your skills: Diagnosis and management of psychosis with bipolar
How would you treat this patient?
Mr S is 20-year-old single white college student experiencing
his second lifetime hospitalization for assessment of acute psychosis.
He has become increasingly isolated and does not attend class. Instead
of sleeping, he writes obscure essays and gambles on the Internet.
He believes that al-Qaeda has infiltrated the Internet and chosen
him as a military operative, sending messages from tree stumps.
He has previously been diagnosed with attention-deficit/hyperactivity
disorder (ADHD) and depression. Amphetamine/dextroamphetamine and
escitalopram were prescribed. Mr S discontinued the latter because
of weight gain and erectile dysfunction. An empty amphetamine bottle
was found in his room (a urine toxicology screen is positive for
The patient’s older brother was diagnosed with
bipolar disorder and completed suicide at age 28. His father’s
recurrent episodes of depression are treated with antidepressants.
His mother has panic disorder and is treated with selective serotonin
reuptake inhibitors (SSRIs) and benzodiazepines.
Misdiagnosis in bipolar disorder
Was the initial diagnosis of ADHD and depression correct? 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 this patient.
- Is Mr S one of the many individuals whose initial diagnosis
is incorrect? The National Depressive and Manic Depressive Association
2000 survey showed a nearly 70% misdiagnosis rate for patients
ultimately shown to have bipolar disorder. The average patient
with bipolar disorder sees at least 4 different physicians, and
one-third of these patients wait at least 10 years before receiving
a correct diagnosis.
- Could faulty diagnosis and inappropriate pharmacologic
intervention contribute to Mr S’s deterioration and symptom
exacerbation, complicating future management? In a patient with
mixed features, what strategies can help the clinician select
the most effective treatment regimen?
- Is it possible that antidepressant use may have induced
this patient’s mania? Individuals with a family history
of bipolar disorder have been shown to be particularly at risk of switching to hypomania, mania, mixed mania, or rapid-cycling mania.
- Could the presence of hypomania, characteristic of bipolar
II, have resulted in a misdiagnosis of ADHD?
- Did stimulant abuse contribute to psychotic symptoms?
- What may be the effects of weight gain on treatment adherence?
Do patients who stop medications because of weight gain admit
Additional questions considered by this panel of experts include:
- What additional laboratory tests should be performed, such as sleep studies?
- Should we help this patient lose weight?
- Should an EEG be conducted?
If weight gain occurs as a treatment-related side effect, it may
In such cases, it may be appropriate to evaluate metabolic profiles
and/or switch treatments (FIGURE).
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