Psychosis with bipolar mania

Test your skills: Management of treatment-resistant psychosis and schizophrenia

How would you treat this patient?

Mr M is 54 years old, divorced, has a history of chronic schizophrenia, and presents to the emergency department unkempt, agitated, paranoid, and combative. He claims that his mother plans to kill him and that, as a child, she seduced him.

He has experienced psychotic symptoms since age 17. Although he completed college, he has not maintained employment. In recent years, and with increasing frequency, he has been hospitalized and has ongoing problems with treatment adherence. He lives alone and receives financial support from his parents, who also help him with household tasks and monitor his behavior. There is no family history of mental illness.

He receives depot administration of haloperidol decanoate 100 mg/mo, divalproex 1200 mg/d, and risperidone intramuscular injection 25 mg every other week. Ten days prior to this admission, he refused his injections. His main adverse effect is pseudoparkinsonism, which causes him to demand reduction in medications. Other side effects include tardive dyskinesia and erectile dysfunction.

Is prior diagnosis of schizophrenia accurate?

This patient’s disease course has spanned 37 years, during which he has experienced occasional symptoms of depression and suicidal ideation. Antidepressants, however, did not provide consistent improvement. Could this patient be experiencing severe psychotic bipolar disorder?

For more information, to go 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 and history, as well as issues related to noncompliance and a future likelihood of decreased social support as his parents age.

Key Clinical Concerns

What are the diagnostic implications of the patient’s level of functioning given the early onset of his illness?
What might the presence of symptoms such as depression and suicidal ideation suggest?
Should new or additional diagnostic tests be performed?
Are episodic depressive symptoms accurately reflected in his diagnosis?
Does careful patient evaluation show evidence of manic traits?

Practical pearls

Systematic effects of symptoms may be side effects of pharmacologic agents.
Erectile dysfunction may be related to increased serum prolactin associated with some dopamine-receptor blocking agents.
Tardive dyskinesia may stem from chronically blocked D2 receptors; other neuroreceptors are associated with side effects ranging from orthostatic hypotension to urinary retention, to weight gain.
Psychosocial planning may require that treatment goals change over time and may be based on such practical needs as patient and caregiver safety.