Patient Profile: SarahOnset of illness:
rapid
Course: chronic remittent
Duration: 10 years
Aged 34
Single
Teacher
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 don't 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.
Sarah diagnosed with major depression
Case study: diagnosis and treatment
Prescribed amitryptiline
100 mg
6-week follow-up
As usual she felt some improvement at first weeks
Then worsened again
Sarah is still experiencing depressive
symptoms although appears agitated
and restless
Sarah has had several heated arguments with
her mother
Sarah reports that she is still only getting
2-4 h sleep per night
Psychiatrist’s Decision
Increased dose 150 mg
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
Congratulations
Sarah does not appear depressed now
Inpatient, one week later
Sarah hospitalised with acute
manic episode
More thorough
psychiatric history taken
Diagnosis changedto bipolar disorder
Premorbid : Sarah
On the other side , they described her also by some negatives as she is risk taker, impulsive, lack of reliability, steadiness and perseverance in work, a tendency to building castles in the air,
impatience, and a tendency to be easily annoyed.
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 peoplehigh energy, remarkable capacity for productive work,
Hyperthymic temperament
Final diagnosis
She was a soft bipolar case
But now after strong ADD
drug
Severe manic
breakdown
Take home message
Lewinsohn et al 1995; Hirschfeld et al 2003
Bipolar disorder
frequently begins with a depressive
episode
Misdiagnosis as MDD
Correct diagnosis can be delayed by up to
10 years
• Patients with Bipolar disorders are missed , under-diagnosed and under-estimated
Admissionswitchedto lithium
Case study: treatment
Dose titrated
to 1.1 mEq/L
Slow resolution
of symptoms
Cognitive dulling
and tremors
Change intreatment?
Case study: treatment
Dose of lithium
reduced
Atypicalant
psychoticadded?
Few weeks later
Calm , cooperative, euthymic
She could concentrate again
her insomnia vanished
she lost weight
she went back to work
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