Test
your skills:
Distinguishing unipolar and bipolar disorders
in a
patient with depression and anxiety
How would you diagnose and treat this patient?
A 20-year-old single man experiences mood swings, anxiety, and
confusion. For more than a year, he has experienced unremitting
sadness and feels “dead inside” or “like a zombie.”
These sensations are relieved for periods lasting 3 to 4 days, when
he feels worried, ruminative, tired, irritable, and unable to “sort
out” his thoughts. He believes he is physically too small
and exercises frequently, and has a history of using supplements
to increase testosterone levels and promote muscle growth. After
breaking up with his girlfriend, he showed symptoms of “mini
stalking.”
The patient has no history of hospitalization or suicidal or homicidal
ideation. An only child, he suspects that his parents hid a birth
defect from him that is related to his current issues and difficulties.
The mother receives treatment for situational anxiety and depression
and a paternal aunt for panic disorder. Family history does not
include schizophrenia, bipolar disorder, or suicide.
The patient’s social and academic performance deteriorated
during his senior year in high school. He has no specific plans
for the future and works part-time at a fast-food restaurant.
Does the use of steroids and supplements mask the true condition?
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 (DHM). 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
within the context of personal and family history clues and suggest
treatment strategies that may improve outcomes for him.
- What is the likelihood of a mood disorder in this patient?
Despite the absence of clear manic symptoms, the cyclical nature
of symptoms, significant irritability, and “crowded”
thoughts suggest Bipolar II disorder.
- Given the patient’s symptoms and history, is it appropriate
to order an MRI of the brain along with psychological testing?
- How can the Mood Disorder Questionnaire (MDQ) be used as part of the evaluation of the patient? Would it be useful to ask family members to complete
the form and provide their observations about the patient?
- Could this patient have a body dysmorphic disorder as another Axis I condition?
- What might be the effect of the patient’s use of power
drinks to help with exercise and muscle building knowing that these products
contain stimulants?
- Could depression, irritability, and volatility have been instigated
by anabolic steroid use?
- Is it possible that this patient has a bipolar spectrum disorder
exacerbated by steroid use (TABLE)?
Practical pearls
- Psychological testing can yield answers about the potential
for psychotic thinking, especially under stress, and help determine
whether a Cluster A personality disorder exists
- Agitated depression in the late teens can often herald
the onset of bipolar disorder
- In a young adult, careful evaluation should help distinguish
the patient who shows characteristics of psychosis from one who
is experiencing bipolar-related mood and thought disorder
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