Question

Jon is a psychiatric mental health nurse in a large metropolitan clinic, which is connected to a research hospital. Jon likes the fact that it’s a walk-in clinic. One day he is just getting ready to eat his sack lunch, when a slender young woman who looks exhausted and timid knocks at his open door. “Excuse me,” she says. “Can I get into a research project?” Jon puts down his bologna sandwich. “What’s that?” he says. He’s confused. “Research?” “Yes,” she says, stepping inside and slipping into the chair beside his desk. Jon wraps up his sandwich for later. “I want to know if I can be part of a study for depression,” the woman says. Her mouth trembles. “This is a research hospital, right?” Jon hesitates, trying to take in what she wants. As he pauses, he does a visual assessment. The woman is in her late 20s or early 30s, attractive, but somewhat bedraggled. She looks as if she’s been on a long, difficult road trip. “Well,” he says. “I don’t know of any studies going on off hand, but does that matter? I’m sure we can get you the help you need without a study. What seems to be the problem? And what’s your name, by the way? Mine’s Jon.” “I’m Erika,” she says when her face crumples and she begins to cry. “I’ve screwed up big time!” she says. “I’ve just ruined my life and my son’s life!” And just like that, she is sobbing. “I’m sure you haven’t ruined anything,” Jon says. He glances at the clock behind Erika, wondering what time the psychiatrist will be back from her luncheon meeting. “Why don’t you tell me what’s happened?” “I ran away,” she says, still sobbing. “I ran away, walked off my job, and hit the road with my little boy Oscar!” She lowers her hands from her face. “We just now got back into town. We’ve been sleeping in the car for 3 days.” “Are you homeless? Do you need a shelter?” “No,” she cries. “That’s just it! We had a perfectly decent life, and now I’ve blown it.” “There’s usually something that can be done,” Jon says, handing her a box of tissues. “Why don’t you start at the beginning, and let’s see what we can do.” “Thank you,” she says, blowing her nose and really looking Jon in the eye for the first time. Jon smiles. “You’re welcome. Now. Just start anywhere.” Erika tells Jon that she is a 28-year-old mother who was a “wild teen,” saying that she had a tumultuous relationship with her parents. At age 20, Erika gave birth to her son Oscar, who is now 8. “Oscar,” she says “is the sweetest, most supportive son ever.” Shortly after Oscar’s birth Erika suffered from severe postpartum depression that plunged her into what she calls “a hellish paranoia. I was some kind of hormonal, psychotic witch for a while. No wonder my fiancé broke it off with me.” She says this with a sad smile and starts to cry again. Erika has come into the clinic because, she says, “sometimes I think I never recovered from my postpartum depression. I mean, I’ve always been hyper and bad-tempered, which I freely admit. But now I just can’t seem to pull out of it. I can’t sleep; I’m angry all the time; I can’t concentrate on anything, and I’m so depressed I can’t function.” But things are even worse than Erika is letting on. “Okay,” she says. “There’s something else. Something even worse.” She has trouble pulling her tears under control, and it takes her a moment to struggle with that. “I flipped out at work last week,” she says. “I slapped my supervisor because she was very unfair. She had it in for me. Then I stormed out of work, grabbed my son out of school, and got in the car and just drove, furious and feeling hopeless. We drove and drove and then it was like I woke up and realized I was in another state. I drove all the way to Wyoming, two states away to Oscar’s dad’s house, and all he said was, ‘You walked out on a good job? Well, you can’t stay here and freeload! Get back to Denver and get your job back!’” “We slept in the car, and I was crying and yelling, and Oscar was crying. It was awful. I’m the worst mother ever. So now I’m back in Denver, with no job and overdue on my rent and no money left in the bank to pay it.” “No money?” She shakes her head. “I blew it all on the trip. I was so mad about work, I told Oscar, ‘We’re going on a road trip.’ I thought maybe we’d go to Yellowstone, or maybe Disneyland. And at first he thought it was fun till he saw I was a mess, and then he was just scared. And now we’re back, and I’m broke and unemployed. I never sleep, and I know I talk too much and too fast, but my head is always full of more thoughts and ideas than I can keep track of, and they rush through me like the Indianapolis 500, and sometimes they just come bursting out of my mouth.” 1. Jon is able to complete an intake assessment of Erika, and when the doctor comes back from her meeting and sees the state Erika is in, she meets with her immediately. She gets Erika help with her most immediate needs, and when Erika refuses hospitalization, concerned about uprooting Oscar any further, the doctor makes a diagnosis and writes her a small, temporary prescription—but only after Erika agrees to come back and start treatment. Erika readily agrees. The doctor subsequently diagnoses Erika with bipolar I disorder. Assuming that the doctor is right, what evidence do you see of this disorder? 2. In addition to her diagnosis of bipolar I disorder, which signs of mania does Erika displays the most.

Answer 1

BIPOLAR AFFECTIVE DISORDER

THE FUNDAMENTAL ABNORMALITY OF AN AFFECTIVE DISORDER IS A DISTURBANCE O MOOD,EITHER DEPRESSION OR MANIA. DEPRESSION IS BY FAR THE COMMONER; MOST PATIENTS WHO HAVE MANIC SYMPTOMS ARE ALSO PRONE TO DEPRESSIVE EPISODES BUT THE REVERSE DOES NOT APPLY.INA FEW CASES DEPRESSIVE AND MANIC SYMPTOMS OCCUR SIMULTANEOUSLY OR IN RAPID SUCCESSION (MIXED AFFECTIVE STATE )

THE SIMPLEST CLASSIFICATION OF BIPOLAR AFFECTIVE DISORDERS ARE FOLLOWING

1. PRIMARY AFFECTIVE DISORDER : THESE ARE NOT SECONDARY TO ANY OTHER PSYCHIATRIC OR PHYSICAL ILLNESS BUT MAY BE PRECIPITATED BT A WIDE RANGE OF ENVIRONMENTAL FACTORS.THEY ARE OFTEN RECURRENT;IF RECURRENCE ALWAYS TAKE A DEPRESSIVE FORM THE TERM UNIPOLAR DISORDER IS USED ; IF THE RECURRENCES ARE BOTH MANIC AND DEPRESSIVE THE TERM BIPOLAR IS USED.
2. SECONDARY AFFECTIVE DISORDERS : THESE FOLLOW ANOTHER PSYCHIATRIC (ALCOHOLISM , SCHIZOPHRENIA , ) OR PHYSICAL ILLNES. IN THE LATTER CASE THE MOOD CHANGE IS USUALLY DUE TO THE EMOTIONAL IMPACT OF THE ILLNESS BUT IN SOME PATIENTS IT IS DUE TO ANATOMICAL OR PHYSIOLOGICAL CHANGES IN THE BRAIN AND MAY BE THE PRESENTING FEATURE OF THE UNDERLYING PHYSICAL ILLNESS . THESE ARE DESCRIBED AS ORGANIC OR SYMPTOMATIC AFFECTIVE DISORDERS.

EPIDEMIOLOGY

COMMUNITY STUDIES HAVE SHOWN THAT THE PREVALENCE RATE FOR DEPRESSION ,DEFINED BY STRICT OPERATIONAL CRITERIA ,IS APPROXIMATELY 6-8 % FOR WOMEN AND 3-5 % FOR MEN.DEPRESSION IS COMMONER IN THE LOWER SOCIAL CLASSES AND AMONG INNER CITY DWELLERS.WOMEN IN THEIR CHILD BEARING YEARS ARE ESPECIALLY VULNERABLE.

BIPOLAR DISORDER IS LESS COMMON ,HAVING A PREVALENCE RATE 1%. THERE IS NO DIFFERENCE IN PREVALENCE BETWEEN THE SEXES NOR BETWEEN SOCIAL CLASSES.

AETIOLOGICAL FACTORS

GENETICS : THERE IS CONVINCING EVIDENCE FROM ADOPTION AND TWIN STUDIES OF A GENETIC CONTRIBUTION TO BIPOLAR DISORDERS ALTHOUGH THE MODE OF INHERITANCE IS NOT CLEAR. THE GENETCS BASIS OF UNIPOLAR DEPRESSION HAS NOT BEEN ESTABLISHED WITH SUCH CERTAINITY.

ENVIRONMENT : MANY ENVIRONMENTAL FACTORS HAVE BEEN IMPILCATED BUT THE THREE MOST CONSISTENTLY INVOLVED ARE LOSS OF A PARENT IN CHILDHOOD ,LACK OF SOCIAL SUPPORT AND RECENT ADVERSE LIFE EVENTS. FOR WOMEN A PROFILE OF VULNERABILITY FACTORS HAS BEEN DEFINED .

VULNERABILITY FACTORS FOR AFFECTIVE DISORDERS

1. LOSS OF MOTHER BEFORE AGE OF 11
2. THREE OR MORE CHILDREN UNDER 14 LIVING AT HOME
3. LACK OF CONFIDING RELATIONSHIP
4. LACK OF FULL -TIME OR PART TIME EMPLOYMENT

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PHYSICAL ILLNESS : ALL PHYSICAL ILLNESS CAN BE FOLLOWED BY DEPRESSION, ESPECIALLY THOSE LIKE CANCER,AND HEART DISEASE WHICH CARRY SERIOUS IMPLICATIONS.THERE IS CONSIDERABLE INTEREST IN THE ROLE OF VIRAL ILLNESS IN CAUSING DEPRESSION.

PERSONALITY : SOME DEPRESSIVE HAVE PERSONALITY CHARACTERISTIC WHICH ARE THOUGHT TO PREDISPOSE TO THE ILLNESS.THESE INVOLVE A NEGATIVE ATTITUDE TO ONESELF ,THE OUTSIDE WORLD AND THE FUTURE; THE TERM COGNITIVE TRIAD HAS BEEN APPLIED TO THESE ATTITUDES .THE PERSONALITY MOST TYPICALLY ASSOSIATED WITH BIPOLAR ILLNESS IS A CYCLOTHYMIC

CLINICAL FEATURES OF DEPRESSION AND MANIA

DEPRESSION

• UNHAPPINESS
• ANHEDONIA (LOSS OF PLEASURE IN LIFE )
• LOW SELF ESTEEM
• SUICIDAL THINKING
• PASSIVE WISH TO DEATH

​​​​​​​SOMATIC SYMTOMS OF DEPRESSION

• SLEEP DISTURBANCES ( INITIAL INSOMNIA ,EARLY MORNING ,WEAKNESS ,OR HYPERSOMNIA)
• FATIGUE
• HEADACHE
• OTHER PAINS (e.g. CHEST PAIN , ABDOMINAL PAIN )
• ANOREXIA
• WEIGHT CHANGE
• CONSTIPATION
• REDUCED LIBIDO
• POOR CONCENTRATION
• PSYCHOMOTOR RETARDATION

DIAGNOSTIC CRITERIA FOR DEPRESSION

• DEPRESSED MOOD MOST OF THE DAY
• MARKEDLY DIMINISHED INTEREST IN ALMOST ALL ACTIVITIES MOST OF THE DAY
• SIGNIFICANT WEIGHT LOSS OR WEIGHT GAIN ( AT LEAST 5% IN ONE MONTH )
• INSOMNIA OR HYPERSOMNIA
• PSYCHOMOTOR RETARDATION OR AGITATION
• FATIGUE OR LOSS OF ENERGY
• FEELING OF WORTHLESSNESS OR EXCESSIVE GUILT
• DIMINSHED ABILITY TO THINK OR CONCENTRATE ,OR INDECISIVENESS
• RECURRENTS THOUGHTS OF DEATH OR SUICIDE ; A SUICIDE ATTEMPT OR A SPECIFIC

MANAGEMENT

OUTPATIENT MANAGEMENT IS APPROPRIATE IN MOST CASES. ADMISSION IS NECESSARY WHEN THERE IS A STRONG RISK OF SUICIDE OR WHEN SOCIAL SUPPORTS ARE INADEQUATE. COMPULSORY ADMISSION UNDER THE MENTAL HEALTH ACT IS REQUIRED FOR SUICIDAL PATIENTS WHO DONOT ACCEPT VOLUNTARY TREATMENT.

ANTIDEPRESSANT DRUGS

TRICYCLIC DRUGS : FIRST CHOICE OF TREATMENT .GIVEN FOR 6 WEEKS  ​​​​​​​ LEAST

SEROTONIN REUPTAKE INHIBITOR : IF POOR RESPONSE TO TRICYCLICS IS POOR SRI'S ARE INTRODUCED

MONAMINE OXIDASE INHIBITOR

COGNITIVE THERAPY

THIS HAS BEEN SUCCESSFULLY IN COMBINATION WITH ANTIDEPRESSANTS AND IS INDICATED ESPECIALLY FOR PATIENTS WHOSE DEPRESSION SEEMS TO BE PERPETUATED BY A NEGATIVE PATTERN OF THINKING

ELECTROCONVULSIVE THERAPY

THIS IS INDICATED WHEN THE RISK OF SUICIDE IS SO GREAT THAT ONE CANNOT WAIT FOR DELAYED THERAPEUTIC EFFECT OF ANTIDEPRESSANTS DRUGS.

MANIA

• SENSE OF WELL BEING
• ELATION
• ECTASY
• CONFIDENCE AND SELF ESTEEM ARE HIGH
• GRANDIOSE IDEAS
• HIGHLY ENERGETIC
• THOUGHTS COME RAPIDLY
• SPEECH IS SO FAST
• FLIGHT OF IDEAS
• RHYMING OF SPEECH
• MOTOR ACTIVITY IS INCREASED
• APPETITE IS ENHANCED
• SLEEP HOURS REDUCED
• EXPOSURE TO SEXUALLY TRANSMITTED DISEASES

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MANAGEMENT

NEUROLEPTIC DRUGS - HALOPERIDOL,PHENOTHIAZINE,

LITHIUM CARBONATE

RECENTLY CARBAMAZEPINE HAS BEEN USED AS AN ALTERNATIVE FOR PATIENTS WHO DONOT RESOND TO LITHIUM.

IN THIS CASE THE PATIENT IS IN MOOD OF MANIA WHEN SHE EXHAUSTED AND WHEN LEFT FROM HER JOB.MOST OF THE TIME SHE IN DEPRSSIVE SWING.