid ideation ((Calvo et al., 2016). K.G. presents with symptoms of Bipolar I that are easily confused for BPD, manic episodes are characterized by partly impulsive behaviors, irritability, and aggressiveness that are typical of patients with BPD. Manic episodes and BPD both have intense anger and difficulty managing emotions. However, K.G. manifest more symptoms of Bipolar I than BPD.

Reflections: K.G. presented with symptoms that apply to different mental health disorders that make it challenging to arrive at the actual diagnosis. If I were to conduct this evaluation all over again, I would examine the patient's socioeconomic conditions because children in lower socio economic areas are more prone to crimes, and use of illicit drugs at an earlier age which could be

contributing factors to K.G's symptoms. Also being an African-American, environmental factor such as peer pressure can contribute to violent behaviors. I will also dig deeper into the family history and social history of K.G. to find out contributing factors to his symptoms. I will use a widely used diagnostic tool such as the Mood Disorder Questionnaire which is a 15-item self-

report tool used for screemng patients most likely to have Bipolar disorder. This tool distinguishes Bipolar disorder from other disorders. I will also use the PHQ-9 to rule out major depression as the primary diagnosis. The patient was started on Depakote 250 mg daily. I would have started this patient on Lithium 150 mg twice daily. Lithium is not only an FDA recommended first-line medication for Bipolar I with manic episodes, but lithium also helps to treat depression and will benefit K.G. since he also has depressive symptoms. I will have K.G. start with one medication and follow up in two weeks for tolerance and effectiveness. Starting the patient on Lithium will also require a lab for lithium level, kidney function, and EKG. Lithium has a narrow therapeutic range (0.6-1.2) and must be monitored closely to prevent

toxicity.

Case Formulation.

K.G. is a minor and cannot make informed decisions for himself therefore his parents would have to be part of the treatment team. Also, other stakeholders such as a psychiatrist, and a psychotherapist would be part of the treatment team. The psychiatrist will help the patient with medication management, and the psychotherapist will educate the patient and family on identifying K.G.'s triggers and provide supportive coping skills to manage the symptoms. The parents will help the patient at home to reinforce medication compliance and the use of coping

skills as needed.

Treatment Plan:

K.G. was started on Depakote 250 mg daily at bedtime.

Lexapro 5 mg every morning for depressive symptoms.

K.G. will participate in psychotherapy twice a week for two months.

Questions

1. Which medications are best for managing Bipolar I in children and Adolescents?

2. Do you agree with my differential diagnoses? If yes why? and if not why?

3. Do you agree with my suggested choice of medication, starting the patient with lithium only and not Depakote and Lexapro? Why?

4. Some antipsychotic medications like Seroquel are frequently used to treat Bipolar in children. It stabilizes their thought process and can help K.G. sleep longer. Would you consider this medication a better first-line treatment for K.G.? Why or why not?

5. What other non-FDA-approved medications are used to treat Bipolar disorder?

6. Are there advantages of starting a patient with one medication over two or more medications? Why or why not?

References

American Psychiatric Association (2013), Diagnostic and statistical Manual of Mental Disorders (5th ed). Arlington, VA. Author. Doi:10.1176/appi. Books.9780890425596.dsmlS

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Bobo, W. V. (2017). The Diagnosis and Management of Bipolar I and II Disorders: Clinical Practice Update. Mayo Clinic Proceedings, 92(10), 1532-1551. https://doi.org/10.1016/j.mayocp.2017.06.022

Calvo, N., Valero, S., Saez-Francas, N., Gutierrez, F., Casas, M., & Ferrer, M. (2016). Borderline Personality Disorder and Personality Inventory for DSM-5 (PID-5): Dimensional personality assessment with DSM-5. Comprehensive Psychiatry, 70, 105-

111. https://doi.org/10.1016/j.comppsych.2016.07.002

Brown, T. A., & Tung, E. S. (2018). The Contribution of Worry Behaviors to the Diagnosis of Generalized Anxiety Disorder. Journal of Psychopathology & Behavioral

Assessment, 40(4), 636-644. https://doi.org/10.1007/s10862-018-9683-5

Van Loo, H. M., Aggen, S. H., & Kendler, K. S. (2022). The structure of the symptoms of major depression: Factor analysis of a lifetime worst episode of depressive symptoms in a large

general population sample. Journal of Affective Disorders, 307, 115-124. https://doi.org/10.1016/j.jad.2022.03.064

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