Patient Profile: Sarah Onset of illness: Aged 34 rapid Single Course: chronic Teacher remittent Duration: 10 years
Each episode Sarah has feeling tearful with low self-esteem Has trouble sleeping at night but sleep many hours at day time Has nothing in her life which brings her enjoyment Has suicidal ideas Gained weight Feeling despair Isolation from friends and family sense of worthlessness Concentration difficulty Symptoms are worsening over episodes
Sarah said• When I am down, I want to be alone• I shut out everyone and hide• I cry for no reason• I dont know why I am scared• I can not see anything good in my future• My head is filled with dark thoughts• I no longer want to be here• I often think about ways to end this misery life• I have to fight the thoughts in my head• I feel like I cannot breath• The depression has given me the worst days in my life especially the mornings , I hate my morning because of my depression and I hate myself.• It was true that while I was sunk in gloom at morning, I could laugh, be animated in the evenings, entertaining friends with mimicry and hiding my true state of mind.
Previous treatment trials• She responded rapidly to different SSRIs on start of treatment and within few days but soon she lost the response and she stopped drugs out of her despair.• She tried to adapt herself for her symptoms .• Each episode lasted on average 5-7 months and they had seasonal preference and disappeared suddenly.• She had a lot of episodes and never free for more than few weeks.
Case study: diagnosis and treatment Sarah diagnosed Prescribed with major amitryptiline depression 100 mg
6-week follow-up Sarah is still experiencing As usual she felt some depressiveimprovement at first weeks symptoms although Then worsened again appears agitated and restless Sarah has had several Sarah reports that she heated arguments with is still only getting her mother 2-4 h sleep per night
One week later , Sarah• Spent hours and hours on her computer• Did not sleep at all for days• She heard music in the distance all the time• She left her work• She started to self medicate herself with amphetamine and cannabis• She wrapped wet towels around her head afraid her brain was going to over heat from thinking so much
Two weeks later• She thought she is more intelligent than Albert Einstein• She thought she was going to walk through invisible time gap• She thought she discovered the theory of everything• She thought the ancient Egyptians knew she had discovered the theory of everything and they wanted her back in their time• Her sex drive went through the roof and she called some of her colleagues at work for marriage at late night.• She wrote to all journals and magazines in the country and TV stations• She wrote to the prime minister and the US president• She wrote to Pope in Vatican• She thought she is going to get Nobel prize• She thought she is a God
CongratulationsSarah does not appear depressed now
Inpatient, one week later Sarah More hospitalised thorough Diagnosis changed with acute psychiatric to bipolar disordermanic episode history taken
Premorbid : Sarah She is described by her family and friends that she is a nice person and known between her friends with her Brilliant abilities, versatility, wealth of ideas, artistic capability, sociability and supportive attitude for weak people high energy, remarkable capacity for productive work, On the other side , they described her also by some negativesas she is risk taker, impulsive, lack of reliability, steadiness andperseverance in work, a tendency to building castles in the air, impatience, and a tendency to be easily annoyed. Hyperthymic temperament
Final diagnosisShe was a soft But now after Severe manic bipolar case strong ADD drug breakdown
Take home message• Patients with Bipolar disorders are missed , under- diagnosed and under-estimated Bipolar disorder Correct frequently Misdiagnosis diagnosis can be begins with a delayed by up to as MDD depressive 10 years episode Lewinsohn et al 1995; Hirschfeld et al 2003
Case study: treatment Dose SlowAdmission titrated resolution switched to of symptomsto lithium 1.1 mEq/L Cognitive Change in dulling treatment? and tremors
Case study: treatmentDose of Atypical lithium antreduced psychotic added?
Few weeks later Calm , cooperative, euthymic She could concentrate again her insomnia vanished she lost weight she went back to work