Test
your skills:
Diagnosis and management
of bipolar depression and
anxiety
How would you treat this patient?
A 26-year-old single woman referred for evaluation of severe mood
and anxiety symptoms exhibits somatic complaints of lethargy and
fatigue. She is disheveled, irritable, anxious, and depressed.
Her
stellar career performance with a national retail firm has deteriorated precipitously, with
characteristics that include agitation, disinterest in her appearance,
poor concentration, and neurologic and anxiety-related complaints.
Diagnosed with presumed conversion disorder and anxiety, she took
a leave of absence from work. She had been prescribed a regimen
of venlafaxine XR, 225 mg/d (for 12 weeks), clonazepam, 1 mg bid,
and bupropion SR, 300 mg/d (for 1 year). She has been referred for
reassessment of her condition.
Beginning in her teens, the patient
experienced several episodes of anxiety and depression and had symptoms
of obsessive-compulsive disorder (OCD). She did not experience euphoria
or any other typical symptoms of bipolar disorder. However, on further
questioning, she acknowledges feeling overstimulated and tremendously
irritable.
Her father had bipolar disorder and her mother had been
diagnosed with depression. A brother 2 years her senior was doing
quite well.
She exhibits paresthesias of her legs and feet. The results of the
laboratory workup show macrocytosis and B12 deficiency.
Would a
diagnosis of bipolar mixed disorder and OCD be appropriate for this
patient? For more information, go to Diagnosing
and Managing Psychotic and Mood Disorders, a CME activity
developed through the joint sponsorship of the University of Cincinnati
and Dowden Health Media. It was edited and peer reviewed by Annals
of Clinical Psychiatry and Current Psychiatry. This CME activity
is supported by an educational grant from AstraZeneca.
The expert faculty consists of Henry A. Nasrallah, MD, Donald W.
Black, MD, Joseph F. Goldberg, MD, David J. Muzina, MD, and Stephen
F. Pariser, MD.
Learn how these psychiatrists assess the patient’s symptoms
and personal and family clues and suggest treatment strategies that
may improve outcomes for this patient.
Key clinical concerns
- Was this patient’s history fully examined before a diagnosis
was made? What are the pitfalls of focusing on current symptoms without
sufficiently considering the patient’s past history and family
history?
- Many patients with Axis I disorders are mislabeled with personality
disorders. How can you guard against such misdiagnoses?
- How can clinicians communicate effectively to accurately characterize
symptoms, in this case those of irritability and overstimulation,
which suggested the bipolar spectrum?
- How can this patient be protected against mania? Cycle acceleration?
- What is the impact of work-related stressors?
- What represents an effective strategy for managing patients
with dual diagnoses, such as bipolar depression with comorbid
OCD?
- How can the medical regimen be simplified in a complex case
featuring depression, anxiety, and somatic complaints?
Practical pearls
- Patients with OCD may say that they have “racing
thoughts,” but they may be describing obsessional thinking.
- A diagnosis of conversion disorder made on the basis of
paresthesias and other somatic complaints is often unjustified because such symptoms can be due to anxiety disorder.
- The possibility of an organic basis should be considered.
- The effects of nutritional deficiencies should be considered;
in this case, B12 deficiency may have been a factor.
- The discontinuation syndrome may be more likely with some
agents than with others (TABLE).
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