Yasir Hameed (ST4 Dual Training)
Jaap Hamelijnck (consultant psychiatrist)
Eastern Recovery Team
Northgate Hospital
12 Nov...
Overview
 Why we chose this case?
 Clinical details
 Congenital Adrenal Hyperplasia CAH
 The rare side effect (with li...
NS
 33 year old white Caucasian female
 Driving instructor
 Living alone
 Congenital Adrenal Hyperplasia (CAH, 21 Hydr...
More information
 Bouts of depression since age of 18
 Was told about her genetic condition aged 15
 Only appreciated t...
 GP initiated Citalopram 20 mg, felt worse on
40 mg
 Temazepam 10-20 mg nocte
 Prednisolone 7 mg od
 Fludrocortisone 1...
Initial assessment
 Seen by psychiatrist in August 2010
 Talked about the diagnosis of the genetic
disorder and its impa...
 Mood up and down. No middle ground. Since
teenager.
 Features of hypomania: overspending, easily irritable,
much more t...
Presentation
Hypomanic Depressed
 Elated
 Lots of motivation
 Less need for sleep
 Impulsive
 Overconfident
 Last up...
Anxiety
 Following a breakdown in 2010
 Very difficult to go out by herself
 Worries that something catastrophic might ...
Personal history
 Born in East Runton
 Normal delivery
 Delayed walking
 Main stream schools
 Care home assistant and...
Bit more of history
 Social history
 Premorbid personality
 Medical history
 Drugs and alcohol
 Forensic history
 Fa...
Diagnosis?
Diagnosis
 Bipolar affective disorder (current episode
mixed) F31.6
Formulation
 Predisposing factors:
 Genetics, family background, early life experience,
trauma, abuse, neglect.
 Precip...
Simplified representation of the early stages of bipolar disorder.
Elanjithara T E et al. APT 2011;17:283-291
©2011 by The...
Progress
 Quetiapine gradually increased to 300 mg
XL preparation
 Good response
 Discharged in November 2010
Re-referred January 2011
 Low mood
 Given up work
 Now living with parents
 Quetiapine increased to 400 mg without
goo...
Psychiatrist review February 2011
 Short hypomanic spells lasting 1-2 weeks followed
by longer periods of depression
 An...
August 2011 to March 2012
 Sodium valproate 600 mg daily
 Mirtazapine 45 mg nocte
 Good effect
 Referred to IAPT
 Dis...
Re-referred by link worker July 2012
 Mood swings
 Medication review
 Prednisolone 7 mg od
 Fludrocortisone 100 mcg od...
Consultant psychiatrist September
2012
 Significant mood swings
 Severe anxiety
 Clear hypomanic symptoms alternating w...
Discussion around lithium
 Endocrinologist opinion needed
 Fludrocortisone dose may need increase
 Monitoring level of ...
October 2012-May 2013
 Good response to lithium even with low
levels
 Subsequent levels approached therapeutic
levels
 ...
CBT Assessment
 Situation: shopping with mum
 Thoughts: “here we go, people are attacking me”.
 Enhanced awareness: sca...
July 2013
 Mainly low mood with some brief elevations
 Agreed to introduce a second agent
 Lamotrigine commenced with 2...
Current situation (Oct-Nov 2013)
 Lamotrigine stopped and lithium increased to gain
better therapeutic level
 Still on t...
Discussion and literature
 CAH and psychiatry
 Lamotrigine and hallucination
Congenital Adrenal Hyperplasia (CAH)
 Autosomal recessive
 21 Hydroxylase deficiency is most common
 Incidence is 1:500...
Dehydroeplandrosterone
(DHEA)
Cholesterol
Pregnenolone 17-hydroxypregnenolone
Progesterone 17-
hydroxyprogesterone
(17-OHP...
Symptoms
Male
 Enlarged penis
 Failure to regain birth weight
 Weight loss
 Dehydration
 Vomiting
 Precocious pubert...
Symptoms
Young woman with
excess hair growth
Baby girl with
ambiguous genitalia.
Treatment
 Glucocorticoids which suppress ACTH, are used to reduce
the levels of adrenal sex steroids in the blood
 Indi...
Psychiatric manifestations of CAH
 According to Riepe et al., 71% of female CAH patients suffer
from psychosexual problem...
 However, specific problems, such as gender identity, sexual
orientation and sex-typed behavior, psychosexual function,
b...
Male-type behaviours
 Studies in females suffering from CAH have documented a
higher than expected prevalence of male-typ...
Hallucination with Lamotrigine
Only one case report describing this in patients
without an underlying neurological disorde...
Psychiatric symptoms related to the use
of Lamotrigine: a review of the literature
Lamotrigine is generally well tolerated...
eHealthMe data
 On Oct, 19, 2013: 33,726 people reported to have side effects when taking
Lamotrigine. Among them, 275 pe...
Conclusions
 Role of CAH (the disorder itself and its treatment) in
her presentation
 Significance of the rare Lamotrigi...
MCQ Select the single best option for each question stem
1. Age at onset of bipolar disorder:
a) has little prognostic rel...
MCQ Select the single best option for each question stem
1. Age at onset of bipolar disorder:
a) has little prognostic rel...
 2. Individuals with bipolar disorder:
a) rarely receive a diagnosis of unipolar depression
b) have longer episodes of ma...
 2. Individuals with bipolar disorder:
a) rarely receive a diagnosis of unipolar depression
b) have longer episodes of ma...
3. When compared with bipolar I disorder,
bipolar II disorder:
a) is associated with better inter-episode functioning
b) i...
3. When compared with bipolar I disorder,
bipolar II disorder:
a) is associated with better inter-episode functioning
b) i...
4. Regarding the treatment of bipolar disorder:
a) delays in initiating treatment are rare
b) the vast majority of patient...
4. Regarding the treatment of bipolar disorder:
a) delays in initiating treatment are rare
b) the vast majority of patient...
5. Common comorbid conditions include:
a) anxiety disorders in 5% of patients
b) rheumatoid arthritis
c) thyroid disease
d...
5. Common comorbid conditions include:
a) anxiety disorders in 5% of patients
b) rheumatoid arthritis
c) thyroid disease
d...
Thanks
Between a laugh and a tear (case presentation on bipolar disorder)
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Between a laugh and a tear (case presentation on bipolar disorder)

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Between a laugh and a tear (case presentation on bipolar disorder)

  1. 1. Yasir Hameed (ST4 Dual Training) Jaap Hamelijnck (consultant psychiatrist) Eastern Recovery Team Northgate Hospital 12 November 2013
  2. 2. Overview  Why we chose this case?  Clinical details  Congenital Adrenal Hyperplasia CAH  The rare side effect (with literature review)  CAH and psychiatric morbidity  MCQs
  3. 3. NS  33 year old white Caucasian female  Driving instructor  Living alone  Congenital Adrenal Hyperplasia (CAH, 21 Hydroxylase Deficiency)  No previous contact with mental health services  Referred by her GP in July 2010 due to mood swings, lack of sleep and thought racing with suicidal ideas.
  4. 4. More information  Bouts of depression since age of 18  Was told about her genetic condition aged 15  Only appreciated the full impact in her late 20s and needed counselling  Disturbed relationship with parents  Thoughts of suicide and harming others (stabbing her parents)  Not psychotic  No drugs or alcohol
  5. 5.  GP initiated Citalopram 20 mg, felt worse on 40 mg  Temazepam 10-20 mg nocte  Prednisolone 7 mg od  Fludrocortisone 100 mcg od
  6. 6. Initial assessment  Seen by psychiatrist in August 2010  Talked about the diagnosis of the genetic disorder and its impact on her mental health  Became reclusive, unable to speak to anyone  Relationships difficulties  Anxious and suspicious  Thoughts of killing her parents
  7. 7.  Mood up and down. No middle ground. Since teenager.  Features of hypomania: overspending, easily irritable, much more talkative, racing thoughts, easily distracted , getting overly childish and giggling lasting about 2 weeks at a time. Depressed mood longer.  Mood Disorder Questionnaire: 13 out of 13 for Q.1, and considered these mood changes as having serious effect on her life.
  8. 8. Presentation Hypomanic Depressed  Elated  Lots of motivation  Less need for sleep  Impulsive  Overconfident  Last up to 3-4 weeks  Low  Lacks motivation  Withdrawn  Negative thoughts  Feels useless  Suicidal ideas  Last 2-3 months
  9. 9. Anxiety  Following a breakdown in 2010  Very difficult to go out by herself  Worries that something catastrophic might happen  Unable to sleep, worrying that someone might break into her home  Great impact on her mood and her relations
  10. 10. Personal history  Born in East Runton  Normal delivery  Delayed walking  Main stream schools  Care home assistant and driving instructor  Bisexual
  11. 11. Bit more of history  Social history  Premorbid personality  Medical history  Drugs and alcohol  Forensic history  Family history
  12. 12. Diagnosis?
  13. 13. Diagnosis  Bipolar affective disorder (current episode mixed) F31.6
  14. 14. Formulation  Predisposing factors:  Genetics, family background, early life experience, trauma, abuse, neglect.  Precipitating factors:  Triggers, relationship tensions, employment issues.  Perpetuating factors:  Avoidance, mistrust, unemployment, dependent on parents.
  15. 15. Simplified representation of the early stages of bipolar disorder. Elanjithara T E et al. APT 2011;17:283-291 ©2011 by The Royal College of Psychiatrists
  16. 16. Progress  Quetiapine gradually increased to 300 mg XL preparation  Good response  Discharged in November 2010
  17. 17. Re-referred January 2011  Low mood  Given up work  Now living with parents  Quetiapine increased to 400 mg without good effect
  18. 18. Psychiatrist review February 2011  Short hypomanic spells lasting 1-2 weeks followed by longer periods of depression  Angry, anxious and easily frustrated  Quetiapine switched to Olanzapine  Mirtazapine started  Very sedated on olanzapine, switched to Sodium Valproate
  19. 19. August 2011 to March 2012  Sodium valproate 600 mg daily  Mirtazapine 45 mg nocte  Good effect  Referred to IAPT  Discharged in March 2012
  20. 20. Re-referred by link worker July 2012  Mood swings  Medication review  Prednisolone 7 mg od  Fludrocortisone 100 mcg od  Sodium Valproate 600 mg daily  Mirtazapine 30 mg nocte
  21. 21. Consultant psychiatrist September 2012  Significant mood swings  Severe anxiety  Clear hypomanic symptoms alternating with depression  Thoughts of planning her funeral but no active suicidal plans
  22. 22. Discussion around lithium  Endocrinologist opinion needed  Fludrocortisone dose may need increase  Monitoring level of renin  Prednisolone role  Lithium started in October 2012
  23. 23. October 2012-May 2013  Good response to lithium even with low levels  Subsequent levels approached therapeutic levels  Offered CBT for Panic Disorder with Agoraphobia and was very successful
  24. 24. CBT Assessment  Situation: shopping with mum  Thoughts: “here we go, people are attacking me”.  Enhanced awareness: scanning the area, heart racing, body is shaking  Behaviours: scanning area for potential threats from others, “I need to protect my mum and stay close”, keep others at safe distance  Catastrophic misinterpretation: “I’d die in the hands of some idiot” (random attacks in public places)  Safety behaviours: scan the area, get out, avoid.  After: headaches, “fed up with myself”, what was the fuss about
  25. 25. July 2013  Mainly low mood with some brief elevations  Agreed to introduce a second agent  Lamotrigine commenced with 25 mg od  Started to experience auditory and visual hallucinations  Never had them before  “Weird but not frightening”
  26. 26. Current situation (Oct-Nov 2013)  Lamotrigine stopped and lithium increased to gain better therapeutic level  Still on the low side. Frustrated. Want to get back to work.  Discussed adding Quetiapine or Topiramate  Current medication: Lithium 1 g od (latest level 0.8 on 29.10.13), Mirtazapine 30 mg od. Prednisolone and Fludrocortisone. Vitamin D3.
  27. 27. Discussion and literature  CAH and psychiatry  Lamotrigine and hallucination
  28. 28. Congenital Adrenal Hyperplasia (CAH)  Autosomal recessive  21 Hydroxylase deficiency is most common  Incidence is 1:5000 to 1:15000 live birth  The enzyme deficiency causes reduction in end-products, accumulation of hormone precursors & increased ACTH production
  29. 29. Dehydroeplandrosterone (DHEA) Cholesterol Pregnenolone 17-hydroxypregnenolone Progesterone 17- hydroxyprogesterone (17-OHP) Androstenedione Deoxycorticosterone 11-deoxycortisol Testosterone Corticosterone Cortisol Aldosterone 21-hydroxylase 21-hydroxylase
  30. 30. Symptoms Male  Enlarged penis  Failure to regain birth weight  Weight loss  Dehydration  Vomiting  Precocious puberty  Rapid growth during childhood, but shorter than average final height. Female  Ambiguous genitalia  Failure to regain birth weight  Weight loss  Dehydration  Vomiting  Precocious puberty  Rapid growth during childhood, but shorter than average final height.  Infertility  Irregular or absent menstruation  Masculine characteristics
  31. 31. Symptoms Young woman with excess hair growth Baby girl with ambiguous genitalia.
  32. 32. Treatment  Glucocorticoids which suppress ACTH, are used to reduce the levels of adrenal sex steroids in the blood  Individuals with salt wasting CAH also require mineralocorticoids and sodium chloride supplements  Surgery on virilised females  Growth monitoring to detect over and under treatment  Counselling
  33. 33. Psychiatric manifestations of CAH  According to Riepe et al., 71% of female CAH patients suffer from psychosexual problems. Of these, only 17% undertook routine psychiatric diagnosis and counseling.*  Berenbaum et al. found that adult females with CAH as a result of 21-hydroxylase (21-OH) deficiency had good overall psychological adjustment, similar to that of the control group. ** *Riepe FG, Krone N, Viemann M, Partsch CJ, Sippell WG. Management of congenital adrenal hyperplasia: results of the ESPE Questionnaire. Horm Res 2002;58:196-205. **Berenbaum SA, Korman Bryk K, Duck SC, Resnick SM. Psychological adjustment in children and adults with congenital adrenal hyperplasia. J Pediatr 2004;144:741-6.
  34. 34.  However, specific problems, such as gender identity, sexual orientation and sex-typed behavior, psychosexual function, body images, psychiatric adjustment and quality of life, have been evaluated and found to be associated with the illness when using different assessment instruments.  With regard to childhood psychiatric comorbidity, few studies have revealed that intersex people have an increased prevalence of mental disorders, except that some individuals with CAH struggled to adjust to their condition.
  35. 35. Male-type behaviours  Studies in females suffering from CAH have documented a higher than expected prevalence of male-typical traits and behaviours, more male typical childhood play, show more interest in male-typical activities and careers, and exhibit more aggression than unaffected females.  Most women with congenital adrenal hyperplasia have good long term psychological outcome, with no dramatic increase in psychological morbidity, good social adjustment, and no deficit in self esteem Morgan et al. Long term psychological outcome for women with congenital adrenal hyperplasia: cross sectional survey. BMJ VOLUME 330 12 FEBRUARY 2005 bmj.com
  36. 36. Hallucination with Lamotrigine Only one case report describing this in patients without an underlying neurological disorder “To our knowledge, this is the first report of Lamotrigine-induced hallucinations in a subject without neurological illness.” Uher R, Jones HM. 2006. Hallucinations during lamotrigine treatment of bipolar disorder. Am J Psychiatry, 163:749–50.
  37. 37. Psychiatric symptoms related to the use of Lamotrigine: a review of the literature Lamotrigine is generally well tolerated; however, some psychiatric problems have been reported in patients using the drug to treat mental disorders (mainly bipolar) or epilepsy The clinical features of these psychiatric side effects are: affective switches, full acute psychotic episodes, and hallucinations Villari et al. Functional Neurology 2008; 23(3): 133-136
  38. 38. eHealthMe data  On Oct, 19, 2013: 33,726 people reported to have side effects when taking Lamotrigine. Among them, 275 people (0.82%) have Hallucinations.  Time when people have Hallucinations: 40% less than one month after starting Lamotrigine. 48% between 1-6 months, lower thereafter.  Top conditions involved for these people : 1. Bipolar disorder (86 people, 31.27%) 2. Epilepsy (53 people, 19.27%) 3. Depression (47 people, 17.09%) 4. Drug use for unknown indication (19 people, 6.91%) 5. Anxiety (16 people, 5.82%)
  39. 39. Conclusions  Role of CAH (the disorder itself and its treatment) in her presentation  Significance of the rare Lamotrigine reaction  Future long term management  Role of Multidisciplinary team
  40. 40. MCQ Select the single best option for each question stem 1. Age at onset of bipolar disorder: a) has little prognostic relevance b) is not a heritable trait c) has been observed to be higher in more recent studies d) is higher in women than men e) has implications for clinical course.
  41. 41. MCQ Select the single best option for each question stem 1. Age at onset of bipolar disorder: a) has little prognostic relevance b) is not a heritable trait c) has been observed to be higher in more recent studies d) is higher in women than men e) has implications for clinical course.
  42. 42.  2. Individuals with bipolar disorder: a) rarely receive a diagnosis of unipolar depression b) have longer episodes of mania than depression c) commonly have psychiatric comorbidities d) have fewer depressive episodes than those with unipolar depression e) show poorer prognosis if they have predominantly manic episodes
  43. 43.  2. Individuals with bipolar disorder: a) rarely receive a diagnosis of unipolar depression b) have longer episodes of mania than depression c) commonly have psychiatric comorbidities d) have fewer depressive episodes than those with unipolar depression e) show poorer prognosis if they have predominantly manic episodes
  44. 44. 3. When compared with bipolar I disorder, bipolar II disorder: a) is associated with better inter-episode functioning b) is similar and frequently develops into bipolar I disorder c) is associated with fewer affective episodes overall d) has a less chronic course e) has a significantly higher age at onset
  45. 45. 3. When compared with bipolar I disorder, bipolar II disorder: a) is associated with better inter-episode functioning b) is similar and frequently develops into bipolar I disorder c) is associated with fewer affective episodes overall d) has a less chronic course e) has a significantly higher age at onset
  46. 46. 4. Regarding the treatment of bipolar disorder: a) delays in initiating treatment are rare b) the vast majority of patients respond to lithium or an anticonvulsant treatment when in a manic phase c) quetiapine leads to remission in over 50% of patients in the depressive phase d) there are a number of well-tolerated treatments that are effective in all phases of the illness e) the majority of patients are maintained on monotherapies.
  47. 47. 4. Regarding the treatment of bipolar disorder: a) delays in initiating treatment are rare b) the vast majority of patients respond to lithium or an anticonvulsant treatment when in a manic phase c) quetiapine leads to remission in over 50% of patients in the depressive phase d) there are a number of well-tolerated treatments that are effective in all phases of the illness e) the majority of patients are maintained on monotherapies.
  48. 48. 5. Common comorbid conditions include: a) anxiety disorders in 5% of patients b) rheumatoid arthritis c) thyroid disease d) tension headache e) unipolar depression.
  49. 49. 5. Common comorbid conditions include: a) anxiety disorders in 5% of patients b) rheumatoid arthritis c) thyroid disease d) tension headache e) unipolar depression.
  50. 50. Thanks

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